Medical Students What Educational Resources Are TH
Medical Students What Educational Resources Are TH
Medical Students What Educational Resources Are TH
Abstract
Background: The number of resources available to medical students studying a degree in medicine is growing
exponentially. In addition to traditional learning resources such as lectures and textbooks, students are increasingly
using e-learning tools like commercially available question banks to supplement their learning. Student preference
for learning resources has not been described in detail, and a better understanding of the tools perceived to be
useful could provide essential information to medical educators when designing and implementing medical
curricula.
Methods: We invited 1083 undergraduate and postgraduate medical students from two major Australian
universities to complete an online survey. Questions asked students to indicate the frequency with which they
use various types of resources when learning new material or when revising previous content.
Results: Approximately one third (32.3%, N = 350) of invited participants completed the survey, and of those who
responded, the gender distribution was even with a median age of 25 years. Making written notes and reading
textbooks were the most frequently utilized resources for learning new material. Online or downloaded question
banks were the most frequently used resource for revision. In addition to the use of traditional learning tools, the
majority of students report using a variety of e-learning tools including online teaching videos (92%, n = 322) and
question banks (90.6%, n = 317).
Conclusion: Despite the trend towards e-learning, traditional resources like attendance at face-to-face lectures
remain the most popular for learning new material. The increasing use of question banks raises potential issues of
poor alignment to medical school curricula. With the advantages of exam technique practice, time efficiency and
multiplatform availability, their popularity is likely to continue. Evaluation of existing question banks is required to
facilitate appropriate integration into the curricula, with equitable access for all students.
Keywords: Question banks, E-learning, Learning resources
11 were aimed at medical students, possibly explaining [17]. A systematic review of gender and learning in sur-
the low uptake of apps for study purposes [9]. Only four gery found no significant difference in the uptake of
years later, a simple search for “medical student app” in e-learning resources [18]. It is important to clarify if
the iPhone App store yields a staggering 726 results [10], there is a gender difference in the uptake of new med-
including diagnostic tools, anatomy handbooks, surgical ical education resources to avoid inadvertent gender
simulators, lab values, drug references and multiple choice bias in medical education.
questions covering a range of topics..
Lecture attendance
Online resources Reported in-person lecture attendance by medical stu-
Students are also utilizing a multitude of other online re- dents is also inconsistent. Some argue that lecture attend-
sources. A recent survey in Illinois of students in their ance is in decline [19, 20], with many students opting to
final two years of medical school found students using watch recorded lectures online in their own time. One
online tools including Google docs, Youtube, Twitter, survey of medical students studying molecular biology
Facebook and Wikipedia for study purposes [11]. In a sur- found 97.9% wanted to be able to access recorded lectures
vey of Welsh medical students, 70% report using ‘Meduca- [21]. At Harvard Medical School, a survey of first and sec-
tion’, an online learning tool consisting of videos, problem ond year students reported that 57.2% of students attend
based learning cases, tutorials and quizzes [12]. lectures, whilst 29.9% watch them online [19]. Another
survey of 190 medical students from New York University
Question banks reported that 80% of students attend lectures and 20% use
Question banks have also emerged as a popular online mainly online or computer based learning [22]. Lecture at-
learning tool. There are several commercially available tendance may vary between institutions, depending on
question banks for medical students and doctors in their importance and frequency within the curriculum,
training, including: ‘Passmedicine’, ‘PasTest’, ‘OnExamina- quality of lecturers and the content, whether they are
tion’, ‘Examdoctor’ and ‘NEJM knowledge +’. Each has available online or if attendance is compulsory. If students
between 1500 and 6500 practice questions in the form are no longer routinely attending lectures, medical educa-
of single best answer or extended matching questions, tors may need to shift their focus to newer technologies.
accompanied by practice exams, quizzes, images and Further clarity in how today’s medical students learn is
feedback. Students are able to track their own progress necessary for three key reasons. Firstly, without knowing
over time and often compare their results with other which of the multitude of resources are being utilised,
students. They are used by students studying for the medical schools are at risk of falling out of touch with
United States Medical Licensing Examination [13], and their students’ educational needs. Secondly, to ensure
associated with improved rates of passing the Emergency consistent delivery of quality education, the most popu-
Medicine certification examinations in the United States lar resources need to be identified so that their quality
[14]. In these contexts, students are using the question and relevance to university curricula can be evaluated.
