A comparative study: do “clickers” increase student engagement in multidisciplinary clinical microbiology teaching?

The traditional, didactic lecture is a common learning activity in medical education as it is an efficient, and economical, mechanism to transfer knowledge and fundamental concepts in medicine to large groups of students. However, lectures are not without their draw-backs. Students can find these very one directional, teacher-centric, passive and even monotonous [1, 2]. Despite the best efforts of the teacher to encourage students to focus and understand the core concepts during lectures, the actual format of the learning activity is thought to encourage a focus on the superficial learning points [3]. Furthermore, the lecture may not always suit the learning needs of all students and they may opt to not attend as a result. [4].

Encouraging active learning and making lectures, and other large group teaching sessions, engaging is now of great interest to health professions educators [5–8]. One widely used method involves “clickers”, which are small hand-held devices that students can use to respond to questions, most often multiple choice questions (MCQs), posed during a teaching session. These devices are increasingly being used in both large and small classes in many third level institutions to improve the learning experience [6, 8–11]. Generally they are used to introduce variety into a teaching session and to assess understanding of a topic in real-time [9]. The student’s response is received using wireless technology by the software in which the PowerPoint presentation was created and the combined responses from the whole class are compiled to create a bar chart. At this point the individual(s) delivering the session discuss the bar chart and explain why the answer options are correct or incorrect. Their application in the clinical teaching environment is also becoming more common and numerous studies have shown their use to be beneficial due to their ability to increase student engagement and to promote knowledge retention [12–15].

Multidisciplinary, and interprofessional, approaches to teaching students are also becoming more common and desirable within the health sciences as they seek to model real world interactions [16, 17]. One early study noted the benefits of a multidisciplinary approach in the delivery of paediatric pathology during a residency rotation and the authors suggested that this novel method of teaching could be applied to medical education as a whole to create a more informative and engaging experience [17]. More recently, an inter-disciplinary approach to the training of first year residents on a labour ward and delivery unit was evaluated by the Faculty of Midwives, the Department of Obstetrics and Gynaecology at the University of Colorado who found this was well received [16].

The Royal College of Surgeons in Ireland (RCSI) is a university level institution with over 2000 registered medical, pharmacy and physiotherapy students from over 60 countries. The Department of Clinical Microbiology delivers content across all three disciplines both online and through traditional modalities of didactic teaching, such as lectures and tutorials. In 2012, the Department led the introduction of a multidisciplinary teaching (MDT) session on peritonitis with the third year (Intermediate Cycle, IC) medical students. Since then five additional MDTs with a clinical microbiology theme have been introduced and they cover topics such as community-acquired pneumonia (CAP), infective endocarditis (IE), pulmonary tuberculosis (TB), viral hepatitis, bloodstream infection (BSI) with pyelonephritis, and bacterial meningitis. Depending on the case, and subject material, other teaching staff may include those from medicine, surgery, pathology and radiology/imaging. The aim of the MDT is to demonstrate to the students that the management of patients with complex or systemic infections requires a multi-disciplinary approach. The sessions highlight the key contributions of each discipline, at what stage this contribution is made and they demonstrate clearly the level of communication required between the disciplines when a management plan is being devised for the patient in the case presented. Case-based teaching is now a well established pedagogical tool in the health sciences. Students and teachers alike enjoy when the class centres around a case as it reflects the “real”-life environment and can enhance the learning experience but it should be noted that there is incomplete evidence to suggest that case-based teaching is better than any other method [18].

Student feedback from the first MDT session was very positive. However, a major issue with this method of large-group teaching was the lack of engagement between those delivering the session and the students. Furthermore, those delivering the teaching sessions felt that students did not wish to volunteer answers when questioned directly or they were reluctant to engage in discussion in the presence of so many of their peers. One study also reported that “clickers” provide a sense of anonymity that the students seem to prefer [19]. For these reasons, the Department of Clinical Microbiology decided to evaluate the use of “clickers” during these microbiology themed MDTs. Our overall aims were to assess the impact of the “clickers” on learning during our MDT sessions and to assess student attitudes to the use of these devices in their teaching.

As a mode of teaching for undergraduate medical students, the MDT helps show the professional interactions and multidisciplinary approach required in the management of patients with common infections. The majority of third year medical students polled in this study found the MDTs to be more enjoyable and interesting than their routine didactic lectures delivered by a single medical expert of one specific discipline. Several issues have been raised about the effectiveness of the lecture as a teaching activity. It is often said that the lecture is more teacher centred, that there are few opportunities for student reflection and that they do not promote problem-solving, patient management or the development of professional identity [21, 22]. It has also been said that lectures lacking interaction are not engaging enough for students to foster their critical skills [23] but do highlight the need for students to incorporate skills learned into their daily practices [24].

