Advan. Physiol. Edu. 27: 53-61, 2003;
doi:10.1152/advan.00049.2002
1043-4046/03 $5.00
ADV PHYSIOL EDUC 27:53-61, 2003
© 2003 American Physiological Society
HOW WE TEACH
HYPERTENSION MODULE: AN INTERACTIVE LEARNING TOOL IN PHYSIOLOGY
Ç. A. 
man,
M. A. Gülpinar,
H. Kurtel,
. Alican and
B. Ç. Ye
en
Department of Physiology, Marmara University School of Medicine, Istanbul 813267, Turkey
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Abstract
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The aim of the present study was to evaluate the strong or weak aspects of an interactive study module introduced during the "Cardiovascular and Respiratory Systems Subject Committee" in the second year of the medical program. Five study groups consisting of 25 students attended two-hour module sessions for six weeks with the same tutor. According to the module assessment questionnaire, the majority of the students assessed the module as excellent or good. The students reported that they had gained not only in knowledge but also in skills development. The general opinion of the students was that both the organization and the implementation of the module met their expectations. Nearly one-half of the students reported that their expectations with regard to the educational environment and the participation of students were fully met. The major weakness in this new educational trial appears to be assessment of the module.
Key words: physiology education; didactic lectures; small-group study; student feedback
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Introduction
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In recent years, medical educators have been challenged to develop new, innovative, and creative educational materials that will enhance problem-solving skills and encourage small-group discussions that will engage students in interactive learning (6). Active learning, based on the concept of the "learner’s autonomy and independence," has gained momentum, and the focus of control has shifted from teachers to learners, leading to greater responsibility and encouraging self-learning. Besides the willingness of students, active learning also requires 1) empathetic teachers, 2) a more learner-centered curriculum designed toward learning with increased capacity for detachment, critical reflection, decision-making, and independent action, and 3) an institutional setting that promotes interaction (9, 10).
Similar winds of change in education have also affected the medical curriculum of the Marmara University School of Medicine. In the curriculum, physiology is taught with standard didactic lectures, along with the other basic sciences, during the first two years of the medical school, with interdisciplinary interaction. In the academic year 1999–2000, so-called "interactive study modules" were introduced to serve as an adaptational bridge between the traditional lecture-based curriculum and the new curriculum consisting of interactive learning methods.
One of these modules was conducted by the Department of Physiology during the "Cardiovascular and Respiratory Systems Subject Committee" in the second year of the medical program. At the end of this module, students were expected to recall the mechanisms controlling blood pressure, to gain knowledge and skills about blood pressure measurement, to define and classify hypertension, to discuss the clinical approach to patients with hypertension, and to describe the basic principles of antihypertensive treatment. In addition, by encouraging the active-learning process through interactive learning methods, students were also expected to gain skills in literature searching and problem solving. Therefore, the aim of the present study was to evaluate the strong or weak aspects of the implemented module to improve or guide the related educational activities.
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METHODS
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Educational setting.
To motivate the faculty for student-centered interactive teaching techniques and to optimize the use of small-group teaching methods, five-day courses were given to faculty members, including all tutors of the Hypertension Module (authors of the present study). During a preparation period of two months before the module, the aims and objectives of each session were prepared based on the target gains of knowledge and skills. In an attempt to standardize the activities of each study group, a tutor’s guidebook was prepared. Similarly, study guides for the students, including the outlines of daily activities, subjects, checklists, and sources for self-study, were prepared.
Students were divided into five study groups, each consisting of 25 students. Groups attended the two-hour module sessions for six weeks with the same tutor (Table 1). In the program, an extra three hours were given each week to be spent in the library or the classroom for individual preparation for the forthcoming module session. During the session, each group was further divided into smaller groups of four or five, and they were given extra time to prepare a particular part of the session as a group. Each small group gave an oral presentation of 10 minutes, followed by five minutes of whole-group discussion. The tutors and the students wore name badges to facilitate communication. To achieve standardization among the tutors, all tutors were reponsible for following the timetables. General goals and learning objectives of the module were determined by the tutors, whereas detailed learning objectives for each week were specified by the students (Table 2).
On the first day of the module, the students received instructions concerning the program, and the roles of the students and tutors were defined. The students were then given a written case. The case was about a second-year medical student on a plane who meets a hypertensive patient and finds himself helpless in approaching the case. The students were asked to answer the questions, "What do you need to know to understand this case?" and "What would you do if you were in his place?" After working in small groups, the reporters presented the topics they needed to learn. The outcome of this first group study was used by the tutors to frame the general goals and learning objectives of the module. Moreover, at each session of the module, flashbacks were made to different components of the case.
In the second session of the module, students were given a chance to follow a demonstration of indirect blood pressure measurement using a sphygmomanometer, and then they were given sufficient time to try the procedure repeatedly to develop their performance skill based on the consecutive steps of the prepared guide (Table 3). During this session, smaller groups of three students were formed. While one of the students made the measurement, the other two completed checklists to evaluate the development of the skill. This procedure was repeated until each student had applied the steps correctly and in the right order.
Evaluation.