banks to revise and practice exam technique for specific Finally, so that universities can more effectively allocate
examinations. It is also possible that students are using resources to develop education tools that students are
question banks more broadly than this, for example, to likely to use. This study sought to assess today’s medical
learn new information for the first time. Harris and col- students’ preference for educational resources; to investi-
leagues, generated a question bank of student-written gate, if this preference shifts when learning new mate-
multiple choice questions and made them available on- rials, or when revising; and if students’ preference for
line to medical students at Cardiff University [15]. They educational resources are related to their age, previous
found a significant uptake, with 600 students using the educational exposure or future career aspirations.
resource within a three month trial period. It is not cur-
rently known, however, what proportion of students use Methods
commercial online question banks and for what purpose: Study context
revision or learning new information. The study was conducted in June 2015 at the University
of Sydney and the University of New South Wales
Gender differences (UNSW). Both universities are located in Sydney, New
Gender differences in the acceptance and use of e-learning South Wales, Australia. The University of Sydney offers a
have previously been explored. In comparison to females, four-year graduate entry medical program. The University
males have been reported to be more likely to consider of New South Wales offers a six-year undergraduate med-
e-learning easy to use, useful and efficient [16]. However, a ical program. At the time of the study, participants from
study of first year medical students in Austria found no sig- both universities were in their final two years of study.
nificant gender difference in attitudes towards e-learning Most of their teaching occurred at hospital-based clinical
Participants Results
All (n = 1083) penultimate and final year medical stu- Demographics
dents from The University of Sydney and the University In total, 350/1083 (32%) of students completed the survey,
of New South Wales, Australia, were invited to partici- with a mean respondent age of 25.6 (Range 18 to 30+
pate in an anonymous online questionnaire hosted on years). The gender distribution was even, with male (n =
SurveyMonkey. 173, 50%) and female (n = 174, 50%) students responding
to the survey. Of the respondents, 46.3% of students were
Data collection and analysis in their penultimate year (n = 162), 53.7% were in their
Students were invited to participate in the study via an final year (n = 188), 65.2% reported to have completed a
email sent from their respective university administra- previous degree while 34.7% were completing their first
tors in June 2015. Two reminder emails were then sent degree. Around 1% of respondents reported not owning a
at two week intervals and the survey was closed after a smart phone (Yes 98.9%, No 1.1%).
total of six weeks. No remittance or reward was offered
to students for participating in the study. General uptake of resources
The survey was designed by the authors. Students were Students’ uptake of resources ranged between individ-
asked to identify, on a seven point Likert scale (never, uals reporting low use on most items to those reporting
rarely, occasionally, sometimes, often, mostly or always), high use on most items. The uptake of resources was
to what extent resources were used for learning new skills calculated by converting items of the Likert scale to 0–7
and knowledge, and revising old skills and knowledge, point, where 0 represented “never” and 7 represented
with a list of ten options, ranging from traditional “always”. The distribution of responses are summarized
methods of learning to e-learning platforms and apps. The in Fig. 1. Frequency was calculated from a conversion of
ten options included: the Likert scale to numerical values. The distribution of
the frequency of self-reported resources uptake appears
making written notes to be similar when learning new content and revising
attending lectures in person old materials.
reading medical textbooks Figure 2 shows the distribution of terms used by stu-
using online or downloaded question banks (single dents to indicate the rates of uptake of the common learn-
best answers and extended questions) ing resources and tools, when learning new material.
attending small group tutorials The learning resources where high-use responses were
watching online teaching videos the most common choice (Always or Mostly) included
watching lectures online “Attending lectures in Person” (Mostly 24.5%, Always
consulting medical literature 21.4%), “Using downloaded online question banks” (Mostly
using interactive online materials (not question 24%, Always 16.9%) and “Using medical apps” (Mostly
banks) 24.6%, Always 22.9%). The most common response did not
using medical apps (other than question banks)
Statistical analysis
Survey scales employed ordinal measures of self-reported
use of resources (Never = 1, Rarely = 2, Occasionally = 3,
Sometimes = 4, Often = 5, Mostly = 6, Always = 7). A
Wilcoxon Signed Ranked Test was employed to assess
if a difference in preference for a particular resource was
indicated between learning new content and revision. A
Principal Components Analysis was undertaken to investi-
Fig. 1 The frequency with which students indicate the use of
gate whether clusters exist within students’ preference for
resources used when learning new materials or revising
resources.
