Effectiveness of student-led objective tutorials in pharmacology teaching to medical students.

OBJECTIVES: Current teaching in pharmacology is passive with less emphasis on clinical application. There is a need to incorporate newer instructional designs into pharmacology. Student-led objective tutorial (SLOT) is one of the novel designs to enhance interest among learners, provide opportunities for group learning, and facilitate self-directed learning. This study aims to assess the effectiveness of SLOTs over conventional tutorials (CTs) in pharmacology and to obtain feedback from the students regarding their perceptions about it. SUBJECTS AND METHODS: The regular batch of MBBS 2nd professional in pharmacology was randomly divided into two groups. Five topics from central nervous system (CNS) were selected. One group received SLOT as the instructional strategy, whereas the other group went through CTs. At the end of the module, a written test was conducted to assess the effectiveness of both strategies. The students provided feedback regarding their experience using a prevalidated questionnaire. STATISTICAL ANALYSIS: The mean scores of both the groups were analyzed using Mann-Whitney U-test.
RESULTS: There was no significant difference in the mean scores of the end of the module test. However, the overall passing percentage was significantly higher in the intervention group (P = 0.043). A total of 45.71% students favored it as a future tutorial method and expressed that SLOT enhanced their ability to learn independently.
CONCLUSION: SLOT is an effective teaching-learning method to teach pharmacology to medical undergraduates. It enhances interest among learners and increases the ability to learn independently.

RCT Entities:   Population Interventions Outcomes

Pharmacology is a subject requiring in-depth understanding of the basic concepts that need to be applied later while dealing with varied clinical situations. To achieve this, students should be engaged in learning activities that enhance deeper understanding of course content through skill development.[12]

Pharmacology is a paraclinical subject, taught in the second professional of MBBS for three semesters of 6 months each. The content is mainly delivered through didactic lectures for large groups and tutorials for small groups. The lectures planned for larger groups (more than 100 students), which continue to be the most common instructional design, are mostly passive.[1] Lectures alone are poor means of transferring or acquiring information. Lectures also are less effective at skill development.[3] Students should be, therefore, encouraged to learn in small groups through peer and faculty interaction.[3] Tutorials are one such small group teaching–learning strategy used in pharmacology. Although tutorials are designed to encourage teacher–student interaction, critical thinking, and application of general concepts to problem-solving, they often end up being small lectures by the instructor.[45] As a result, though students gain knowledge through these types of tutorials, they fail to develop skills to apply knowledge thus acquired to real-world clinical problems. This hinders the development of self-directed learning (SDL) process, and students await assistance. The students, therefore, learn superficially, lack motivation and are unable to adapt themselves to rapid changes in terms of both knowledge and technology.[6] Hence, there is a need to introduce innovative active teaching–learning strategies.

To meet these challenges, SDL can be used.[7] As defined by Knowles, “SDL is a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes, that is, they take responsibility for, and control of, their own learning.”[8] The main characteristic of such learning is that students take some significant responsibility for their own learning over and above responding to instruction.[7]

One form of SDL is through student-led objective tutorial (SLOT) which enables students to learn using the recommended learning resources.

SLOT is one of the novel designs of tutorial to enhance interest among learners, provides opportunities for group learning, and facilitates SDL.[2] In previous studies, SLOT has been judged to be superior as compared to conventional tutorials (CTs) and was also appreciated as the method of active learning by the students. Students also expressed that the mechanics of SLOT were a key to effective learning and mastering the techniques of answering the multiple-choice questions (MCQs) in the examination.[2] However, published literature regarding effectiveness of SLOT to teach pharmacology is scarce.

In view of the beneficial features of SLOT and lack of similar studies in pharmacology, the present study was planned with the objectives to assess the effectiveness of SLOT over CTs in pharmacology.

Subjects and Methods

The present study was planned for 2nd professional MBBS students (n = 173) and was conducted in Department of Pharmacology. Ethical clearance was obtained from the Institutional Ethics Committee. After giving brief introduction on this new type of tutorial SLOT, informed consent was sought from all the students. Students were randomly divided into two groups, i.e., CT group and SLOT group, with the help of sealed envelopes. The randomization was in a 1:1 ratio, with 86 students in SLOT group and 87 students in CT group. The study module selected was drugs acting on CNS. All the students had prior knowledge about these topics as they were already dealt in lecture classes.

