Comparison of a Traditional Practical-Based Identification for Microscopic Image Examination with a Microsoft PowerPoint Examination in the Influence of Dental and Medical Students’ Learning Outcome and Motivation in a Histology Laboratory Course at NDMC in Taiwan

Background: Histology laboratory courses are morphologic study in the structure of the cells, tissues, and organs of the body that are mainly examined with a microscope. There are two types of examinations to assess learning outcomes in Taiwan. The first is a traditional practical-based identification for microscopic image (PBIMI) examination, and the second is Microsoft PowerPoint (MS PPT) examination. Whether these two types of examinations exhibit different influences on students’ learning motivation has not been evaluated. Methods: In this study, we compared the grades of dental students and medical students in the National Defense Medical Center who completed PBIMI or MS PPT examinations and investigated the influence of the type of examination on the students’ learning outcomes and motivation. We also conducted a survey among the medical students to confirm the hypothesis concluded from the grade analysis. Results: There was a significant decrease in the percentage of students scoring 61 to 80 in the MS PPT group compared to that in the PBIMI group in the midterm examination of dental students. The average score on the MS PPT examination was significantly higher than that on the PBIMI examination among medical students who completing both examinations. The average failing scores on the midterm examination among the students tested with the PBIMI examination were significantly lower than the scores among the students tested with the MS PPT examination. The results of the survey also showed that the MS PPT examination is easier for students and that they will spend less time learning the material when the MS PPT examination is utilized for assessment. Conclusion: This study suggests that the type of examination affects learning motivation in less self-demanding students. The MS PPT test is easier for the students and leads to less time spent studying for the histology laboratory course, especially among the students with fewer self-demands or less interest in the course.

examinations exhibit different influences on students' learning motivation has not been evaluated. Methods: In this study, we compared the grades of dental students and medical students in the National Defense Medical Center who completed PBIMI or MS PPT examinations and investigated the influence of the type of examination on the students' learning outcomes and motivation. We also conducted a survey among the medical students to confirm the hypothesis concluded from the grade analysis. Results: There was a significant decrease in the percentage of students scoring 61 to 80 in the MS PPT group compared to that in the PBIMI group in the midterm examination of dental students. The average score on the MS PPT examination was significantly higher than that on the PBIMI examination among medical students who completing both examinations. The average failing scores on the midterm examination among the students tested with the PBIMI examination were significantly lower than the scores among the students tested with the MS PPT examination. The results of the survey also showed that the MS PPT examination is easier for students and that they will spend less time learning the material when the MS PPT examination is utilized for assessment. Conclusion: This study suggests that the type of examination affects learning motivation in less self-demanding students. The MS PPT test is easier for the students and leads to less time spent studying for the histology laboratory course, especially among the students with fewer self-demands or less interest in the course. 3 Background Histology, also called microscopic anatomy, is a morphologic study in the structure of the cells, tissues, and organs of the body and is mainly examined with a microscope [1,2]. It is a traditional curriculum in both the school of dentistry and the school of medicine [3] and serves as a basic foundation for the future study of pathology [4]. Although it is a subject with a long history, histological studies are still a major challenge in medical schools [5]. There are many changes in the methods of teaching histology [6,7]. The teaching of histology using a practical microscope has been complemented with the use of computers [8], especially in laboratory courses [9,10]. In fact, a common trend in the teaching of histology laboratory courses is the replacement of the traditional light microscope with virtual microscopy [5].
Students' motivation to learn histology includes career motivation, intrinsic motivation, self-determination and grade motivation [11,12]. A previous study demonstrated that a high level of intrinsic motivation is associated with higher academic performance, especially among male students [13]. Furthermore, examination is also a stress for medical students [14]. The attitude of teacher in assessing the performance of the students during examination affects medical students' enthusiasm in learning [15]. The type of examination plays an important role in the influence of students' learning motivation.
There are 13 medical schools in Taiwan. Additionally, in Taiwan, histology is taught in separate lecture and laboratory courses. As the type of examination used in the histology lecture course of histology has changed, many medical schools in Taiwan have changed the type of examination used in the histology laboratory course from a traditional practical-based identification for microscopic image (PBIMI) examination to a computerbased Microsoft PowerPoint (MS PPT) examination. In histology lecture and laboratory courses at National Defense Medical Center (NDMC) in Taiwan, we coordinated the use of practical traditional light microscope laboratory exercises and internet video demonstrations in teaching. With respect to the type of examination, we still utilized the PBIMI examination among the dental students before the class of 2014 of dental students and changed it to the MS PPT examination beginning with the class of 2015. Among the medical students, the PBIMI examination was changed to the MS PPT examination in the middle of the school year for the class of 2016. However, the advantages and disadvantages of this change have not been evaluated.
In this study, we compared the grades of the dental students and medical students who took the PBIMI or MS PPT examination and investigated the influence of the type of examination on the learning outcomes and motivation of these students. We also conducted a survey among medical students to confirm the conclusion from the grade analysis. We concluded that the type of examination will affect students' study motivation in the histology laboratory course, especially among less self-demanding students.
Methodological improvements in the assessment of the learning outcomes of the histology laboratory course are still necessary.

