A controlled study of the short- and long-term effects of a Train the Trainers course

Objectives  This study aimed to establish the longterm effects of a 3-day 'Training for Trainers' course (TTC) on doctors' knowledge, teaching behaviour and clinical learning climate.
Methods  The study was designed as an intervention study with pre-, post- and long-term measurements. The intervention group (I-group) included 118 doctors from the departments of internal medicine and orthopaedic surgery at one university hospital. The control group (C-group) consisted of 125 doctors from the corresponding departments at another university hospital. Gains in knowledge about teaching skills were assessed by a written test. Teaching behaviour and learning climate were evaluated by questionnaires.
Results  In the I-group, 98.4% of doctors, both specialists and trainees, participated in a TTC. Response rates on the written test varied from 90% at baseline to 70% at 6 months after the intervention. Knowledge about teaching skills increased in the I-group by 25% after the TTC and was sustained at 6 months. Questionnaire response rates varied from 98.4% at baseline to 84.8% at 6 months. Post-course, the teaching behaviour of the I-group significantly changed and its learning climate improved compared with the C-group. Scores for use of feedback and supervision in the I-group increased from 4–5 to 6–7 (maximum score = 9). This was significantly higher than in the C-group.
Conclusions  A 3-day residential TTC has a significant impact in terms of gains of knowledge concerning teaching skills, teaching behaviour and learning climate after 6 months. The positive effects demonstrated in this study were rooted in both the specialists and trainees who attended the course.     

Student perceptions of a portfolio assessment process

Objectives  The objectives of this study were to identify and analyse students' attitudes to the portfolio assessment process over time.
Methods  A questionnaire containing statements and open questions was used to obtain feedback from students at the University of Dundee Medical School, Scotland. The responses to each statement were compared over 4 years (1999, 2000, 2002 and 2003).
Results  Response rates were 83% in 1999, 70% in 2000, 89% in 2002 and 88% in 2003. A major finding is that students perceived that portfolio building heightened their understanding of the exit learning outcomes and enabled reflection on their work. Student reactions to the portfolio process were initially negative, although they appreciated that senior staff took time to become familiar with their work through reviewing their portfolios. Student attitudes became more positive over the 4 years as the process evolved. Although portfolio assessment was recognised as supporting student learning, portfolio building was perceived to interfere with clinical learning as a result of the excessive amounts of paper evidence required.
Conclusions  Paperwork should be kept within manageable limits. A student induction process that highlights the importance of providing evidence for achieving all learning outcomes, not just theoretical knowledge and skills, may be helpful in allaying student concern over portfolio building and assessment and support preparation for lifelong learning and reflective clinical practice.     

The testing effect on skills learning might last 6 months

In a recent study we found that testing as a final activity in a skills course increases the learning outcome compared to spending an equal amount of time practicing. Whether this testing effect measured as skills performance can be demonstrated on long-term basis is not known. The research question was: does testing as a final activity in a cardio-pulmonary resuscitation (CPR) skills course increase learning outcome when assessed after half a year, compared to spending an equal amount of time practicing? The study was an assessor-blinded randomised controlled trial. A convenient sample of 7th semester medical students attending a mandatory CPR course was randomised to intervention course or control course. Participants were taught in small groups. The intervention course included 3.5 h skills training plus 30 min of skills testing. The practice-only control course lasted 4 h. Both groups were invited to a retention assessment of CPR skills half a year later. Participants included 89/180 (50%) of those invited to participate in the study. Mean performance score was 75.9 (SD 11.0) in the intervention group (N = 48) and 70.3 (SD 17.1) in the control group, effect size 0.4. The difference between groups was not statistically significant, P = 0.06. This study suggests that testing as a final activity in a CPR skills course might have an effect on long-term learning outcome compared to spending an equal amount of time practicing the skills. Although this difference was not statistically significant, the identified effect size of 0.4 can have important clinical and educational implications.     

