PURPOSE:A healthy work-life balance and an environment where students feel valued are goals of increasing importance in medical education. When these essential elements are absent or lacking, educators run the risk of losing their trainees, either physically or mentally, via a silent "check out," referred to as "quiet quitting." This study examined the maturation of value-based student engagement and students' tendency to disengage from academic tasks during their first year of college and shortly before graduation. METHOD:This longitudinal mixed methods study was conducted at the 6-year Doctor of Medicine program at the Radboud University Medical Center, Nijmegen, the Netherlands, 2017-2023. Scales for the Assessment of Learning and Performance in Students questionnaire data were connected with qualitative insights from focus group interviews from 10 student participants at 3 key points in their academic progression: the beginning and end of their first academic year and shortly before graduation. Through concurrent, exploratory, inductive analysis, the authors examined patterns, relationships, and discrepancies among the data, comparing and contrasting to ultimately draw overarching conclusions. RESULTS:Data analysis revealed a transformation in students' learning and performance motivation, becoming more intrinsically driven and connected to personal values. The willingness to invest effort was not a constant, varied among individual students over time, and became less pronounced when considering future employment prospects. Intellectual analysis on desired future work-life balance prompted students to consider a plan B for their career choice. Work-life balance concerns were mainly discussed within close-knit social circles. CONCLUSIONS:Student engagement or disengagement appeared to be a dynamic construct. Workplace learning seemed to trigger committed action. However, healthy work-life balance concerns grew stronger as students got closer to graduation. When drivers and barriers of engagement are not discussed, potential talent could be lost, quietly or openly.

PurposeThe ability to perceive assessments as learning instruments calls upon flexible perspective taking and flexible responding. We investigated the maturation of the student perspective on assessment as learning and explored the (in)flexibility of student responses during their development towards graduation.MethodsIn a longitudinal study with an extensive 6-year timeframe, we tracked the development of 12 medical students. We used a mixed-methods research design with consecutive association tests, focus group interviews and a concluding open-ended questionnaire to obtain a balanced and comprehensive dataset. Results from discourse analysis were integrated and connected to explore existing viewpoints and applied behaviours.ResultsDuring the first year of college, assessments often coincided with rigid perspective taking and inflexible responses. As students progressed, workplace-learning stimulated them to embrace assessment as a valuable tool for enhancing their learning experiences thereby broadening their behavioural repertoire. However, high-stakes summative assessments during the clinical rotations challenged this adaptive behaviour.ConclusionUndergraduate students tended to perceive their environment as controllable, avoiding or dismissing unwanted thoughts and feelings. In order to develop and maintain adaptive behaviour during high-stakes assessments, future research should focus on teaching our students skills for effective and flexible responding, enabling them to reach their full potential.

Introduction Knowledge, once acquired, degrades over time. Exams that contain questions related to previously acquired knowledge (‘retrieval practice questions’) may promote retrieval practice and spaced learning, and subsequently prevent knowledge loss. To investigate this hypothesis, we compare the score of retrieval practice questions to regular questions in exams of a two-year (bio)medical study program. Methods The two-year “Mechanisms of Health and Disease”-program for biomedical sciences and medical students in Nijmegen (the Netherlands) contains 14 spaced exams of 80 questions each. The percentages of correct-, false-, and non-answers were compared between regular questions and retrieval practice questions. Using Pearson correlations between question scores and exam scores ( RiT -values), the impact of retrieval practice questions on the internal consistency of exams was determined. Mixed model analyses determined changes in outcomes across time. Results Analysis of 2006 regular questions and 1728 retrieval practice questions revealed a significantly higher percentage of correct and false answers, and a significantly lower percentage of non-answers, in retrieval practice questions versus regular questions (all P < 0.05). Scores did not change across time. RiT -values were slightly lower in retrieval practice questions, with a small inverse trend across time. Conclusion Our data indicate preservation of knowledge, possibly related to retrieval practice and/or spaced learning. Although the RiT -values of retrieval practice questions were slightly lower than those of regular questions, the discriminative capacity was well within acceptable range. These data highlight the potency of retrieval practice questions to prevent knowledge decrement, without altering exam quality.

