Copyright 2002, Benny C. Shaw, Jr.

THE EVALUATION OF A WEB-BASED METACOGNITIVE TOOL:

THE EFFECT OF PROBLEM-CENTERED REFLECTION ON THE

DEVELOPMENT OF LEARNING STRATEGIES ASSOCIATED

WITH THE DIAGNOSTIC REASONING PROCESS

by

BENNY CHARLES SHAW, JR., B.S., M.S.

A DISSERTATION

IN

INSTRUCTIONAL TECHNOLOGY

Submitted to the Graduate Faculty of Texas Tech University in

Partial Fulfillment of the Requirements for

the Degree of

DOCTOR OF EDUCATION

Approved

Chairp/r^ of the Committee

Accepted

Dean of the Graduate School

December, 2002

ACKNOWLEDGEMENTS

1 would like to express my appreciation to my friends and family who have

supported and encouraged me during the completion of this dissertation. 1 would also

like to thank the members of my committee for their guidance during this process.

First, 1 wish to thank the chair of my doctoral committee. Dr. Nancy J. Maushak,

for her support and continued encouragement during my graduate studies and the

dissertation process. Her willingness to work with me through a year of uncertainty has

been instrumental in the successful completion of this dissertation.

1 also wish to express my gratitude to the other members of my doctoral

committee, Dr. Steven Crooks, Dr. Reid Norman, and Dr. Roman Taraban, for giving

their time, guidance, and support in the completion of this dissertation.

I dedicate this work to my family. Without their support and encouragement

during the last four years, this endeavor would not have been possible. To my son, Tony,

I want to say thanks for your patience and understanding in this seeming endless

undertaking. To my wife, Rayma, thank you for your love and support during this

process. A lifetime of thank yous would still not express the gratitude, appreciation, and

love that my family deserves for their patience during this last year.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ii

ABSTRACT vi

LIST OF TABLES viii

LIST OF FIGURES x

CHAPTER

I. INTRODUCTION 1

Statement of Problem 1

Purpose of the Study 4

Research Questions 6

Null Hypotheses 6

Significance of the Study 7

Limitations of the Study 8

Definitions of Terms 9

II. REVIEW OF THE LITERATURE 12

Introduction 12

Instructional Models 12

Medical Diagnostic Reasoning Process and Cognitive Theories 16

Cognitive and Metacognitive Tools in Healthcare Education 19

Summary 23

111

III. METHODOLOGY 25

Introduction 25

Web-Based Tool Design 25

Variables 28

Population, Sample, and Participant Characteristics 29

Design and Treatments 36

Instruments 48

Statistical Analysis 51

Measuring the Effects of Problem-Centered Reflection 52

Measuring the Development of Learning Strategies

and the Changes in Motivation 55

Summary 56

IV. RESULTS 58

Introduction 58

Statistical Analyses 58

Findings for Null Hypothesis 1 59




Findings for Null Hypothesis 5 68 Summary 75

iv

V. DISCUSSION, CONCLUSION, AND IMPLICATIONS

FOR FURTHER RESEARCH 78

Introduction 78

Discussion 80

Conclusions 89

Limitations of the Study 92

Implications for Further Research 93

Summary 94

LIST OF REFERENCES 96

APPENDIX

A. CONSENT FORM AND DEMOGRAPHIC DATA 101

B. MSLQ QUESTIONNAIRES 104

C. SESSION OBJECTIVES 116

D. ACHIEVEMENT EXAMINATION 118

E. EXAMPLES OF ESSAY CODINGS FOR EACH RATER 133

F. IRB APPROVAL AND TRANSCRIPT 137

ABSTRACT

Medical students in a conventional medical curriculum are unable to integrate

knowledge learned in the basic sciences and apply that knowledge to clinical situations

(Gruppen, 1997; Bamett, 1995). This study examined the effect of a web-based

metacognitive tool on medical student development of learning strategies and the changes

in motivation that are associated with the diagnostic reasoning process.

The data presented in this study provide information on the development of

learning strategies in a hybrid instructional environment consisting of lecture-based

instruction and problem-centered reflection. The questions addressed by this study were:

1. What are the effects of problem-centered reflection on achievement?

2. What are the effects of problem-centered reflection on depth of learning?

3. What are the effects of problem-centered reflection on the use of reflection

time during examinations?

4. What are the effects of problem-centered reflection on the structure and

complexity of learned knowledge?

5. What effect does problem-centered reflection have on the development of

learning strategies and the changes in motivation?

The study of medical diagnostic decision-makmg has mainly been based on the

reasoning process in simulated case studies. The theoretical approaches to these studies

include information processing theory and schema theory (Greenwood, 1998, 2000). In

problem-centered reflection, a clinical problem is the focal point about which data are

vi

organized, interpreted, and integrated. Problem-centered reflection combines aspects of

both Information Processing and Schema Theories.

The participants in this study were medical students who were enrolled in the first

year of medical school and were randomly assigned to the direct instruction and problem-

centered reflection groups. The direct instruction group accessed the web-based direct

instruction tutorial while the problem-centered reflection group accessed the web-based

metacognitive tool. The participants accessed the appropriate web-based learning

activities for approximately one hour each day for two weeks which corresponded with

the Upper Extremity Unit in Gross Anatomy. This quasi-experimental study examined

the effects of problem-centered reflection on achievement, depth of learning, reflection

time during examinations, and structure and complexity of learned knowledge.

vu

LIST OF TABLES

3.1 Sample by Age 30

3.2 Sample Demographics 31

3.3 Direct Instruction Participants by Age 33

3.4 Direct Instruction Demographics 34

3.5 Problem-Centered Reflection Participants by Age 35

3.6 Problem-Centered Reflection Demographics 36

3.7 Experimental Design 47

3.8 Cronbach Alpha's for MSLQ Scales 50

3.9 Three Levels of Knowledge Structure and Complexity 54

4.1 Description of Achievement by Groups 59

4.2 Two-Way Analysis of Variance between Treatment Groups

and Question Type on Achievement 60

4.3 Description of Time Needed to Answer Question by Groups 62

4.4 t-Test between Treatment Groups on Time to Answer Question 64

4.5 Muhivariate Analysis of Essay Statement Types by Treatment Groups 66 4.6 Means and Standard Errors of Essay Statement Types by

Treatment Groups ^7

4.7 Cronbach Alphas for Form A, Form B, and from the Literature 69

4.8 Description of Pre Test Scales by Groups 70

4.9 Description of Post Test Scales by Groups 71

viu

4.10 Analysis of Variance between Pre/Post Test and Treatment Group for the Intrinsic Motivation Scale 72

4.11 Analysis of Variance between Pre/Post Test and Treatment Group for the Extrinsic Motivation Scale 72

4.12 Analysis of Variance between Pre/Post Test and Treatment Group for the Elaboration Scale 73

4.13 Analysis of Variance between Pre/Post Test and Treatment Group for the Critical Thinking Scale 74

4.14 Analysis of Variance between Pre/Post Test and Treatment Group for the Metacognitive Self-Regulation Scale 75

5.1 Description of Participants 80

IX

LIST OF FIGURES

1.1 An Example of a Clinical Vignette with Multiple Choice Answers 4

3.1 Curricular Systems Integration 26

3.2 Layout and Relationships of the SQL Tables in the Student Information, Curriculum Management, and Student Portfolio Systems 28

3.3 Objectives Presented at the Beginning of the Session 38

3.4 Content Delivery During Session 39

3.5 Content Delivery Followed by Practice 40

3.6 Formative Feedback when Selecting an Answer 42

3.7 Problem-Centered Reflection at the End of a Session 43

3.8 Peer Review of Another Participant's Reflection 45

3.9 Reviewed the Peer Evaluation of the Participant's Reflection 46

5.1 Achievement Means by Treatment Group 81

5.2 Essay Statement Types by Treatment Groups 86

E.l Researcher Essay Coding Example 1 133

E.2 Researcher Essay Coding Example 2 134

E.3 Researcher Essay Coding Example 3 134

E.4 Subject Matter Expert Essay Coding Example 1 135



CHAPTER I

INTRODUCTION

The aim of medical education is to produce competent physicians. A competent

physician has the knowledge and diagnostic skills to deliver patient care in an increasing

complex environment. Medical knowledge is immense and constantly changing, which

creates a difficult task for students in learning this expanding medical knowledge base.

The challenge for medical educators is to teach students to utilize the knowledge and

diagnostic skills that are required in our complex health care delivery system.

This chapter will state the problem with the instructional strategies currently used

in medical education. The constraints imposed on medical education by the United States

Medical Licensing Examination (USMLE) will be stated. The conclusion of this chapter

will put forth the purpose of this study.

Statement of Problem

Advances in the cognitive sciences over the past two decades have had little effect

on medical education. Nearly all medical students pass the required courses and make

acceptable scores on USMLE exams regardless of the curriculum design. This may be

due to the fact that high-aptitude students, like medical students, succeed regardless of the

instructional strategy used (Cronbach & Snow, 1977).

Medical students in a conventional lecture-based curriculum are unable to

integrate knowledge learned in the basic science courses and apply that knowledge to

clinical situations involving diagnosis and treatment of patients (Gruppen, 1997; Bamett,

1995). In response to medical students' inability to integrate and apply basic science

knowledge in clinical situations, a curriculum solely based on problem-based learning

(PBL) was implemented at numerous institutions (Camp, 1996). However, in most

studies comparing conventional lecture-based curricula to problem-based curricula, little

or no significant difference in medical student performance as measured by the USMLE

was reported (Way, Hudson, & Biagi, 2000; CoUiver, 2000). Norman and Schmidt

(1992) reviewed experimental evidence supporting possible differences in medical

students' learning and found that PBL students retain knowledge much longer than

students in a conventional curriculum. However, the PBL students' initial knowledge

base may be less extensive (Albanese & Mitchell, 1993).

An inability to integrate basic science knowledge in clinical situations may also be

the result of the system used to select students for admission to medical school. Students

accepted to medical school have survived the highly selective admission process. This

admission process begins by examining the students past academic record. According to

Norman and Schmidt (2000), students admitted to medical school are "a highly selected

and atypical group." These students have demonstrated the ability to succeed in lecture-

based courses for fifteen or more years. These students have also succeeded on the

Medical College Admission Test (MCAT). The admission criteria select for students that

thrive in a lecture-based environment and do not select for critical-thinking skills

(Albanese, 2000; Norman & Schmidt, 2000).

Most comparisons of conventional lecture-based curricula to problem-based

curricula m medical education have been based on performance on USMLE

examinations (Way et al., 2000). Students relying on rote memorization adopt a

"surface" approach to learning (Nu, Van Der Vleuten, & Lacombe, 1998). The USMLE

may contribute to a medical student's reliance on rote memorization and a "surface"

approach to learning. The USMLE is a three-step examination that assesses a physician's

ability to apply knowledge, concepts, and prmciples that are important in health care

(http://www.usmle.org). The format and construction of the USMLE Step 1 imposes

constraints on medical education by requiring a broad knowledge base in order to obtain a

passing score. These questions can arise from a large number of concepts and the content

of the examination can change from year-to-year.

A full content outline for the Step 1 examination ...describes the scope of the examination in detail... The content outline is not intended as a guide for curriculum development or examinee preparation. It provides a flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis. The categorizations and content coverage are subject to change. Broadly based learning that establishes a strong general understanding of concepts and principles in the basic sciences is the best preparation for the examination. (United States Medical Licensing Examination, 2001, p. 4)

The questions on the USMLE examinations are based on clinical vignettes with multiple

choice answers. An example of a clinical vignette with multiple choice answers is

presented in the USMLE Content Outline (Figure 1.1).

http://www.usmle.org

A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She has not yet started dialysis. Examination is noncontributory. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular volume is 94 |im3. A blood smear shows normochromic, normocytic cells. Which of the following is the most likely cause?

A. Acute blood loss B. Chronic lymphocytic leukemia C. Erythrocyte enzyme deficiency D. Erythropoietin deficiency E. Immunohemolysis F. Microangiopathic hemolysis G. Polycythemia vera H. Sickle cell disease I. Sideroblastic anemia J. 6-Thalassemia trait

Figure 1.1. An Example of a Clinical Vignette with Muhiple Choice Answers (United States Medical Licensing Examination, 2001, p. 4).

The problem in medical education is to provide students with a broad, integrated

knowledge base, and to enable students to develop learning strategies that are essential to

diagnostic reasoning.

Purpose of the Study

The purpose of this study is two-fold. First, this study will examine the effects of

problem-centered reflection on various indicators of learning. These indicators include

achievement, depth of learning, reflection time during examinations, and structure and

complexity of learned knowledge. Achievement and depth of learning will assess the

reliance on rote memorization or the use of integrated knowledge. The reflection time

during examinations will measure, m milliseconds, the amount of time needed to reflect

on and answer each question in the achievement examination. The integration of

knowledge will be assessed by using an essay question to elicit the structure and

complexity of the knowledge the student has on an anatomical area.

Second, this study will examine the effect of the use of this web-based

metacognitive tool on medical student development of learning strategies and the changes

in motivation that are associated with the diagnostic reasoning process. The diagnostic

reasoning process is a series of actions carried out in order to propose a solution to a

clinical problem. Underlying the diagnostic reasoning process are learning sfrategies that

are applied by the healthcare practitioner or student to analyze and reflect on clinical data

and prior knowledge in order to arrive at a diagnosis. The diagnostic reasoning process

consists of:

• Identifying relevant data,

• Organizing and nesting data, and

• Integrating prior knowledge with these data to diagnose the patient.

This study will also document the development of two integrated web-based

systems. The two systems will integrate with one another in order to provide a web-based

tool for problem-centered reflection. A web-based metacognitive tool that integrates

problem-centered reflection with course objectives will be developed as part of a student

portfolio system. A student information system will be simulated and used to regulate

access to the system.

Research Questions

The research questions addressed by this study are:

1. What are the effects of problem-centered reflection on achievement?

2. What are the effects of problem-centered reflection on depth of learning?

3. What are the effects of problem-centered reflection on the use of reflection

time during examinations?

4. What are the effects of problem-centered reflection on the structure and

complexity of learned knowledge?

5. What effect does problem-centered reflection have on the development of

learning strategies and the changes in motivation?

Null Hypotheses

In this study comparing direct instruction to problem-centered reflection, I will

address the following null hypotheses:

1. Problem-centered reflection will not enhance learning as measured by a

multiple choice examination.

2. Problem-centered reflection will not contribute to the development of deep,

integrated knowledge as measured by muhiple choice questions.

3. Problem-centered reflection will not resuU in an increase in the use of

reflection to determine an answer during an examination.

4. Problem-centered reflection will not increase the structure and complexity of

learned knowledge.

5. The use of a problem-centered reflection tool will not enhance the

development of learning strategies and the changes in motivation in medical

students as measured by the Motivated Strategies for Learning Questionnaire

(MSLQ):

a. infrinsic and extrinsic goal orientation,

b. metacognitive self-regulation,

c. critical-thinking,

d. organization, and

e. elaboration.

Significance of the Study

This study will document the development of a web-based metacognitive tool that

integrates problem-centered reflection with course objectives. The design of the student

portfolio database will allow the association of clinical vignettes or problems with

lecture-based material.

This study will examine the effect of the use of this web-based metacognitive tool

on medical student development of learning strategies and the changes in motivation that

are associated with the diagnostic reasoning process. The researcher contends that

integrating this web-based tool with conventional lecture instruction will provide students

with a broad, integrated knowledge base, and enable the students to develop the learning

strategies needed to integrate and apply this knowledge base. The data presented in this

study will also provide information on the development of learning sfrategies in a hybrid

instructional environment consisting of lecture-based instruction and problem-centered

reflection.

Limitations of the Study

There are several limitations to the generalizability of this study. The study was

based on self-selected, voluntary participation of medical students and the generalization

of results to other populations of students may be lunited. The study collected data from

questionnaires and an achievement examination with a small sample of students. It is

important to note that the sample is a convenience sample taken from one university

setting. They were randomly assigned to the comparison groups, but they were not

randomly sampled from the total population.

This study also examined a very specific computer tool for medical education,

which was designed to promote problem-centered reflection on prior basic science

knowledge and the structure of learned basic science knowledge. Other computer tools

have different purposes, and may not have similar effects on reflection and knowledge

structure. One cannot generalize that using this tool in another course outside of a basic

science course in medical education would have the same effects.

The overall focus of this study is on the development of learning sfrategies and the

changes in motivation that are essential for the development of diagnostic reasoning

skills. However, it should be noted that this study does not attempt to examine the role of

collaboration in the development of these skills.

Definitions of Terms

Cognitive tools are technologies that support knowledge construction, exploration,

collaboration, or elaboration when used by students to learn (Jonassen, 2000).

Problem-based learning (PBL) is an instructional practice used in medical

education where students in small groups solve clinical problems. Through these clinical

problems, students identify, research, and discuss learning issues relevant to the problem

(Irby, 1996).

Problem-centered reflection is a term I created to describe the process of reflecting

on the structure and organization of prior knowledge with respect to a clinical situation

(problem).

Reflection is an intellectual process whereby a learner takes time to consider an

experience in order to lead to new understandings (Boud, Keogh, & Walker, 1985).

