This thesis comprises several chapters on the relation between aspects of the curriculum and students’ knowledge development and skill acquisition at different levels, ranging from the effect of feedback characteristics to the effect of massed or spaced curricula. The main research question of this thesis is: How do aspects of the curriculum relate to students’ knowledge development and skill acquisition? To answer our research questions and because of the complexity of studying aspects of the curriculum, we used different methodologies.
In Chapter 2 and 3 the relation between curriculum characteristics and knowledge development was explored. In order to do so we choose oncologic knowledge since many medical disciplines are represented in this topic.
In Chapter 2, students’ knowledge development was explored by analyzing data from the Dutch progress test on 1440 medical students of four undergraduate medical schools. To better understand the differences between the curricula, the four oncology curriculum coordinators were interviewed. Students’ knowledge development was compared using mixed model analysis. The results demonstrated that two curriculum characteristics seem to have a positive impact on students’ knowledge development: the presence of a pre-internship course and concentration of the discipline in one semester. Although it seems that these two characteristics benefit students’ knowledge development, this study was exploratory and, therefore, implications based on the results do not presuppose causality.
In Chapter 3, the findings of Chapter 2 were investigated in more depth and in a more controlled environment, although the study was still conducted in a naturalistic setting. For this purpose, the development of students’ knowledge of oncology in one medical school was compared between students who were taught in a concentrated semester and students who were taught in a spaced format. The medical school offers a six-year medical training; the first three years are predominantly preclinical and the last years predominately clinical. Comparing these two parallel cohorts decreased the number of confounders, since the context (within the same university), teachers, teaching methods and assessment were similar in both cohorts. The results showed that at the beginning of preclinical training, students in the spaced curriculum scored higher and at the end of preclinical training, students in the spaced curriculum scored lower than students in the concentrated semester. The results of Chapter 2 and 3 suggest that students’ knowledge development may be related to the way the content is presented over time: distributed over a longer period or concentrated in one semester.
In Chapter 4 and 5 the relation between assessment characteristics and knowledge development was investigated.
Medical students do not only acquire knowledge, but they are also expected to apply knowledge and reflect on it. In Chapter 4, the development of students’ ability to apply their knowledge and their judgment of knowledge were investigated. Since we were interested in students’ scores on lower and higher order questions during their preclinical and clinical training, progress test data from the beginning and end of their preclinical or clinical training were analyzed. To investigate students’ cognitive processing development, specific assessment characteristics were used, based on Bloom’s taxonomy: lower-order questions requiring students to only recall their knowledge and higher-order requiring students to apply their knowledge. To investigate the educational aspect of the judgment of knowledge, the question mark option in successive progress tests was used. Subsequently, the growth in students’ ability to apply and judge their knowledge was compared in the preclinical and clinical phase. Whereas preclinical (Year 1 and 3) and Year 4 students scored lower on vignette questions (higher order), the Year 6 students scored higher on vignette questions than on simple questions (lower order). Students’ judgement of knowledge decreased over time for both cohorts, possibly indicating that the question mark option does not support students’ judgment of knowledge development.
In addition to investigating the educational aspect of judgement of knowledge (Chapter 4), it is important to verify the effect of adding the “question mark option” as an assessment characteristic on students’ scores. In Chapter 5, the psychometric properties of two scoring methods, a number-right scoring and the formula scoring (with “question mark option”), were compared. More specifically, we investigated whether the question mark option as an assessment characteristic provides less dysfunctional items and a more reliable score in a 2x2 crossover design. The majority of dysfunctional items was found in the formula scoring test condition. Furthermore, the reliability for the tests using number-right scoring were higher than for formula scoring. Chapter 4 and 5 suggest that adding the question mark option as an assessment characteristic may not be optimal for two reasons. First, as students progress, more questions were guessed and answered incorrectly. Second, the addition of the question mark decreases the reliability of the test and increase the number of dysfunctional items.
In Chapter 6 and 7 the relation between curriculum characteristics and skill acquisition was investigated.
During medical training, medical students do not only acquire knowledge, but also skills. Students should have the opportunity to practice and receive feedback during their skill acquisition and retention. Without practice and feedback, learning a new technical skill would be very challenging. Trainees may practice either in one session, known as massed training, or in multiple sessions spread over time, known as spaced training. In Chapter 6 a systematic review was conducted to investigate the effect of spacing training sessions on long-term retention of surgical skills. The Medline, PsycINFO, Embase, Eric and Web of Science online databases were searched. Only randomized trials with a sample of medical trainees acquiring surgical motor skills in which the spacing effect was reported were included in the study. The quality and bias of the articles were assessed using the Cochrane Collaboration’s risk of bias assessment tool. 11 articles met all inclusion criteria and were included. The overall quality of the articles was “moderate”. Students in the spaced condition scored higher on a retention test than students in the massed condition. Although the optimal gap between study sessions remains unclear, our systematic review suggests that when designing a technical skill training, spacing the training sessions improves students’ skill retention when compared to massed practice.
In Chapter 7 a randomized experiment was conducted to investigate the effect of expert and augmented feedback on the acquisition and retention of a complex medical skill. 36 medical students were randomly assigned to one of three types of feedback: expert feedback only (EF), augmented visual feedback (simulator help screen) (HS), and expert feedback with augmented visual feedback (EF+HS). Immediately after the training, students in the EF group were faster than students in the two other groups. After 11 days, students in the EF+HS group scored significantly higher for image quality than students in the two other groups.
This thesis has demonstrated that there is a relation between a few aspects of the curriculum and knowledge development and skill acquisition. Furthermore, this thesis has shown how and when the spacing effect may benefit students’ knowledge development and skill acquisition, how the “I don’t know” option affects students’ scores and, finally, that different sources of feedback are needed to enhance students’ skill acquisition and retention.