The chapters selected from the module were sedatives and hypnotics, antiepileptic drugs, opioid analgesics and antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs), antipyretic analgesics, and anti-Parkinsonian drugs. NSAIDs were included in this module so as to make the students understand the difference between peripherally acting analgesics (NSAIDs) and centrally acting analgesics (opioid analgesics). These topics were same for both the groups, and the students were notified about the topics for discussion 2 weeks before the session.

A workshop was conducted on constructing the MCQs for SLOT group. Followed by this, students in SLOT group were divided into seven subgroups, with 6–7 students in each subgroup. These students remained in their respective groups till the end of the study. The main topic was divided into different subtopics [Figure 1]. Each subgroup was allotted one such subtopic for discussion. The students in their own subgroups worked together and prepared 4–5 MCQs related to their subtopic. The objective of preparing each MCQ was stated by them, as an assignment in the form of a powerpoint presentation. They were asked to consult the faculty and revise their MCQs if required at least 3 days before the tutorials. The faculty also validated the MCQs.

Figure 1

Flow chart depicting the division of subgroups of medical undergraduate students along with their respective subtopics for conducting the student-led objective tutorial

On the day of the tutorials, students of the SLOT batch assembled in the lecture room which was equipped with a computer and projection system. One member from subgroup 1 projected the first MCQ which was related to their subtopic. Subgroup 2 was expected to respond while other subgroups observed, and if the answer was incorrect, the question was passed on to subsequent subgroups. Irrespective of the nature of the response, the next slide displayed the correct answer. The third slide showed the objective for setting the question. This process was repeated until all the subgroups completed their presentations. All subgroups had equal chance of posing and answering questions. The tutor also intervened and assisted the proceedings. The interventions included explanations and suggestions on the MCQs presented, wherever appropriate. This was followed by discussion and the summary of the whole topic by the tutor. Figure 1 shows the overall scheme followed during the antiepileptic session.

Example of MCQ presented by students:

Slide 1: Which of the following is the advantage of fosphenytoin over phenytoin?

Higher efficacy

Can be given intravenously

Lesser teratogenic effects

Faster action.

Slide 2: Can be given intravenously

Slide 3: Explanation - Fosphenytoin is a water-soluble prodrug of phenytoin and has been introduced to overcome the difficulties in intravenous administration of phenytoin.

In CT group, tutorials conducted were mainly dominated by the tutor who discussed the content in the form of various aspects of drugs (pharmacological actions, mechanism of action, uses, and adverse effects) without specific consideration to clinical application or clinical decision-making.

To assess the overall performance on the CNS module, a written test in the form of essay questions, short answer questions, and MCQs was conducted at the end of the module for both SLOT and CT groups. All the answer sheets were corrected by only one staff and the procedure was blinded. The scores of the students in the two methods were compared. A minimum of 50% of maximum allotted marks for the test was considered as passing score.

Feedback was obtained from the students regarding their experience with the innovative instructional design on a questionnaire with a rating scale ranging from strongly agree to strongly disagree.[2]

Statistical Analysis

Data were expressed as a mean ± standard deviation. Mean scores at the end of the module test between the groups were analyzed using Mann–Whitney U-test. Comparison of proportion of students who passed the module test was done using Chi-square test. Gender difference in the mean scores among the groups was analyzed by two-way ANOVA. P < 0.05 was considered statistically significant.

Results

A total of 173 students participated in the study. A total of 151 students appeared for the test. The number of absentees for the test in CT group was 13 while that in SLOT group was 9. Most of the students were regular attendees in the tutorials and had attended at least 3 sessions out of 5. The test conducted carried a maximum of 30 marks. Students scoring 50%, i.e. 15 marks out of 30 were considered as pass. Mean scores of the end of module test in SLOT group were 12.6 ± 5.50 and in CT group were 11.5 ± 4.99. The mean scores of both the groups were analyzed using Mann–Whitney U-test. There was no significant difference between the mean scores of two groups (P = 0.391) [Table 1].

Table 1

Comparison of mean scores of student-led objective tutorial and conventional tutorial end of module of undergraduate medical students in pharmacology

Out of 151 students who appeared for the test, 63 were boys and 88 were girls. Gender difference in the mean scores among the groups was analyzed by two-way ANOVA and was found to be statistically significant (P = 0.022) [Table 2].