The following terms are scales defined by the Motivated Strategies for Learning

Questionnaire. Metacognitive self-regulation, critical thinking, organization, and

elaboration are learning strategies that are associated with the diagnostic reasoning

process.

Critical-thinking is the activation and application of prior knowledge to new

situations in order to solve a problem or make a decision (Pinfrich et al., 1991). The

identification of relevant data in the diagnostic process activates prior knowledge and

thus, utilizes a critical thinking learning sfrategy. Critical thinking is a learning strategy

that incorporates an evaluation of various factors that are important to decision-making.

Critical thinking is the use of those cognitive skills or sfrategies that increase the probability of a desirable outcome. It is used to describe thinking that is purposeful, reasoned and goal directed - the kind of thinking involved in solving problems, formulating inferences, calculating likelihoods, and making decisions when the thinker is using skills that are thoughtful and effective for the particular context and type of thinking task. (Halpem, 1996, p. 5)

This definition of critical thinking suggests that critical thinking learning sfrategies would

also be used when the student mtegrated prior knowledge with learning issues.

Elaboration is a leammg strategy that helps students to build internal connections

between knowledge items. Elaboration strategies are used to reorganize and classify

information (Pinfrich et al., 1991). The integration of prior knowledge with the learning

issues identified in the diagnostic reasoning process would be the use of an elaboration

learning strategy.

Goal orientation is a student's perception of the reasons for engaging in a learning

task. The goal orientation can be infrinsic or exfrinsic. Intrinsic goal orientation refers to

"participating in a task for reasons such as challenge, curiosity, and mastery" while an

extrinsic goal orientation refers to "participating in a task for reasons such as grades,

rewards, performance, evaluation by others, and competition" (Pintrich, Smith, Garcia, «&

McKeachie, 1991, pp. 9-10). The confidence a learner has in his ability to succeed in a

course can affect the learner's motivation (Gibson, 1996; Powell, Conway, & Ross,

1994). A learner will be intrinsically motivated to continue in a situation if he believes he

can succeed in that situation (Coggins, 1988).

10

Metacognitive self-regulation is a sfrategy that consists of planning, monitoring,

and regulating the integration, application, and organization of information and prior

knowledge with respect to a task (Pinfrich et al., 1991). The entire diagnostic reasoning

process uses the metacognitive self-regulation learning sfrategy. The identification of

relevant data and learning issues associated with the clinical problem requires the learner

to monitor their knowledge structures. The organization and nesting of data and the

integration of information use the metacognitive self-regulation learning sfrategy.

Organization is a learning strategy that helps students construct connections

within the information to be learned through the clustering and nesting of information

(Pintrich et al., 1991). In the diagnostic reasoning process, an organization learning

sfrategy would be used when the learner organizes and nests data to generate learning

issues.

11

CHAPTER II

REVIEW OF THE LITERATURE

Introduction

The overall focus of this study is on the development of learning sfrategies and the

changes in motivation associated with the diagnostic reasoning process. The purpose of

this chapter is to provide an overview of the research in medical education concerning the

development of a broad, integrated knowledge base and the application of this knowledge

in a clinical setting. This review is comprised of three main sections. First, the two main

instructional models and their limitations will be discussed. Second, research on the

medical diagnostic decision process will be presented in relation to two cognitive

theories. Third, the use of cognitive and metacognitive tools in healthcare education will

be discussed.

Instructional Models

Conventional Lecture-Based Instruction

Conventional lectures have a place in well-designed curricula and are a very

efficient use of the faculty's time. Conventional lectures provide students with a structure

for learning and an exposure to a broad knowledge base (Way et al., 2000). However,

lectures alone have limited effectiveness because sfridents are passive recipients of

information rather than actively engaging information. In studies comparing classrooms

that use active learning as opposed to passive learning, active learning results in a greater

12

retention of material, superior problem-solving skills, and motivation for fiiture learning

(McKeachie, Pintrich, Lin, & Smith, 1987).

In lecture-based curricula, students adopt a "surface" approach to leammg by

relying on rote memorization (Nu et al., 1998). Students using a "surface" approach to

learning have at best a superficial imderstanding of the material. A superficial

understanding of the material may contribute to an incomplete integration of prior

knowledge with the new information.

This conventional curriculum is based on presenting students with a broad, up-to-

date knowledge base over the first two years of the curriculum. In the second two years,

the students are expected to integrate this knowledge in clinical medicine. In clinical

medicine, students are divided into small groups that spend six to twelve weeks in a

clinical clerkship. In the third year, students complete four six-week clinical clerkships in

Family Medicine, Pediafrics, Psychiatry and Obstefrics/Gynecology; and two twelve-

week clinical clerkships in Internal Medicine and Surgery.

Problem-Based Learning

In some schools, medical education is beginning to move away from traditional

didactic lectures to acquisition of knowledge through problem-based leaming (Trelstad &

Raskova, 1993; Wu, LaRocco, Fath, & Simon, 1990). The problem-based leaming (PBL)

curriculum is based on authentic problems from clinical practice that stmiulate the

leaming process (Barrows, 1994). PBL utilizes a student-centered approach to leaming

by actively involving the student in information gathering, information evaluation, and

13

problem solving. PBL is based on the idea that expertise is a repository of cases that

emphasizes leaming through experience (Macura et al., 1994).

Problem-based leaming was developed in the medical education community in the

mid-1960s (Camp, 1996). Central to PBL is the learner's ability to take an active role in

the leaming process, to collaborate with others, and to acquire transferable knowledge.

The PBL model is used in many medical schools in the first two years of the basic science

curriculum mstead of the conventional lecture-based courses (Savery & Duffy, 1995).

Students are divided into groups and presented with a simulated patient or patient record.

The students must identify relevant data within the patient record, organize and nest data

to generate leaming issues, integrate prior knowledge with these issues, and diagnose the

patient. In PBL, the students' prior knowledge relevant to the problem is insufficient to

understand the problem in depth (Norman & Schmidt, 1992). Therefore, the students,

like physicians, are responsible for gathering information pertinent to the learning issues

from any available resources. Students are encouraged to utilize all resources available to

them including fellow students, textbooks, joumal articles, elecfronic databases, and

experts. By identifying and gathering information relating to the leaming issues, students

direct or self-regulate their own leaming activities (Pintrich et al., 1991).

Problem-based curricula are assumed to reflect the understanding of the

conditions of human leaming (Norman & Schmidt, 1992). According to Dohnans,

Gijselaers, Schmidt, and Van Der Meer (1993), PBL is assumed to promote situational

learning, activate prior knowledge, increase infrinsic motivation, and promote lifelong

leaming skills. Research in the cognitive sciences has shown that knowledge acquired

14

through activities that are motivating and related to one's interest is leamed more deeply

than rote memorization (Cognition and Technology Group at Vanderbik, 1993). Self-

directed leaming, information gathering, and reflection are skills used in PBL that are

conducive to lifelong leaming.

Smdents in a problem-based curriculum, as compared to conventional lecture-

based settings, determme what information is relevant, and they modify their leaming to

satisfy their own needs and interests (Dohnans et al., 1993). Sfridents in a PBL

curriculum adopt a "deep" approach to leaming by engaging in meaningfiil leaming that

enables the student to better understand the material (Nu et al., 1998). In PBL curricula, a

potential disadvantage is the development of a narrow knowledge base that is applicable

only to the clinical situations studied (O'Neill, 2000).

Qualitative methods have also been used to document how students make sense of

the PBL environment. Biley (1999) found that students were concemed about not being

exposed to a broad enough knowledge base in the PBL process. According to Biley

(1999), prior experiences in fraditional didactic lectures may contribute to the

development of the leamer's perception of his ability to succeed in the educational

setting - the leamer's academic self-concept. Students found it difficult to reconcile their

academic self concept with the requirements of PBL. The students saw themselves as

fact-leamers instead of problem-solvers.

The confidence a leamer has in his ability to succeed in a course can affect the

leamer's motivation. If a leamer believes he can succeed in a given situation, then that

leamer will be intrinsically motivated to continue in that situation. Otherwise, if the

15

leamer does not have confidence in his ability to succeed in that sittiation, then the leamer

has little or no motivation to continue in that situation (Coggins, 1988). The leamer is

basically resigning himself to fail in that situation. An exfreme resignation by the leamer

to fail in a particular situation is known as leamed helplessness (Dweck, 1986). In PBL,

the lack of stmcture and the sttadents' negative academic self-concept could lead to a

leamed helplessness situation. This is suggested by statements from student interviews,

the students believed that they were not leaming at all in the PBL environment (Biley,

1999).

Medical Diagnostic Reasoning Process and Cognitive Theories

Understanding the process in which clinicians make medical diagnostic decisions

has long held the interests of researchers in medical education. In order to understand the

medical diagnostic reasoning process, a number of quantitative and qualitative studies

have been undertaken to describe and document this process (Bordage, Grant, &

Marsden, 1990; Benner, Tanner, & Chesla, 1996; Greenwood, 1998, 2000; Taylor, 1997).

According to Greenwood (1998), theoretical approaches to the study of medical

diagnostic decision-making have mainly been based on the reasoning process in

simulated case studies. The approaches include mformation processing theory and

schema theory (Greenwood, 1998, 2000).

16

Information Processing Theory

Information Processing Theory focuses on how a person processes information

they receive from the environment. Information Processing Theory describes the mental

events in cognition as a flow of information. The information flow consists of receiving

the data, interpreting the data and integrating the data with a goal. Elstein, Shuhnan, and

Sprafka (1990) developed a model of the medical diagnostic reasoning process based on

Information Processing Theory that consists of four phases: (1) data collection, (2)

hypothesis generation, (3) cue interpretation, and (4) hypothesis evaluation.

According to Benner et al. (1996), Information Processing Theory consists of

conscious and unconscious processing of information. They go on to state that the more

knowledgeable or expert a person, the more that person processes information

unconsciously. In comparing the decision process in expert and novice nurses, Taylor

(1997) demonstrated differences in each of the four stages of the medical diagnostic

reasoning process theory put forth by Elstein. Pre-encounter data (data collection) is

collected at moming report or from the chart before meeting the patient. Expert nurses

are more involved and engaged with the moming report. Novice nurses are unable to

interact because they recognize few cues due to limited experience. When meeting the

patient, expert nurses are able to recognize many of the patient's signs and symptoms (cue

interpretation). The novice nurses are unable to recognize any signs or symptoms in a

meaningful way. When generating hypotheses, novices use single cues to generate a

single hypothesis and ignore cues that do not fit that hypothesis. On the other hand,

expert nurses use muhiple cues and generate muhiple hypotheses (Taylor, 1997).

17

Schema Theory

In Schema Theory, a body of knowledge is organized about a specific topic. In

other words, knowledge is grouped and generalized to form mental models (Ormrod,

1999). Schemas formed about events are called scripts. Procedural knowledge translated

into hierarchically organized instmctional units is also called scripts (Greenwood, 2000).

Therefore, expert medical diagnostic reasoning can be classified as scripts of diagnostic

decisions.

Script acquisition, or the hierarchical organization of procedural knowledge,

occurs in three phases: cognitive, associative, and autonomous. As a leamer progresses

through these phases, they become less reliant on declarative knowledge (Greenwood,

2000). In examining how radiologists interpret radiographs, a "think aloud" process was

used to document the reasoning process (Prime & Masurier, 2000). This procedure

demonstrated that radiologists were making decisions by rapidly processing the clinical

sittxation. The radiologists were also using knowledge that was organized into integrated

chunks. For example, a statement such as "I can't see if he's doing an oblique..." is,

according to Prime and Le Masurier (2000), indicative of encapsulating anatomy,

pathology, and radiological knowledge into a single script.

To understand the medical diagnostic reasoning process, qualitative and

quantitative studies have compared expert and novice medical diagnostic decision

making processes (Bordage et al., 1990; Benner et al., 1996; Greenwood, 1998, 2000;

Taylor, 1997). Little work has been conducted on the change in the use of leaming

18

sfrategies and motivation that may occur when a sttxdent fransitions from a didactic to an

applied environment.

Cognitive and Metacognitive Tools in Healthcare Education

Information technology has been used in PBL in order to facilitate and document

the leammg process. According to Jonassen (2000), students use technologies to leam

when the technology supports knowledge constmction, exploration, collaboration, or

elaboration. As students leam with technology, the technology becomes a cognitive tool.

When students use technology to analyze their leaming and intemalized knowledge

stmctures, the technology becomes a metacognitive tool. A number of computer-based

tools have been used in Healthcare education including concept maps, patient

simulations, and reflection.

Concept Maps

Concept maps are metacognitive tools that allow a student to diagram and assess

their thmking process (Daley, Shaw, & Balistrieri, 1999). Diagnostic Ability was

measured by Bordage et al. (1990) using a self-reporting tool (Diagnostic Thinking

Inventory) that they developed and validated. The Diagnostic Thinking Inventory (DTI)

measures flexibility in thinking and the stioicture of knowledge in memory as it pertains to

diagnostic thinking (Sobral, 1995). DTI scores increase with the level of clinical

experience and the stmcture of knowledge in memory is related to the level of diagnostic

expertise (Bordage et al., 1990). Concept maps are spatial representations of the stt^cttire

19

of knowledge in memory with concepts as nodes and connecting lines that represent

relationships between each concept (Jonassen, 2000). In this section, I will discuss how

concept maps are being used with problem-based leaming to help students to sttiicttire

knowledge in their memory.

Students used concept maps to generate clinical concepts and their relationships in

a PBL case (Baugh & Mellott, 1998). By mapping concepts, subconcepts, and

relationships in a PBL case, the student is able to assess thek own knowledge and gaps

within their knowledge (Baugh & Mellott, 1998; Daley et al., 1999). Several studies have

examined the use of clinical concept mapping with case studies of patients in advanced

nursing courses (Baugh & Mellott, 1998; Daley et al., 1999). In a medical-surgical

nursing course, one concept map was requfred for each assigned patient in the clinical

setting and each map was updated as the students leamed throughout the course (Baugh

& Mellott, 1998).

In a senior level course, students created three concept maps depicting the

relationships of the patients, pathophysiologic factors, pharmacologic factors, and nursing

intervention (Daley et al., 1999). In both studies, students were infroduced to concept

mapping at the beginning of the course and the complexity of the concept maps improved

as the courses progressed. The student responses were positive overall. However, the

sttadents felt that leaming and applying the technique of concept mapping required an

adjusttnent period to get comfortable in using the technique (Baugh & Mellott, 1998) and

some students stated that they felt "lost" during the process of creating the maps at the

beginning of the course (Daley et al., 1999).

20

Simulating Patient Assessment

A current application of PBL is as a simulation of patient assessment and

diagnosis (Rendas, Pinto, & Gamboa, 1999; Schor et al., 1995; Wrosch & Morgan,

1998). The PBL computer system presents clinical information about a simulated patient

assessment in six steps: step 1 - corresponds to the initial patient encounter; step 2 -

present mitial details about the ilhiess; step 3 - gives a review of the body systems; step 4

- personal and social background information gathering; step 5 - physical examination;

and step 6 - laboratory and diagnostic findings (Rendas et al., 1999). Different portions

of the PBL presentation can use muhimedia aspects of the computer to present digital

images of the patient, radiographs, and other test resuhs; digital heart and lung sounds;

and digital videos of movement of tt-emors to name a few (Molino, 1991; Schor et al.,

1995).

Reflection

Reflection is an intellectual process whereby a leamer takes time to consider an

event in order to lead to new understandings (Boud et al., 1985). With respect to the

event, reflection can occur before, during, and after the event (Boud, 2001). After an

event, reflection allows the leamer to analyze and evaluate information gained from the

event (Bunkers, 2000). Reflection during an event was best described by Schon (1983) as

reflection-in-action - interpreting information during the event and the affect of the

leamer's participation in the event. Reflection before an event allows the leamer to focus

on the context of the event, to activate prior leaming that is perceived to be associated

21

with the event, and to focus on the leaming sfrategies needed to acquire knowledge from

the event (Boud, 2001).

In PBL, computer-based tools have been used in a limited way for reflection -

through documentation of the process. The initial presentation of the clinical problem is

followed by the generation of clinical concepts or leaming issues that need to be

considered for that particular clinical presentation (Mooney, Bligh, Leinster, & Warenius,

1995; Ohles & Maritz, 1998; Rendas et al., 1999; Wrosch & Morgan, 1998). In some

cases these lists were elicited and stored in a notepad provided by a computer interface

(Mooney et al., 1995; Rendas et al., 1999).

Hypotheses are generated from the initial patient encounter (Rendas et al., 1999;

Schor et al., 1995) and can be documented using computer software. As fiirther

information is presented or located, the student integrates the new knowledge with prior

knowledge and the hypotheses may be modified and saved using a computer interface. In

this way, the evolution of the hypotheses generation and modification is documented

(Rendas etal., 1999).

