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Original Research |
1 Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Ave.,
Cincinnati, OH 45229.
2 Department of Radiology, University of Virginia, Charlottesville, VA.
3 Department of Psychiatry, Yale University School of Medicine, New Haven,
CT.
Received December 8, 2006;
accepted after revision December 14, 2007.
Address correspondence to E. I. Rubio
(eva.rubio{at}cchmc.org).
Abstract
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SUBJECTS AND METHODS. Radiology residents in our program were randomized into two groups stratified by level of training. The control group received a standard didactic midday lecture, and the experimental group received the identical lecture material with an audience response system integrated into the lecture delivery.
RESULTS. The group who used the interactive audience response software had significantly higher learning (p = 0.02) and long-term retention (p = 0.001) scores on postlecture quizzes administered to both groups of residents on the day of the lecture and 3 months later.
CONCLUSION. Use of appropriate interactive teaching techniques facilitates residents' learning and retention of material. In our study, long-term retention was especially improved with use of an interactive lecture style.
Keywords: audience response • education • learning retention • resident education
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The audience response system (Connect Pro, MeridiaARS) is a commercial product. The components were easily installed database soft ware, 40 or more individual handheld keypads (Fig. 1) for audience voting, and a wireless receiver attached to a PC running the presentation program (PowerPoint, Microsoft). Questions were built in the database and displayed throughout the lecture with the presentation software. Trainees used the handheld keypads to select from an array of possible answers to the lecturer's questions. The wireless receiver recorded the votes. The results can be displayed to the audience immediately or reviewed at another time. In this experiment, the trainees' responses were not recorded individually and were anonymous. Various report ing tools can be used to analyze the response data (e.g., compare the correct answers between groups, such as first-through fourth-year residents). Results can be saved or presented in HTML format on a Web page that can be accessed by trainees.
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The lecture to the control group followed the standard didactic format, and the audience response system was not used. After the lecture, the resi dents were given the opportunity to ask questions and then received the same 10-question quiz administered to the audience response system group. The five questions posed during the audience response lecture were not posed to the control group.
Every attempt was made to equalize lecture delivery to the two groups, including pace and volume, additional points of emphasis, and discussion of specific images. Results on the postlecture quizzes were analyzed with Student's t tests for statistical differences between groups. Approximately 3 months after the lecture, the same postlecture quiz was readministered to both groups, and the results were analyzed for statistical significance with the Student's t test.
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The two basic lecture formats in most radiology training programs are formal didactic lectures and teaching file, or hot seat, conferences. Each style carries its attendant pitfalls: boredom in the former and often unintentional public embarrassment in the latter. The primary justification for the hot seat style of conference is the necessity of preparation for oral board examinations. The flaw in this line of reasoning is that oral boards are undertaken in a private one-on-one format with a previously unknown examiner rather than in front of a room full of peers. As the structure of radiology training and examination evolves in the near future, our educational strategies should also change.
As has been found in experimental and educational settings [2], optimal learning and performance can be plotted against stimulation in a bell curve distribution with retention of material represented on the y-axis and stimulation represented on the x-axis (Fig. 2). On the left end of the bell curve, both retention (y) and stimulation (x) are insufficient, indicating an unsatisfactory overall outcome. Retention is expected to be poor when the audience is understimulated or bored. On the opposite end of the bell curve, stimulation (x) is sufficiently high enough to result in distraction or frustration and to negatively influence learning and retention; again, retention is low. Examples of extremely high stimulation include excessive use of public embarrassment, a fast or confusing pace, and presentation of too much material in one session. Optimal learning and retention can be achieved with an appropriate balance of teaching elements. Teaching methods that result in successful audience engagement and stimulation without reliance on negative emotions, such as embarrassment, are optimal. The challenge is to discern which teaching methods embody this optimal stimulation for the most efficient retention of material.