Test-enhanced learning may be a gender-related phenomenon explained by changes in cortisol level

Medical Education 2011: 45 : 192–199 Context Testing increases memory of a topic studied more than additional study or training. The mechanisms by which this occurs are not clearly understood. Testing can be stressful and studies suggest that the stress hormone cortisol has modulating effects on memory, predominantly in men. The aim of this study was to investigate whether cardiopulmonary resuscitation (CPR) skills testing induce a cortisol increase, whether the cortisol increase enhances retention of CPR skills, and how this relates to gender. Methods We randomised a convenience sample of medical students attending a mandatory course to one intervention and one control group. Students received a 4‐hour course on CPR skills. During the final half‐hour of the intervention course, participants were tested in CPR scenarios, whereas the control group underwent additional training. We assessed learning outcomes 2 weeks later by rating student performance in a CPR scenario using a checklist and a single blinded assessor. We measured salivary cortisol pre‐course, half an hour before the end of the course and post‐course, and compared learning outcomes and cortisol responses between groups and genders. Results In total, 146 of 202 (72%) students completed the study. We found a significant difference in learning outcome between the intervention and control groups for both genders (mean ± standard deviation, 5.0 ± 3.5; p = 0.006). We found a significant effect of increase in cortisol on learning outcome in men. The correlation between learning outcome and cortisol increase was medium to large for men (r = 0.38), but not for women (r = ? 0.05). Conclusions Cardiopulmonary resuscitation skills testing induces a rise in cortisol in men, which is related to the better retention of skills in men. Cortisol modulates test‐enhanced learning in men.     

Validity of the visual analogue scale as an instrument to measure self-efficacy in resuscitation skills

Context  Self-efficacy is an important factor in many areas of medical education, including self-assessment and self-directed learning, but has been little studied in resuscitation training, possibly because of the lack of a simple measurement instrument.
Objective  We aimed to assess the validity of a visual analogue scale (VAS) linked to a single question as an instrument to measure self-efficacy with respect to resuscitation skills by comparing the VAS with a questionnaire and using known-groups comparisons.
Methods  We developed questionnaires to measure self-efficacy for a number of resuscitation tasks and for computer skills. These were compared with VASs linked to a single question per task, using a multi-trait, multi-method matrix. We also used known-groups comparisons of self-efficacy in specific professional groups.
Results  There was good correlation between the questionnaires and the VASs for self-efficacy for specific resuscitation tasks. There was a less clear correlation for self-efficacy for paediatric resuscitation overall. There was no correlation between self-efficacy for resuscitation and computer tasks. In specific professional groups, measured self-efficacy accorded with theoretical predictions.
Conclusions  A VAS linked to a single question appears to be a valid method of measuring self-efficacy with respect to specific well defined resuscitation tasks, but should be used with caution for multi-faceted tasks.     

Randomised, controlled study investigating the optimal instructor: student ratios for teaching suturing skills

INTRODUCTION: Recently, there has been a shift away from practising procedures on patients for the first time and towards bench model teaching of clinical skills to undergraduate medical students. However, guidelines for the most effective instructor : student ratio for technical skills training are unclear. This has important implications for staffing laboratory based teaching sessions. The purpose of this study was to assess the optimal ratio of teachers to learners during the teaching of a simulated wound closure. METHODS: A total of 108 undergraduate medical students participated in a 1-hour course on wound closure. They were randomised to 3 groups, each with a different instructor:student ratio (Group A: 6-12; Group B: 3-12; Group C: 1-12). Students were evaluated on a pre-test, an immediate post-test and a delayed retention test using an objective, computer-based technical skills assessment method. Collectively termed the "economy of movements", the total time taken to complete the task and the number of movements executed were the primary outcome measures. RESULTS: Improvements in the economy of movements were the same for Groups A and B and were better than in Group C (P < 0.005). DISCUSSION: The optimal instructor:student ratio was 1 instructor for 4 students. Higher ratios of instructors to students resulted in no improvements in learning, and lower ratios of instructors to students resulted in significantly less learning. These findings are in keeping with current motor learning theories.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.     