The initial clinical presentation activates prior knowledge (cognitive tool) while

also helping the students to identify areas where they have a gap in knowledge

(metacognitive tool). In allied health and nursing, web-based search engines for the

World Wide Web (AltaVista, Yahoo, etc.) and web-based search engines for library

databases (First Search, ERIC, etc.) are used to locate the pertinent information

(Niederhauser, Bigley, & Hale, 1999; Ohles & Maritz, 1998). In all health sciences,

especially medicine, web-based search engmes for biomedical databases (MEDLINE,

22

MD Consult, etc.) are used to locate the information needed to 'fill-in the gaps' in the

student's knowledge (Mooney et al., 1995; Rendas et al., 1999; Schor et al., 1995;

Wrosch & Morgan, 1998).

The use of different technologies as higher-order-thinking tools in health science

education has been accomplished using problem-based leaming. PBL utilizes a

constmctivist approach to leaming by actively involving the student in information

gathermg and problem solving. Problem-based leaming involves the use or creation of

clmical cases to promote the leaming of particular concepts that are targeted to leamer's

level of study (Wofford & Wofford, 1997). Higher-order thinking is used when

technology helps students employ concept maps, simulations, and reflection in clinical

problem-solving scenarios.

Summary

This chapter provided an overview of the research in medical education

conceming the development of a broad, integrated knowledge base and the application of

this knowledge in a clinical setting. The review of the literature presented two main

instmctional models, conventional lecture-based instmction and problem-based leaming,

and their limitations. Conventional lecture-based instmction has limited effectiveness

because students are passive recipients of information rather than actively engagmg

information. Students in a PBL curriculum engage in meaningfiil leaming that enables

the student to better understand the material. However, a potential disadvantage in PBL

23

is the development of a narrow knowledge base that is applicable only to the clinical

situations studied.

This chapter continued with a discussion of the research on the medical diagnostic

decision process and related the process to two cognitive theories, information processing

theory and schema theory. The chapter ended by discussing the use of cognitive and

metacognitive tools in healthcare education.

24

CHAPTER III

METHODOLOGY

Infroduction

This quasi-experimental study examined the effect of the use of a web-based

metacognitive tool on the development of leaming sfrategies and changes in motivation

associated with the diagnostic reasoning process. This chapter describes the methodology

that was used in this study including the web-based tool design, independent and

dependent variables, population and sample selection, the research design and treatments,

instmments and the statistical analysis of the data.

Web-Based Tool Design

The web-based metacognitive tool prompted students to reflect on prior leaming

objectives and document their relationship to a particular clinical situation. This

metacognitive tool is a component of a Student Portfolio System. The concepttial design

of the portfolio system and its relationship to other curricular systems is illusttated in

Figure 3.1. For the purposes of this study, the Sttident Information Systems component

was simulated to protect the integrity of the data within this critical system.

The basic design of the web-based tool relied on the integration of a Student

Portfolio System with a Sttident Information System. The integration of these systems

provided the sttident with the appropriate web-based interface depending upon the group

(direct insttiiction or problem-based reflection) to which the sttident was assigned. The

25

web-based interface presented the sttident with problem-centered reflection exercises and

peer evaluation of the reflections (feedback) or direct instiiiction ttitorials with computer-

based feedback. In both groups, the content of the insttoiction was held constant by using

the same set of objectives while the delivery of the insttuction was varied.

Student Information System • Student Identification • Group status

•Control • Treatment

Student Portfolio System • Control Group

• Direct instmction tutorials • Computer-based feedback

• Treatment Group • Reflection on Knowledge Stmcture •Peer evaluation of reflections (feedback)

Figure 3.1. Curricular Systems Integration.

The two systems are basically information systems that store their information in a

relational database. The Student Portfolio System was constmcted using a Microsoft

SQL database (http://www.microsoft.com). The Student Information System at the

institution is a proprietary database from SCT Corporation (http://www.sct.com).

However, the Student Information System was simulated using Microsoft SQL in this

26

http://www.microsoft.com

http://www.sct.com

study in order to protect the anonymity of the participants and to protect the mtegrity of

the data in the institution's student information system.

The Student Portfolio System integrated with the Student Information System to

identify and authenticate students through a web-based interface. The Student

Information System was also used to validate the participants' status withm the study.

The status of the participant was classified as either a member of the direct instmction or

problem-centered reflection group. At the beginning of the study, each participant used a

web-based interface to the Student Information System to register for the study. As each

participant registered, the Student Information System sequentially placed the participant

into either the direct instmction or problem-centered reflection group.

The student's stams and the current date were used to determine the appropriate

instmctional delivery. The web-based interface for the treatment group provided the

student with a clinical vignette and related course objectives, and the opportunity to

reflect on the stmcture of knowledge associated with the vignette. Students within the

problem-centered reflection group also evaluated the reflections of other students. The

direct instmction group was presented with tutorials with computer-based feedback.

The Student Portfolio System recorded the fracking information for both groups.

All evaluation insttiiments were web-based and the answers for each student were stored

in the Sttident Portfolio System. The times spent on each reflection or direct instmction

exercise was recorded in the sttident portfolio system. The layout and relationships of the

SQL tables in the Sttident Information, Curriculum Management, and Sttident Portfolio

Systems are presented in Figure 3.2.

27

Miulciil liitiinii.iluin

S\slt"in

S l i i i l c i i l I N ' i l t ' i i l i o S \ • .Ki l l

Figure 3.2. Layout and Relationships of the SQL Tables in the Student Information, Curriculum Management, and Student Portfolio Systems.

Variables

The independent variable was the instmctional method which had two levels in

this study: problem-centered reflection and direct instmction. The dependent variables

were the leammg sfrategies and motivation scales that were used as a measure of

diagnostic reasoning, the score on the achievement examination, the tune needed to

complete each question in the achievement examination, and the score on the essay

component of the achievement exammation. The content of the mstmction in both groups

28

was held constant by using the same set of objectives while the delivery of the instmction

was varied.

Population. Sample, and Participant Characteristics

The population in this study was first-year medical students who were enrolled in

a fraditional medical education curriculum. The sample chosen for this study was a non-

random cluster sample of at a School of Medicine in a large public university in the

Southwestem United States. A cluster sample is a group of participants that is formed by

selecting naturally occurring groups. The non-random cluster sample contained 130 first-

year medical students with an average age of 23 (Table 3.1). This sample was 40%

female, 68% Caucasian, and 94% Texas residents (Table 3.2).

29

Table 3.1: Sample by Age.

Age

20

21

22

23

24

25

26

27

28

29

30

Over 30

Total

Frequency

7

6

39

16

23

15

7

4

3

3

2

5

130

Percent

5.38

4.61

30.00

12.31

17.69

11.54

5.38

3.08

2.31

2.31

1.54

3.85

100.00

30

Table 3.2: Sample Demographics.

Value Frequency Percent

Gender

Female

Male

Ethnicity

Caucasian

Minority

Residency

Texas

Other

52

78

88

42

122

40.00

60.00

67.69

32.31

93.85

6.15

An application was submitted to the Institutional Review Board for the use of

human subjects in this sttidy. The application was approved and this sttidy was conducted

under the IRB Protocol #02222. Participants were recmited by direct person-to-person

contact through three visits to the Gross Anatomy classroom prior to the start of the sttidy.

During these visits, a franscript was used to recmit the participants (Appendix F). As an

incentive to motivate participation, the web-based examination contained questions that

similar in style and difficulty to those seen on the block examination for the Gross were

Anatomy course.

The recmitinent franscript was used to begin an organizational meeting that

occurred before the beginning of the sttidy. Risks and benefits of the sttidy were

31

discussed in this organizational meeting and the participants were asked to complete the

consent form and to ask any questions they may have conceming the study. The consent

form was completed by the participant before the participant was allowed to register for

the study.

Eighty-six undergraduate medical students enrolled in the Human Gross Anatomy

course attended the organizational meeting and registered for the study. Demographic

data were collected and participants were sequentially assigned to either the direct

instmction or problem-centered reflection group during the regisfration process.

Participation in the study was voluntary and was not required as part of the anatomy

course. The study was conducted for two weeks in the middle of a five week block of

first-year medical school classes. The study ended one week prior to major block

examinations in Gross Anatomy, Biochemistry, and Histology. As the study progressed

and the block examinations approached, the number of participants in the study

decreased. Five of the participants completed ahnost all aspects of the study including the

achievement examination. However, these five participants did not complete the final

questionnaire and were elunmated from the study. Fiffy-one participants completed the

entire study and were included in the subsequent statistical analyses.

The direct instmction group contained 30 participants with an average age of 24

(Table 3.3). Participants in the direct insttaiction group were 33% female, 73%

Caucasian, and 93% Texas residents (Table 3.4).

32

Table 3.3: Direct Instmction Participants by Age.

Age Frequency Percent

21

22

23

24

25

27

28

30

Over 30

Total

1

9

6

4

5

1

2

1

1

30

3.33

30

20

13.34

16.67

3.33

6.67

3.33

3.33

100.00

33

Table 3.4: Direct Instmction Demographics.


Gender

Female

Male

Ethnicity

Caucasian

Minority

Residency

Texas

Other

10

20

22

8

28

2

33.33

66.67

73.33

26.67

93.33

6.67

The problem-centered reflection group contained 21 participants with an average

age of 23 (Table 3.5). Participants in the problem-centered reflection group were 38%

female, 62% Caucasian, and 95% Texas residents (Table 3.6).

34

Table 3.5: Problem-Centered Reflection Participants by Age.

Age Frequency Percent

20 i 4.76

21 1 4.76

22 7 33.34

23 4 19.05

24 5 23.81

25 2 9.52

30 1 4.76

Total 21 100.00

35

Table 3.6: Problem-Centered Reflection Demographics.


Gender

Female

Male

Ethnicity

Caucasian

Minority

Residency

Texas

Other

8

13

13

8

20

1

38.10

61.90

61.90

38.10

95.24

4.76

Design and Treatments

The purpose of this study was to examine the effect of the use of a web-based

metacognitive tool on medical students' diagnostic skills development. In order to

examine this effect, the direct instmction group accessed the web-based tutorial while the

problem-centered reflection group accessed the web-based metacognitive tool. The

participants in both groups were asked to complete the Motivated Sfrategies for Leaming

Questionnaire with 81 items at the begmning and end of the study. The questionnaire

rated the participants' study habits, leammg skills, and motivation in the gross anatomy

course and the web-based exercises. After completing the mitial questionnaire, the

participants accessed the appropriate web-based leaming activities for approximately one

36

hour each day, Monday through Friday, for two weeks. Participants accessed the web-

based leaming activities through the web from home or school. This time period

corresponded with the Upper Exfremity Unit in Gross Anatomy. During this study, all

participants were also enrolled in the gross anatomy course. The web-based exercises

were designed such that the content was presented in lecture one to two days prior to the

web-based exercise. Therefore, the web-based exercises enhanced the leammg of the

content through practice for the direct instmction group and reflection for the problem-

centered reflection group. At the end of the unit, the participants completed a web-based

achievement examination covering the upper exfremity objectives used in this study.

Access to each web page was fracked using a curriculum management system that

was developed using Microsoft SQL (Figure 3.2). The curriculum management system

imposed gating mles that ensured that each participant viewed each page in a session

before being allowed to progress to the next page in the session. Participants were also

required to complete one session before progressing to another. In this way, progression

through the study was regulated and no part of the study could be skipped. The

curriculum management system fracked and identified the participants that completed the

entire study.

The direct instmction group accessed web-based tutorials with programmed

practice and feedback. Both freattnent groups were presented with the objectives for the

exercise when they logged in for the session (Figure 3.3). The objectives for one exercise

and the content (Figure 3.4) and practice (Figure 3.5) for these objectives were divided

into two sessions on two consecutive days.

37

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M e w i n g Radiological Images

1 L,itet!ig::-iav: •:• Tl-ierule: are arth.-uc. m>: • •n.-i:teut md .-••n.etirije; cTifu.-ing, but the ::-i.r; is labelel u, the liieiti^i m

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.Approaching Cross Sectional Images

When first p.irounteiing a cross sertional iriiaze, wliether a radaverir sperilnen oi a CT srai.. orienting

yoursplf to rlip iniagp will ronsist of thp foUowing steps:

EBB

10':

Figure 3.3. Objectives Presented at the Beginning of the Session.

38

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Part l : P a g e 6 o r i i

Objective: Describe the muscles tliat attach tlie scapula to the spine and their actions and nerse supply.

m

Move mouse over image to display labels.

Cross Section of tlie Shoulder:

Henbfy the following structure; in the cr.jss section above

Muscles that attach the Scapula to the spine.

MUSCLE

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i

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FUNCTION

elevates, dep.resses & retracts scapula

addnrts eYtflnds A" mediallv

INNERVATION

sf'inal accessc.ry C 3,4 ventral rami

thorarftdorsal f or midclle

Figure 3.4. Content Delivery During Session.

a

39

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Objective: Describe the muscles that attach the scapula to the spine and their actions and

ner\ e supply.

M 2 3

Move mouse os'er image lo display labels.

Cross Section of the Shoulder:

I'ientify the following strucpjie; m thie cross section above

Muscles that attach the Scapida to the spine.

M U S C L E

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' Tjiti<;ciTniw /ior-n

F U N C T I O N

elevates. .Jep.resses & retracts

scapula

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I N N E R V A T I O N

sf.inal accessory

C 3,4 ventral ranru

1 AoraroHorsal (CT micl.^Je

Figure 3.5. Content Delivery Followed by Practice. Moving the mouse over the image displays the labels.

The feedback consisted of muhiple choice rote memory and clinical vignette

questions that corresponded to the objectives of that session. As the participant chose a

muhiple-choice response, a pop-up window indicated whether the selection was correct

40

or incorrect (Figure 3.6). The curriculum management system ensured that the participant

viewed the page; however, the selection of the practice muhiple choice answers was not

tracked. The only requirement or gating rules unposed by the curriculum management

system for the direct instruction group was to view each page in the session or exercise.

The problem-centered reflection group accessed the same tutorial content (Figure

3.4) and practice (Figure 3.5). However, the content, practice, and problem-centered

reflection for all the objectives for the exercise were delivered in one session.

41

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Part 1: Page 12 of U

Practice Questions

Identify the lat.ele.J structure

^m Trapeaus

^m Fiiornboi'i major

^ R FJiomboid minor

^g} LevatC'r scapulae

Neid Page

Figure 3.6. Formative Feedback when Selecting an Answer. In this case the trapezius muscle is indicated by the red line and selectmg trapezius from the items list causes a window to appear indicating a correct answer.

The problem centered reflection portion of the session consisted of a clinical

scenario and questions related to the objectives of the session that guided the participant

through the diagnostic reasoning process (Figure 3.7).

42

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Clinical Correlation

Page 10 of 12

A 21-year-old collegiate swimmer, went to visit her .ioctor because of shoulder pam and a re.iuced range of motion in the shoulder joint ' Jn eKaminatic.n. tfie athlete was able tc. achieve about U'5'*' of shoiilder fleiaori/elevation. v/ith pain near the end of that range I'linng ab.iucti.:.n, pain was demonstrated between about 70° and 120°. after which the patient did not feel p-am Shoulder abduction against resistance yielded pain only d'inng the first 35° of movemerit All o&er resisted movements were pain-free Palpation c-f the shoulder only pro.iuced pain on the superior surface of ttie greater tubercle of the hianerus P're^siore at this locati-^n also produced pairi that ra-iiated do.'ATi the lateral side of tire student's arm

\Miat muscles participate in the movements of the shoulder described above? What nerves innervate these muscles?

I NertPage

Figure 3.7. Problem-Centered Reflection at the End of a Session. The students are prompted to reflect on the objectives of the session. The prompts are basically the objectives restated as questions.

Three questions were presented along with the clinical scenario on three separate

web pages. These questions guided the participant to identify relevant data, organize and

43

nest data, and integrate prior knowledge with these data to diagnose the patient in the

clinical scenario.

The curriculum management system ensured that the participant viewed teach

page in the content and practice portion of the session. The curriculum management

system imposed a requirement or gating rule during this session for the problem-centered

reflection group to prevent a participant from moving from one reflection question to

another without typmg in a reflection. Participants had to enter at least 250 characters

into the text area before they could progress to the next reflection question.

During the second session, the problem-centered reflection group evaluated the

reflection of another member of the problem-centered reflection group (Figure 3.8). The

curriculum management system imposed a gating rule during the second session that

required the peer reviewer to enter at least 250 characters into the text area before they

could proceed.

Since a participant could not progress from the peer review to the next session

until another participant had peer reviewed their reflection, the curriculum management

system had to be monitored. The assignment of a reflection to a peer reviewer would be

modified by the researcher so that participants were not hindered from progressing

because of the self-removal from the study of one of the participants.

44

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Peer Re\iev»t

A 21-year-old collegiate swimmer, went to visit her doctor because of shoulder pain and a re.iuced range of motion m the shoulder joint On eKanriinabon, the atl-Jete was able to achieve about 165° t.f shoul'ier fleaon/elevation, with pain near the end of that range T'lmng ab.iuction. pam was demonstrated between about 70° and 120°. after whch the patient .id not feel pain Shoul.ier abduction against resistance yielded pain only during the first 35° of movement All otiier resisted movements were pam-free Palpation of the shoulder only produced pam on the supenor surface of the greater tubercle of the humerus Presswe at this location also produced pam that radiated down the lateral side of the student's arm

What muscles participate in the movements of the shoulder described above?