Table 2

Gender difference in the mean scores in student-led objective tutorial and conventional tutorial groups of undergraduate medical students in pharmacology

The pass percentage of students in both the groups was calculated and analyzed using Chi-square test. Total pass percentage was 35.1% in SLOT group and 20.3% in CT group, the difference of which was statistically significant (P = 0.042) as depicted in Table 1. However, the gender difference was not significant for pass percentage in SLOT (boys 33.3%; girls 36.2%) and in CT group (boys 18.2%; girls 21.9%) as shown in Tables 3 and 4.

Table 3

Gender difference in pass percentage in student-led objective tutorial group of undergraduate medical students in pharmacology

Table 4

Gender difference in pass percentage in conventional tutorial group of undergraduate medical students in pharmacology

Majority of the students agreed that SLOT stimulated their interest and improved their understanding in the topic. Students also expressed that SLOT enhanced their ability to learn independently and in an effective manner. Students also appreciated the adequate feedback and help offered by the tutors. Students enjoyed working in a team and also 45.71% of the students favored SLOT as a future tutorial method [Table 5]. However, some students expressed that SLOT was time consuming and required a lot of prior preparation by the students. Few students were not satisfied with some of the members of their group who were not actively involved in framing MCQs and other activities, which increased the work burden of other students.

Table 5

Feedback of undergraduate medical students regarding student-led objective tutorial (assessed over a scale of 1-4)

Discussion

The present study was conducted to assess the effectiveness of SLOT over CT in pharmacology. The results of the present study showed that there was no significant difference in the mean scores of the end of the module test. However, the overall passing percentage was significantly more in the SLOT group as compared to the CT group. This could be explained on the basis that not all the students from the SLOT group were actively involved in the sessions. This was also expressed by a few students who were burdened with the activity of framing the MCQs for the group. These students must have been able to understand the content in depth and to retain the same. Those students who were not actively involved might have scored less in the test which reduced the mean score of the entire group. These results might suggest that the mechanics of SLOT help the students to understand the course content in depth, to concentrate on the important aspects of the topic, and retain the course content for a longer period of time as suggested earlier.[8]

Statistically significant gender difference was observed with mean scores being high in girls in both the SLOT and CT groups. However, the gender difference was not significant for pass percentage in SLOT and CT group. This could be attributed to improvement in the performance of female groups which is supported by a study involving problem-based learning tutorial where such gender difference was seen.[9] Students appreciated SLOT as a novel teaching–learning method. Students expressed that they had a better understanding of the topic and they enjoyed working in a team. This increased their ability to learn independently as well as led to the success of the group. This correlates with the suggestion of a previous study that peer tutoring can be more appealing with a constructive educational opportunity for the students’ academic development.[10] However, some students expressed that SLOT was time consuming and required a lot of prior preparation by the students. Such a response is expected with the implementation of any new teaching–learning method, but students engaged in SDL undergo a transformation that begins usually with negative feelings and ends with confidence and skills for lifelong learning.[11]

Introducing SLOT into the existing curriculum was one of the approaches followed to make teaching in pharmacology more student centered. This type of tutorial requires more contribution from the students to conduct it with their active involvement. Framing MCQs for a given topic requires the student to read the topic thoroughly and to understand the most important aspects about individual topic in a better way. Furthermore, discussing every option of the MCQs helps improve the reasoning skills of the students. As the students make the presentation using power point, this provides them an opportunity to improve their communication skills.[2]

Such student-generated learning issues could serve as critical determinants for self-learning and improve their analytical skills.[12] These characteristics of SLOT, challenge the Student’s thinking, enabling them to master their subject, develop independence, and become problem solvers, critical thinkers, and lifelong learners which are essential for dealing with real-world clinical problems and patient care.[2] Communication skills are improved as the students interact with their teammates and the rest of the class while constructing and presenting the MCQs. By working in a group, students tend to gain qualities such as teamwork, leadership, professionalism, and cooperation.[13]

Conclusion

SLOT has certain advantages over CTs as a teaching method such as enhanced interest among learners, increased ability to learn independently, and helps them achieve the learning objectives. SLOT can be incorporated into the present curriculum to facilitate learning of pharmacology for medical undergraduates.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.