Methods
This was a prospective study in a single obstetrics and gynecology department in a teaching medical center, affiliated academically to the faculty of medicine of a large university. In our department we teach medical students over a decade and use TBL in over 50% of our lectures. Every academic year we teach 3-4 groups of 8-10 medical students in each group, at their 5th year of MD studies. The clerkship includes rounds with the senior physicians, clinical meetings with the staff, participating in surgeries and deliveries and lectures on central subjects of obstetrics, infertility and gynecology. We recruited all groups of students since we started the study and alternately used one of the educational approaches on them, TBL or TBL+VaKE. Our study’s module was “diabetes in pregnancy”. The moral dilemma presented was whether or not to suggest a termination of a 6 weeks’ first pregnancy achieved in a 42 years old diabetic woman suffering of uncontrolled type 2 diabetes and chronic hypertension, treated with oral hypoglycemic medications and Ramipril (a teratogenic antihypertensive drug) and having HbA1C of 12%.
The tutor of the “diabetes in pregnancy” module was a single senior physician (YP) trained in teaching these educational approaches. All students agreed and gave their consent to participate in the study after being reassured that they will not be harmed in any way by participating or not in the study. The study was approved by the ethics committee of the Faculty of Medicine, Bar Ilan University at 24/1/2017. The module length was a two 45 minutes split session. The module flow chart is presented in fig. 1. The students were instructed to read the relevant chapter in their reference Obstetrics and Gynecology book before class. A five multiple choice anonymous test of knowledge was given to the entire students group at the beginning of the module. The dilemma and values which were at stake were introduced to the class by the tutor, together with all necessary clinical information. Based on the information presented by the tutor and their preparations at home, the students made their first decision about how to solve the dilemma and split to two groups, representing their opinions, respectively. The test questions were discussed and answered again, together, by the students in each group. Then, the first dilemma discussion took place with arguments exchanged and challenged within the group (moral viability check). This discussion raised the information that should be required, identified or developed. Students worked in groups to search for this information. The new information was shared between groups (content related viability check) and the possibility to switch groups was given. Then, the students engaged in groups once again to discuss and arrange their solution to the dilemma and to answer the clinical medical issues related to the module. In the following day, a new second round of moral arguments presentation (second dilemma discussion – moral viability check) included the whole class with the tutor. Both groups described and summarized their solution to the dilemma and presented their answers related to the clinical aspects of the module. A summary discussion was performed by the tutor concerning the dilemma and the other related issues of the module. A second anonymous five multiple question test and a self, anonymous detailed questionnaire finalized the module. The questions presented in the questionnaire were as follows:
1) To what extent have the last two classes about diabetes in pregnancy contributed to your ability to work in a group?
2) To what extent did the class format contribute to your ability for high-level thinking about diabetes in pregnancy (i.e. knowledge and thinking beyond memory, applied thinking, general inference, judgment and assessment, etc.)
3) To what extent did the last two classes on diabetes in pregnancy illustrate the complexity of the decision-making process?
4) To what extent have you enjoyed the last two classes on diabetes and pregnancy?
5) To what extent has the teaching/learning method contributed to shaping your conception of work as a future physician?
6) To what extent did the last two classes on diabetes in pregnancy cause you to look for knowledge in other sources of information, outside the class and textbook?
7) Have the last two classes on diabetes in pregnancy affected you in other areas beyond knowledge (beliefs, values, self-confidence, interpersonal abilities, etc.)?
8) How satisfied are you with the last two classes on diabetes in pregnancy?
The answers were rated from 1-5, 1- Absolutely unsatisfied and 5 – Absolutely satisfied.
In addition, for each question, an option was added to explain the answer in an open form and three more open questions were considered. These findings were evaluated by qualitative analysis that presented aspects that emerged from students’ responses.
The statistical analysis was performed using the Mann-Whitney-Wilcoxon test. We chose this test as being a non-parametric test, most suitable to these small groups. P< 0.05 was considered as statistically significant. Furthermore, the results of the final test were compared between the two groups.