Student assessment, which had a 10% impact on the total subject committee score, was composed of three components: 1) the average score of daily individual performances (i.e., participation in groups and presentations throughout the module), 2) group score given to the presentation on the last day of the module, and 3) a posttest in multiple-choice question (MCQ) format, prepared to test whether the major learning objectives of the module were met or not. At each session, the individual performance of each student was evaluated by the tutor, using standardized checklists of performance, evaluating the intellectual and communication skills of the students. On the last day, group performance charts were used to evaluate the performance of the groups, who used the role play technique in simulating the clinical pictures of the hypertension types outlined by the given keywords of case scenarios (Table 4). Apart from these, a pretest composed of true-or-false questions was applied on the first day of the module to evaluate the background knowledge levels about blood pressure and hypertension. In both pre- and posttests, different learning objectives were covered using different types of questions, and these reciprocal objectives were then compared to identify the level of gain in knowledge accomplished during the module.
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TABLE 4 Directions and keywords to outline case scenarios for role play presentations on the last day of the module
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A "module assessment questionnaire" (MAQ) was distributed on the last day of the module (Table 5
) to test the role of active-learning techniques in gaining knowledge and in the development of skills and attitude. To simplify the data, the items of the questionnaire were then classified under eight main themes regarding the relevance and usefulness of the module. These themes were organization (MAQ item nos. 1a-1h), implementation (nos. 2a, 2b, 2e, 2t, 2u, 2v, 2y), educational environment (nos. 2c, 2j, 2k, 2l, 2m), individual participation (nos. 2d, 2f, 2g, 2h, 2i, 2n, 2o, 2p, 2r, 2s), overall gains of the students (no. 4), tutor qualities (nos. 5a-5k), assessment criteria used in the module (nos. 3a-3e), and overall score given to the module.
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TABLE 5 Evaluation instrument designed to assess the module
Part I. Directions: This questionnaire has been prepared to evaluate the module in terms of reaching the planned targets and to improve the organization when necessary. Circle the number that most accurately defines the way you feel regarding each statement using the scale 1–4 given below. Hoping to get sincere answers, thank you for your participation.
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Part II. Directions. To compare sessions of the hypertension module with subject committee didactic physiology lectures, please mark the box under the option you selected for the validity of the item in the left column. To give an explanation for this selection is voluntary.
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Part III. Directions. Please mark this module on maximum 5 points and write further comments and suggestions on the module below.
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The data are expressed as a percentage of the total responses to designated item groups. A comparison between the module and the didactic lectures was made using the 
2 test. Differences were considered statistically significant if P < 0.05.
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RESULTS
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The module assessment questionnaire was returned by 95% of the students. Regarding the overall scoring of the module, the majority of students marked the scale as excellent (65%), good (27.5%), or fair (5.8%), whereas 1.6% scored the module as poor. When responses to the questionnaire were evaluated as a percentage of the total number of students who returned the questionnaire, the module was found successful in organization (84.9%) and implementation (59.7%) by most of them. In addition, tutors were found good in attitude (84.9%) and in coaching the groups (78.2%). In contrast to this consensus, only one-half of the students were fully satisfied with the educational environment created during the sessions (Table 6). Many students reported that the module was "very detailed and well organized" and "a good combination of entertainment and learning." Some others stated that the time given for either "preparation" or "discussions and summaries" was not appropriate compared with the "extensive material."
Compared with didactic lectures, although many students found both types of classes well organized, timing and programming were found to be better in the module sessions (2 (3) = 29.7, P < 0.05; Table 7). The majority of the students found that both types of lectures were given in a complementary and goal-directed manner (2 (3) = 68.1, P < 0.05). The social environment, creating a peaceful atmosphere in the class, was found to be very high in the interactive modules compared with didactic lectures (2 (3) = 121.5, P < 0.05). Although a significant number of students had no preparation before the lectures or modules (35.3%), most of the students (57.1%) signified that they had studied only before the module sessions (2 (3) = 129.6, P < 0.05). Students used "effective listening" in both lecture types to "learn in class" (P > 0.05).
In general, students were of the opinion that the assessment criteria of the module were appropriate (64.7%; Table 6). Pretest of the module in true-or-false format showed that the preexisting knowledge of students about "definition-classification and clinical findings of hypertension" was the highest (65%), whereas the questions related to "secondary hypertension, target organ damage, and treatment" were answered by only 40% of the group. Regarding the average individual performances and group performances recorded by the tutors using the assessment charts throughout the module, 85% of the students were found good or very good. However, the number of the students with passing scores (50 of 100 points) at MCQ exam was only 59%. Apart from these quantitative data on the performances of the students, in nearly one-half (46.2%) of the students’ opinions, assessment of both the module and the didactic lectures was found to be nonobjective and incompetent (2 (3) = 50.3, P < 0.05).