During the initial implementation of the MDT to our teaching program, when “clickers” were not used, we quickly identified limitations in a diverse and highly competitive student body. For example, it is known that aspiring surgeons are highly competitive [25]. Often, medical students do not wish to answer questions in front of their peers in case they are wrong. It is not surprising that the students (75%) in this study found the MDTs where “clickers” were used to be more enjoyable. These sessions most likely provided them with a “safe” learning environment and a sense of anonymity that students prefer [19]. Students also found the interactive “clicker” sessions to be more engaging than those when none were used. One recent study has shown that medical students studying biochemistry preferred interactive large group teaching sessions, such as lectures, to non interactive session [7]. This same study found that their interactive lectures enhanced understanding, created an interest in the lecture, motivated students to study, enhanced recollection and removed any doubts or misunderstandings [7]. However, this study did not describe the intervention that created the interactive learning environment. Importantly, 54% of the students surveyed in our study found the use of “clickers” and the additional interaction they created between the teacher and the class when the question and answers were discussed in detail enhanced their understanding. One study also found that students in a physician assistant program were more attentive when the devices were used but they also noted that the students found the teaching to be more enjoyable and engaging [26]. Another study also found that “clickers” made a lecture delivered to a variety of qualified healthcare professionals, which included clinicians, pharmacists and nurses, more interesting while still keeping their attention [14]. Furthermore, other studies have shown that “clickers” can promote advanced reasoning skills [27] and improve knowledge gain directly after teaching sessions [28]. In contrast to this, we saw no difference on retention of knowledge immediately after MDT between “clicker” and no “clicker” sessions. Similar to this, Duggan et al., [6] also saw no difference in MCQ scores from questionnaires based on lectures using “clickers” and normal lectures without the devices.

Most students who completed the online quizzes obtained between 80 and 100% (data not shown) grades on the same day after sessions regardless of whether a device was used or was not. This suggests their ability to, for example, make a differential diagnosis, or to identify the most likely causes of the infection or to develop a management plan, regardless of the topic being covered, was already well developed and understood. In fact, analysis of the data showed that there was evidence of a small negative impact on the grades of the whole class when the “clickers” were used. However, no positive or negative impact on the grades of the nineteen students who engaged with the entire study, and completed all six online quizzes, could be seen following statistical analysis. In a systematic review of 21 articles that evaluated the use of “clickers” in teaching, it was found that only fourteen identified a statistically significant positive impact on knowledge when the devices were used. [29] This would suggest our findings are not unusual in the context of large group teaching.

The lack of engagement with the online quizzes, particularly closer to the end-of-semester examinations and a lack of interest for non summative examinations hindered this study. Other studies have shown there to be no impact of the use of audience response devices in long-term knowledge retention [28, 30]. Contrary to this, one recent randomised clinical trial assessing the impact of audience response devices on medical student learning did find that the devices, along with three embedded questions in a 30 min lecture, improved students’ knowledge immediately after the session and again two weeks later [15]. They speculated that this effect was due to forced information retrieval by the students brought on by the learning process [15]. However, most students in this study believed that the “clickers” enhanced their understanding of the topic being covered, but 38% were ambivalent (neither agreed nor disagreed) and this cannot be ignored. Nayak & Erinjeri [31] found there to be a mutual benefit for both the learner and the presenter in teaching sessions involving medical students. Here, and in peer teaching sessions, students indicated that the “clickers” allowed them to gauge the understanding of the audience while in non peer-led interactive sessions the students indicated that the “clickers” gave them more confidence to verbally answer questions in subsequent lectures [31]. Student feedback in our institution indicates that they enjoy MDTs and the “clickers” are a benefit to their own learning. This is consistent with other studies where student attitudes to “clickers” have been evaluated [32, 33].

From the students’ perspective, the sessions when “clickers” were used were more enjoyable and engaging and the majority perceived the devices to have a positive impact on their understanding of the topic being covered. However, statistically we could not find evidence of a positive impact of the “clickers” on the retention of knowledge or understanding in this study, in this cohort of medical students, after the clinical microbiology focussed MDT. However, “clickers” are a useful tool to promote engagement of undergraduate medical students in this learning environment as they can improve the learning experience for all involved. Such an approach, or others involving newer technologies that utilise applications on smart portable devices for the same purpose, should be considered for large group teaching sessions.