Testing an empirically derived mental health training model featuring small groups, distributed practice and patient discussion

Objectives  Internationally, family doctors seeking to enhance their skills in evidence-based mental health treatment are attending brief training workshops, despite clear evidence in the literature that short-term, massed formats are not likely to improve skills in this complex area. Reviews of the educational literature suggest that an optimal model of training would incorporate distributed practice techniques; repeated practice over a lengthy time period, small-group interactive learning, mentoring relationships, skills-based training and an ongoing discussion of actual patients. This study investigates the potential role of group-based training incorporating multiple aspects of good pedagogy for training doctors in basic competencies in brief cognitive behaviour therapy (BCBT).
Methods  Six groups of family doctors ( n  = 32) completed eight 2-hour sessions of BCBT group training over a 6-month period. A baseline control design was utilised with pre- and post-training measures of doctors' BCBT skills, knowledge and engagement in BCBT treatment.
Results  Family doctors' knowledge, skills in and actual use of BCBT with patients improved significantly over the course of training compared with the control period.
Conclusions  This research demonstrates preliminary support for the efficacy of an empirically derived group training model for family doctors. Brief CBT group-based training could prove to be an effective and viable model for future doctor training.     

Competency-based learning in neonatology

An educational model integrating structured teaching with clinical experience, or clerkship, has been designed to enable students to learn the core knowledge, skills and attitudes necessary to care for the newborn. The programme is run for fifth year medical students as part of four, 9-week periods in Obstetrics and Gynaecology each year. A SCORPIO teaching session is held in week 1 to introduce students to the core competencies in the subject areas of newborn examination, breastfeeding, resuscitation, respiratory distress and anthropometry. Groups of four students rotate through each topic, which is conducted by a neonatologist or registrar in training. Eight problem-based learning sessions are held during weeks 2–9. Several students assess a clinical problem, identify learning issues and meet colleagues and a facilitator to share their learning experiences and resolve the problem. The clinical experience, or clerkship, is based in the neonatal nursery where 2–3 students spend a week consolidating their clinical and procedural skills. A study group was assessed at the end of the programme by an Objective Structured Clinical Examination (OSCE) and a Multiple Choice Questionnaire (MCQ). A control group did the same assessment in week 1. All students were asked to rate the educational value of the three learning methods on a 5-point Likert scale. The study group (   n = 20  ) achieved a mean composite mark of 66% (SD 10%). This was significantly higher (   P < 0.001  ) than that of the control group (   n = 18  ), mean 45% (SD 7%). All students (100%) rated the educational value of SCORPIO as high or very high, and the comparative rating for problem-based learning and clerkship was 65%, respectively. The programme was enthusiastically received by the students and resulted in mastery of a range of core competencies necessary for care of the newborn.     

A needs-based study and examination skills course improves students' performance

BACKGROUND: Adult learning theory suggests that learning is most effective when related to need, when driven by the learner and when it is flexible. We describe the effect of an educational intervention that was driven by student need, and largely designed by students. METHODS: We undertook a needs assessment of fifth year medical students' study needs. Based on this, we helped them design a course to meet these needs. This was predominantly related to study skills and a practice objective structured clinical examination (OSCE). We evaluated the course by asking for student opinion and by measuring the effect on student performance in a high stakes medical school examination (written examination and OSCE). FINDINGS: Despite the course being run voluntarily and in after-hours sessions, 80-90% of the medical student class attended each session. Student performance on the end of year examinations was significantly enhanced in the year of the intervention, compared with previous years and with students from other schools sitting identical examinations in the same year. INTERPRETATION: Learning activities that are directly based on student needs, that focus on study and examination techniques, and that are largely student-driven, result in effective and valuable outcomes.     

Learning basic surgical skills with mental imagery: using the simulation centre in the mind

Context  Although surgeons and athletes frequently use mental imagery in preparing to perform, mental imagery has not been extensively researched as a learning technique in medical education.
Objective  A mental imagery rehearsal technique was experimentally compared with textbook study to determine the effects of each on the learning of basic surgical skills.
Methods  Sixty-four Year 2 medical students were randomly assigned to 2 treatment groups in which they undertook either mental imagery or textbook study. Both groups received the usual skills course of didactic lectures, demonstrations, physical practice with pigs' feet and a live animal laboratory. One group received additional training in mental imagery and the other group was given textbook study. Performance was assessed at 3 different time-points using a reliable rating scale.
Results  Analysis of variance on student performance in live rabbit surgery revealed a significant interaction favouring the imagery group over the textbook study group.
Conclusions  The mental imagery technique appeared to transfer learning from practice to actual surgery better than textbook study.     