UTiat nerves iniierv ale these muscles' '

r>eltiod-Axialary n (C5.C6) Ant Portion of C5. Me.iaL'Lat Portion of C5.C6 Latissmus Dorsi-Th:.radorsal n (C5, C6) Levator Scapulae-dorsal subscapular n (C5). Ventral Rami (C3.C4) Trapeaus-Accessory n (CN XI), Ventral Rami of (C3.C4) Teres Minor-Axialaiy a (C5,C6) Teres Major-''?7

When the arm was abducted without resistance, pain was felt between "0 and UO" of abduction; however , abduction aeainst resistance produced pain only duruia-

Write a brief revie^v of the answers given to the quesrions above. Vou ran use your notes or textbooks to verify the ans^^•ers. Hease site your resource so that the person wlio wrote the ononal answer wiU kno^v where to Tmd the information. Use constructive and positive comments!

r

ngure3 8 Peer Review of Another Participant's Reflection. The other participant's reflection is presented in the scrolling text area. A text area at the bottom of the page is where the student would evaluate the other participant's reflection.

At the beginning of the next session, the participant reviewed the peer evaluation

of their reflection (Figure 3.9). The curriculum management system only required the

45

participant to view this page before continuing. This process was repeated three times for

each section of the upper extremity (shoulder, arm, and forearm and wrist).

3 Axilla a Arm Microsoft hiterncl Explorer

He Ed* Vtew Favortes Tools Help ^

O ^ ' O B i ^ ^ l l /-search j , . j-Favcrtes |j[>Mcd» ^

^ 1 h^^p I'/L-..-Jh.^c^l'^v.•..-J•l).^s. f M ^ i n f i » . « 4 i > r f F .(iflf-HTn .^cp tO':

Avilla & Arm

Peer Review of Your Answers to Exerdse 2:

A 1'1-year-old collegiate swimmer, went t.j visit her doctor because of shoulder pain and a re.Juced range of moti. n in the shoulder joint Cin examination, tfie athlete was able to achieve about 165°of shoulder fleaon/elevahon, v/ith pain near the en.l of that range During ab.lucti.on, pam was .Jem.^nstrate.i between about 70° and 120". after which the patient did not feel pain Shoul.Jer ab.Juctj.>n against resistance yielded pain only during Ae first 35° of movement All other resisted movements were pain-free Palpati.jn of the shoulder .jnly pro.duced pain on the supenor surface o.f the greater tubercle of the humerus Pressiire at this location also pro.Juced pain tfiat radiated .icwn the lateral si.de of the stU'dent's arm

Wliat muscles participate in the movements of the shoulder descnbed above' '9/hat nerves mnen'ate ' these muscles' Deltiod m -innervated by aaallary n (Ant C5, and Med/Lat C5.C6) Supraspinatus m -innervated by suprascapular n (C5.Cf.) L I M i i i l i i ^ l g B T O ' ^ e n the ama was ab'ducte.J with.jut resistance, pain was felt between 70° and VJi" of at..-tucti.;.n. however, abduction against resistance pro.duced pam .-..nly during the first 35° How wc.uld you e;:plam this' I wojd explam tfus by subacromial bursitis The mflanamation and calcification of the subacromial bursa causes artculah.jn -.vitfi the coracoacromial ligament, thereby causing pressure upon the lateral portion of the supraspinatus muscle Subacromial t-ursitis is charactenzed by pam m al:..iuction fi^om 50 to 130 degrees »*Moore's 698 Ezf.lam tfie ra.diation of pain down the patient's arm' Ttie lateral porti.:.n of the supraspinatus muscle is pnmanly irmenfated by the sixtti cenacal ner.;e Tfie sixtfi cemcal nerve also innervates the lateral cutaneous p.- rtion of the arm Therefore the pam tKpenenced m the lateral supraspmatus muscle as a result of subacromial bursitis, is refered throughout the sixth cervical

Ne»i Page

Figure 3.9. Review of the Peer Evaluation of the Participant's Reflection.

This study examined the effects of problem-centered reflection on achievement,

depth of leaming, reflection time durmg examinations, and structure and complexity of

46

http://si.de

leamed knowledge. Achievement and depth of leaming assessed the reliance on rote

memorization or the use of integrated knowledge. The reflection time during

exammations measured, m milliseconds, the amount of time needed to reflect on and

answer each question in the achievement examination. The integration of knowledge was

assessed by using an essay question to elicit the stmcture and complexity of the

knowledge the student had leamed.

Diagnostic reasonmg was assessed through six scales of the Motivated Strategies

for Leammg Questionnaire. Two scales were measured from the motivation portion of

the questionnaire (intrmsic and extrinsic goal orientation), and four scales from the

leaming strategies portion of the questionnaire (critical thinking, metacognitive self-

regulation, elaboration, and organization). Table 3.7 illustrates the experimental design.

Table 3.7: Experimental Design

Assignment Pre Test Groups Post Tests

SA O PCR O, Oi, O2,03

SA O DI 0 ,0 , , 02,03

SA - Participants were sequentially assigned to the groups as they registered online PCR - Indicates the problem-centered reflection group DI - Indicates the direct instmction group O - Motivated Strategies for Leammg Questionnaire as a pre and post test Oi - 20 Item achievement test 02 - Average time needed to answer individual questions on the achievement test 03 - Stmcture and complexity of knowledge measured by an essay question

47

Instmments

At the begmning of the study, participants were asked to read and sign a consent

form and to complete a demographic questionnaire (Appendix A). The resuhs from the

demographic questionnaire were compared to the demographics of the participants in

order to verify that the participants were representative of the sample.

Motivated Strategies for Leaming Questionnaire

The Motivated Strategies for Leammg Questionnaire (MSLQ) is a self-report

mstmment designed to measure motivational orientations and leaming strategy use of

college students (Pintrich et al., 1991). The MSLQ consists of 15 scales that can be used

singly or together (McManus, 2000). The fifteen scales are intrinsic motivation, extrinsic

motivation, task evaluation, control of leaming beliefs, self efficacy, test anxiety,

rehearsal strategies, elaboration strategies, critical thinking, metacognitive self-regulation,

tune and study environment, effort regulation, peer leaming, and help seeking.

The Motivated Strategies for Leaming Questionnahe consists of 81 hems on a

seven-point Likert scale. There are two sections to the Motivated Strategies for Leaming

Questionnau-e, a motivation section, and a leammg strategies section. The motivation

section consists of 31 items. These items assess three areas associated with motivation:

(1) students' goals and value beliefs for a course, (2) their beliefs about their skill to

succeed in a course, and (3) their anxiety about tests m a course. The leaming strategy

section mcludes 31 items regarding students' use of different cognitive and metacognitive

strategies, and 19 items concemmg student management of different resources.

48

The Motivated Sfrategies for Leaming Questionnau-e has also received broad

acceptance and use by other researchers. Pintrich and Smith (1993) and McClendon

(1996) demonstrated that the Motivated Strategies for Leaming Questionnaire is a valid

instrument. Self-efficacy and leammg strategies have been found to be associated with

academic performance (Chye, Walker, & Smith, 1997; Barker & Olson, 1999). Barker

and Olson (1999) have recently found that the motivational factors and self-efficacy

exammed by the Motivated Strategies for Leaming Questionnafre are the test items that

best correlate with first-year medical student success (GPAs). The Cronbach alphas, a

measure of intemal consistency for the fifteen scales, were documented by Pintrich et al.

(1991) from a group of Midwestem undergraduate students and by Barker and Olson

(1999) for a group of first-year medical students (Table 3.8).

49

Table 3.8: Cronbach Alpha's for MSLQ Scales

Scale Undergraduate Students Pintrich etal.( 1991)

First-Year Medical Students Barker and Olson (1999)

Intrinsic Motivation

Extrinsic Motivation

Elaboration Strategies

Organization Strategies

Critical Thinking

Metacognitive Reflection

.74

.62

.76

.64

.80

.79

.72

.71

.75

.70

.83

.78

(Barker & Olson, 1999)

Multiple-Choice Achievement Examination

In this study, achievement was measured through the use of a muhiple choice

examination containing nme rote memory and ten clinical vignette questions. The

twentieth question was an open-ended essay question based on a clinical vignette

(Appendix D). These questions are derived from the set of objectives (Appendix C) that

were used to ensure the consistency of content in both the direct mstmction and problem-

centered reflection groups. The multiple choice questions used in the web-based

exercises for the du-ect mstmction group, the clinical vignette reflection question for the

problem-based reflection group, and the muhiple choice and essay questions on the

achievement exammation were all developed from the objectives. This ensured that all

50

questions throughout the study were relevant to the material covered in the content and

practice portions of the study.

The web-based achievement examination was administered in a computer

laboratory at the university. Access to the web-based examination was restricted to the

computer laboratory and could not be accessed outside of that room. The examination

was proctored by the researcher and the university computer laboratory staff (3 total

proctors) and a one hour time limit to complete the exammation was imposed.

Statistical Analysis

Statistical analysis of the effects of problem-centered reflection on achievement,

depth of leaming, reflection time during examinations, stmcture and complexity of

leamed knowledge, and the development of leaming strategies and motivation associated

with diagnostic reasoning skills, included:

1. Descriptive statistics such as the mean and standard error, and

2. Analysis of variance to determine differences between means.

The data was analyzed using the Statistical Package for the Social Sciences (SPSS) for

Windows version 10.0. An alpha level of 0.05 was used through the analyses as a level

of significance (alpha levels greater than 0.05 but less than 0.10 were considered

marginally significant).

51

Measuring the Effects of Problem-Centered Reflerfioti

The effects of problem-centered reflection on the development of leaming

strategies were measured by comparmg the following indicators of leaming with the

direct instmction group:

1. Achievement on a multiple choice exam that covers the objectives presented

in the exercises,

2. The depth of leaming through rote memorization and clinical vignette multiple

choice questions,

3. The tune, m milliseconds, required to answer rote memory versus clinical

vignette muhiple choice questions, and

4. The stmcture and complexity of leamed knowledge conveyed in a clmical

vignette essay question.

Achievement

Medical students have survived the highly selective admission process, and

accordmg to Norman and Schmidt (2000), these students are "a highly selected and

atypical group." Medical students have demonstrated the ability to succeed in various

achievement examinations including the MCAT. Most comparisons of medical school

curricula have been based on USMLE examinations and have found little or no

significant difference in performance (Way, Hudson, & Biagi, 2000; Colliver, 2000).

In this study, achievement was measured through the use of a muhiple choice

examination containing rote memory and clmical vignette questions (Appendix D).

52

These questions are derived from the set of objectives (Appendix C) that were used to

ensure the consistency of content m both the direct mstmction and problem-centered

reflection groups. The achievement scores for each group were analyzed to determme if

there is a difference m achievement when using problem-centered reflection as compared

to direct mstmction.

Depth of Leaming

Since medical students are a highly selected group and have demonstrated their

ability to succeed in other studies (Norman & Schmidt, 2000; Cronbach & Snow, 1977),

achievement was analyzed according to the depth of leaming that may be used m direct

instmction and problem-centered reflection. In comparing the two modes of instmction,

direct instmction is a more passive leaming environment than the problem-centered

reflection envfronment. Therefore, accordmg to Nu et al. (1998), passive leaming leads

to a "surface" approach to leammg by relymg on rote memorization, while active leaming

leads to a "deep," more integrative approach to leaming. The reliance on rote

memorization or the use of an integrative approach to leammg was measured by

comparing achievement on rote memory versus clinical vignette muhiple choice questions

in both groups.

53

The Use of Reflection tune During Examinations

The use of problem-centered reflection was measured by recording, in

milliseconds, the amount of time needed to answer each question. The students using

problem-centered reflection may take longer to answer the clinical vignette questions by

reflectmg on the prior knowledge associated with the clmical problem. The time needed

to answer each rote memory and clinical vignette question by subjects in the two groups

was tracked by the curriculum management system and measured to determine the use of

reflection time in examinations.

Stmcture and Complexity of Leamed Knowledge

Students were asked to answer an essay question at the end of the study that

incorporated the concepts of several objectives through out the entire web-based study.

An open-codmg process was performed on three randomly selected essays to look for

pattems described in Table 3.9.

Table 3.9: Three Levels of Knowledge Stmcture and Complexity

Level Example Statement

Declarative Muscle A is innervated by Nerve B.

Integrative Muscle A, like all flexors of the forearm, is innervated by Nerve B, a branch of the Brachial plexus.

Relational Vessel A and Nerve B travel within the Groove m Bone C and are in danger of mjury as a result of a fracture of Bone C possibly leading to defichs in the action of Muscle D.

54

A codmg scheme was developed to measure the stmcture and complexity of

leamed knowledge in the essays. The researcher and subject matter expert discussed the

coding scheme and agreed that each statement, phase, or element of a list would be coded

as declarative, integrative, or relational. The codmg scheme was used by the researcher

and another subject matter expert to obtam two independent analyses of the different

levels of complexity in each of the 51 essays. Examples of each rater's coding applied to

three of the essays are mcluded in Appendix E.

The quantities in each level were tallied in all essays for each rater and the inter-

rater reliability of the codmg was calculated. Each level of complexity in the dhect

mstmction group was compared to the level in the problem-centered reflection group to

determine if the stmcture and complexity of leamed knowledge increased with problem-

centered reflection. The essay question is included at the end of the achievement test in

Appendix B.

Measuring the Development of Leammg Strategies and the Changes in Motivation

The development of leammg strategies and the changes in motivation that are

associated with the diagnostic reasoning process was assessed through six scales of the

Motivated Strategies for Leaming Questionnaire (MSLQ). Two scales were measured

from the motivation portion of the questionnaire (intrinsic and extrinsic goal orientation),

and four scales from the leaming strategies portion of the questionnaire (critical thinking,

metacognitive self-regulation, elaboration, and organization). At the beginning of the

55

study and the end of the study, each group completed the MSLQ. As a measure of

mtemal consistency, the Cronbach alphas for the sbc scales were calculated and compared

to those documented by Pmtrich et al. (1991) and Barker and Olson (1999).

The mstmctions for each section of the MSLQ were modified to produce two

fonns of the questionnaire. Form A was modified to reflect the use of this instmment for

the Gross Anatomy course and was used at the begmning of the study. The instmctions

and questions for each section of Form B were modified to focus the students on the

leaming strategies and motivation used during the web-based exercises m the study.

Form A and Form B can be found in Appendix A.

The scores for each group from each of the six scales at the end of the study will

be compared using an analysis of variance to the scores at the beginnmg of the study.

These comparisons evaluated the effect of the use of this web-based metacognitive tool

on medical student development of leammg strategies and the changes in motivation that

are associated with the diagnostic reasoning process.

Summary

This chapter describes the methodology that was used in this study including the

web-based tool design, independent and dependent variables, population and sample

selection, the research design and treatments, instmments and the statistical analysis of

the data. The independent variable was the instmctional method which had two levels m

this study: problem-centered reflection and direct mstmction. The dependent variables

were the leaming strategies and motivation scales that were used as a measure of

56

diagnostic reasonmg, the score on the achievement examination, the time needed to

complete each question in the achievement examination, and the score on the essay

component of the achievement examination. This quasi-experimental study examined the

effect of the use of a web-based metacognhive tool on the development of leaming

strategies and changes in motivation associated with the diagnostic reasonmg process.

57

CHAPTER IV

RESULTS

Infroduction

The purpose of this study was to examme the effects of a web-based metacognitve

tool that promotes problem-centered reflection on the development of leammg strategies

and the changes in motivation that are associated with the diagnostic reasonmg process m

first-year medical students. This study compared the effects of problem-centered

reflection on achievement, depth of leaming, reflection time during examinations, and

stmcture and complexity of leamed knowledge. This chapter will describe the results of

the study.

Statistical Analyses

The effects of problem-centered reflection on the development of leaming

strategies were measured by comparing different indicators of leaming with the dkect

instmction group. The data analysis used the Statistical Package for the Social Sciences

(SPSS) for Windows version 10.0. An alpha level of 0.05 was used through the analyses

as a level of significance (alpha levels greater than 0.05 but less than 0.10 were

considered marginally significant).

58

Findmgs for Null Hypothesis 1

Null Hypothesis 1: Problem-centered reflection will not enhance leaming as measured by a multiple choice examination.

The percent correct on the muhiple choice portion of the examination was used as

the measure of achievement. The means and standard errors of the percent correct were

calculated for both groups (Table 4.1). The assumption of equal variances was

reasonable for these data (Folded F statistic F' = 1.53,p = 0.2903) and the pooled t test

was used to determine a difference in the means. There was no significant difference in

achievement between the direct instmction and problem-centered reflection groups {t -

0.03, df= 49,/7 = 0.9748). Therefore, the null hypothesis was not rejected.

Table 4.1: Description of Achievement by Groups

Standard Group N Mean Error t Value Pr > 111

Du-ect Instmction 30 62.28 230 003 0.9748

Problem-Centered Reflection 21 62.16 3.40

Findings for Null Hypothesis 2

Null Hypothesis 2: Problem-centered reflection will not contribute to the development of deep, integrated knowledge as measured by muhiple choice questions.