Participating students
Students participating in this study were from the school of dentistry or school of medicine in National Defense Medical Center, Taipei, Taiwan. The dental students included

Structure of online anonymous survey
The results presented in this study are derived from an online survey that was administered to the medical students in the class of 2016 at NDMC. The questionnaire contains four questions: 1) What type of examination is easier for you?; 2) For what type of examination will you spend more time studying histology?; 3) What type of examination do you prefer?; and 4) What type of examination do you consider to be more fair? All the responders were anonymous and given information on the study and agreed to the publication of the results of this survey. (Cardiovascular System) to 16 (Endocrine Organs). The final grade for this course is calculated by summing the scores of 30% attendance and class performance, 35% midterm and 35% final examinations. The passing standard is a score of ≥ 60. To avoid the interference of the 30% attendance/class performance score, we only analyzed the scores for midterm and final examinations. The passing standard in each examination was also a score of ≥ 60. In an analysis of the average scores on the midterm and final examinations for dental students in these class years, we found no differences between the PBIMI group and the MS PPT group in either the midterm or the final examinations (Figs. 4A and 4B).

Statistical analysis
To further clarify the influence of the type of examination in these students, we analyzed the percentage of scaled scores. We found that there was a significant decrease in the percentage of the students with a score of 61 to 80 in the MS PPT group compared to the PBIMI group for the midterm examination (Fig. 5A). However, this difference was not observed for the final examination (Fig. 5B). We also analyzed the percentage of dental students who passed and failed and who completed the PBIMI or the MS PPT examinations.
Our results showed that the percentage of failed students was slightly higher in the MS PPT group for the midterm examination (Fig. 6A). However, the percentage of failed students was slightly lower in the MS PPT group for the final examination (Fig. 6B). We also found that the average failed scores among the students tested with the PBIMI examination were significantly lower than those among the students tested with the using MS PPT examination for the midterm examination (Fig. 6C). The average failed score was only slightly lower among the students tested with the PBIMI examination for the final examination (Fig. 6D). These results suggested that these dental students may underestimate the difficulty of the MS PPT examination, leading to lower motivation to study for the histology laboratory course in the midterm examination in the MS PPT group.
However, when these students faced the crisis of the failed stress of this course, their study motivation increased, and they spent more time studying for this course.
Comparison of the grades assessed by the PBIMI examination with those assessed by the MS PPT examination in the same population The limitation of the above analysis in this study is that the data analyzed included dental students in different class years. Therefore, the difference in the classes' atmosphere or  (Fig. 7). Moreover, in this class, we changed the type of examination from the traditional PBIMI examination to the MS PPT examination due to the expansion of the number of medical students (n = 145). The traditional PBIMI examination is too time-consuming with multiple test takers (spend more than 3 hours at one examination). Therefore, these students were tested by utilizing the PBIMI examination in the first and second examinations and by utilizing the MS PPT examination in the third and fourth examinations. Thus, we can compare the influence of the type of examination on the study motivation of the same population in students in this class year.
To evaluate the influence of the type of examination on the performance and study motivation in a population composed of the same undergraduate medical students, we first compared their average scores that were evaluated by using the PBIMI examination or the MS PPT examination. The average score of the first and second examinations (PBIMI examination) and the average score of the third and fourth examinations (MS PPT examination) were compared with Student's paired t-test. We found that the average score on the MS PPT examination was significantly higher than that on the PBIMI examination (Fig. 8A), suggesting that the MS PPT test was easier than the PBIMI examination for these medical students. By analyzing the percentage of the number in scaled scores of these students, we found that there was an increase, although with no statistical significance, in the highest interval (81-100) (Fig. 8B). We also analyzed the percentage of passed and failed students. Our results showed a slight decrease in the failed medical students who tested by using the MS PPT examination (Fig. 8C). However, when we analyzed the average score of the failed medical students, the results showed that the average score of failed students in the MS PPT examination group was significantly lower than that in the PBIMI examination group (Fig. 8D). These results suggested that the MS PPT test is easier for these undergraduate medical students; however, this factor also led to students (especially less self-demanding students) exhibiting lower study motivation in the histology laboratory course.
Analysis of the survey on the population of medical students who experienced both the PBIMI and MS PPT examinations Because the medical students in the class of 2016 experienced both the PBIMI and MS PTT examinations, to confirm the conclusion drawn from the analysis of dental and medical students' grades, we performed a survey for the medical student in the class of 2016. For the first question, what type of examination is easier for you? A total of 54.7% of the medical students consider the MS PPT examination to be easier, 24.5% consider PBIMI examination to be easier and 20.8% consider the difficulty of these two types of examination to be equal (Fig. 9A). This result is consistent with the comparison of the average scores among the medical students (Fig. 8A). In the second question, for what type of examination will you spend more time studying histology? Only 3.8% of the students will spend more time on the MS PPT examination. A total of 37.7% of students will spend more time on the PBIMI examination, and 58.5% of the students will spend equal time on these two examinations (Fig. 9B). This result showed that few students spend more time in the study of histology laboratory when they will be examined with the MS PTT examination. In the third question, what type of examination are you prefer?
Surprisingly, a total of 47.2% of the medical students preferred the PBIMI examination, 39.6% of the students preferred the MS PPT examination, and 13.2% of students had no specific preference in these two types of examinations (Fig. 9C). This result indicated that although the MS PPT examination is easier for these students, more students prefer to undergo traditional PBIMI examination. In the last question, what type of examination do you consider to be more fair? Interestingly, 58.5% of the medical students considered the PBIMI examination to be a fairer examination. Only 24.5% of the students considered the MS PTT examination to be fairer, and 17% of the students considered it equally in both examinations (Fig. 9D). This is mainly because the position of the test taker will affect the performance of the students in the MS PTT examination.