Fig. 2 Distribution of terms used by students to indicate the rates of uptake of the common learning resources and tools, when learning new material
include any of the low-use (Never or rarely) options. The person” (Never 18%, Rarely 19.4%). The most common
most common rate of use for the remaining resources were: rate of use for the remaining resources were: “watching
“watching lectures online” - sometimes (24%); “reading text lectures online” - sometimes (15.7%); “reading text
books” – often (27.7%); consulting medical literature – books” – often (26.3%); consulting medical literature –
sometimes (30.2%); watching online teaching videos – sometimes (22.6%); watching online teaching videos –
sometimes (25.4%); “using interactive online materials” sometimes (23.4%); “using interactive online materials”
sometimes (26%) and “attending group tutorials” often sometimes (23%) and “attending group tutorials” some-
(22%). times (20.9%).
Resources used when revising old material Change in preferred resource when learning new and
Figure 3 shows the distribution of terms used by students when revising old material
to indicate the rates of uptake of the common resources A Wilcoxon Signed rank test revealed a statistically signifi-
and tools, when revising old material. The learning re- cant difference between the frequencies with which stu-
sources where high-use responses were the most common dents indicate using the following resources: (i) attending
choice (Always or Mostly) included “Use of downloadable lectures;(ii) watching lectures online; (iii) consulting med-
online question banks” (Mostly 22%, Always 29.4%), ical literature; (iv) watching online videos; (v) using online
“using medical apps” (Mostly 18.3%, Always 5.1%) and or downloaded question banks; (vi) using interactive on-
“revising written notes” (Mostly 21.4%, Always 28%). The line materials and (vii) attending small group tutorials.
most common response for the low-use (Never or rarely) The effect size and direction of use preference is summa-
options was reported only for “attending lectures in rized in Table 1.
Fig. 3 Distribution of terms used by students to indicate the rates of uptake of the common resources and tools, when revising old material
Table 1 Wilcoxon Signed Rank Test, Comparison of the frequency of use of each educational resource, for either learning new skills
and knowledge or revision
Significance Z- score Effect size Preferred time of use
attending lectures < 0.0001 −12.215 0.46 (large) Learning new materials
watching lectures online < 0.0001 −7.157 0.27 (medium) Learning new materials
consulting medical literature < 0.0001 −0.128 0.01 (small) Learning new materials
watching online videos 0.007 −2.712 0.10 (small) Learning new materials
using online or downloaded question banks < 0.0001 −6.190 0.2 (small - medium) Revision
using interactive online materials 0.022 −2.291 0.08 (small) Revision
attending small group tutorials < 0.0001 −3.932 0.15 (small) Learning new materials
As students use all resources for both revision and and for revision. The majority of students reported using
learning, a comparison of the frequency of use of each medical apps, question banks, online interactive resources
educational resource was undertaken, demonstrating and online lectures, as well as traditional learning re-
that students attend lectures in person, watch lectures sources. However, their preference for use was dependent
online, attend small group tutorials and consult medical upon whether students were seeking to revise or learn
literature significantly more frequently for the purpose new information. Results indicate that the use of question
of learning new material than they do for revision (see banks is the most popular resource. However, traditional
Table 2). Students use question banks and other online educational formats, including attendance at lectures and
interactive materials significantly more frequently for the tutorials remain the most popular resource for learning
purpose of revision than they do when learning new ma- new knowledge.