The muhiple choice examination contamed two types of questions: rote

memorization and clinical vignette questions. A two-way analysis of variance on

59

achievement by question type and treatment groups was conducted to determine a

difference in the means (Table 4.2).

Table 4.2: Two-Way Analysis of Variance between Treatment Groups and Question Type on Achievement

Source

Model

Treatment Group

Question Type

Interaction

Error

DF

3

1

1

1

21

Mean Square

449.7275

0.5931

6.5076

1342.0818

334.9730

F Value

1.34

0.00

0.02

4.01

Pr>F

0.2650

0.9665

0.8894

0.0481

There was a significant interaction between question type and treatment group (p

= 0.0481). Therefore, Bonferroni muhiple comparison tests using the least square means

for achievement by question type and treatment groups were calculated. In the direct

mstmction group, the achievement mean for the clinical vignette questions was not

significantly different from the mean for rote memory (p = 0.1333). In the problem-

centered reflection group, the achievement mean for the clinical vignette questions was

not significantly different from the mean for rote memory (/? = 0.1910). There was no

significant difference m the clmical vignette question means across treatment groups (p =

0.1347). There was also no significant difference m the rote memory question means

across treatment groups (p - 0.1910). No statistically significant differences were found

m the achievement means for the rote memorization and clmical vignette question types

60

between the direct instmction and problem-centered reflection groups. Therefore, the

null hypothesis was not rejected.

Findmgs for Null Hypothesis 3

Null Hypothesis 3: Problem-centered reflection will not result in an mcrease in the use of reflection to determine an answer during an examination.

The means and standard errors of the time needed to answer each question were

calculated for both groups (Table 4.3). The assumption of equal variances was

determined for each question and the appropriate t test was used to determine a difference

in the means. Questions 9 and 14 were found to be significant, and Question 3 was found

to be marginally significant m the time needed to answer the question between the direct

mstmction and problem-centered reflection group (Table 4.4),

61

Table 4.3: Description of Time Needed to Answer Question by Groups

Standard

Question Group N Mean Error

Question 1 (Rote Memory) Direct Instmction 30 96.306 13.855


Question 2 (Clinical Vignette) Direct Instmction 30 94.441 13.055


Question 3 (Rote Memory) Direct Instmction 30 20.434 2.119 Problem-Centered Reflection 21 33.414 6.557



Question 5 (Clmical Vignette) Dhect Instmction 30 67.512 9.464




Question 7 (Clmical Vignette) Dfrect Instmction 30 85.586 11.542


Question 8 (Clmical Vignette) Direct Instmction 30 55.964 8.907




62

Table 4.3: Continued.

Standard Question Group N Mean Error

Question 10 (Clinical Vignette) Dfrect Instmction 30 40.947 4.544












Question 16 (Rote Memory) Dkect Instmction 30 50.360 9.310






63

Table 4.3: Continued.

Question Group Standard

N Mean Error

Question 19 (Rote Memory) Direct Instmction 30 79.393

Problem-Centered Reflection 21 61.139

12.857

19.087

Table 4.4: t-Test between Treatment Groups on Time to Answer Question

Question Method DF t Value Pr > 11

Question 1 (Rote Memory)

Question 2 (Clinical Vignette)



Question 5 (Clmical Vignette)









Pooled t-test

Satterthwaite t-test



Pooled t-test

Pooled t-test


Pooled t-test


Pooled t-test

Pooled t-test


Pooled t-test

49

44.5

24.2

43.3

49

49

48.7

49

47.4

49

49

48.7

49

0.16

0.34

-1.88

1.50

0.06

0.04

-0.05

0.88

2.58

0.70

1.57

0.48

0.49

0.8708

0.7338

0.0717

0.1419

0.9516

0.9683

0.9601

0.3814

0.0129

0.4884

0.1217

0.6306

0.6256

64

Table 4.4: Contmued.

Question





Method DF t Value Pr > 11

Satterthwaite

Pooled t-test

t-test


Pooled t-test

Pooled t-test

Pooled t-test

36.8

49

46.8

49

49

49

2.51

1.16

0.90

1.26

0.28

0.82

0.0165

0.2513

0.3717

0.2120

0.7804

0.4137

Considering that the time needed to answer the majority of muhiple choice

questions was not significantly different between the two treatments, measuring the time

needed to reflect on an answer would be better measured using the essay question. The

time needed to answer the essay question was examined for both the problem-centered

reflection and direct instmction groups. The assumption of equal variances was

reasonable for these data (Folded F statistic F' = 1.95,;? = 0.1246) and the pooled t test

was used to determine a difference in the means. There was no signiflcant difference in

the tune needed to answer the essay question between the direct mstmction and problem-

centered reflection groups {t = 0.42, df= 49,/? = 0.6728). Therefore, the null hypothesis

was not rejected.

65

Fmdings for Null Hypothesis 4

Null Hypothesis 4: Problem-centered reflection will not increase the stmcture and complexity of leamed knowledge.

After examining three essays selected at random, the researcher and another

subject matter expert agreed to classify each statement in all 51 essays as declarative,

mtegrative, or relational. The inter-rater reliability of each type of statement was

calculated usmg Pearson correlation coefficients. The inter-rater reliability for declarative

statements was r = 0.95; for integrative statements r = 0.96; and for relational statements r

= 0.91. A muhivariate analysis of variance was calculated using treatment groups as

factors and the number of declarative, integrative, and relational statements as dependent

variables.

The results of the muhivariate analysis of variance indicated a significant effect of

essay statement types by group (Table 4.5).

Table 4.5: Multivariate Analysis of Essay Statement Types by Treatment Groups

Source DF MS F Value Sig!

Model 3798 2.898 0.039

Univariate Tests

Declarative 1, 100 3.322

Integrative 1, 100 16.001

Relational 1, 100 6.354

2.816

3.471

6.112

0.096

0.065

0.015

66

A marginally significant difference was found in the number of declarative (p =

0.096) and mtegrative (p = 0.065) statements m the essay between the direct mstmction

and problem-centered reflection groups. Statistically significant differences were found

m the number of relational statements in the essay between the direct instmction and

problem-centered reflection groups (p = 0.015). Therefore, the null hypothesis was

rejected. The means and standard errors of declarative, mtegrative, and relational

stmcture types were calculated for both groups (Table 4.6).

Table 4.6: Means and Standard Errors of Essay Statement Types by Treatment Groups.

Stmcture Type Group Mean Standard Error

Declarative

Integrative

Relational

Direct Instmction

Problem-Centered Reflection

Direct Instmction


Direct Instmction


2.30

2.67

1.77

2.57

0.52

1.02

0.17

0.12

0.30

0.28

0.13

0.17

67

Fmdings for Null Hypothesis 5

Null Hypothesis 5: The use of a problem-centered reflection tool will not enhance the development of leaming strategies and the changes in motivation in medical students as measured by the Motivated Sfrategies for Leaming Questionnaire (MSLQ) scales: intrmsic and extrmsic goal orientation, metacognitive self-regulation, critical-thinkmg, organization, and elaboration.

The Cronbach alphas for each of the sbc scales were calculated for both Form A

and Form B (Appendix B) of the Motivated Strategies Leammg Questionnafre as a

confirmatory factor analysis of the scale constmcts. Form A from the 51 participants that

completed the study was compared to Form B from the same 51 participants. Table 4.7

shows the Cronbach alphas from Form A and Form B for this study and those reported

for undergraduate students and medical students (Pmtrich et al., 1991; Barker & Olson,

1999). The organization strategies scale was not utilized in the rest of this study because

the low Cronbach alpha did not support the reliability of this constmct.

68

Table 4.7: Cronbach Alphas for Form A, Form B, and from the Literature.

Scale

Intrinsic Motivation



Organization Strategies

Critical Thinking

Metacognitive Self-Regulation

Form A

0.74

0.75

0.72

0.55

0.78

0.76

FormB

0.84

0.65

0.89

0.53

0.85

0.81

Pintrich et al., 1991

0.74

0.62

0.76

0.64

0.80

0.79

Barker and Olson, 1999

0.72

0.71

0.75

0.70

0.83

0.78

The means and standard errors of each scale for the pre and post tests were

calculated for both groups (Table 4.8 and Table 4.9). The organization strategies scale

was not utilized m the rest of this study because the low Cronbach alpha did not support

the reliability of this constmct.

69

Table 4.8: Description of Pre Test Scales by Groups

Scale Group Standard

N Mean Error Intrinsic Motivation



Critical Thinking

Direct Instmction 30 4.90


Direct Instmction 30



Problem-Centered Reflection 21



Metacognitive Self-Regulation Direct Instmction 30


0.17

0.22

4.92

5.18

5.04

5.17

3.66

4.28

4.66

5.00

0.26

0.21

0.16

0.23

0.22

0.23

0.11

0.22

70

Table 4.9: Description of Post Test Scales by Groups

Scale Group Standard

N Mean Error Intrinsic Motivation



Critical Thinking

Direct Insttaiction 30 4.41 0.19


Direct Instmction


Direct Instmction


Direct Instmction


Direct Instmction


30

21

30

21

30

21

30

21

4.43

4.88

4.26

4.55

3.97

4.32

4.08

4.27

0.23

0.23

0.18

0.31

0.16

0.32

0.12

0.20

A two-way analysis of variance on mtrinsic motivation by pre/post test and

tt-eatinent groups showed significant difference between pre/post test, and between direct

msttaiction and problem-centered reflection (Table 4.10). There was no significant

interaction between the pre/post test and treattnent groups.

71

Table 4.10: Analysis of Variance between Pre/Post Test and Treattnent Group for the Infrinsic Motivation Scale

Source DF Mean Square F Value Pr>F

Model 3 4.389 3.94 0.0107

Pre/Post Test 1 6.006 5.38 0.0224

Treatment Group 1 7.154 6.41 0.0129

Interaction 1 0.008 0.01 0.9332

Error 98 1.115

A two-way analysis of variance on extrinsic motivation by pre/post test and

treatment groups showed no significant difference (Table 4.11).

Table 4.11: Analysis of Variance between Pre/Post Test and Treatment Group for the Extrinsic Motivation Scale

Source

Model

Pre/Post Test

Treatment Group

Interaction

Error

DF

3

1

1

1

98

Mean Square

2.580

4.324

3.183

0.233

F Value

1.78

2.98

2.19

0.16

Pr>F

0.1566

0.0876

0.1419

0.6899

72

A two-way analysis of variance on elaboration by pre/post test and ti-eattnent

groups showed significant difference between pre/post test, and no significant difference

between direct insttuction and problem-centered reflection (Table 4.12). There was no

significant interaction between the pre/post test and tteatment groups.

Table 4.12: Analysis of Variance between Pre/Post Test and Treattnent Group for the Elaboration Scale

Source

Model

Pre/Post Test

Treatment Group

Interaction

Error

DF

3

1

1

1

98

Mean Square

4.753

13.061

1.032

0.167

F Value

4.19

11.52

0.91

0.15

P r > F

0.0078

0.0010

0.3425

0.7023

A two-way analysis of variance on critical thinking by pre/post test and treatment

groups showed no significant difference (Table 4.13). There was no significant

interaction between the pre/post test and tteatment groups.

73

Table 4.13: Analysis of Variance between Pre/Post Test and Treatment Group for the Critical Thinking Scale

Source DF Mean Square F Value Pr > F

Model 3 2.423 LST 0.1400

Pre/Post Test 1 1.060 0.82 0.3681

Treattnent Group 1 5.772 4.45 0.0375

Interaction 1 0.436 0.34 0.5633

Error 98

A two-way analysis of variance on metacognitive self-regulation by pre/post test

and tteatment groups showed significant difference between pre/post test, and a moderate

significant difference between direct instmction and problem-centered reflection (Table

4.14). There was no significant interaction between the pre/post test and tteatment

groups.

74

Table 4.14: Analysis of Variance between Pre/Post Test and Treatment Group for the Metacognitive Self-Regulation Scale

Source

Model

Pre/Post Test

Treatment Group

Interaction

Error

DF

3

1

1

1

98

Mean Square

4.121

10.462

1.770

0.131

F Value

6.84

17.37

2.94

0.22

Pr>F

0.0003

<0.0001

0.0896

0.6420

Overall there was a slight decline in inttinsic motivation and metacognitive self-

regulation when the scales are compared by groups or by pre/post tests. There was a

statistically significant decrease in the means of the elaboration scale when the scale is

compared by pre/post tests. No statistically significant differences in the means of the

extrinsic motivation and critical thinkmg scales when they are compared by groups or by

pre/post tests. The results of these tests do not provide any evidence to reject this null

hypothesis.

Siunmary

The first null hypothesis stated that problem-centered reflection will not enhance

leaming as measured by a multiple choice examination. The results of this study

indicated no significant difference in achievement between the dhect insttaiction and

problem-centered reflection groups. Therefore the first null hypothesis was not rejected.

75

The second null hypothesis stated that problem-centered reflection will not

contt-ibute to the development of deep, integrated knowledge as measured by muhiple

choice questions. Achievement as measured by rote memorization and clinical vignette

muhiple choice questions was also found to be not significantly different between the

direct msttoiction and problem-centered reflection groups. Consequently, the second null

hypothesis was not rejected.

The thu-d null hypothesis stated that problem-centered reflection will not result in

an mcrease m the use of reflection to determine an answer during an examination. The

tune needed to answer each of the multiple choice questions was compared for the two

tteattnent groups. The majority of multiple choice questions were not significantly

different between the two tteatments. There was no significant difference in the time

needed to answer the essay question between the dkect instmction and problem-centered

reflection groups. Therefore, the null hypothesis was not rejected.

The fourth null hypothesis stated that problem-centered reflection will not

increase the stmcture and complexity of leamed knowledge. The numbers of declarative

and integrated statements in the essays from problem-based reflection group was different

from those of the direct instmction group at a moderate level of significance. The number

of relational statements used to answer a clinical vignette essay question in the problem-

centered reflection group was significantly different from the direct instmction group.

The results of this study indicated that problem-centered reflection has an effect on the

stmcture and complexity of knowledge. Therefore, the null hypothesis was rejected.

76

The fifth null hypothesis stated that the use of a problem-centered reflection tool

will not enhance the development of leaming sfrategies and the changes in motivation in

medical students as measured by the Motivated Sfrategies for Leaming Questionnaire

(MSLQ) scales: infrinsic and extrinsic goal orientation, metacognhive self-regulation,

critical-thmking, organization, and elaboration. Measurmg the leammg sfrategies and

motivations associated with diagnostic reasoning resulted in a significant difference in

infrmsic motivation and metacognhive self-regulation when comparing the pre/post tests

and the two freatment groups. However, the means of these scales showed a declme in

intrinsic motivation and metacognitve self-regulation as they were compared between the

two freatment groups and between the pre/post tests. Therefore, the null hypothesis was

not rejected.

77

CHAPTER V

DISCUSSION, CONCLUSION, AND IMPLICATIONS

FOR FURTHER RESEARCH

Infroduction

The goal of this study was to examme problem-centered reflection and its effects

on the development of leammg sfrategies and changes m motivation that are related to the

diagnostic reasonmg process. In a conventional lecture-based curriculum, medical

sttadents are unable to mtegrate knowledge leamed in the basic science courses and apply

that knowledge to clinical situations mvolving diagnosis and tteatment of patients

(Gmppen, 1997; Bamett, 1995). In response to the medical sttidents' mability to integrate

and apply basic science knowledge m clinical situations, this study exammed the use of a

web-based tool to promote problem-centered reflection m order to enable the students to

develop the leammg sfrategies needed to mtegrate and apply knowledge in a clinical

settmg. The data presented m this study also provided mformation on the development of

leaming sfrategies in a hybrid instmctional envhonment consisting of lecture-based

instmction and online problem-centered reflection.

This study compared two modes of web-based delivery of instmction and their

effect on the development of leaming sfrategies associated with the diagnostic reasoning

process. The modes of instmction were direct instmction tutorials and problem-centered

reflection.

78

The population in this study was first-year medical students who were enrolled in

a fraditional medical education curriculum. The sample chosen for this study was a non-

random cluster sample of at a School of Medicme in a large public university in the

Southwestem United States that contained 130 fkst-year medical students with an

average age of 23 and was 40% female, 68% Caucasian, and 94% Texas residents (Table

4.1 and Table 4.2).

Fifty-one participants (30 in the direct mstmction group and 21 in the problem-

centered reflection group) completed the study and were included in the statistical

analyses. The demographics of the freatment group were similar to the demographics of

the cluster sample (Table 5.1)

79

Table 5.1: Description of Participants.

Value

Gender

Female

Male

Ethnicity

Caucasian

Minority

Residency

Texas

Other

Average Age

Cluster Sample

(%)

40

60

68

32

94

6

23

Direct Instmction Group

(%)

33

67

73

27

93

7

24

Discussion

Problem-centered Reflection Group

(%)

38

62

62

38

95

5

23

Null Hypothesis 1

Null hypothesis one indicated that problem-centered reflection would not enhance

leaming as measured by achievement in a multiple choice examination. No statistically

significant differences were found in overall achievement means between the direct

instmction and problem-centered reflection groups {t =0.03, df= 49,/? = 0.9748).