Binocular disparity provides one of the important depth cues within stereoscopic three-dimensional (3D) visualization technology. However, there is limited research on its effect on learning within a 3D augmented reality (AR) environment. This study evaluated the effect of binocular disparity on the acquisition of anatomical knowledge and perceived cognitive load in relation to visual-spatial abilities. In a double-center randomized controlled trial, first-year (bio)medical undergraduates studied lower extremity anatomy in an interactive 3D AR environment either with a stereoscopic 3D view (n = 32) or monoscopic 3D view (n = 34). Visual-spatial abilities were tested with a mental rotation test. Anatomical knowledge was assessed by a validated 30-item written test and 30-item specimen test. Cognitive load was measured by the NASA-TLX questionnaire. Students in the stereoscopic 3D and monoscopic 3D groups performed equally well in terms of percentage correct answers (written test: 47.9 ± 15.8 vs. 49.1 ± 18.3; P = 0.635; specimen test: 43.0 ± 17.9 vs. 46.3 ± 15.1; P = 0.429), and perceived cognitive load scores (6.2 ± 1.0 vs. 6.2 ± 1.3; P = 0.992). Regardless of intervention, visual-spatial abilities were positively associated with the specimen test scores (η2 = 0.13, P = 0.003), perceived representativeness of the anatomy test questions (P = 0.010) and subjective improvement in anatomy knowledge (P < 0.001). In conclusion, binocular disparity does not improve learning anatomy. Motion parallax should be considered as another important depth cue that contributes to depth perception during learning in a stereoscopic 3D AR environment.

Spatial ability (SA) is the cognitive capacity to understand and mentally manipulate concepts of objects, remembering relationships among their parts and those of their surroundings. Spatial ability provides a learning advantage in science and may be useful in anatomy and technical skills in health care. This study aimed to assess the relationship between SA and anatomy scores in first‐ and second‐year medical students. The training sessions focused on the analysis of the spatial component of objects' structure and their interaction as applied to medicine; SA was tested using the Visualization of Rotation (ROT) test. The intervention group ( n = 29) received training and their pre‐ and post‐training scores for the SA tests were compared to a control group ( n = 75). Both groups improved their mean scores in the follow‐up SA test ( P < 0.010). There was no significant difference in SA scores between the groups for either SA test ( P = 0.31, P = 0.90). The SA scores for female students were significantly lower than for male students, both at baseline and follow‐up ( P < 0.010). Anatomy training and assessment were administered by the anatomy department of the medical school, and examination scores were not significantly different between the two groups post‐intervention ( P = 0.33). However, participants with scores in the bottom quartile for SA performed worse in the anatomy questions ( P < 0.001). Spatial awareness training did not improve SA or anatomy scores; however, SA may identify students who may benefit from additional academic support.

Anatomical examinations have been designed to assess topographical and/or applied knowledge of anatomy with or without the inclusion of visual resources such as cadaveric specimens or images, radiological images, and/or clinical photographs. Multimedia learning theories have advanced the understanding of how words and images are processed during learning. However, the evidence of the impact of including anatomical and radiological images within written assessments is sparse. This study investigates the impact of including images within clinically oriented single-best-answer questions on students' scores in a tailored online tool. Second-year medical students (n = 174) from six schools in the United Kingdom participated voluntarily in the examination, and 55 students provided free-text comments which were thematically analyzed. All questions were categorized as to whether their stimulus format was purely textual or included an associated image. The type (anatomical and radiological image) and deep structure of images (question referring to a bone or soft tissue on the image) were taken into consideration. Students scored significantly better on questions with images compared to questions without images (P < 0.001), and on questions referring to bones than to soft tissue (P < 0.001), but no difference was found in their performance on anatomical and radiological image questions. The coding highlighted areas of "test applicability" and "challenges faced by the students." In conclusion, images are critical in medical practice for investigating a patient's anatomy, and this study sets out a way to understand the effects of images on students' performance and their views in commonly employed written assessments.