Comparison of directed and self-directed learning in evidence-based medicine: a randomised controlled trial

OBJECTIVES: To compare 2 educational programmes for teaching evidence-based medicine (EBM). DESIGN: Prospective randomised controlled trial accompanied by a qualitative evaluation. SETTING: University of Oslo, Norway, 2002-03. PARTICIPANTS: A total of 175 students entered the study. All tenth semester medical students from 3 semesters were eligible for inclusion if they completed baseline assessment and consent forms and either attended teaching on the first day of the semester or gave reasons for their absence on the first day in advance. Interventions One intervention was based on computer-assisted, self-directed learning (self-directed intervention), whilst the other was organised as workshops based on social learning theory (directed intervention). Both educational interventions consisted of 5 half-day sessions. MAIN OUTCOME MEASURES: The primary outcomes were knowledge about EBM and skills in critical appraisal. A secondary outcome measured attitudes to EBM. Outcomes were compared on an intention-to-treat basis using a stratified Wilcoxon rank-sum test. RESULTS: There were no differences in outcomes for the 2 study groups in terms of EBM knowledge (mean deviation 0.0 [95% confidence interval - 1.0, 1.0], P = 0.8), critical appraisal skills (MD 0.1 [95% CI - 0.9, 1.1], P = 0.5), or attitudes to EBM (MD - 0.3 [95% CI - 1.4, 0.8], P = 0.5). Follow-up rates were 96%, 97% and 63%, respectively. CONCLUSIONS: This trial and its accompanying qualitative evaluation suggest that self-directed, computer-assisted learning may be an alternative format for teaching EBM. However, further research is needed to confirm this and investigate alternative educational models.     

Cohort study on predicting grades: is performance on early MBChB assessments predictive of later undergraduate grades?

Objective  Timely intervention, based on early identification of poor performance, is likely to help weaker medical students improve their performance. We wished to identify if poor performance in degree assessments early in the medical degree predicts later undergraduate grades. If it does, this information could be used to signpost strategically placed supportive interventions for our students.
Methods  We carried out a retrospective, observational study of anonymised databases of student assessment outcomes at the University of Aberdeen Medical School. Data were accessed for students who graduated in the years 2003−07 ( n  = 861). The main outcome measure was marks for summative degree assessments from the end of Year 2 to the end of Year 5.
Results  After adjustment for cohort, maturity, gender, funding source, intercalation and graduate status, poor performance (fail and borderline pass) in the Year 2 first semester written examination Principles of Medicine II was found to be a significant predictor of poor performance in all subsequent written examinations (all P  < 0.001). Poor performance in the Year 3 objective structured clinical examination (OSCE) was a significant predictor of poor performance in Year 4 and 5 OSCEs. Relationships between essay-based summative assessments were not significantly predictive. Male gender appeared to significantly predict poor performance.
Discussion  Examinations taken as early as mid-Year 2 can be used to identify medical students who would benefit from intervention and support. Strategic delivery of appropriate intervention at this time may enable poorer students to perform better in subsequent examinations. We can then monitor the impact of remedial support on subsequent performance.     

Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West

Objectives  We aimed to develop a Korean version of the Communication Skills Attitude Scale (CSAS) created by Rees et al . in order to elucidate the positive and negative aspects of Korean pre-medical and medical students' attitudes towards communication skills (CS) learning.
Methods  We performed two surveys. In the first of these, 325 pre-medical and medical students completed a translated version of the CSAS. In the second survey, 257 medical students and doctors-in-training answered five open-ended questions to obtain more qualitative data about their attitudes.
Results  Principal component analysis with direct oblimin rotation performed with the data from the first survey produced the following five factors: facilitation of interpersonal skills; doubts about the importance of CS learning in medicine; motivation; negative attitudes towards assessment, and overconfidence. Results from the second survey indicated that facilitation and importance within a medical context were two core attitudinal factors and suggested some modification to the CSAS to improve its fit for Korean pre-medical and medical students.
Conclusions  Using a Korean version of the CSAS (CSAS-K), we determined five factors that revealed a somewhat complex attitude structure among students towards CS learning. The CSAS required some modification, possibly because CS teaching and learning in Korea are in the development stage. Finally, the educational implications of the results are discussed.     