It was evident from the responses that only a small group of the students required extra time to study before the exam of the interactive module (5.9%), whereas the topics of didactic lectures needed to be reviewed more before the exam (2 (3) = 58.7, P < 0.05; Table 7). Although less credit was given to didactic lectures (10%) in the storage of information, 26.1% of the students felt that the acquired knowledge during the module would be long-lasting. However, others (32.8%) claimed that the information obtained from either of the lectures would not be remembered in the long term. When students were asked to identify the gains in three different fields of learning, 24.4% indicated that they had acquired knowledge, skill, and attitude change at the same time at the module, whereas some of the students gained knowledge and skill (21.8%), skill and change in attitude (8.4%), only knowledge (12.6%), or only skill (16. 8%).
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DISCUSSION
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Most of the students found the module instructive, well constructed and worthwhile. They defined the module experience as a dynamic, comfortable, and interactive process during which they found themselves learning effectively in the classroom. The general opinion of the students indicates that both the organization and the implementation of the module met their expectations. However, the expectations of the students about the educational environment and their participation were not fully met. This finding may be attributed to the large groups and limited time given for the module, which reduced the outcomes of the module. The students reported that they had gained not only in knowledge but also in skills development. The major weakness in this new educational trial appears to be assessment of the module.
Regarding the organization of the module, students were satisfied with different aspects of the program, including realistic goals, objectives, and schedule of the module. In addition, the application of the predesignated program was found successful. Several students indicated that hypertension, being a frequently met health issue, was a suitable subject to select. Students appreciated that the module was presented in a detailed manner and that they were asked about their expectations on the first day of the module. From the tutors’ point of view, the extensive work done on preparation of the module organization developed an effective interaction among the tutors, which was in turn reflected in the organization of the module program. In support of this notion, the comparison of didactic lectures with the modules indicates that the organization and implementation of the didactic lectures were not as satisfactory as those of the modules. One of the factors that may be responsible for this difference may be the limited cooperation among the instructors of the didactic lectures.
According to Chickering and Zelda (3), learning is not a spectator sport and students do not learn "by simply sitting in a classroom listening to the teacher, memorizing prepackaged assignments and spitting out answers." Students must talk about what they are learning, write about it, relate it to past experiences, and apply it to their daily lives. So one of the factors useful in effective learning may be the effectiveness of small-group study, a pedagogical method that promotes student participation in class and increases students’ interactions with one another and with the instructors. It is well known that when the proper social environment is present, effective communication and interaction between the group members lead to the "feeling of doing something very necessary," by which concentration on effective listening, willingness to participate actively, and curiosity of the unknown are processed. Teamwork during the sessions, oral presentations, and discussions are known to require a high level of cognition, including analytical thinking and synthesizing, which results in the improvement of communication skills (2). This issue is also supported by Nekvasil (8), who stated that, by detailing the material orally, the student was forced to make her/his explanation more concrete and specific, which in turn facilitates the student’s self-learning and reinforces long-term memory (4, 5, 7). Our students reported that they retained information of the module relatively longer than when they were passively instructed and claimed that the requirement of repetition before the exams was less than that before the didactic lectures. Moreover, the applied module served in gaining of both knowledge and skills, with some change in attitude, whereas the didactic lectures have a limited impact on the latter two gains.
Among all assessment criteria, individual and group performance assessments were regarded to be appropriate by the majority of the students, and the results also show that most of the students’ performances were good or very good. Last-day role plays were found very useful and entertaining, and the students were very competent in enabling mutual interaction and creating a positive learning atmosphere. However, the level of success was not that high on the multiple-choice (MCQ) exam. On written expression, some of the students mentioned that the MCQ exam was "very difficult and questions were related with very detailed parts of the subject." This finding showed that, in small-group studies, in which active participation of students is included in addition to assessment by performance, structured tests measuring "analytical reasoning" (Objective Structured Clinical Examination or Clinical Objective Reasoning Examination) would be more appropriate.
It has been stated that active learning causes a shift in roles for both the teacher and the student (1). The instructor, who is responsible for presenting information actively to the students in the didactic lecture, has a more indirect role in the module. Although the students were expected to be more responsible for their own learning process through the preparations, presentations, and discussions, students showed some resistance to adapting to independent learning principles. For instance, there was a tendency to ask for a confirmation of knowledge from the tutor, which appears to be a remnant of didactic lectures. This supports the notion that the tutors are envisioned as another source of information. Nevertheless, both the tutors and the students seemed to enjoy the interaction and collaboration that this module encouraged, which was lacking in didactic lectures.
In conclusion, the hypertension module was an interesting, worthwhile, and useful experience for both students and tutors. Our experience demonstrates that well-structured and -organized small-group studies covering common health issues may be beneficial in encouraging self-learning, and equal and adequate effort must be made to innovate the various components of the educational design.
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Acknowledgments
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Address for reprint requests and other correspondence: B. Ç. Yeen, Department of Physiology, Marmara University, School of Medicine, Haydarpaa, Istanbul 34668, Turkey (E-mail: yegen{at}superonline.com).
Received for publication September 16, 2002.
Accepted for publication January 31, 2003.
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References
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- Chickering AW and Zelda FG. Seven principles for good practice. Am Assoc Higher Educ Bull 39: 3–7, 1987.
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Copyright © 2003 by the American Physiological Society.
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Abstract
Introduction