To prepare the faculty of the Medical School of the Radboud university medical center in Nijmegen for the new curriculum based on components of self-directed learning that started in 2015, the behaviour in registration, presence and educational experiences of old curriculum students towards one of the components of self-directed learning: the letting go of mandatory classes was studied in 2014. Freedom to attend was introduced in human anatomy laboratories during a Year-1 and a Year-2 course. A web-based enrolment system was used, and student’s choices and changes were logged. Student’s opinions on the optional classes were probed with a questionnaire. Year-2 students liked the optional classes more than Year-1 students. Both groups disliked classes that were scheduled at the end of the day. Both groups perceived that the freedom to attend stimulated their responsibility and learning experience. In conclusion, the freedom to attend classes caused perceptions that are congruent with self-directed learning. The findings suggest that feelings of autonomy and being competent to the required task were stimulated by the freedom of choice. Implementing the freedom to attend classes in medical education is therefore recommended whereas one should also consider the feasibility with respect to organisation, efficient use of teachers and financial resources.

Neuroanatomy education is a challenging field which could benefit from modern innovations, such as augmented reality (AR) applications. This study investigates the differences on test scores, cognitive load, and motivation after neuroanatomy learning using AR applications or using cross-sections of the brain. Prior to two practical assignments, a pretest (extended matching questions, double-choice questions and a test on cross-sectional anatomy) and a mental rotation test (MRT) were completed. Sex and MRT scores were used to stratify students over the two groups. The two practical assignments were designed to study (1) general brain anatomy and (2) subcortical structures. Subsequently, participants completed a posttest similar to the pretest and a motivational questionnaire. Finally, a focus group interview was conducted to appraise participants' perceptions. Medical and biomedical students (n = 31); 19 males (61.3%) and 12 females (38.7%), mean age 19.2 ± 1.7 years participated in this experiment. Students who worked with cross-sections (n = 16) showed significantly more improvement on test scores than students who worked with GreyMapp-AR (P = 0.035) (n = 15). Further analysis showed that this difference was primarily caused by significant improvement on the cross-sectional questions. Students in the cross-section group, moreover, experienced a significantly higher germane (P = 0.009) and extraneous cognitive load (P = 0.016) than students in the GreyMapp-AR group. No significant differences were found in motivational scores. To conclude, this study suggests that AR applications can play a role in future anatomy education as an add-on educational tool, especially in learning three-dimensional relations of anatomical structures.

This study examines the long-term retention of anatomical knowledge from 180 students after various repetition activities. The retention of anatomical knowledge was assessed by multiple-choice tests at five different points in time: before and after a course in Functional Anatomy, before and after repetition activities that occurred 14 weeks after this course, and 28 weeks after this course to establish long-term retention. Students were divided into five groups: one without any repetition activity, one with a restricted repetition activity (the multiple-choice test), and three groups that were offered repetition activities (traditional lecture, e-learning module, and small group work in the dissection room). During all three repetition activities the same information was conveyed, and this content was not revisited in other courses for the duration of the study. The results showed that students who did not engage in a repetition activity scored significantly lower on the long-term retention test compared to all other groups (ANCOVA: P = 0.0001). Pair-wise comparison with estimated means showed that the other four groups, regardless of the type of repeating activity, did not differ in the amount of knowledge they retained during any of the five assessments (P = 0.008, P = 0.0001, P = 0.001, and P = 0.0001, respectively). This study suggests that the type of repetition activity has no effect on knowledge retention both immediately following the activity and in the long term. It is concluded that the repetition of anatomical knowledge in any form is beneficial for students and will likely improve student outcomes in a curriculum that builds on prior knowledge.

Background: It is generally assumed that learning in context increases performance. This study investigates the relationship between the characteristics of a paper-patient context (relevance and familiarity), the mechanisms through which the cognitive dimension of context could improve learning (activation of prior knowledge, elaboration and increasing retrieval cues), and test performance. Methods: A total of 145 medical students completed a pretest of 40 questions, of which half were with a patient vignette. One week later, they studied musculoskeletal anatomy in the dissection room without a paper-patient context (control group) or with (ir)relevant-(un)familiar context (experimental groups), and completed a cognitive load scale. Following a short delay, the students completed a posttest. Results: Surprisingly, our results show that students who studied in context did not perform better than students who studied without context. This finding may be explained by an interaction of the participants’ expertise level, the nature of anatomical knowledge and students’ approaches to learning. A relevant-familiar context only reduced the negative effect of learning the content in context. Our results suggest discouraging the introduction of an uncommon disease to illustrate a basic science concept. Higher self-perceived learning scores predict higher performance. Interestingly, students performed significantly better on the questions with context in both tests, possibly due to a ‘framing effect’. Conclusions: Since studies focusing on the physical and affective dimensions of context have also failed to find a positive influence of learning in a clinically relevant context, further research seems necessary to refine our theories around the role of context in learning.