Discussion
Histology is a compulsory subject in dental and medical schools. In Taiwan, all of the medical collages divide this subject into lecture and laboratory courses. Learning histology as well as completing the laboratory course are important parts of students' professional education [16]. Because of the convenience of the MS PPT examination, the assessment of the learning outcomes of the histology laboratory course tended to utilize the MS PPT examination to replace the traditional PBIMI examination in Taiwan. However, this change in the type of examination on the influence of students' learning outcomes and learning motivation has not been evaluated.
Our analysis revealed that although there was no influence of examination types on the average scores of dental students in the different class years (Fig. 4A), the average score was significantly higher in the MS PPT examination among the medical students who completed both types of examinations (Fig. 8A). These different results may be due to the different class years in the dental students with different study atmospheres and class cultures. However, the percentage of the number of students with scores of 61 to 80 in the MS PPT group was significantly lower than that in the PBIMI group for the midterm examination (Fig. 5A). These results suggested that these dental students underestimated the difficulty of the MS PPT examination, which led to lower motivation in studying for the midterm examination of the histology laboratory course. This result is consistent with the result of the survey among the medical students that the MS PPT examination was considered easier than the PBIMI examination. Furthermore, when we analyzed the grades in the same population that completed both types of examinations, an influence of the type of examination on learning outcomes was exhibited, and the average score was significantly higher in the MS PPT group than in the PBIMI group (Fig. 8A).
The analysis of the grades of the failed students revealed that the average scores in the MS PPT group were significantly lower than those in the PBIMI group for the midterm examination of dental students (Fig. 6C) as well as for the results of medical students (Fig.   8D). The result of the survey among medical students also exhibited a trend indicating that students spent less time studying histology laboratory course when they would be completing the MS PPT examination (Fig. 9B).
Although the MS PPT examination is easier to implement and is a time-saving assessment method, several factors should be considered in the utilization of the MS PPT examination for the assessment of learning outcomes in dental and medical students. The first factor is fairness in the examination, which is mainly due to the position of the test takers in the examination room. A worse position provides a worse view of the picture presented on the screen, which may critically influence the performance of the test taker. This issue is reflected in the survey of the medical students (Fig. 9D) and can be improved through the use of multiple examination classrooms or utilization of a computer classroom to provide students with an individual screen to give them a better view. The second factor is highquality equipment in the examination room, such as computers and projectors, to maintain high picture quality for the test takers. Furthermore, introducing a reward system in the examination for histology laboratory course may also provide a beneficial effect for promotion of students' learning motivation [17].

Limitations of this study
The first limitation of this study is that the analyzed data were acquired from a medical school only. Future study should include more medical schools if they have students experienced both types of examinations. Second limitation is that only two types of examinations were compared. Although novel assessments for the learning outcome have been development, some of the attempts have failed. For example, a student selfscheduling of computer-based examination has been tested. This type of examination does not appear to provide a better performance and may even be detrimental [18]. The third limitation of this study is that this change in the type of examination on the influence of teacher did not been evaluated. A better assessment strategy for the histology laboratory course is still needed, not only for the students but also for the teachers. High job demands including heavy examination loading leads to a high stress on teachers [19,20].
Moreover, there is an interaction effect between teachers' teaching and students' learning motivation [21]. Therefore, it is still highly worthwhile in medical education to identify novel ways of assessing student performance in a histology laboratory course.

Conclusions
In conclusion, the type of examination affects learning motivation among less selfdemanding students. The MS PPT test is easier for the students and leads to less time spent studying for the histology laboratory course, especially among students with fewer self-demands or less interest in this course. An improvement in the assessment methods of the learning outcomes of students in the histology laboratory course is still necessary.

Consent for publication
We confirm that participants gave informed consent for the publication of anonymized quotations from their survey.

Availability of data and material
All data and materials are contained and described within the manuscript.

Competing interests
The authors declare that they have no competing interests.        The analysis of the average score of the failed medical students. There was a significant decrease in the average score of failed students in the MS PPT examination group (n = 7) compared to the PBIMI examination group (n = 26).
Data are expressed as the mean ± SD.