Ethical approval & student recruitment
Ethical approval was sought from the RCSI Research Ethics Committee to collect data from the IC medical students in January 2014. The study took place over both semesters in this cycle and ended in December 2014. All consenting students were asked to complete quizzes associated with the study on the virtual learning environment, Moodle. Students were recruited before the first MDT when a short presentation and demonstration of the “clickers” was also given.
Automated student response system
PowerPoint presentations addressing the intended learning outcomes with embedded interactive questions were prepared using the software obtained from Turning Technologies (Northern Ireland). The software allows for the creation of PowerPoint presentations with embedded questions such as multiple choice or true or false that can be posed to the students during class and polled in real-time. The students then use handheld “clickers” to assess their understanding by choosing the corresponding option on the key-pad of the device. The software allows the user to limit the length of time the polling of each question is open and the students can also see a count-down timer on the slide. When polling is closed, the software collates all responses to generate a graph indicating the percentage responses for each option. The software allows the user to indicate the correct answer using a variety of markers.
This was a comparative observational study in which three MDTs (CAP, peritonitis and meningitis), spread over both semesters, involved the use of the “clickers” and three MDTs (TB, IE and BSI with pyelonephritis), spread over both semesters, took place without the use of the clickers. The MDT is a case-based large group teaching session that takes place in a lecture theatre and lasts approximately 90 min. MDTs with an infection theme are coordinated by the Department of Clinical Microbiology and the presentation and sessions are prepared by senior clinician academics. The MDT is case-based and problem-orientated. The students are presented with the patient’s history initially and the different disciplines take them through the various aspects of the case, where appropriate. For example, medicine will work through the differential diagnosis, then clinical microbiology will discuss specimen collection and the possible laboratory results, then possibly radiology would discuss the findings from imaging and then the case may revert to clinical microbiology and a discussion around appropriate antibiotics. Material covered in lectures is put into a clinical context at the MDT.
In each MDT, whether “clickers” were used or were not used, five MCQs that covered the same topics i.e. signs & symptoms, appropriate diagnostic tests, the most common causative pathogen, the most appropriate antimicrobial to treat the infection and the most appropriate prevention strategy/other appropriate management relating to the case, were posed at various stages throughout the MDT. When “clickers” were used the students answered the MCQ in real-time. The MCQ was then discussed to ensure that the reasons for the most appropriate correct answer were understood. When no “clickers” were used the MCQ was simply posed verbally to the class by the teacher and answered by a show of hands only. The most appropriate correct answer and wrong answers were again discussed for consistency in the non “clicker” sessions.
To assess the impact of “clickers” on the learning
The “clickers” were not assigned to any one student but instead were collected prior to the commencement of class and during the taking of attendance. After each MDT, students were asked to answer the same five MCQs, as those posed in class, again via the virtual learning environment (online). Each student who had consented to participate was asked to complete the quiz over a 24 h period. A recent prospective cross-over interventional study assessing the impact of interactive lectures of biochemistry in a medical curriculum found that there was a statistically significant increase of comprehension in students who attended an interactive session compared to a non interactive session and that this was more evident when the topic covered was clinically orientated and when the students were assessed immediately after the session . Our rationale was similar, although we did not assess immediately after, we did assess our student’s comprehension and simple recall within a 24 h period after the MDT, which was also clinically focused. For maximum effect on learning, students again were given instant feedback once they had completed and submitted the quiz online. Each quiz consisted of five MCQs all worth two marks. The highest possible grade was therefore ten. Examples of the MCQs posed in the class and online can be seen in Appendix.
To assess student attitudes to the use of the “clickers”
On the same day of the last MDT, and immediately after the class had finished, a survey was conducted using the actual “clickers”. To comply with our ethical approval, to ensure student anonymity, for efficiency and to ensure maximum responses by avoiding survey fatigue, it was decided to conduct the student attitudes survey in this manner. Moreover, the Turning Technologies automated response system and software is designed for such purposes and to obtain immediate feedback. Students were asked to give their opinions on the use of the devices and the potential positive and negative impact they had on the learning environment. A 5-point Likert scale (strongly disagree to strongly agree) was used to assess student attitudes. The statements included in the study were as follows; (1) The “clickers” were easy to use; (2) MDTs were more enjoyable & interesting than normal lectures; (3) MDTs where “clickers” were used were more engaging than MDTs without “clickers”; (4) The use of a “clicker” during teaching distracted me from learning; (5) The use of a “clicker” enhanced my understanding of the topic being covered; (6) The use of the “clicker” during the MDT made important concepts more memorable.
Attendance was taken at all MDTs, including the last session where the survey was conducted. This facilitated the extraction of the demographic details of the cohort of students that participated in the survey.
The responses to each question on the survey were summarised using percentages and bar charts.
For all six MDT sessions, the average online post-MDT grade for each student was calculated. Only students who completed at least one post-MDT quiz in which a device was used and one post-MDT quiz in which no devices were used were included in this analysis. To assess the impact of the “clickers” on knowledge retention, a paired t-test was used to compare the difference in the means of the post-MDT grades, in which devices were used, with those in which no devices were used. Furthermore, a paired t-test was conducted including only students who completely engaged in the process and completed all online post-MDT quizzes (i.e. completed all three post-MDT quizzes in which no devices were used and all three post-MDT quizzes in which devices had been used). All analysis was conducted using Strata version 14 .