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.