terial (see Table 2). The results indicate that student reporting of the use
of resources cluster around whether the resource is on-
Clusters in preference for resource types line or not. Our results indicate that students likely use
A principal components analysis (PCA) was undertaken online resources similarly, independent of whether it is
to assess whether particular preferences for resources for revision or leaning of new content. New media and
showed clustering. Twenty six items were included in mobile technology has fundamentally changed the way
the analysis, suitability of the data was confirmed with medical students learn new material and consolidate
Kaiser-Meyer-Olkin test (0.664) and Bartlett’s Test of this knowledge. Mobile technology in medical education
Sphericity (p < 0.001). PCA revealed the presence of four is now mainstream [23]. This is almost certainly a reflec-
components with Eigen Values above the recommended tion of the depths to which these new technologies have
cut off point of 1, however the inspection of the scree been incorporated in to our everyday social, emotional
plot revealed only two of the factors to be above the and professional lives. Masters et al. explain the uptake of
clear break point (Catell, 1966). The two retained com- mobile technologies in the context of “learner-centred”
ponents account for 30.5% of the variance in the data; educational theory. Learners now engage teaching tools
component 1 contributing to 17.9% and component 2 to for the specific outcome of becoming a doctor rather than
12.5% of the variance. Oblim rotation technique produced a more teacher-centred approach of previous generations
a solution with strong loading by most of the items load- [23]. As a result, students are more self-directed and have
ing to only one of the components and a correlation effect greater independence in their learning. Patel et al., re-
between the two components (r = 0.57). The clustering ported that resident medical officers perceive mobile
into the components indicate that age, gender, career learning as an efficient use of their time [24], a result
aspirations and completion of a previous degree was not which can likely be extrapolated to medical students. On-
related to the preferred use of learning materials. As illus- line resources that can be accessed on multiple platforms
trated in Table 2, PCA also revealed clustering occurred are also convenient and provide instant access to informa-
along the on-line and off-line differentiation of resources tion in any setting. For example, using mobile technology,
with component one containing online resources and students can look up reference material on a ward round
component 2 containing off-line resource, please refer or test their knowledge on the bus on the way home.
Table 2 for detail. This facilitates opportunistic learning, which may be of
particular importance to those juggling work, family life
Discussion and study commitments. Recent developments in edu-
This study sought to explore today’s medical students’ cation technology have seen increasingly more “serious
use of educational resources for learning new materials games” being developed for teaching medicine, successfully
Table 2 Principal Components Analysis, Oblimin rotation method with Kaiser Normalization
Item Component 1 Component 2
New – online or downloaded question banks 0.763
New - interactive online materials 0.734
Revision – use of interactive online materials 0.729
New – using medical apps 0.704
Revision – using online apps 0.701
Revision - online or downloaded question banks 0.663
Revision – watching online teaching videos 0.59
New – watching online teaching videos 0.579
Revision – watching lectures online 0.392
New – watching lectures online 0.357
Revision – attending small group tutorials 0.724
New – attending small group tutorials 0.705
Revision – attending lectures 0.658
New – attending lectures 0.654
New – making written notes 0.477
Revision – using written notes 0.464
Revision – reading textbooks 0.45
Revision – consulting medical literature 0.354 0.431
New – consulting medical literature 0.384 0.389
Age −0.356
New – reading textbooks 0.333
employing the concept of fun in learning [25]. Online learning [26, 27]. The immediate feedback also allows
interactive and mobile learning tools may be popular as students to identify knowledge gaps. Many questions
they are more engaging than traditional teaching tools, banks also provide high-quality, referenced content
with cross-over entertainment appeal to the gaming gen- explaining why a particular answer is right or wrong. The
eration. Online, interactive and mobile learning technolo- commercially available question banks provide a score for
gies are easily accessible and convenient for on-the-go, each section of questions answered, compared with the
learner-centred medical students and their widespread use learner’s previous attempts and with the average scores of
is likely to continue to grow. their colleagues. This makes answering the questions
more like a game with a top score that needs to be beaten.
Question banks The exposure to high volumes of single best answer ques-
Our results indicate that question banks have emerged as tions also allows students to practice exam technique.
the most popular revision tool and the most widely used The widespread use of question banks by medical stu-
overall e-learning resource. They are used most frequently dents raises two main questions: are they effective and
for revision but also for learning new material. The only if so, are they available to all students? The majority of
other published data on the topic of online questions question banks are made available on a subscription
banks identified a similarly high prevalence of use (82%), basis. They have presumably been designed to match
an almost universally positive attitude towards online students’ perceived needs and to maximise commercial
question banks, and a high adoption of a student-devel- viability. Commercially available question banks have not
oped and university-sponsored online question bank [15]. been thoroughly evaluated in terms of efficacy or quality,
We hypothesise a number of factors contribute to their and may not align with university curricula or current best
popularity, that could be incorporated into novel educa- practice. Their widespread use suggests that universities
tional tools. The popularity of question banks for revision should consider formally evaluating popular question
may be as a result of the ‘testing effect’. Repeat testing has banks or develop their own curriculum-focused banks.
