ME is a core component of most medical programs in many countries and is required for program accreditation in a great number, including Australia, New Zealand, USA, Canada and the UK. Despite this, there remains no consensus in the literature or in practice about the main goal or best methods of teaching medical ethics [18]. Hence the delivery of this component of medical curricula is often uneven and can be problematic, as clinicians vary in their ability to discuss the ethical aspects of clinical scenarios. This study provided evidence that the use of CLASSIE modules were a very useful teaching tool for teaching ME. They were extremely well received and had a positive impact on student learning in this competency. The students were highly engaged by this learning activity, and the reflections showed that this learning was being well integrated with real clinical experiences of the students.
Although, the data could only be assessed using descriptive statistics, they showed a very high level of positive user experience, self-perceived learning gains and moderate objectively assessed learning gains. If we relate this evaluation to the Kirkpatrick model [19], we not only show learning at level one (reaction) and two (learning), analysis of student reflections shows definitive evidence of transfer of this knowledge (level three) in over ¾ of students. In their reflections, the students specifically described how these modules enabled them to identify areas of personal improvement and consciously apply their new knowledge to clinical situations, consistent with intensive reflective learning on the non-reflective to reflective learning continuum [20]. This is particularly important, as skill development and application in relation to competency in medical ethics is notoriously difficult to assess. Using evidence of reflective learning to evaluate the transfer of knowledge into clinical practice is well supported by the medical education literature, particularly that looking at development of ‘professionally competent clinical practice’, [21] professional identity [22,23,24] and personal growth [25]. This is based on the belief that our ‘professional identities’ are constantly being re-shaped by our experiences and environment [26, 27]. Educators can track this development (to some extent) by examining the narratives (or reflections) of students. Reflective writing is generally considered in itself to be a means of developing ethical mindfulness [28], critical thinking skills [29, 30], clinical reasoning [31] and the ability to manage complex and ambiguous situations in medicine [32], such as those described in the Classie modules. Even this assessment of knowledge transfer however is limited, in that we cannot determine if the students’ capacity for decision making or action in a clinical situation was also changed.
In clinical settings, ME may be taught variably, hence this approach allows the delivery of high quality, calibrated educational deliverable to all medical students, independent of their clinical placements and tutors. The use of mastery learning in the quiz is consistent with an increasingly popular paradigm for medical education. The basic principle is that educational excellence is expected, with minimal variation in measured outcomes, but students will take varying amounts of time to get to that point [33, 34]. In addition to filling a potential teaching gap, the fact that the CLASSIE modules can be accessed flexibly in time and place, was also positively received by students. This approach to the use of internet learning to fill gaps in clinical exposure or experience can be usefully adapted for teaching in any context where either we have inconsistent teaching skills (such as ME) or even difficulties with student access (such as obstetrics or paediatrics) [35]. It will also allow medical programs to share the best teaching materials, eventually saving on resources and ensuring best practice. The specific negative feedback in the pilot helped us to explain the context and improve on technical issues. The VR video format definitely added to the immersive and emotional nature of the doctor-patient encounter videos and made it similar to being in the room during the consultation. According to adult learning theory, it is thought that emotion and cognition are interdependent and that emotions are important for learning and problem solving, as they enable more flexible and adaptive thinking [36]. This modern approach to instructional design goes beyond the pure cognitive aspects of learning and incorporates the ‘affective’ aspects. ‘How has VR value-added in this space?’ is a difficult question to answer. The simulated environment in general, is aimed at replicating real life, and in doing so, lets the learner act (or at least think about how they would act) as in real life. VR involves a totally immersive world and one of the benefits is that is makes access to the clinical experience simply and flexibly available [37]. There is evidence in addition to this study that demonstrates that VR and the immersion it offers adds to effective experiential learning [38]. That fact that students were highly engaged and enjoyed this as a learning experience, also adds to its learning value [36]. These experiences should be integrated with, and complement everyday clinical practice [39]. In extreme times when clinical placements become difficult, such as during the COVID-19 pandemic, VR can become a very useful resource. The role of VR in anatomy teaching [40] and assisting with teaching technical skills [41, 42] has been well evaluated [39]. If VR is not available, these scenarios could definitely be created in other ways, dependent on the available resources. These modules could be created using normal video equipment, with volunteer actors, with live simulated patients or alternatively, if this is not feasible, they could use animations or just a description of the scenario to prompt the interactive online learning activities.
Although it is evident that technology won’t solve all our problems as educators and we need to be aware of the limitations [43], technology such as this, can dramatically assist in providing some calibration of learning opportunities for medical students. This study also revealed that although we like to encourage a deeper level of learning in all our students, some are still quite strategic and will try to skim through learning activities, particularly online ones. Trying to change this approach is still a challenge for medical educators but explaining the rationale for why we do things and providing high quality educational deliverables definitely helps. In general, the students were very appreciative of efforts such as these to improve learning resources.