Therefore, the null hypothesis was not rejected. Figure 5.1 illusfrates the achievement

means and standard errors for both freatment groups.

80

100 r

Direct Instruction Problem-Centered Reflection

Treatment Groups

Figure 5.1: Achievement Means by Treatment Group.

Problem-centered reflection did not enhance leaming as measured by a muhiple-

choice achievement exammation. Most comparisons of the effects of instmctional

delivery methods in medical education have been based on performance on the USMLE

Step 1 examinations and have found little or no significant difference (Way et al., 2000;

Colliver, 2000). This study supports the findings reported by Way et al. (2000) and

Colliver (2000) in that no significant difference was found in the performance of the

participants in the two instmctional delivery methods when measuring the effect by

muhiple choice exammations. Both the dfrect mstmction group and the problem-centered

81

reflection group performed sunilarly on the achievement exam indicating that the

problem-centered reflection method was as effective in delivering content and feedback

to learners as the dkect mstmction method.

Null Hypothesis 2

Null hypothesis two stated that problem-centered reflection would not contribute

to the development of deep, integrated knowledge as measured by muhiple choice

questions. No statistically significant differences were found in the achievement means

for the rote memorization and clinical vignette questions type between the dkect

instmction and problem-centered reflection groups (Table 4.8). Therefore, the null

hypothesis was not rejected.

Neither dkect instmction nor problem-centered reflection enhanced performance

on specific multiple-choice question types (clinical vignette and rote memory questions).

The USMLE Step 1 examination is based on clinical vignettes with muhiple choice

answers (United States Medical Licensmg Examination, 2001). Norman and Schmidt

(2000) suggest that medical students are an atypical group that has demonsttated the

ability to succeed m lecture-based classes and standardized muhiple choice tests.

Accordmg to the USMLE, an enhanced performance on clinical vignette questions

would mdicate an mtegrated knowledge base and the ability to apply this knowledge m a

clmical situation (http://www.usmle.org). Prior experiences ki ttadhional didactic lectures

may contribute to the development of the participants' perception of themselves as fact-

leamers instead of problem-solvers (Biley, 1999). As fact-leamers, the participants may

82

http://www.usmle.org

be relying on rote memorization to answer all types of multiple choice questions. Nu et al.

(1998) suggested that a "surface" approach to leaming is employed when sttidents rely on

rote memorization. As fact-leamers usmg rote memorization, the participants m this sttidy

may have adopted a "surface" approach to leaming that leads to a superficial

understandmg of the material. A superficial understanding of course content may

conttibute to an incomplete integration of knowledge. The sttncture of the questions on

the achievement exam may not reflect an mtegration of knowledge and fiirther sttidy is

needed.

Null Hypothesis 3

Null hypothesis 3 stated that problem-centered reflection would not resuh in an

increase in the use of reflection to determine an answer during an examination. In this

portion of the study, tkne was used as a measure of the use of reflection. Time was

chosen as a possible measure of reflection based on Information Processmg and Schema

Theory. Information Processing Theory consists of conscious and unconscious

processing of information (Bermer et al., 1996; Greenwood, 2000). Bermer et al. (1996)

go on to state that the more knowledgeable or expert a person, the more that person

processes information unconsciously. The participants in the problem-centered reflection

group are novices in the problem-centered reflection process. As novices in problem-

centered reflection, the participants in the problem-centered reflection group would

reflect on the clinical vignette and process information consciously takmg more time in

answering the clinical vignette question as compared to the dkect instmction group.

83

Except for three of the nineteen muhiple choice questions, the time needed to

answer each of the muhiple choice questions was not significantly different between the

freatment groups. The time needed to reflect on an answer was also measured usmg the

essay question. No statistically significant differences were found in the time spent on

answermg the essay question between the dkect instmction and problem-centered

reflection groups. Therefore, the null hypothesis was not rejected.

The significant differences found with questions 9 and 14 and the marginal

significance with question 3 may be the result of a number of factors that would not be

related to reflection. These questions could be more difficult that the rest of the muhiple

choice questions. The questions could also requke the participant to choose the most

correct answer from a list that contakis answers with different degrees of correctness. In

this study, using time requked to answer a question as a measure of reflection may be

confounded by other factors. The fact that this study was not a requked element of the

Gross Anatomy course could also effect the time needed to answer a question. There were

no consequences of choosing an mcorrect answer for the participants. This may have

effected the tkne needed to answer a question by shortening the thought or reflection

process as the students chose an answer m order to move to the next question.

84

Null Hypothesis 4

The fourth null hypothesis stated that problem-centered reflection would not

mcrease the stmcture and complexity of leamed knowledge. A marginally significant

difference was foimd in the number of declarative and integrative statements in the essay

between the dkect mstmction and problem-centered reflection groups. A statistically

significant difference was found in the number of relational statements in the essay

between the dkect mstmction and problem-centered reflection groups. Therefore, the

null hypothesis was rejected. Problem-centered reflection increased the stmcture and

complexity of leamed knowledge. Figure 5.2 illusfrates the number of statements for

each classification for both freatment groups.

85

I I Direct Instruction

^M Problem-Centered Reflection

B it

a «

o « a s

Declarative Integrative

Statement Types

Relational

Figure 5.2: Essay Statement Types by Treatment Groups. A marginally significant difference (p < 0.10) was found in the number of declarative and integrative statements in the essay between the dkect instmction and problem-centered reflection groups. A statistically significant difference (p < 0.05) was found in the number of relational statements ki the essay between the dkect instmction and problem-centered reflection groups.

The stmcture and complexity of leamed knowledge measured by classifying the

statements made in response to a clinical situation can be related to the type of stmcture

and complexity of knowledge that is requked for the diagnostic reasoning process.

Elstem, Shuhnan, and Sprafka (1990) developed a model of the medical diagnostic

reasoning process based on Information Processing Theory that consists of four phases:

(1) data collection, (2) hypothesis generation, (3) cue interpretation, and (4) hypothesis

86

evaluation. As stated in Chapter 1, the diagnostic reasoning process consists of

identifymg relevant data (data collection), organizing and nesting data (hypothesis

generation and cue interpretation), and mtegratmg prior knowledge with the data to

diagnose the patient (cue mterpretation and hypothesis evaluation). In this study,

participants m the problem-centered reflection group were prompted to reflect on the

objectives presented in the session and relate the objectives to a clmical situation. By

promptmg the participants to relate the objectives presented m the session to a clinical

situation, the participants were usmg a reflective leammg sfrategy to simulate the

diagnostic reasonmg process. Bunkers (2000) stated that reflection after an event allows

the leamer to analyze and evaluate information gained from the event. In this study, the

event was the presentation of content during the session.

The progression of questions at the end of the session guided the participant

through a reflective process that mirrored the diagnostic reasonmg process. As the

questions were presented, the participants were guided ki identifying the relevant data in

the clmical situation and mtegratmg this data with the objectives presented in the session.

At the same time, the participants were asked to relate this leamed knowledge to the

clinical findings. As described by Boud et al. (1985), a reflective leaming sfrategy resuhs

m an organization of knowledge that could lead to new understandmgs. As a resuh of

problem-centered reflection, the mcreased numbers of mtegrative and relational

statements indicates an mcrease in the stmcture and complexity of leamed knowledge that

is related to the diagnostic reasoning process.

87

Null Hypothesis 5

Null hypothesis 5 states that the use of a problem-centered reflection tool will not

enhance the development of leaming sfrategies and the changes in motivation in medical

students as measured by the Motivated Sfrategies for Leaming Questionnake (MSLQ)

scales: mfrinsic and exfrmsic goal orientation, metacognitive self-regulation, critical-

thinking, organization, and elaboration. The Cronbach alphas for each of the six scales

were calculated for both Form A and Form B (Appendbc B) of the Motivated Sfrategies

Leammg Questiormake as a confirmatory factor analysis of the scale constmcts. The

organization sfrategies scale was not utilized m the rest of this study because the low

Cronbach alpha did not support the reliability of this constmct.

The participants in this study showed a declme m mfrmsic motivation,

elaboration, and metacognitive self-regulation sfrategies from the begmnmg to the end of

the study. The findmgs by Barker and Olson (1999) mdicated that as medical sttidents

progress through thek first year, the competitive nattu-e of medical school resuhs in a

declme m infrmsic motivation which indicates a move away from participating with goals

for leammg to participatkig with goals that are more test and grade oriented. A decrease

m elaboration and metacognhive self-regulation sfrategies indicate a move toward

rehearsal sfrategies such as memorization and rereadmg of texts and notes without

checkmg for understandmg of the material (Pmfrich et al., 1991). As the sttidy was

completed, the participants were withm one week of major examinations in Gross

Anatomy, Biochemistty, and Histology. The pressure of the upcoming exams may have

88

confributed to the decrease in mfrinsic motivation, elaboration, and metacognitive self-

regulation.

The fifth null hypothesis stated that the use of a problem-centered reflection tool

would not enhance the development of leammg sfrategies and the changes in motivation

m medical students as measured by the Motivated Sfrategies for Leaming Questionnake.

The results of these tests do not provide any evidence to reject this null hypothesis.

Conclusions

Studies documenting medical students' inability to integrate knowledge leamed in

the basic science courses and apply that knowledge to clmical situations demonsfrate the

need for innovative approaches in instmctional delivery (Gmppen, 1997; Bamett, 1995).

In response to this need, this study mfroduces a new method of instmctional delivery that

mcorporates the theory behmd the diagnostic reasoning process with the principles of

problem-based leaming and reflection.

Ahnost all medical students pass the requked courses and make acceptable scores

on USMLE exams regardless of the curriculum design m medical school. Cronbach and

Snow (1977) suggested that this may be due to the fact that high-aptittide sttidents, like

medical students, succeed regardless of the instioictional sttategy used. In so far as this

study only applies to one section of Human Gross Anatomy, the resuhs presented here

also demonsfrate the difficulty in usmg achievement as a measure of the effectiveness of

an kistmctional sfrategy m medical education.

89

Measuring achievement by muhiple choice question type (rote memorization or

clinical vignette) also showed no significant difference between the two instmctional

methods (dkect mstmction and problem-centered-reflection). No matter the constmction

of a multiple choice question, the researcher contends that creating a multiple choice

question that tmly measures the stmcture and complexity of knowledge leamed is very

difficuh.

Usmg the tune needed to answer kidividual questions as a measurement of the

reflection process showed no significant difference between the dkect mstmction and

problem-centered reflection groups. The essay question was valuable in determining the

stmcture and complexity of knowledge and will be discussed below. However, the time

needed to answer the essay question was not significantly different for the dkection

instmction and problem-centered reflection groups. Even though three questions showed

a significant difference between the groups, time was not a measure of the reflection

process. Time may be a measure of the difficulty of the question, the ambiguity of the

question, or various other factors related to question development that have not been

mvestigated ki this study.

A margmally significant difference was found in the number of declarative

statements m the essay answers between the direct mstmction and problem-centered

reflection groups. Statistically significant differences were found in the number of

mtegrative and relational statements in the essay answers between the dkect insttaiction

and problem-centered reflection groups. The results of this sttidy demonsttated that

problem-centered reflection increases the sttaicttu-e and complexity of leamed knowledge

90

that is related to the diagnostic reasoning process. This finding is important in that other

studies have found that medical students in a conventional lecture-based curriculum are

unable to mtegrate knowledge leamed in the basic science courses and apply that

knowledge to clinical situations (Gmppen, 1997; Bamett, 1995). The results of this study

shows that participants m the problem-centered reflection group put together more

declarative, integrative, and relational statements as an answer to a clinical vignette essay

question than participants m the dkect instmction group. The combination of these

statements demonsfrates a more stmctured and complex arrangement of integrative

knowledge.

Overall there was a slight declme in mtrinsic motivation and metacognhive self-

regulation when the scales are compared by groups or by pre and post tests. There was a

statistically significant decrease m the means of the elaboration scale when the scales are

compared by pre and post tests. No statistically significant differences m the means of

the exfrmsic motivation and crkical thinkmg scales when they are compared by groups or

by pre and post tests. The evaluation of the leaming sfrategies scales and motivation

scales did not provide any evidence that would reject the null hypothesis that the use of a

problem-centered reflection tool would not enhance the development of leammg

sfrategies and the changes in motivation m medical sttidents as measured by the six

Motivated Sfrategies for Leammg Questionnake.

91

Lunitations of the Study

There are several lunitations to consider m terms of the generalizability of the

resuhs.

1. The study was based on self-selected, voluntary participation of medical

students and the generalization of results to other populations of students may be lunited.

It is unportant to note that the sample is a convenience sample taken from one university

settmg. The participants were randomly assigned to the comparison groups, but they

were not randomly sampled from the total population.

2. The study collected data from questionnaires and an achievement exammation

with a small sample of students. The study, while tied to the upper exttemity section of

the Human Anatomy course, was not a requked element of the course. Therefore, as

curricular demands increased, participants removed themselves from the study decreasmg

the sample size. Further studies will provide a larger sample size and makmg the study a

requked element should yield better data.

3. The participants accessed the web-based leaming activities for approximately

one hour each day, Monday through Friday, for two weeks. During this study, all

participants were also enrolled in a gross anatomy course and the time period

corresponded with the Upper Exttemity Unh m Gross Anatomy. The web-based

exercises were designed such that the content was presented in lecture one to two days

prior to the web-based exercise. This may have been too short a time period for the

participants in the problem-centered reflection group to engage fully m the reflection

process.

92

4. This sttidy also examined a very specific computer tool for medical education,

which was designed to promote problem-centered reflection on prior basic science

knowledge and the sttoicttire of leamed basic science knowledge. Other computer tools

have different purposes, and may not have similar effects on reflection and knowledge

sttoicttire. One cannot generalize that usmg this tool m another course outside of a basic

science course in medical education would have the same effects.

Implications for Further Research

The lunitations and results of this study provided suggestions for improvement

and further research.

1. The study could be repeated with similar procedures but with the followmg

modifications: elimmate the frackmg of time as a measurement of reflection, make the

study a requked element of the course, extend the study to mclude other sections of the

anatomy course, and include within the study the development and analysis of a multiple

choice examination tool that measures stmcture and complexity of knowledge.

2. By expanding the scope of the study to include other sections of the course, the

essay component could be expanded to measure four levels of stmcture and complexity.

The resuhs of this study suggest that other sections of the anatomy course may allow the

incorporation and measurement of interdisciplmary statements. For example, in the

section dealing with the abdommal cavity, an essay question could elicit information

concemmg the kidney. An mterdisciplinary statement would incorporate knowledge of

the kidney from biochemistry, histology, and physiology.

93

3. Another study could be conducted utilizing the web-based metacognhive

reflection tool in order to examme the portfolio process as an altemative evaluation

measure. The reflections and peer evaluations of the reflections are basically a begmning

of an onlme portfolio for first year medical students. The effects of collaboration and

peer evaluation on the stmcture and complexity of knowledge could be mvestigated.

Summary

The goal of this study was to examine problem-centered reflection and hs effects

on the development of leaming sttategies and changes in motivation that are related to the

diagnostic reasoning process. This study compared two modes of web-based delivery of

instmction and thek effect on the development of leaming sfrategies associated with the

diagnostic reasoning process. The modes of instmction were dkect instmction tutorials

and problem-centered reflection. The data presented m this study also provided

information on the development of leaming sfrategies m a hybrid mstmctional

envkonment consistmg of lecture-based mstmction and online problem-centered

reflection.

The sample chosen for this study was a non-random cluster sample at a School of

Medicme m a large public university in the Southwestem United States that contamed

130 first-year medical students with an average age of 23 and was 40% female, 68%

Caucasian, and 94% Texas residents (Table 4.1 and Table 4.2). Fifty-one participants (30

m the dkect insttaiction group and 21 m the problem-centered reflection group) completed

the study and were included m the statistical analyses.

94

A marginally significant difference was found in the number of declarative and

mtegrative statements in the essay answers between the dkect mstmction and problem-

centered reflection groups. Statistically significant differences were found in the number

of relational statements m the essay answers between the direct instmction and problem-

centered reflection groups. The results of this study demonstrated that problem-centered

reflection mcreases the stmcture and complexity of leamed knowledge that is related to

the diagnostic reasoning process. The results of this study shows that participants in the

problem-centered reflection group put together more declarative, integrative, and

relational statements as an answer to a clinical vignette essay question than participants in

the dkect instmction group. The combmation of these statements demonsttates a more

stmctured and complex arrangement of integrative knowledge.

By expanding the scope of the study to include other sections of the course, the

essay component could be expanded to measure four levels of stmcture and complexity.

The results of this study suggest that other sections of the anatomy course may allow the

measurement of interdisciplmary statements that would mcorporate knowledge from other

basic science disciplmes such as biochemistry, histology, and physiology.

95

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APPENDIX A

CONSENT FORM AND DEMOGRAPHIC DATA

The Development of a Web-based Metacognitive Tool: The Effect of Problem-centered Reflection on Medical Student Development of Diagnostic Reasoning Skills

Consent Form

You are invhed to be m a research study about how a student leams new knowledge. Benny C. Shaw, Jr. at Texas Tech University Health Sciences Center is conductmg this study. Please read this document and ask any questions you may have before agreeing to be in the study.

