In this study of an active learning approach for teaching CAN to medical students, we developed and conducted a series of participatory educational workshops with the use of role playing and dummies that was incorporated into the NKUA medical school curriculum. To this effect, we successfully gathered, trained and established a thriving peer-to-peer teaching group, and participants showed significant gains in knowledge and increase in self-confidence in the recognition and management of CAN.
Although the initial gains observed right after the workshop decreased in the six-month follow-up evaluation, even six months after the workshop, participants performed better than before, both in the cognitive questions and the self-assessment confidence questions. In addition, self-selection bias testing indicated that the entire sample was statistically homogenous, since the group of 69 participants who completed all three questionnaires was representative of the starting and each subsequent group. This conclusion is based on the increases in knowledge and self-confidence right after the workshop and six months after the workshop, that were observed in every comparison between each group of our starting sample.
Based on the qualitative data gathered, medical students expressed their enthusiasm and provided useful tips to help improve the conduction of the workshops. Medical student evaluations at the NKUA are not requested consistently, but, when provided, have the potential of influencing medical curriculum decisions. Although there was initial reluctance to allow two teaching hours on CAN, this participatory workshop has been highly rated by students and, therefore, has become a staple part of the clerkship in Pediatrics.
Limited existing data suggest inadequacies in CAN education for medical students [6–8]. Interactive case-based workshops on CAN recognition and reporting for healthcare professionals have been previously shown to be effective and having stronger and longer lasting effects compared to didactic lectures [2–4]. Previous studies have indicated that participation during educational sessions enhances the participants’ ability to learn . To the best of our knowledge, this study is the first to involve role-playing with designated actors; previous studies of educational interventions used traditional lectures, cards-illustrations, written scenarios or virtual patients [6–7]. In contrast, our workshop relied on role-playing and peer-to-peer teaching, both of which are increasingly used in medical school curriculums worldwide and have multiple potential benefits for learners and teachers .
The development of the workshops was based on expert recommendations on CAN education [28–32]. It has been suggested that certain social characteristics of the patients themselves and/or their families might affect identification, investigation and reporting of the possibility of CAN by physicians [33–35]. Therefore, an attempt to break certain stereotypes through our carefully selected socially diverse case scenarios was made. Case scenarios included real life examples of sexual and physical abuse, neglect, and accident. The goal of the scenarios was to illustrate diagnostic uncertainties and the importance of determining the threshold to report child safety concerns. However, it was stressed that accidents do happen, and although preventive efforts should be made, overdiagnosis of CAN should be avoided.
Contrary to most studies available in literature [2–4,6–8], this workshop was designed and conducted exclusively for medical students. Since CAN is widespread in the general population, all physicians are expected to encounter at least one case of CAN during their career. Therefore, instead of focusing on training physicians of specific specialties, we opted to engage medical students to ensure that all medical graduates will possess basic skills and knowledge to recognize, evaluate and appropriately report suspected CAN. Adopting an interdisciplinary approach is crucial in the management of CAN , hence particular efforts were made to discuss the role of other health care professionals in the evaluation and management of CAN, including nursing staff and hospital and community social workers.
We postulate that several features of this workshop may have contributed to the significant and long-lasting gain of knowledge and improvement of self-confidence for participants. First, several screening clinical tools were provided in a checklist form that participants were repeatedly encouraged to use. Second, as scenarios, dummies and corresponding laboratory and imaging studies were derived from everyday clinical practice, the experience was rendered practical for participants. Third, engaging participants in the decision “to report or not to report” and discussing common pitfalls and facilitators regarding the reporting procedure, may have increased self-reported confidence in reporting suspected CAN.
A strength of our study was the use of questionnaires both short- and long-term to assess the effectiveness of the workshop on two important dimensions for practicing future physicians, knowledge and confidence. Most students had not previously had any education on CAN, strengthening the results of our study. The improvement of self-confidence demonstrated in our study may enhance responsible practices related to CAN. Completion of the questionnaires themselves both right after and six months after the workshop may have boosted self-confidence and served as a reminder of the CAN issues discussed.
There are at least four limitations of this study. The main limitation is the lack of a control group, rendering comparison of gain and retention of knowledge and self-confidence between the workshop and a traditional power-point lecture impossible. However, there are previous studies indicating that interactive, case-based learning is indeed more effective than a traditional didactic lecture [2–4,37]. Second is our use of dolls, thus precluding the practice by medical students of communicating with and examining children. Third, since all patients described in the scenarios were infants and toddlers, participants may have developed the false impression that only young children are affected by CAN. Finally, although all cases were presented to the participants at the end of the workshop, time did not suffice for participants to manage more than one case scenario.