The learning environment and medical student burnout: a multicentre study

Objectives  Little is known about specific personal and professional factors influencing student distress. The authors conducted a comprehensive assessment of how learning environment, clinical rotation factors, workload, demographics and personal life events relate to student burnout.
Methods  All medical students ( n  = 3080) at five medical schools were surveyed in the spring of 2006 using a validated instrument to assess burnout. Students were also asked about the aforementioned factors.
Results  A total of 1701 medical students (response rate 55%) completed the survey. Learning climate factors were associated with student burnout on univariate analysis (odds ratio [OR] 1.36–2.07; all P  ≤ 0.02). Being on a hospital ward rotation or a rotation requiring overnight call was also associated with burnout (ORs 1.69 and 1.48, respectively; both P  ≤ 0.02). Other workload characteristics (e.g. number of admissions) had no relation to student burnout. Students who experienced a positive personal life event had a lower frequency of burnout (OR 0.70; P  ≤ 0.02), whereas those who experienced negative personal life events did not have a higher frequency of burnout than students who did not experience a negative personal life event. On multivariate analysis personal characteristics, learning environment and personal life events were all independently related to student burnout.
Conclusions  Although a complex array of personal and professional factors influence student well-being, student satisfaction with specific characteristics of the learning environment appears to be a critical factor. Studies determining how to create a learning environment that cultivates student well-being are needed.     

An experiment in problem-based learning

Summary: Problem-solving skills are important for medical students and problem-based learning (PBL) is especially suited to general practice. Therefore an experiment using a form of PBL was introduced into a new 4-week course in general practice for final rotation students at the University of Glasgow in the session 1992–93. The experiment aimed to introduce students to an alternative method of learning to the traditional one previously used by them in their course, to encourage teamwork and to encourage the use of alternative methods of obtaining information. The method, centred around allowing the students to investigate problems they choose themselves, is described. The evaluation of the course by written standard form, free written comments and audiotape recorded interviews with a one in four sample of the class is presented.
Summary: The students selected many interesting problems and used many different and unusual sources of information in researching them. This method of learning was compared with the parallel lecture course and was thought by the students to be more interesting but less relevant than the lecture course.
Summary: The experiment showed that it is possible to introduce a problem-based form of learning into a new course in parallel with more traditional methods of teaching and for it to be at least partially successful for students much more used to a traditional didactic curriculum. Ways of improving the course in the future to make it more sensitive to the students' learning needs are discussed.     

Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination?

OBJECTIVES: Learning to perform physical examination of the abdomen is a challenge for medical students. Medical educators need to find engaging, effective tools to help students acquire competence and confidence in abdominal examination techniques. This study evaluates the added value of ultrasound training when Year 1 medical students learn abdominal examination. METHODS: The study used a randomised trial with a wait-list control condition. Year 1 medical students were randomised into 2 groups: those who were given immediate ultrasound training, and those for whom ultrasound training was delayed while they received standard instruction on abdominal examination. Standardised patients (SPs) used a clinical skills assessment (CSA) checklist to assess student abdominal examination competence on 2 occasions - CSA-1 and CSA-2 - separated by 8 weeks. Students also estimated SP liver size for comparison with gold-standard ultrasound measurements. Students completed skills confidence surveys. RESULTS: Proficiency in abdominal examination technique acquired from traditional instruction boosted with ultrasound training showed no advantage at CSA-1. However, at CSA-2 the delayed ultrasound training group showed significant improvement. Students uniformly underestimated SP liver sizes and the estimates were not affected by ultrasound training. Student confidence in both groups improved from baseline to CSA-1 and CSA-2. CONCLUSIONS: Ultrasound training as an adjunct to traditional means of teaching abdominal examination improves students' physical examination technique after students have acquired skills with basic examination manoeuvres.     