been shown to improve retention of information as it en- The possibility of contracting private sector providers with
gages the student in active learning and recall as well as this task is also available. Harris et al. have published their
providing a platform for feedback, which improves experience developing a framework for a student-authored,
clinician reviewed question bank [15]. They achieved a high This was a quantitative study, and use of qualitative
degree of participation and utilisation in a population of data collection and analysis may have provided a deeper
students with a high pre-intervention prevalence of ques- understanding of students’ responses.
tion bank use. With a shift towards commercial resources
universities need to take seriously the task of ensuring Conclusion
equitable access to the highest quality and most relevant re- This study sought to gain a better understanding of med-
sources across age, gender, and discipline. ical students’ preferences for use of existing resources
when learning new material, and undertaking revision.
Lecture attendance Question banks have emerged as a popular learning and
Traditional resources such as attending lectures in per- revision resource, which are as yet unevaluated by educa-
son, making written notes and reading textbooks remain, tional institutions. Factor analysis revealed that students
the most utilized resources for learning new material. describe the use of online resources and the uptake of
Although attending lectures or watching them online off-line learning tools in two separate clusters, indicating
were identified as the least utilised resource for revision, that the online/offline nature of the material plays an im-
medical schools should continue to focus on delivering portant role in determining their preference for use in
high quality lectures for the purpose of students learning both revision and the learning of new materials. An in-
new material. While our results did not identify gender creased understanding of students’ preferences may assist
as a determinant of online or off-line resources, others medical educators in design and implementation of med-
have reported a gender bias in student preference for ical curricula that is aligned with student needs.
learning styles. Mehmood et al. studied the personality
Abbreviations
traits and gender of medical students and found that UNSW: University of New South Wales; USyd: The University of Sydney
men were significantly more ‘impulsive sensation seek-
ing’, [28]. Acknowledgements
The authors would like to acknowledge and thank the students who took
the time to participate in the study.
Student age and career aspirations
Students' self-reported age clustered with responses de- Funding
scribing the use of off-line resources. This finding may be No funding was received for this research study.
confounded by the inclusion of a combination of under- Availability of data and materials
graduate and graduate entry medical programs in our Datasets supporting the conclusions of this article are included within the
study. Unfortunately, our ethics committee approval for article. Additional data at the level of students is not available as per
confidentiality agreements approved by the Human Research Ethics
this study did not allow for direct comparison between Committees.
participating medical schools. Students aspiring to a car-
eer in ‘general practice’ or ‘other’ were also less likely to at- Authors’ contributions
tend small group tutorials, which may be a reflection of LW and JB contributed to the study design, data collection, data analysis and
drafting of the manuscript. LW, JB, JEH, AB contributed to the writing and
age, as they tended to be older than their peers. critical review of the manuscript. EK contributed to the statistical data
analysis, and writing and critical review of the manuscript. All authors read
Limitations and approved the final manuscript.
The response rate for the study was 32%. It is possible Ethics approval and consent to participate
that students who respond to an online survey are more The University of Sydney Human Research Ethics Committee approved the
likely to use online learning materials than those who do study. Completion of the survey was assumed as consent to participate in
the study.
not. However, both medical schools use online learning
management systems and online assignment submission, Consent for publication
so it is likely that most students are comfortable with Not applicable.
using online platforms.
Competing interests
Inclusion of participants from two different universities Annette Burgess is a member of the Editorial Board for BMC Medical Education.
potentially weakens this study, as the lecture programs, All other authors declare that they have no competing interests.
online resources and assessments will differ between uni-
versities which may influence the learning resource prefer- Publisher’s Note
ences of students. Furthermore, the ethics committee Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
approval for this study did not allow for direct comparison
between universities and we were therefore not able to Author details
draw comparisons between the graduate entry program at
1
The University of Sydney School of Medicine – Education Office, Faculty of
Medicine and Health, The University of Sydney, Sydney, Australia. 2Sydney
the University of Sydney and the undergraduate program Health Education Research Network (SHERN), The University of Sydney,
at the University of New South Wales. Sydney, Australia.
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