A new wave of virtual reality headsets has become available. A potential benefit for the study of human anatomy is the reintroduction of stereopsis and absolute size. We report a randomized controlled trial to assess the contribution of stereopsis to anatomy learning, for students of different visuospatial ability. Sixty-three participants engaged in a one-hour session including a study phase and posttest. One group studied 3D models of the anatomy of the deep neck in full stereoptic virtual reality; one group studied those structures in virtual reality without stereoptic depth. The control group experienced an unrelated virtual reality environment. A post hoc questionnaire explored cognitive load and problem solving strategies of the participants. We found no effect of condition on learning. Visuospatial ability however did impact correct answers at F(1)=5.63 and p=.02. No evidence was found for an impact of cognitive load on performance. Possibly, participants were able to solve the posttest items based on visuospatial information contained in the test items themselves. Additionally, the virtual anatomy may have been complex enough to discourage memory based strategies. It is important to control the amount of visuospatial information present in test items.

Medical students consider anatomy, neurology, and traumatology as difficult study topics. A recent study showed that the daily quiz ‘Two Opportunities to Practice per day (TOPday)’ positively supported biomedical students in analyzing and solving biomechanical problems. The main purpose of this study was to investigate the effect of TOPday on self-confidence, enthusiasm, and test results for the topics anatomy, neurology and traumatology. Second-year medical students were enrolled in a four-week course on the human skeletal system at the Radboudumc (n = 799). They were randomized over three topic groups (anatomy, neurology, and traumatology) and received TOPday quizzes on every course day. At the end of the course students filled in a non-anonymous questionnaire. Students highly appreciated TOPday (7.5±0.9) and this did not differ between groups (anatomy: 7.4±0.8; neurology: 7.4±1.1; traumatology: 7.5±0.8; P = 0.68). Many students reported that TOPday increased their self-confidence (65% of the students) and enthusiasm (69% of the students) for their topic. However, test results of the students did not improve. A potential explanation for the latter result may relate to the different cognitive processes that are required to study anatomy, neurology, and traumatology compared to biomechanics. In conclusion, appreciation, self-confidence and enthusiasm were positively associated with TOPday, but test results were not.

Background: It was hypothesized that cooperation would be stimulated in small groups preparing for peer-teaching when the required formality level of the subsequent actual peer-teaching event would be higher. This higher formality level was supposed to increase the appeal on the individual accountability of the students to the shared result, being the preparation of the execution of peer- teaching. Aim: This study explores whether in-class formality during peer-teaching in a small group stimulates perceived participation, satisfaction and learning gain. Methods: Four in-class formality levels of peer-teaching (A-D) were defined and practiced in thirty group assignments of about 15 students, using a randomized cluster design with four arms: A) absence of peer-teaching, B) informal peer-teaching, C) and D) peer-teaching with the use of a frontal class presentation. Peer-teacher selection was either executed by the peers (B and C) or by throwing a dice just prior to the presentation (D). All students took a pretest, a post-test and a follow-up test and completed a questionnaire. The Friedman test, Wilcoxon’s signed ranks test and ANOVA were used to analyze the questionnaires. Learning gain was analyzed using a repeated measures ANOVA. Results: The overall scores on the satisfaction and perceived participation increased significantly from A to D (p = 0.000) and the students in D scored higher than those in C (p = 0.007). For 10 out of 19 individual questions a significant difference was found. Mostly A scored lower than D or than C and D, but also differences between B, C and D were found in which D scored highest. The learning gain did not differ significantly between the arms. Conclusion: This study shows that, although student’s perceived participation and satisfaction rise with in-class formality level, the learning gains do not increase simultaneously.