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If material is successfully taught at the initial presentation, learners successfully transfer new material and concepts from short-term memory to long-term retention. The many theories on facilitating this transfer include use of repetition, mnemonic devices, abstract analogies, humor, comparisons, and interactive methods, such as small groups, calling on individuals, projects, and self-testing. Almost all methods have shortcomings and virtues. It is the rare and gifted educator who intuitively knows which delivery mode works best for a particular audience and specific subject. Appropriate teaching methods matched to a particular audience by a skilled instructor can yield inspirational results. On the other hand, miscalculation of the same elements can quickly alienate the audience as both enjoyment and learning plummet.
An audience response system is a simple way to incorporate fun and the concept of benign stress application to enhance attention, learning, and retention. The combination of game show-style interaction and the learners' opportunity to test themselves without being singled out and possibly embarrassed is a potentially important step in recognizing the importance of teacher-audience psychology, even at the postgraduate level. Use of audience response software has been well received by both medical and nonmedical adult learners [3-6]. It has been shown that the anonymity of techniques such as the audience response system allows residents and students who would otherwise shy away from being called on during a lecture to participate more freely. [6] Taken a step further, depending on how it is used the audience response software provides immediate feedback on the audience's comprehension of the material as the lecture proceeds, allowing the presenter to revisit or reexplain concepts not fully understood by the audience at initial presentation. With immediate feedback, lecturers can fine-tune their delivery style and discern which aspects of a lecture are more or less successful at conveying a point. This ability to tailor the presentation to the audience is a powerful tool in teacher education [3, 5].
The findings of our randomized trial comparing the average immediate and long-term retention of the lecture material between a group that used the audience response software and a control group that did not confirm that the audience response system can be an effective tool in educational development. Although there was a modest decrease in average postlecture test scores in the audience response system group 3 months after the lecture, there was a dramatic decrease in average test score in the control group, showing the long-term beneficial effect of use of this technique.
In the months after the experiment, residents were polled several times by lecturers at our institution to determine whether they enjoyed the audience response format. Not only did the audience members enjoy the interactive style, nearly all preferred it over the didactic format. A subjective finding was that the group who used the audience response software was more alert during the lecture and asked more questions about the material at the conclusion of the talk. This level of audience enthusiasm is in keeping with the findings of other investigators using similar audience response techniques [3, 5]. Survey responses in the nonmedical educational setting [4, 6] confirm that this approach to education is well received. In other areas of medicine, such as continuing medical education review courses, lectures delivered with the audience response technique have been consistently rated more favorably than lectures delivered in the traditional format [5].
Limitations to our study included the modest sample size and the inability to retest all of the participants at follow-up. We emphasize, however, the robust statistical significance observed at both time points despite the limited sample size. In addition, the anonymity of the testing results precluded matched analyses, in which each participant's follow-up test score would be compared with his or her previous performance. Future research should include a unique participant identifier to allow analysis of repeated tests. Investigation of each subject's scores over time would more fully elucidate the effect of the audience response system on immediate learning and long-term retention of material. In addition, further investigations could be designed with a pretest and posttest format to compare performance between control and audience response system groups. Finally, it is possible that other factors influenced test performance, particularly at follow-up assessment. For example, it is possible that in the interim, members of the audience response system group were exposed to relevant subject material that had the effect of independently improving their knowledge of renal masses, therefore spuriously improving their scores. This phenomenon, however, is somewhat unlikely.
The data obtained during this two-part experiment support the theory that use of a non-threatening and interactive technique such as an audience response system significantly improves retention of new material. Although improvements were observed in the short term, the differences in the posttest performance were even greater at the 3-month follow-up retest. Use of audience response software in lectures at the postgraduate level benefits the audience members through interaction with the presenter. It also aids presenters in gathering immediate feedback regarding the clarity of the presentation, allowing instructors to recalibrate and optimize their teaching techniques immediately or in subsequent lectures. We acknowledge that audiences are heterogeneous groups for whom no one lecture style is sufficient. The success of new teaching methods such as the audience response system should prompt exploration of other innovative educational avenues.
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