Participants
In this prospective study, 100 medical students who were entering their ninth semester in August 2015 and taking classes in Sun Yat-sen University were enrolled. All students were randomly allocated into 4 groups in order to guarantee the teaching quality. The students participated in a 1-week integrated modular ophthalmology learning course in Zhongshan Ophthalmic Centre. All the procedures in this study were videotaped, with the approval of the institutional review board of Zhongshan Ophthalmic Centre of Sun Yat-sen University (IRB-ZOC-SYSU) (Ethic ID: 2016MEKY062). Written informed consents have been obtained from all students.
Integrated modular teaching
Each module was initiated by a clinical teacher from Zhongshan Ophthalmic Centre with a suitable introduction, followed by a discussion of individual topics. Pre- and post-class tests were conducted at the beginning of the first module and the end of the last module, respectively, to assess the effectiveness of the integrated modular teaching system. Test papers were designed based on the teachers’ discussions and approved by the examination administration of Sun Yat-sen University.
The topics of these modules included the anatomy of the eye, ophthalmologic examination, the lids and lacrimal apparatus, conjunctivitis and uveitis, keratitis, glaucoma, cataract and refractive error, the retina and ocular disorders associated with systemic disease, ocular trauma and blindness (Table 1). The details and survey questions of student perceptions regarding various teaching methods are presented in Table 2.
A comprehensive evaluation was conducted among all the enrolled students based on the comparison between the first-day and last-day test scores before and after 1-week integrated modular teaching with innovative teaching methods. The details of the questionnaire utilized in the comprehensive evaluation are illustrated in Supplementary materials. The questionnaire consisted of two parts. The first part was a case with chief complains of single eye redness and blurred vision. Three questions about important signs, diagnosis and recommended examinations of this case were listed to be answered. The second part contained a list of important ocular symptoms and signs, such as photophobia, tearing, itch sensation, foreign-body sensation and swelling pain, etc. Five cases were presented in the 2nd part and the students were asked to select one or more related symptoms or signs for each case.
"Flipped classroom" session
The "flipped classroom" protocol was used for the ocular trauma teaching among the fifth-year medical college students [14]. The selected teachers accumulated a wealth of clinical and teaching experience. Before the "flipped classroom", relevant knowledge and questions based on one case of single ocular trauma were delivered by public email. The students were asked to overview the knowledge of ocular trauma in groups using textbooks, published articles, e-publications or any other reference besides the email.
At 3 days before the "flipped classroom" session, the students were directed to review the subject of ocular trauma. One test consisting of three cases was completed by students in 20 minutes at 1 day before the "flipped classroom" session. These three cases focused on penetrating injuries, contusions of the eyeball and chemical burns. Two or three questions were appended to each case scenario. Before the end of the course, a post-class test was administered immediately to obtain feedback. Simultaneously, a questionnaire was finished by each student to investigate the satisfaction scale.
Team-based learning module
The TBL module [15] was designed according to the guidance [16], which included Individual Readiness Assurance Test (IRAT), preparatory assignments, Group Readiness Assurance Test (GRAT), Group Application Problem (GAP) and Final Examination Scores (FESs). In each group, students were given with a random topic in the morning of the first-day trainee course. The topics were closely linked to the content in this curriculum. The students had to prepare any form of presentation within 5 days according to the assigned topic. Other relevant medical knowledge in addition to ophthalmology was permitted to be discussed in the presentation or display. After students in each group presented their team-work presentations in class, the teachers graded the students’ presentations into 5 criteria.
Statistical analysis
The pre- and post-class-test scores, and the first- and last-day-test scores were statistically compared by using paired t-test at the significance level of 0.05. One-way analysis of variance (ANOVA) was used to compare the average scores among different groups or teaching methods. All data analyses were performed using SPSS 20.0 statistical software (SPSS Inc., Chicago, IL, USA).