Background Exams in anatomy courses are traditionally summative. Formative testing induces retrieval practice, provides feedback and enhances learning results. We investigated the optimal frequency for retrieval practice during an anatomy course.Method During a first-year course, students were offered four online daily quizzes a week that assessed thoracic anatomy. Once a week they received a quiz about abdominal anatomy. Students immediately received feedback afterwards. In the fourth course week, a survey about participation and satisfaction was taken. 424 students participated in the final summative exam. Trunk wall questions were used as a control. Relationship between participation and test results was investigated with a one-way ANOVA.Results More frequent participation in formative tests was correlated to higher scores in the summative exam with no difference between daily and weekly quizzes. This effect was found for thorax-abdomen and 'control' trunk wall questions. Participation in weekly quizzes was higher (p<0.001). All survey responses showed a significant difference in favour of the weekly quiz (p<0.001).Discussion and conclusion Participation in formative quizzes was correlated to summative exam scores. This correlation was not specific for the material tested, probably because of diligence. Student participation and preference were much higher in weekly quizzes.

Background It is generally assumed that learning in context increases performance. This study investigates the relationship between the characteristics of a paper-patient context (relevance and familiarity), the mechanisms through which the cognitive dimension of context could improve learning (activation of prior knowledge, elaboration and increasing retrieval cues), and test performance. Methods A total of 145 medical students completed a pretest of 40 questions, of which half were with a patient vignette. One week later, they studied musculoskeletal anatomy in the dissection room without a paper-patient context (control group) or with (ir)relevant-(un)familiar context (experimental groups), and completed a cognitive load scale. Following a short delay, the students completed a posttest. Results Surprisingly, our results show that students who studied in context did not perform better than students who studied without context. This finding may be explained by an interaction of the participants’ expertise level, the nature of anatomical knowledge and students’ approaches to learning. A relevant-familiar context only reduced the negative effect of learning the content in context. Our results suggest discouraging the introduction of an uncommon disease to illustrate a basic science concept. Higher self-perceived learning scores predict higher performance. Interestingly, students performed significantly better on the questions with context in both tests, possibly due to a ‘framing effect’. Conclusions Since studies focusing on the physical and affective dimensions of context have also failed to find a positive influence of learning in a clinically relevant context, further research seems necessary to refine our theories around the role of context in learning.

Because of a decrease of the time available for anatomy education, decisions need to be made to reduce the relevant content of the anatomy curriculum. Several expert consensus initiatives resulted in lists of structures, lacking analysis of anatomical competence. This study aims to explore the use of anatomical knowledge by medical doctors in an attempt to delineate the nature of anatomical competence. The research question is: what kind of anatomical knowledge do junior medical doctors use during a consultation with a patient presenting with a shoulder complaint? Ten junior medical doctors participated in this stimulated recall study. Each of them was videotaped while performing a consultation with a standardized patient with a complex shoulder complaint. The recording was viewed immediately after. Participants were videotaped again while verbalizing the thoughts they remembered having during the consultation. Verbatim transcriptions were coded by two coders using the qualitative data analysis ATLAS.ti software. Results were that these junior medical doctors used anatomical knowledge in all phases of the consultation, especially during physical examination. The use of anatomical terms was strongly associated with clinical reasoning and it was apparent that every subject visualized relevant anatomical information. Conclusion is that young medical doctors actively use their anatomical knowledge and it seems that the relevant anatomy consists largely of adequate visual representations in memory. Anatomy teachers should focus the students' learning activity on building an adequate visual representation of anatomical structures. This should be supported by assessments that test the quality of the students' visual representations. Anat Sci Educ. © 2015 American Association of Anatomists.

Clay modeling is increasingly used as a teaching method other than dissection. The haptic experience during clay modeling is supposed to correspond to the learning effect of manipulations during exercises in the dissection room involving tissues and organs. We questioned this assumption in two pretest–post‐test experiments. In these experiments, the learning effects of clay modeling were compared to either live observations (Experiment I) or video observations (Experiment II) of the clay‐modeling exercise. The effects of learning were measured with multiple choice questions, extended matching questions, and recognition of structures on illustrations of cross‐sections. Analysis of covariance with pretest scores as the covariate was used to elaborate the results. Experiment I showed a significantly higher post‐test score for the observers, whereas Experiment II showed a significantly higher post‐test score for the clay modelers. This study shows that (1) students who perform clay‐modeling exercises show less gain in anatomical knowledge than students who attentively observe the same exercise being carried out and (2) performing a clay‐modeling exercise is better in anatomical knowledge gain compared to the study of a video of the recorded exercise. The most important learning effect seems to be the engagement in the exercise, focusing attention and stimulating time on task. Anat Sci Educ 7: 420–429. © 2014 American Association of Anatomists.