A Pilot Study To Develop Single Best Answer Questions For Assessing Medical Students Knowledge On Wound Healing

Farah Shazana Muhammad Hisham1, 4th Year Medical Student , Samantha Holloway2, Senior Lecturer, Keith Harding2 , Head of Wound Healing Research Unit, Phillip Smith3, Consultant Neurologist. 1MBBCh, Cardiff University, 2Wound Healing Research Unit, School of Medicine, Cardiff University, Wales, United Kingdom, 3 Cardiff and Vale University Health Board

Introduction The Cardiff School of Medicine curriculum for Medical Undergraduate students is currently undergoing review through the C21 project that aims to create a world-class medical programme(1). The curriculum includes a diversity of subjects organised into subject panels(2). Content related to Wound Healing (WH) is currently taught in a didactic manner in years 1 and 2 with opportunities to consolidate knowledge during clinical blocks in years 3-5. Students knowledge is tested in end of year exams which include Single Best Answer (SBA) questions. The curriculum development team propose that the SBA style of assessment is useful for assessing students application of clinical knowledge, integration, problem solving and decision-making. Diagnostic synthesis skills and derivation of appropriate management and treatments for patients are also assessed through the use of SBA. The purpose of this study was to design a set of preliminary SBA questions on the topic of wound healing for year 3 to 5 medical students, and to evaluate whether they were useful as a summative assessment method. This study was undertaken as part of the Student Selected Component (SSC) module during the 3rd Year of the MB BCh undergraduate programme. Method A set of nine SBA questions was designed (Table 1) to take into consideration the learning outcomes of the curriculum and a range of patient scenarios to reflect relatively common wound aetiologies. An online WH course for all year 3 to 5 Cardiff University medical students based on these scenarios was set up on an online repository known as PeerWise (3) (Figure 1). The data were collected over a 2week period. The same set of SBA questions was also given to a panel of 12 WH experts, the purpose of which was to obtain feedback on the design and content of the questions. Ethical approval was not required for this study. Results (1) Table 1 shows the results for the student responses. Questions 2, 3 and 8 achieved the highest number of correct responses
Table 1: SBA Questions Image 1 Question A 67-year-old man with Crohns disease presents with ulcer on his right leg. The ulcer has recently become worse in appearance and the surrounding skin is erythematous. The appearance is as shown. What would be the first line therapy? A 60-year-old woman presents with a 3-day history of pain and swelling in her left leg. On examination, her temperature is 38.5C. Investigation: HbA1c 7.5% ( normal value 6.5%). The appearance of her leg is as shown. What is the most likely diagnosis? A 75-year old woman who has had a surgery for a hip fracture about 2 weeks ago and has remained in the ward since then. Initial risk assessment shows that this patient is at high risk of developing pressure ulcer. She can stand but cannot walk and her mini-mental state examination score is 24/30. What is her most important risk factor for developing pressure ulcer? A 50-year-old man presents with ulcer on his right foot. On examination, foot is warm and pulses are palpable. There are callus and slough surrounding the ulcerated area. Investigation:HbA1c 7.2% (normal value 6.5%). The appearance of his leg is as shown. What is the most likely ulcer type? A 48-year old woman presents to the general practitioner with 6-week history of ulcer above her left malleolus. On examination, her body mass index is 35 kg/m2 and the area is warm and tender to touch. The appearance of her leg is as shown. What is the most important management step? A 70-year old man presents with ulcer over his toes on his left foot. He complains of severe pain especially whilst walking. He has a 10-year history of thromboangiitis obliterans (Buerger s disease). On examination, his blood pressure is 180/110 mmHg. The appearance of his foot is as shown. The doctor suggests anti-hypertensive drugs for his hypertension. What is the best anti-hypertensive drug to prescribe? A 73-year old man presents with a chronic wound on his right leg above his ankle since an accident about 50 years ago. This has been treated as venous ulcer for many years without improvement. Urgent skin biopsy is requested. The appearance of his leg is as shown. What is the most likely diagnosis? A 59-year-old woman presents with 9-month history of ulcer over the left ankle. She has no exercise-induced pain. On examination, her leg shows no sign of cellulitis, and the pulses were dull but palpable. What is the most appropriate next investigation? A 48 year-old woman presents to the clinic to have dressing on her right medial malleolus removed. She has been treated for venous ulcer for about 3 months. On examination, pink granulation tissue can be seen and the wound bed does not bleed on contact. A bit of yellow, fibrinous tissue covers the wound bed. Her leg is tremendously less swollen than it was few months ago. Which one best describes that the wound is well healing?

Figure 1: An example of question uploaded in PeerWise(3).

Referred to as Question Stem

No image

Option choices

Question

No of Respondents

No of correct responses

Results (2) Responses and feedback were also received from 8 of the 12 experts approached. One-hundred percent agreement for the correct response to all the questions was not achieved in this study. However the 7 of 8 and 6 of 8 experts agreed on the most correct response to Questions 2 and 3 respectively. Discussion It is difficult to draw any firm conclusions from the results as the sample size is small. However it would appear that questions related to diagnostic synthesis (Questions 2,3 and 8) did seem to achieve a higher level of correct responses compared to questions related to patient management. Feedback from the WH experts emphasised the need for clearer clinical images and more detailed clinical scenario information.

1 2 3 4 5 6 7 8 9

11 10 9 10 11 10 10 9 8

3 8 8 4 4 5 6 8 3
9 No
image

8 No
imag e

Table 2: Results for student responses (n=11)

Email : muhammadhishamfs@cardiff.ac.uk Phone No:+44 (0) 7766 5858 94

Conclusion The data obtained from this study may not be able to provide conclusive evidence of whether the use of SBA are an effective method in gauging students knowledge on WH. However, it does provide preliminary information on students level of achievement for questions related to diagnosis of wound type versus appropriate management of a patient. Further research on a larger scale to examine this particular aspect is required to determine if the curriculum should focus more on appropriate treatment options for patients with wounds.
References 1. Cardiff University School of Medicine. Undergraduate studies: Our curriculum. 2012 [Online] Available at: http://medicine.cf.ac.uk/medicaleducation/undergraduate/why-choose-cardiff/our-curriculum/ 2. Cardiff University School of Medicine. C21 at a glance. 2012 [Online] Available at: http://medicine.cf.ac.uk/medical-education/c21/glance/ 3. Peer Wise Cardiff University. Course: Wound healing. 2013. [Online] Available at: http://peerwise.cs.auckland.ac.nz/course/main.php?course_id=7515