Background Information:

The purpose of this study is to examine how a student leams new knowledge and applies this knowledge to a clinical situation.

Procedure:

If you agree to be in this study: • You will be asked to read and sign this consent form. • You will be asked to register online choosing a usemame and password that will

maintain your anonymity during this study (Do not use your name, a portion of your name, your Social Security Number, etc.).

• You will be asked to complete an onlme questionnake with 81 items at the begmnmg and end of the study. You will be asked to rate your study habits, your leammg skills, and your motivation during the course of this study. The questionnake will take approxunately 30 minutes to complete.

• You will be asked to access and complete web-based exercises that will take approximately one-hour each day (Monday - Friday) durmg the upper extremity portion of Gross Anatomy.

• You will be asked to complete a web-based examination on the concepts presented m the web-based exercises. This examination is for research purposes only and will not affect your grade m the Gross Anatomy class.

YOUR PARTICIPATION IS VOLUNTARY AND NOT RELATED IN ANY WAY TO YOUR GRADE IN THE CLASS.

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Risks and Benefits of Being in the Study:

This project is not expected to involve risks of harm any greater than those ordmarily encountered in daily life. All reasonable safeguards have been taken to minimize the potential risks. The resuhs of this project will be coded in such a way that your identity will not be physically attached to the final data. There are no dkect benefits to the participant.

Confidentiality:

The records of this study will be kept private. In any sort of report that may be published, the report will not include any information that will make h possible to identify a subject.

Voluntary Nature of the Study:

Your decision whether or not to participate will not affect your current or future relations with Texas Tech University Health Sciences Center or Texas Tech University. If you decide to participate, you are free to withdraw at any time without affectmg those relationships.

Contacts and Questions

The researcher conductmg this study is:

Benny C. Shaw, Jr. Texas Tech University Health Sciences Center 3601 4thStteet Lubbock, Texas 79430 (806)743-2870 (806)743-1029 fax chip. shaw(^ttuhsc .edu

You may ask any questions you have now. You will be given a copy of this form to keep for your records.

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Statement of Consent:

1 have read the above mformation. I have asked questions and have received answers. I consent to participate in the study.

Signature_ Date

Signature of Investigator or Person Obtamkig Consent_ Date

2.

3.

4.

Gender

Demographic Information

Male

Ethnic Background

American Indian/Alaska Native

Asian/Pacific Islander

Black/African-American

Hispanic or Latmo descent

White/Caucasian

Other

Your age at the time of this study:

Were you a resident of Texas when you entered medical school?

Female

Yes No

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APPENDIX B

MSLQ QUESTIONNAIRES

Form A

Part A. Motivation

The followmg questions ask about your motivation for and attitudes about the anatomy class. Remember there are no right or wrong answers. Answer the questions about how you study in the anatomy class as accurately as possible. Use the scale below to answer the questions. If you think the statement is very tme of you, choose 7; if a statement is not at all tme of you, choose 1. If the statement is more or less tme of you, find the number between 1 and 7 that best describes you.

1 = not at all tme of me 2 3 4 5 6 7 = very tme of me

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In gross anatomy, I prefer course material that really challenges me so I can leam new things. If I study in appropriate ways, then I will be able to leam the material in the gross anatomy course. When I t£ike a test I thmk about how poorly I am domg compared with other students. I thuik I will be able to use what I leam in gross anatomy in other courses. I believe I will receive an excellent grade in gross anatomy. I'm certam I can understand the most difficult material presented in the readmgs for gross anatomy. Gettmg a good grade m gross anatomy is the most satisfying thmg for me right now. When I take a test I thmk about items on other parts of the test I can't answer. It is my own fauh if I don't leam the material m gross anatomy. It is unportant for me to leam the course material in gross anatomy.

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The most important thing for me right now is hnproving my overall grade pomt average, so my main concem in gross anatomy is getting a good grade. I'm confident I can leam the basic concepts taught in gross anatomy. If I can, I want to get better grades m gross anatomy than most of the other students. When I take tests I thmk of the consequences of failing. I'm confident I can understand the most complex material presented by the mstmctors m gross anatomy. In gross anatomy, I prefer course material that arouses my curiosity, even if h is more difficult to leam. I am very mterested in the content area of gross anatomy. If I try hard enough, then I will understand the course material. I have an uneasy, upset feeling when I take an exam. I'm confident I can do an excellent job on the assignments and tests in gross anatomy. I expect to do well in gross anatomy. The most satisfymg thing for me m gross anatomy is trying to understand the content as thoroughly as possible. I think the course material m gross anatomy is useful for me to leam. When I have the opportunity m gross anatomy, I choose course assignments that I can leam from even if they don't guarantee a good grade. If I don't understand the course material, h is because I didn't try hard enough. I like the subject matter in gross anatomy. Understanding the subject matter of gross anatomy is very unportant to me. I feel my heart beating fast when I take an exam.

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I'm certam I can master the skills being taught in gross anatomy. I want to do well in gross anatomy because it is important to show my ability to my family, friends, employer, or others. Considering the difficulty of gross anatomy, the teachers, and my skills, I thmk I will do well ki gross anatomy.

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PartB. Leammg Sttategies

The following questions ask about your leaming sttategies and study skills for gross anatomy. Agam, there are no right or wrong answers. Answer the questions about how you study m gross anatomy as accurately as possible. Use the same scale to answer the remamkig questions. If you thmk the statement is very ttaie of you, select 7; if a statement is not at all ttaie of you, select 1. If the statement is more or less tme of you, find the number between 1 and 7 that best describes you.

1= not at all ttaie of me 2 3 4 5 6 7 = very tme of me

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1= not at all ttaie of me 2 3 4 5 6 7 = very ttaie of me

When I study the readmgs for gross anatomy, I outlkie the material to help me organize my thoughts. During class tkne I often miss unportant pouits because I'm thmkmg of other thmgs. When studymg for gross anatomy, I make up questtons to help focus my readmg. I usually sttady m a place where I can concenfrate on my course work. When readmg for gross anatomy, I make up questions to help focus my readmg I often feel so lazy or bored when I sttidy for gross anatomy that I quh before I finish what I planned to do. 1 often find myself questionmg things I hear or read m gross anatomy to decide if I find them convmcmg When I study for gross anatomy, I practice saymg the material to myself over and over.

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Even if I have frouble leammg the material m gross anatomy, I try to do the work on my own, without help from anyone.

When 1 become confused about somethmg I'm reading for gross anatomy, I go back and tty to figure it out. When I study for gross anatomy, I go through the readmgs and my class notes and try to find the most knportant ideas. I make good use of my study tune for gross anatomy. If course readmgs are difficuh to understand, I change the way I read the material. I try to work with other students from gross anatomy to complete the course assignments. When studying for gross anatomy, I read my class notes and the course readings over and over again. When a theory, mterpretation, or conclusion is presented m class or in the readings, 1 try to decide if there is good supporting evidence. I work hard to do well in gross anatomy even if I don't like what we are doing. I make simple charts, diagrams, or tables to help me organize course material. When studymg for gross anatomy, I often set aside time to discuss material with a group of students from the class. I freat the course material as a startmg pomt and try to develop my own ideas about it. I find h hard to stick to a study schedule. When I study for gross anatomy, I pull together mformation from different sources, such as lectures, readmgs, and discussions. Before I study new course material thoroughly, I often skim h to see how h is organized. I ask myself questions to make sure I understand the material I have been studymg m gross anatomy. I try to change the way I study in order to fit the course requkements and the instmctor's teaching style. I often find that I have been reading for gross anatomy but don't know what h was all about.

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1 ask the msttaictor to clarify concepts I don't understand very well. I memorize key words to remmd me of unportant concepts in gross anatomy. When course work is difficult, 1 either give up or only study the easy parts. I try to thmk through a topic and decide what I am supposed to leam from it rather than just readmg h over when studymg for gross anatomy. I try to relate ideas ki gross anatomy to those m other courses whenever possible. When I study for gross anatomy, I go over my class notes and make an outline of important concepts. When reading for gross anatomy, I try to relate the material to what I akeady know. I have a regular place set aside for studying. 1 try to play around with ideas of my own related to what I am leaming ki gross anatomy. When I study for gross anatomy, I write brief summaries of the main ideas from the readmgs and my class notes. When I can't understand the material in gross anatomy, I ask another student m gross anatomy for help. I try to understand the material m gross anatomy by m£ikmg cormections between the readings and the concepts from the lectures. I make sure that I keep up with the readings and assignments for gross anatomy. Whenever 1 read or hear an assertion or conclusion in gross anatomy, I thmk about possible ahematives. I make lists of knportant items for gross anatomy and memorize the lists. 1 attend gross anatomy class regularly. Even when course materials are dull and uninteresting, I manage to keep working until I finish. I try to identify students in gross anatomy whom I can ask for help if necessary. When studying for gross anatomy I try to determine which concepts I don't understand very well.

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I often find that I don't spend very much time on gross anatomy because of other activities. When I study for gross anatomy, I set goals for myself m order to direct my activhies m each study period. If I get confiised taking notes in class, I make sure I sort it out afterwards. I rarely fmd time to review my notes or readings before an exam. I try to apply ideas from the gross anatomy readings in other class activities such as lecture and discussion.

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FormB

Part A. Motivation

The followmg questions ask about your motivation for and attittides about gross anatomy specifically related to the web-based exercises of the past few weeks. Remember there are no right or wrong answers. Answer the questions about how you sttidy using the web-based exercises m gross anatomy as accurately as possible. Use the scale below to answer the questions. If you think the statement is very ttoie of you, choose 7; if a statement is not at all ttaie of you, choose 1. If the statement is more or less tme of you, find the number between 1 and 7 that best describes you.

1 = not at all ttoie of me 2 3 4 5 6 7 = very ttoie of me

1.

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I preferred the web-based exercises that really challenged me so I could leam new thmgs m gross anatomy. The web-based material helped me leam the concepts ki gross anatomy. When 1 took the web-based test I thought about how poorly I was domg compared with other students. I thmk I will be able to use what I leamed m the web-based exercises in other courses. I believe I will receive an excellent grade in gross anatomy. I'm certain I understood the most difficuh material presented in the web-based exercises for gross anatomy. Gettmg a good grade ki gross anatomy is the most satisfying thing for me right now. When I took the web-based test I thought about items on other parts of the web-based test I could not answer. It was my own fauh if I didn't leam the web-based material in gross anatomy. It was important for me to leam the web-based material m gross anatomy. The most important thmg for me right now is knprovmg my overall grade pomt average, so my main concem in gross anatomy is gettmg a good grade.

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I'm confident I leamed the basic concepts taught in the web-based exercises. If I can, I want to get better grades m gross anatomy than most of the other students. When I took the web-based test I thought about the consequences of failmg. I'm confident I understood the most complex material presented m the web-based exercises in gross anatomy. I preferred the web-based exercises that aroused my curiosity, even if h was more difficuh to leam. I was very mterested m the content areas presented m the web-based exercises. If I fried hard enough, I understood the web-based material. I had an uneasy, upset feelmg when I took the web-based exam. I'm confident I did an excellent job on the web-based assignments and tests in gross anatomy. I expect to do well in gross anatomy. The most satisfymg thmg for me m gross anatomy was trying to imderstand the web-based content as thoroughly as possible. I thought the web-based exercises in gross anatomy were useful for me to leam. When I had the opportunity m gross anatomy, I chose the web-based assignments to leam from even if they didn't guarantee a good grade. If I didn't understand the web-based exercises, h was because I didn't try hard enough. I liked the subject matter in the web-based exercises. Understanding the subject matter in the web-based exercises was very important to me. I feh my heart beatkig fast when I took the web-based exam. I'm certam I mastered the skills bemg taught m the web-based exercises. I want to do well in gross anatomy because h is important to show my ability to my family, friends, employer, or others.

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Considermg the difficulty of the web-based exercises, the teachers, and my skills, I thmk I will do well in gross anatomy.

Part B. Leaming Sfrategies

The following questions ask about your leammg sfrategies and study skills for gross anatomy specifically related to the web-based exercises of the past few weeks. Agam, there are no right or wrong answers. Answer the questions about how you study using the web-based exercises m gross anatomy as accurately as possible. Use the same scale to answer the remamkig questions. If you ttiink the statement is very ttoie of you, select 7; if a statement is not at all ttoie of you, select 1. If the statement is more or less ttoie of you, find the number between 1 and 7 that best describes you.

1 = not at all tme of me 6 7 = yery tme of me

1 =not at all tmeof me 2 3 4 5 6 7 = very tme of me

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When I studied the web-based material for gross anatomy, 1 outlmed the material to help me organize my thoughts. During the web-based exercises, I often missed knportant points because 1 was thinking of other things. When I studied the web-based exercises, I made up questions to help focus my reading. I usually studied in a place where I could concenttate on the web-based exercises. When I read the web-based material, I made up questions to help focus my reading. I often felt so lazy or bored when I studied the web-based material that I quit before I finished what I plarmed to do. I often found myself questioning things 1 read m the web-based material m order to decide if I found them convincing. When I studied the web-based exercises, I practiced saymg the material to myself over and over.

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Even if 1 had frouble leammg the web-based material m gross anatomy, 1 fried to do the work on my own, without help from anyone. When I became confused about somethmg I was readmg in the web-based exercises, 1 went back and tried to figure it out. When I studied the web-based material, 1 went through the readings and my class notes and ttied to find the most knportant ideas. I made good use of my study time for the web-based exercises. If the web-based readmgs were difficuh to understand, I changed the way I read the material. I tried to use the onlme feedback to complete my understandmg of the web-based assignments. When I studied the web-based material, I read my class notes and the course readmgs over and over agam. When a theory, interpretation, or conclusion was presented in the web-based exercises, I tried to decide if there was good supporting evidence. I worked hard to do well on the web-based exercises even if 1 didn't like what I was doing. I made simple charts, diagrams, or tables to help me organize the web-based material. When I studied the web-based material, I set aside time to use the feedback on my performance to guide my review of the material. 1 freated the web-based material as a starting point and fried to develop my own ideas about it. I found h hard to stick to a study schedule. When 1 studied the web-based material, I pulled together information from different sources, such as lectures, readings, and discussions. Before I studied new web-based material thoroughly, 1 often skimmed it to see how h was organized. I asked myself questions to make sure I understood the web-based material I had been studymg m gross anatomy.

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1 fried to change the way I studied m order to fit the course requkements and the insttoictor's teachmg style. I often found that I had been reading the web-based material but didn't know what h was all about. I asked the mstmctor to clarify concepts presented m the web-based material that I didn't understand very well.

I memorized key words to remind me of unportant concepts m the web-based exercises. When the web-based exercises were difficult, 1 either gave up or only studied the easy parts. 1 tried to thmk through a topic and decide what I was supposed to leam from it rather than just reading it over when I studied the web-based material. I fried to relate ideas in the web-based exercises to those in other courses whenever possible. When I studied the web-based material, I went over my class notes and made an outline of important concepts. When I read the web-based material, I fried to relate the material to what I akeady knew. I had a regular place set aside for studying the web-based material. I fried to play around with ideas of my own related to what I was leaming in the web-based exercises. When I studied the web-based material, I wrote brief summaries of the mam ideas from the readmgs and my class notes. When I couldn't understand a concept from the web-based material m gross anatomy, I asked another student m for help with the concept. I fried to understand the web-based material m gross anatomy by making cormections between the readmgs and the concepts from the lectures. 1 made sure that I kept up with the readings and web-based assignments for gross anatomy. Whenever 1 read an assertion or conclusion m the web-based material, I thought about possible ahematives. I made lists of important items in the web-based material and memorized the lists.

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I accessed the web-based exercises regularly. Even when the web-based exercises were dull and uninterestmg, I managed to keep workmg until I finished. I tried to identify students m gross anatomy whom 1 could ask for help with the web-based exercises. When I studied the web-based material, I ttied to determine which concepts I didn't understand very well. I often found that I didn't spend very much tune on the web-based exercises because of other activities. When I studied the web-based material, I set goals for myself in order to dkect my activities m each study period. If I got confused during the web-based exercises, I made sure I sorted it out afterwards. I rarely found time to review my notes or readings before a web-based exam. I ttied to apply ideas from the web-based exercises m other class activities such as lecture and discussion.

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Session 1

1.1

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1.5

1.6

APPENDIX C

SESSION OBJECTIVES

Identify the bones and vessels associated with the shoulder and superficial

upper exfremity m radiological hnages (x-rays, CT's, and MRI's).

Describe the distribution of the major cutaneous nerves of the upper lunb.

Describe the muscles that attach the scapula to the spine and their actions

and nerve supply.

Describe the muscles that attach the scapula to the humems and thek

actions and nerve supply.

Describe the pectoral and rotator cuff muscles and thek actions and nerve

supply.

Discuss the clmical anatomy of the shoulder.

Session 2

2.1

2.2

2.3

2.4

2.5

Identify the bones and vessels associated with the axilla and arm in

radiological unages (x-rays, CT's, and MRI's).

