Case-Based Critical Thinking Questions Case 5-3

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  • 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, 19, 20, 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.

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