This interventional study was the first one conducted at the University of Rwanda testing the impact of student generated MCQs on the current anatomy teaching methodology (team based learning).
This study recruited medical students in their final year of training. They had prior exposure to the anatomy course in their first year of medical school. The best students who were potential candidate for the study should have been the first year medical students without prior knowledge of the anatomy. However, we have selected 2 anatomy topics which are more surgically oriented than gross anatomy and to which they did not deeply learnt during the first year of medical school. Unlike other studies done on the impact of MCQs on learning, this is the only study which evaluated the impact of student generated MCQs on TBL of anatomy course.
The other studies done on the impact of MCQs on student learning have not mentioned the prior knowledge of students on exposed study materials [11, 12]. In the same instance , the fact that the medical students recruited were not on the same level of training (level 6 and level 5) did not resulted into selection bias as all were having almost similar baseline anatomy knowledge with mean score difference of 1.35 (P: 0.245) and 0.117 (P:0.933) for the first and the second chapter respectively.
Students’ scores on 2 different topics are usually expected to increase based on various factors such as complexity difference between the topics, length, environment and available time for studying. These confounders were controlled by selecting 2 almost similar topics in the standard anatomical textbooks and pre-tests for both chapters were undertaken before the start of teaching which showed almost the same level of baseline knowledge [figure1] with student pretest mean score of 25.10/50 and 25.19/50 for chapter one and chapter two respectively. However, the fact that the learning should have improved over time after the first chapter was difficult to control and the decision to start the experiment with the chapter of the upper limb innervation than starting on the lower limb was not based on any other criteria, but also found to be a confounder.
In addition to TBL, students were requested to set MCQs while studying chapter 2. Their mean scores improved from 25.19 to 39.93 for pre-test and post-test respectively (P<0.05). Comparing with chapter one, there was a great improvement in student mean score at the end of the chapter assessments from 32.45 to 39.93 for control and intervention arms respectively. The analysis with independent t-test showed that the difference in scores was statistically significant (P<0.05). These results are comparable to what was found by Abdolhussein et al in their study which was testing the effect of MCQs generation on midwifery students’learning of immunological course where there was a significant increase in post-test score in group which used the MCQs as learning tool than the control group . Unlike this study where the students did not have prior knowledge in immunology course, our students had prior knowledge on anatomy in their first year of medical school which can make interpretation difficult.
Improvement in student scores after chapter two shoud be reviwed into different angles. The fact that chapter 2 was taught after completion of chapter one should have led to improved learning skills of students overtime and therefore improved post test scores. Crossover design should have been suitable for this study or if possible to randomize students in 2 categories where one group can use either method. The improved student score should have also resulted in chapters which are different; though the students demonstrated same baseline medical knowledge based on pre-test score, both chapters were not identical and probably students were having less difficulties to study chapter 2 than chapter one.
During the second chapter, students were asked to set MCQs while studying. The quality of MCQs set were analysed using Bloom’s taxonomy and classified according to its cognitive domain for questions which test knowledge, comprehension, application, analysis, synthesis and evaluation.
For good questions set, 62.5% were testing the knowledge as students were only recalling the memorized anatomical concepts. However, only 37.5% were categorized into the higher cognitive domain. The findings are almost similar to what was found by Palmer et al who evaluated the impact and quality of student constructed MCQs on learning clinical surgery at the University of Adelaide where students were able to produce only 25% of MCQs which test the higher cognitive skills while many questions were testing the knowledge and comprehension . Though students were unfamiliar with the task of setting MCQ, they did not have sufficient time to develop skills necessary for setting MCQs.
Several other studies have highlighted the benefits of MCQs in learning in general which include active learning and development of higher thinking skills in problem solving [10, 11]. Like our study, the adjunctive effect of student generated MCQs on current TBL of anatomy course have been positive based on student performance scores and appreciation after the study, but as this was the first study done on anatomy teaching, randomized studies are needed.
Setting a MCQ is an exercise that requires adequate knowledge of the subject and higher thinking skills. However, all studies which proved the benefits of student constructed MCQs as a stimulus of learning did not evaluate the time required to accomplish this task. As the anatomy constitute a large module in the preclinical years of medical school, students may get overloaded by the fact that generating a MCQ is an extra work to the preexisting huge anatomy study materials, therefore this need to be addressed with further studies.
Unlike our findings, the study by Grainger et al recognized all benefits of students generated MCQs on improvement of learning, but students perceived negatively the task of setting questions mainly because of inadequate question writing skills and extra work requiring high cognitive load for them to generate high quality MCQ .
This study has the following limitations:
First of all, the chapters used in teachings are very small in the standard anatomical textbooks and usually the way TBL is being done at the University of Rwanda, students get assessment after studying a big component of the course such as anatomy of the head, neck, trunk or upper limb. Therefore, students can easily memorize the chapters used in this study which can potentially impact post-test scoresSecondly, the fact that the scores obtained were not having an impact on student continuous assessment could have led to some student not to make effort while studying and finally, the student perceptions on the new learning methodology were based on 5 points Likert scale which does not allow students to express all their thinking.