Describe the axilla and hs boundaries.

Describe the brachial plexus.

Describe the functional compartments of the arm includmg the muscles,

thek actions, and nerve supply.

Discuss the clinical anatomy of the axilla.

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2.6 Discuss the clinical anatomy of the arm.

Session 3

3.1 Identify the bones and vessels associated with the forearm and wrist ki

radiological images (x-rays, CT's, and MRI's).

3.2 Describe the functional compartments of the forearm including the

muscles, thek actions, and nerve supply.

3.3 Discuss the clinical anatomy of the forearm and wrist.

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APPENDIX D

ACHIEVEMENT EXAMINATION

Question 1:

Type: Rote Memory

Objective(s): 3.1, 3.2

Identify the labeled sttoicture:

A. Brachioradialis B. Extensor carpi radialis longus C. Extensor carpi radialis brevis D. Triceps brachii E. Biceps brachii F. Brachialis G. Pronator teres H. Flexor carpi radialis

118

Question 2:

Type: Clmical Vignette

Objective(s):3.1,3.2, 3.3

During surgical removal of a tumor of the upper forearm, the labeled stmcture was cut, mjuring a nerve that passes deep to h. What symptoms would most likely resuh from this nerve mjury?

A. Loss or severe weakness of extension of the forearm at the elbow joint B. Loss or severe weakness of extension of the thumb at the metacarpophalangeal

joint C. Loss or severe weakness of abduction of the index finger. D. Loss of or severely diminished sensation of the skin of the lateral side of the

forearm E. Loss of or severely diminished sensation of the skin of the dorsum of the thumb

119

Question 3:

Type: Rote Memory

Objective(s): 3.1

Identify the labeled stmcture:

A. Triquetmm B. Trapezoid C. Trapezium D. Capitate E. Pisiform F. Lunate G. Hamate H. Scaphoid

120

Question 4:

Type: Rote Memory

Objective(s): 2.1


A. Thyrocervical tmnk B. Thoracoacromial trunk C. Subscapular artery D. Ckcumflex scapular artery E. Lateral thoracic artery F. Intemal thoracic artery G. Thoracodorsal artery H. Posterior humeral circumflex

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Question 5:

Type: Clinical vignette

Objective(s): 3.3

During surgery to repak a bloody wound in the area of the "euiatomical snuffbox," the emergency room resident was carefiil to avoid surgical injury to the stmctures in this region, mcludmg all of the followmg EXCEPT the

A. cutaneous branches of the superficial radial nerve. B. tendon of the extensor pollicis brevis muscle. C. tendon of the abductor pollicis brevis muscle. D. radial artery. E. tendon of the extensor pollicis longus muscle

122

Question 6:

Type: Rote memory

Objective(s): 2.1,2.4


A. Serratus Anterior B. Subclavius C. Pectoralis major D. Pectoralis mmor

123

Question 7:


Objective(s): 1.6

A 16-year-old soccer sttiker was ttipped and fell to the turf on his right shoulder. On exammation, the sports medicme physician determmed that there was a shoulder mjury m which the lateral end of the clavicle slid onto the superior aspect of the acromion. Which of the following ligaments was most likely damaged?

A. Stemoclavicular B. Coracoclavicular C. Costoclavicular D. Coracoacromial E. Glenohumeral

Question 8:


Objective(s): 1.4, 1.5, 1.6

Durmg a sfrenuous game of tennis a 55 year old woman complained of severe shoulder pam that forced her to quh the game. During physical exammation h was found that she could not kihiate abduction of her arm, but if her arm was elevated to 45 degrees from the vertical (at her side) poshion, she had no frouble fully abductmg h. Injury to which muscle was responsible?

A. deltoid B. infraspinatus C. supraspinatus D. teres major E. ttapezius

124

Question 9:

Type: Cluiical vignette

Objective(s): 3.3

In order to check the pulse of a child whose forearm is in a cast, the pediattician presses her finger uito the depth of the "anatomical snuffbox." The tendon lymg immediately medial to the physician's finger belongs to what muscle?

A. Brachioradialis B. Extensor carpi radialis brevis C. Extensor carpi radialis longus D. Extensor pollicis brevis E. Extensor pollicis longus

Ouestion 10:

Type: Clmical vignette

Objectiye(s): 2.6, 3.2, 3.3

If the medial epicondyle of the humems is fracttu-ed and results m nerve mjury, which muscle would be most affected?

A. Extensor carpi uhiaris B. Extensor digitomm C. Flexor carpi uhiaris D. Flexor dighorum profundus E. Flexor digitomm superficialis

125

Ouestion 11:



A man is in an auto accident and sustains several mjuries, among them are:

• Skin lacerations: o on the back of his head in the occipital area, o on his chest just above the nipple, o on the lateral side of his arm, o lateral forearm at midlength, o dorsal hand between his thumb and index finger.

• Abrasions and contusions (bmises) about his right shoulder • A fractured right radius near hs distal end

Later, while undergomg physical therapy because of his shoulder mjury, he comments that it is very painfiil when his forearm is brought across his chest (medial or intemal rotation of the humems). You deduce that the pain is due to sfretching of the lateral (extemal) rotators of the shoulder. Which muscle was most likely the source of his pain?

A. infi-aspinatus B. latissimus dorsi C. rhomboideus major D. supraspinatus E. teres major

126

Ouestion 12:

Type: Rote memory



A. Deltoid B. Subscapularis C. Supraspinatus D. Trapezius

127

Ouestion 13:



A fracture of the surgical neck of the humems would endanger which of the following?.

A. Median nerve B. Suprascapular nerve C. Axillary nerve D. Acromioclavicular joint E. Armular ligament

Ouestion 14:


Objective(s): 3.3

A patient is severely lunited m extension at the wrist joint after several months in a cast followmg a Colles fracture. Which joint would be especially unportant ki therapy to regain full extension?

A. carpometacarpal B. distal radioulnar C. midcarpal D. radiocarpal E. ulnocarpal

128

Ouestion 15:


Objective(s): 3.3

When falling on an outsfretched hand, the most commonly dislocated carpal bone is the

A. Scaphoid B. Trapezoid C. Lunate D. Capitate E. Hamate

Question 16:

Type: Rote memory

Objective(s): 1.4

Which of the following stmctures medially rotate the humems?

A. A B. B C. C

129

Question 17:

Type: Rote memory

Objective(s): 1.2,2.3

Which cutaneous nerve is a branch of the musculotaneous nerve?

A. Lateral antebrachial cutaneous B. Medial antebrachial cutaneous C. Lateral brachial cutaneous D. Superficial radial E. Superficial ulnar

130

Question 18:

Type: Rote memory

Objective(s): 1.1

Identify the labeled stmcture.

A. Greater tubercle B. Fracture of the Greater ttibercle C. Lesser tubercle D. Fracture of the Lesser tubercle E. Fracture ofthe Anatomical neck

131

Ouestion 19:

Type: Rote memory

Objective(s): 3.2

The fimction ofthe posterior uiterosseous nerve is:

A. motor to the brachioradialis B. motor to the extensor carpi ulnaris C. parasympathetic to the dorsum ofthe forearm D. sensory from the wrist joint E. sensory from the dorsum of the forearm

Ouestion 20:

Type: Essay

Objective(s): 1.5,1.6, 2.2, 2.3, 2.4, 2.5

A 52-year-old man is brought to the emergency room after bemg found m the park, where apparently he had lam overnight after a fall. He describes severe pam in his left arm. Physical examination suggests that he has a broken humems. While wahmg for radiology to arrive and x-ray the patient's arm, you recall the locations on the humems that are common sites of fracttires and the sttoictures related to these sites.

Describe the sttoicttu-es that can be injured and the deficits that resuh m each ofthe common locations for a fracture ofthe humems.

132

APPENDIX E

EXAMPLES OF ESSAY CODINGS FOR EACH RATER

UserlD 1° PagelD "2 sTime '•"^^ W'a f'racfut ' Sf the sufgicat Tieek of tfie huiftfenjs We axUlaiy tierve is in danger of being aamaged Tttis would result in loss of innervation to the deltoid and lacii of cutaneous feeling in tlie lateral arm In a fracture of the shaft of the humerus the radial' rterv.e is in danger of tjeing damaged. In this instance the patient will lose innervation to the extensor muscles of the forearm leading to a 'wrisl-drop' If the fracture is of the superior condyle the the medial nerve is in danger. This will result in loss of function in the flexors of the forearm and a 'hand of benediction' If ttie medial epicondyle of the humerus is fractured the ulnar nerve is in danger of tieing fractured This results in lack of innervation to flexor carpi ulnans and to parts of the hand The patient will have a 'claw-hand' due to lack of innervation to the fifth and half of the fourth digit.

Figure E.l: Researcher Essay Codmg Example 1. D = Declarative, 1 = Integrative, and R = relational

133

Isrrin 21 p,jj^,,./p 1'»9>,/7»U' 941827

The areas that the humerus is usually broken can be divided into several areas the surgical neck, a proximal fracture, a fracture of the S h ^ . adistal fracture al the supercondylar ridge, and a medial epicondyle fracture. If the surgical neck is broken, ttife'Sxillary nervals often injured. This nerve supplies motor functions to the deltoid and Teres minor and cutaneous , sensations on the lateral stde of the arm Damage to this nerve vrould limit abduction oi the arm. A proximal fracture and a ^haft fracUjre are likely to damage the Radial nerve. -This nerve supplies motor functions to the extensors of the arm and forearm and cutaneous sensation over the posterior side of the arm and forearm and the first 3 V2 digits of the dorsal side of the hand Loss of this nerve results in "wrist drop" t>ecause the patient cannot extend their arm. wnst, or digits. A distal break ^iTthe supercondylar ridge would likely damage the median nerve This nerve provides motor funtions to most of the forearm flexors, pronators, the first and second lumbricals, and most of the thenar eminence Loss of the nen/e at the humeral level weakens the flexion of the wrist and first two digits It also causes the arm to remain in a supinated position and the ttiumb to remain adducted Because of muscle atrophy, \he hand takes on an "ape-like" appearance. Lastly, a fracture of the humeral ' njedial epicondyle would likely injure the ulnar nerve; The unlar nerve provides motor function to the part of the FDP, the FCU, the 3rd and 4lh lumbncals, the dorsal and palmar interosseous, the hypolhenar eminence, and the adductor pollicis This gives the hand a claw-like appearance.

V ; .

iG

l Figure E.2: Researcher Essay Codmg Example 2. D = Declarative, I = Integrative, and

R - relational

Anatomical and surgical neck of the hurinerus- axillary and (possibly radial) nerves

"Midhumeral fracture- radial nerve in the spiral groove.

Di^ Figure E.3: Researcher Essay Codkig Example 3. D = Declarative, I = Integrative, and

R = relational

134

UserlD 1° PagelD 1 2 sTime 47533 In a fracture of the surgical neck of the humerus the axillary nerve is in danger of being damaged. This would result in loss of innervation to the deltoid and lack of cutaneous feeling in the lateral arm. In a fracture of the shaft of the humerus the radial nerve is in danger of being damaged In this instance the patient will lose innervation to the extensor muscles of the foreami leading to a 'wnst-drop'. If the fracture is of the superior condyle the the medial nerve is in danger. This will result in loss of function in the flexors of the forearm and a 'hand of benediction'. If the medial epicondyle of the humeais is fractured the ulnar nerve is in danger of being fractured. This results In lack of innervation to flexor carpi ulnaris and to parts of the hand The patient will have a 'claw-hand' due to lack of innervation to the fifth and half of the fourth digit.

- r rx r 5 T

IJT

Figure E.4: Subject Matter Expert Essay Coding Example 1. D = Declarative, I = Integrative, and R = relational

UserlD 21 PagelD 1*9 sTime 941827 The areas that the humerus is usually broken can be divided into several areas the surgical neck, a proximal fracture, a fracture of the shaft, a distal fracture at the supercondylar ridge, and a medial epicondyle fracture. If the surgical neck is broken, the axillary nerve is often injured. This nerve supplies motor functions to the deltoid and Teres minor and cutaneous sensations on the lateral side of the arm. Damage to this nerve would limit abduction of the arm. A proximal fracture and a shaft fracture are likely lo damage the Radial nerve. This nerve supplies motor functions to the extensors ofthe arm and forearm and cutaneous sensation over the posterior side of the arm and forearm and the first 3 1/2 digits of the dorsal side of the hand. Loss of this nerve results in "wrist drop" because the patient cannot extend their arm, wrist, or digits. A distal break at the supercondylar ridge vrould likely damage the median nerve. This nerve provides motor funtions to most of the forearm flexors, pronators, the first and second lumbricals, and most ofthe thenar eminence. Loss of the nerve at the humeral level weakens the flexion of the wrist and first two digits. II also causes the arm to remain in a supinated position and the thumb to remain adducted. Because of muscle atrophy, the hand takes on an "ape-like" appearance. Lastly, a fracture of the humeral medial epicondyle would likely injure the ulnar nerve. The unlar nerve provides motor function to the part of the FDP. the FCU. the 3rd and 4th lumbricals, the dorsal and palmar interosseous, the hypothenar eminence, and the adductor pollicis. This gives the hand a claw-like appearance.

b h r b r r

-' ^ J ->

Figure E.5: Subject Matter Expert Essay Codmg Example 2. D = Declarative, I = Integrative, and R = relational

135

UserlD 50 PagelD 172 sTime ' 75387

Anatomical and surgical neck of the humerus- axillary and (possibly radial) nerves.

Mldhumeral fracture- radial nerve in the spiral groove.

' ,

I

Figure E.6: Subject Matter Expert Essay Codmg Example 3. D = Declarative, I Integrative, and R = relational

136

APPENDIX F

IRB APPROVAL AND TRANSCRIPT

INS-nrUTIONAL REVIEW BOARD APPLICATION FORM Protocol for Presentation to the TTUHSC Institutional Review Board (IRB)

TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER - ASSURANCE NO M.1078

1 TITLE OF STUDY: Theeva lua t i on o f a wob-based metacognit ive t o o l : The e f f e c t o f problem-centered

r e f l e c t i o n on the development o f l ea rn ing .•itrategie.'; associated w i th the d iagnos t i c reasoning process.

SPONSOR NAfi/IE (if internally sponsored, list department name):

For Clinical Trials. Protocol No. Please check trial phase. Ph I D Ph II • Ph 111 D Ph IV D

2. NAME PRINCIPAL IMVESTIGATOR: Reid L. Norman

Campus Address/l\^ail Stop:

OTHER INVESTIGATORS:Bcnny C Shaw, Jr

TITLE DEPARTfiflENT/CAMPUS: Professor Pharmacology

E-mail re id . normangttuhsc. oduPhone: 3-2870 Fax:

Asst VP In fo Services In fomia t ion Tech.

STUDY COORDINATOR

rMOTE: The Princinal Invpstiaator MUST bo a facuhv ineinl><>r - Tralnep. littident. resident, fellow, ptc . mav not be a Princinal InvesticMtor.t

Texas Tech University Health Sciences Center policy on the protection of human subjects requires that all activities involving human subjects, or materials of human origin, irrespective of source of funds, which are directed by or involve faculty, staff, students, or patients at TTUHSC have prior approval of an Institutional Review Board (IRB) mechanism. The information requested in this application will provide the basis for review and approval by that Board.

DO NOT WRTTE BENEATH THIS UNE INmAL REVIEW ACTION OF COMMnTEE

IRB NO: Date Reviewed by IRB Date Approved by IRB: APPROVAL Is for YR or MO(s)

EXEMPT; EXPEOrtED RISK assigned

Duration , Subjects approved: Controls approved:. SPANISH consent form: D Yes 0 Optional

Documents Reviewed:

Investigator's Brochure • Date:

Protocol • Version Date

Questionnaire D Date of IRB Stamp:

Advertisement D Date of IRB Stamp

o ther D Identify (i.e , Dmg Insert, SAE, etc )

CONTINUING REVIEW due: . (at>ptoxinYately) «g^nature df Authorized IRB Representative

ipn mannm

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Transcript of Oral Presentation for Subjects

The purpose of this study is to examine the ways in which students leam in order

to apply this leaming in real world situations. This information can be applied to futtire

instmction in medicine.

The subject will be asked to complete a questionnaire at the beginnmg and end of

this study. The questionnaire will rate study habks, leaming skills, and motivation in the

gross anatomy course and the web-based exercises. After the subject completes the initial

questionnake, the subject will be asked to access web-based leaming activhies for

approximately one hour each day, Monday through Friday, for two weeks. This time

period corresponds with the Upper Exttemity Unit in Gross Anatomy. At the end of this

unit, the subject will be asked to complete a web-based achievement examination

covering the upper exttemity objectives used in this study.

There are no perceived risks or benefits to the subject during this study. This

study is completely voluntary and will in no way affect your grade. However, the web-

based achievement examination will contain questions that are similar in style and

difficulty to those that will be seen in the block examination for the Gross Anatomy

course.

The results will be anonymous and in no way identify you individually.

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Copyright 2002, Benny C. Shaw, Jr.

Documents

Transcript of Copyright 2002, Benny C. Shaw, Jr.