Case-based learning and multiple choice questioning methods favored by students

Many more questions aiming on diagnosis

At the end of year 4, students of the MUV had had various lectures but hardly any
actual experiences with therapies. This may explain why significantly more items concerned
the diagnosis of psychiatric diseases than their therapies.

Among questions aiming on therapy, significantly more concerned pharmacotherapy than
psychotherapy

Before Block 20, the seminars concerning therapies in the MUV Curriculum were almost exclusively
pharmacological. After successful attendance of Block 20 most students who did not have any personal experience of psychotherapy only had
little insight into how psychotherapy is developing on the long-term and what psychotherapy
can really provide to the patient. Psychotherapy associations were still loaded with
old stereotypes 13], 16]. This could explain why significantly more therapy questions addressed pharmacology
than psychotherapy.

A huge majority of Step 1 questions

The students mainly offered Step 1 questions. It can be questioned, whether the lack
of case-oriented questions was an indication for insufficient clinical thinking by
the students. An essential explanation could be that students lacked adequate patient
contact until the end of year four. Indeed, MUV students were allowed to begin their
practical experience after year two and eight compulsory clerkship weeks were scheduled
before the beginning of year five 17]. Thus, Austrian medical students gained consistent clinical experience only after
year four, with rotations in year five and the newly introduced Clinical Practical Year in year six. A European comparison of medical universities’ curricula showed that
students of other countries spent earlier more time with patients: Dutch, French and
German medical students began with a nursing training in year one and had 40, 10 and
4 months, respectively, more clerkship experience than Austrian students before entering
year five 18]–21]. French and Dutch universities are extremely centered on clinical thinking, with
a total of 36 clerkship months in France and the weekly presence of patients from
the first lectures on in Groningen 22]. Thus, it would be interesting to repeat a similar case-based exercise in these countries
to explore if medical students at the same educational stage but with more practical
experience are more likely to offer patient vignette items.

Students preferred to work with right facts and did not reject negatively worded questions

As negatively worded questions were usually banished from MCQ exams, it was interesting
to observe that medical students did not reject them. In fact, negatively formulated
questions are more likely to be misunderstood. Their understanding correlates to reading
ability 23] and concentration. Although many guidelines 6], 24] clearly advised to avoid negative items, the students generated 27.5 % of negatively
formulated questions. Also Pick N format-questions with several right answers were offered by the students, despite the recommendations
for this exercise: They offered significantly less total answer possibilities but
significantly more right answers to positively worded questions than to negatively
worded questions. Those results supported the hypothesis that the students preferred
handling right content while keeping wrong content to a minimum.

Several possible reasons can be contemplated. When students lack confidence with a
theme and try to avoid unsuitable answer possibilities, it can be more difficult to
find four wrong answers to a positively worded question instead of several right answers,
which may be listed in a book. Furthermore, some students may fear to think up wrong
facts to avoid learning wrong content. Indeed, among positively worded items, 26.6 %
were offered with 3 or more right answers, which never happened for negatively worded
items (Table 2).

Notably, “right answer possibilities” of negatively worded items’ stems as well as
“wrong answer possibilities” of positively worded items’ stems are actually “wrong
facts”. For example, the right answer of the item “Which of the following symptoms
does NOT belong to ICD-10 criteria of depression?” (Item 177) is the only “wrong fact”
of the 5 answer possibilities. Writing the 4 “wrong answers” of this question, which
are actually the ICD-10 criteria for depression, can help the students learn these
diagnostic criteria. On the contrary, the “right answers” to a positively worded item
such as “Which vegetative symptoms are related to panic attacks?” (Item 121) are the
true facts.

Finally, the students’ interest for right facts supports the theory that a positive
approach, positive emotions and curiosity are favorable to learning processes. Indeed,
asking for right content is a natural way of learning, already used by children from
the very early age. The inborn curiosity — urge to explain the unexpected 25], need to resolve uncertainty 26] or urge to know more 27]— is shown by the amount of questions asked by children 28], 29]. The students’ way to ask for right contents appears very close to this original
learning process.

The inputs of developmental psychology, cognitive psychology as well as of neurosciences
underline this hypothesis. Bower presented influences of affect on cognitive processes:
He showed a powerful effect of people’s mood on their free associations to neutral
words and better learning abilities regarding incidents congruent with their mood
30]. Growing neurophysiological knowledge confirmed the close relation between concentration,
learning and emotions — basic psychic functions necessitating the same brain structures.
The amygdala, connected to major limbic structures (e.g. pre-frontal cortex, hippocampus,
ventral striatum), plays a major role in affect regulation as well as in learning
processes 15], and the hippocampus, essential to explicit learning, is highly influenced by stress,
presenting one of the highest concentrations of glucocorticoid receptors in the brain
31]. Stress diminishes the synaptic plasticity within the hippocampus 32], plasticity which is necessary to long-term memory.

Neuroscientific research also underlined the interdependence of cognitive ability
and affect regulation. Salas showed on a patient after an ischemic stroke event with
prefrontal cortex damage that, due to executive impairment and increased emotional
reactivity, cognitive resources could not allow self-modulation and reappraising of
negative affects anymore 33].

Considering this interdependence, right contents might be related to a positive attitude
and positive affects among the students. It could be interesting to further research
on this relation as well as on the students’ motivations concerning the formulation
of the questions.

The combination of those reasons probably explains why the students offered significantly
more wrong answers to negatively worded items and more right answers to positively
worded items, both resulting in the use of more right facts. All the students’ assessment
questions and associated feedback were used to create a new database at the MUV trying
to integrate more right facts in case-based learning exercises in the future.

The main limitation concerns the small sample size and the focus on only one curriculum
element. Further studies with convenient sampling should include other medical fields
and bridge the gap to learning outcome research.