Evaluation of procedural skills training in an undergraduate curriculum

CONTEXT: A substantial proportion of medical students enter their intern year without any basic skills experience. Lack of experience is a significant source of stress for many junior doctors. OBJECTIVES: To evaluate the effect of a basic procedural skills tutorial for Year 3 medical students on their competence in relevant skills at Year 5. SUBJECTS: The control group consisted of 93 medical students who completed Year 3 in 1996. The intervention group consisted of 92 medical students who completed Year 3 in 1997. The intervention group received a practical skills tutorial in Year 3; the control group did not. Both groups were assessed on their practical skills competence during Year 5. METHODS: A 3-hour practical tutorial on injection and suturing techniques was delivered to the intervention group. The effectiveness of the intervention was assessed by self-reported experience of giving injections, inserting sutures and sustaining needlestick injuries, and by teacher-rated competency in four basic procedural skills. RESULTS: Students who received the Year 3 tutorial were significantly more likely to record a satisfactory assessment for their performance in all four basic skills compared with students who did not receive the tutorial. They were less likely than controls to refuse invitations to give injections, but not invitations to insert a suture, during Years 4 and 5. CONCLUSIONS: A single session of formalised teaching in procedural skills in the early stages of a medical degree can have long-term effectiveness in basic skills competence and may increase students' confidence to practise their skills.     

Fostering diagnostic knowledge through computer-supported, case-based worked examples: effects of erroneous examples and feedback

Objectives  A case-based, worked example approach was realised in a computer-based learning environment with the intention of facilitating medical students' diagnostic knowledge. In order to enhance the effectiveness of the approach, two additional measures were implemented: erroneous examples and elaborated feedback. In the context of an experimental study, the two measures were varied experimentally.
Methods  A total of 153 medical students were randomly assigned to four experimental conditions of a 2 × 2-factor design (errors versus no errors, elaborated feedback versus knowledge of correct result [KCR]). In order to verify the sustainability of the effects, a subgroup of subjects ( n  = 52) was compared with a control group of students who did not participate in the experiment ( n  = 145) on a regular multiple-choice question (MCQ) test.
Results  Results show that the acquisition of diagnostic knowledge is mainly supported by providing erroneous examples in combination with elaborated feedback. These effects were independent from differences in time-on-task and prior knowledge. Furthermore, the effects of the learning environment proved sustainable.
Conclusions  Our results demonstrate that the case-based, worked example approach is effective and efficient.     

Teaching doctors how to diagnose paroxysmal events: a comparison of two educational methods

Objectives  Two educational methods, facilitated case discussion and a computerised tutorial, were compared for teaching about childhood epilepsy. We used a comprehensive and clinically relevant assessment method to evaluate the hypothesis that a computerised tutorial more effectively increases knowledge acquisition than a facilitated case discussion.
Methods  Paediatric trainees ( n  = 66) were arbitrarily allocated to facilitated case discussion or computerised tutorial. The analysis of paroxysmal events was taught by the same teacher, using a standardised protocol and principles of active learning. Outcome measures included knowledge acquisition, clinical confidence and usefulness pre- and post-teaching, and at 3 months follow-up.
Results  Computerised tutorial participants scored significantly higher on knowledge acquisition post-teaching. There was gain in clinical confidence in both modalities post-teaching which did not differ between the groups. Confidence and knowledge were not related post-teaching. Both groups found the teaching relevant to clinical practice. However, facilitated case discussion participants rated the session as more enjoyable, and more useful in reinforcing and acquiring knowledge, and felt more motivated for further learning. At 3 months follow-up, participants in both modalities showed significant increases in knowledge acquisition, with no difference between modalities.
Conclusions  The computerised tutorial more effectively imparted knowledge immediately post-teaching. However, facilitated case discussion is the preferred modality in terms of participant enjoyment and perceived usefulness.