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      How can we teach medical students to choose wisely? A randomised controlled cross-over study of video- versus text-based case scenarios

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          The Choosing Wisely campaign highlights the importance of clinical reasoning abilities for competent and reflective physicians. The principles of this campaign should be addressed in undergraduate medical education. Recent research suggests that answering questions on important steps in patient management promotes knowledge retention. It is less clear whether increasing the authenticity of educational material by the inclusion of videos further enhances learning outcome.


          In a prospective randomised controlled cross-over study, we assessed whether repeated video-based testing is more effective than repeated text-based testing in training students to choose appropriate diagnostic tests, arrive at correct diagnoses and identify advisable therapies. Following an entry exam, fourth-year undergraduate medical students attended 10 weekly computer-based seminars during which they studied patient case histories. Each case contained five key feature questions (items) on the diagnosis and treatment of the presented patient. Students were randomly allocated to read text cases (control condition) or watch videos (intervention), and assignment to either text or video was switched between groups every week. Using a within-subjects design, student performance on video-based and text-based items was assessed 13 weeks (exit exam) and 9 months (retention test) after the first day of term. The primary outcome was the within-subject difference in performance on video-based and text-based items in the exit exam.


          Of 125 eligible students, 93 provided data for all three exams (response rate 74.4%). Percent scores were significantly higher for video-based than for text-based items in the exit exam (76.2 ± 19.4% vs. 72.4 ± 19.1%, p = 0.026) but not the retention test (69.2 ± 20.2% vs. 66.4 ± 20.3%, p = 0.108). An additional Bayesian analysis of this retention test suggested that video-based training is marginally more effective than text-based training in the long term (Bayes factor 2.36). Regardless of presentation format, student responses revealed a high prevalence of erroneous beliefs that, if applied to the clinical context, could place patients at risk.


          Repeated video-based key feature testing produces superior short-term learning outcome compared to text-based testing. Given the high prevalence of misconceptions, efforts to improve clinical reasoning training in medical education are warranted. The Choosing Wisely campaign lends itself to being part of this process.

          Electronic supplementary material

          The online version of this article (10.1186/s12916-018-1090-y) contains supplementary material, which is available to authorized users.

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          Most cited references 34

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          The Power of Testing Memory: Basic Research and Implications for Educational Practice.

          A powerful way of improving one's memory for material is to be tested on that material. Tests enhance later retention more than additional study of the material, even when tests are given without feedback. This surprising phenomenon is called the testing effect, and although it has been studied by cognitive psychologists sporadically over the years, today there is a renewed effort to learn why testing is effective and to apply testing in educational settings. In this article, we selectively review laboratory studies that reveal the power of testing in improving retention and then turn to studies that demonstrate the basic effects in educational settings. We also consider the related concepts of dynamic testing and formative assessment as other means of using tests to improve learning. Finally, we consider some negative consequences of testing that may occur in certain circumstances, though these negative effects are often small and do not cancel out the large positive effects of testing. Frequent testing in the classroom may boost educational achievement at all levels of education.
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            The critical importance of retrieval for learning.

            Learning is often considered complete when a student can produce the correct answer to a question. In our research, students in one condition learned foreign language vocabulary words in the standard paradigm of repeated study-test trials. In three other conditions, once a student had correctly produced the vocabulary item, it was repeatedly studied but dropped from further testing, repeatedly tested but dropped from further study, or dropped from both study and test. Repeated studying after learning had no effect on delayed recall, but repeated testing produced a large positive effect. In addition, students' predictions of their performance were uncorrelated with actual performance. The results demonstrate the critical role of retrieval practice in consolidating learning and show that even university students seem unaware of this fact.
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              Choosing wisely: helping physicians and patients make smart decisions about their care.


                Author and article information

                [1 ]ISNI 0000 0001 0482 5331, GRID grid.411984.1, Department of Cardiology and Pneumology, , Göttingen University Medical Centre, ; Robert-Koch-Straße 40, D-37075 Göttingen, Germany
                [2 ]ISNI 0000 0001 0482 5331, GRID grid.411984.1, Department of Haematology and Medical Oncology, , Göttingen University Medical Centre, ; Robert-Koch-Straße 40, D-37075 Göttingen, Germany
                [3 ]ISNI 0000000121901201, GRID grid.83440.3b, Health Behaviour Research Centre, , University College London, ; 1-19 Torrington Place, London, WC1E 7HB UK
                [4 ]ISNI 0000 0001 2180 3484, GRID grid.13648.38, Department of Legal Medicine, , University Medical Centre Hamburg-Eppendorf, ; Butenfeld 34, D-22529 Hamburg, Germany
                +49 551 39-8922 ,
                BMC Med
                BMC Med
                BMC Medicine
                BioMed Central (London )
                6 July 2018
                6 July 2018
                : 16
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: University Medical Center Göttingen
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                © The Author(s) 2018


                video, medical education, clinical reasoning, choosing wisely, test-enhanced learning


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