Blended learning of radiology improves medical students’ performance, satisfaction, and engagement

Past decades were highly impacted by rapid technological advancements and the introduction of information and communication technologies (ICT). This change led to permanent economic, social, and environmental changes, making nowadays society information-driven and highly connected [1]. This radical shift in societal behavior also reflects in students’ and teachers’ behaviors and must be considered by current educational guidelines. New educational methods must be dynamic and responsive, in order to follow this evolving environment [2].

E-learning formats from massive open online courses (MOOC) to short private online courses (SPOC) are widely used in educational sciences, including medical education courses [3, 4]. This paradigm shift in learning methods is a disruptive force because it challenges the tradition of lectures and shifts the educational experience in a learner-centered way. Health professions use SPOC technologies to improve the professional medical education of all medical students (MSs), ranging from undergraduate to postgraduates’ trainees [1, 5‐8]. These design decisions are driven by economical, logistical, and other planning considerations. However, most of time, the decision is made based on the combined strength of different modalities for presenting course information [3]. Indeed, SPOCs’ widespread acceptability has led to revised policies in educational standards, whatever are their types, ranging from fully online elements, i.e., computer-based learning environment without classroom components, to primary face-to-face learning with minor online elements [8].

Blended learning (BL) refers to a new educational strategy that integrates traditional face-to-face academic sessions with synchronous or asynchronous e-learning, to support and improve meaningful interactions between students, teachers, and electronic resources [9]. Most commonly, BL takes the advantages of both traditional courses and SPOC. Flipped classroom (FC) is one of the most challenging parts of BL, where learners are introduced to new concepts via independent use of “pre-work” from SPOC [10]. This newly acquired knowledge is then applied and consolidated in an interactive classroom [11, 12]. This educational concept has the advantage of allowing students to engage the information of a discipline, at their own pace [13‐15]. SPOC delivery platforms allow educators to create and deliver interactive courses in many forms as online resources, quizzes, virtual patients, or video-based lectures (VBL) [16‐18]. Many undergraduate MSs are auditors who engage primarily with videos while skipping over assessment problems, online discussions, and other interactive course components [19]. They, as young adults from Generation Z, make an extensive use of video in their daily lives [20]. The use of level-adapted VBLs is a new and innovative concept that meets the expectations of both teachers and students [21].

The importance of developing a formal medical imaging program has been demonstrated worldwide [22]. Indeed, medical imaging teaching is often sporadic and taught irregularly during other medical modules rather than on its own [5]. Medical school educational programs, particularly radiology undergraduate training, are not standardized throughout Europe and USA [23‐25]. The educational benefits of different types of radiology clerkships point at improvement in students’ knowledge, interpretation skills, and students’ satisfaction [26]. Additionally, there is a gap in knowledge of the exact benefits of these new educational tools compared to classical ones. Indeed, literature data lacks of reproducible and reliable tools to evaluate these techniques, and in the way to interpret results [1, 9, 27]. In this context, undergraduate medical imaging learning has been restructured in local university hospital using a combination of these new teaching concepts: blended learning based on a FC delivered in the form of VBLs and a face-to-face optional course. The purpose of this study is to decipher the impact of this teaching formula among three MS promotions. For this, three types of metrics were evaluated—performance, satisfaction, and engagement—using both quantitative metrics (pre/posttest results’ differences, students’ attendance, audience retention, and key moments of audience overview) and qualitative assessment criteria (directed and spontaneous feedback).

Learning medical practice requires young MSs to develop practical skills while increasing their knowledge, in order to be prepared for their future profession [33]. During the second cycle of medical studies, students learn how to interact not only with patients and their diseases, but also with the entire medical care team [34]. Additionally, the medical knowledge required for their future exercise is broad, covering fundamental knowledge, practical knowledge, particular gestures, and human contact [35]. For the last decades, new pedagogical techniques were tested in all medical fields, with the clear purpose of increasing students’ knowledge and commitment [36, 37].

Comparison of pre and posttests results showed a significant overall improvement (+ 4.7 ± 17.5, P = P = 10⁻⁹). Moreover, result analysis according to quartiles revealed that the low-achieving group (the lowest quartile) was most impacted by this learning. Indeed, while the vast majority of MSs improved in their posttest performances, low achievers showed the most important improvement. SPOCs delivered in the form of VBLs have important advantages in medical learning: speed of installation, availability, and no need for physical presence [38]. However, a successful blended learning combining several educational concepts requires that MSs adhere to VBLs and watch videos prior to the class. Metrics from this type of formula can be difficult to collect and interpret. In this study, quantitative results comparing pre and posttests were explored in a new manner. Low achievers appropriated VBL and their results have approached those of high achievers allowing for a homogenization in students’ improvement. Social cognitive theory emphasizes self-efficacy as the primary driver of motivated action, and identifies cues that influence future self-efficacy and support self-regulated learning [39]. While high achievers are encouraged and highly praised, less academically inclined students are often marginalized [40]. Low achievers usually report more positively toward the use of video as a learning tool, perceived as more effective learning [12]. Regardless of their level, VBL allows every MS to progress. These benefits are more apparent in low achievers, as shown in this study. High achievers seem to be reinforced by their preset results, and probably focused on other learning tasks or other courses, adapting thus their own learning schedule.

The students were globally very satisfied regarding VBLs (99% of satisfaction), as well as regarding the final face-to-face course. The pedagogical formula used in this study achieved high student engagement and satisfaction. Indeed, 86.1% of included students attended to the optional face-to-face course, showing their interest in keeping a close contact with teachers. E-learning has a major impact on Generation Z students [41]. Its use in teaching radiology for MSs is widely documented, with global student and teacher satisfaction as well as results improvement [39, 40, 42, 43]. The objective is a clear trend toward a highly interactive and self-directed learning environment to support the concept of life-long independent learners [44]. However, the community of teachers has difficulties finding scientific evidence on how they should design their teaching [45, 46].

FC presents benefits of both e-learning and traditional teaching, allowing for a greater educational impact with less instructional time [42, 47]. Students can access learning materials at their own pace [48]. In medical imaging learning, this technique seems to be more effective than traditional learning, but requires greater rigor and commitment from students [27], and a high quality of online imaging content and quizzes [49]. In this study, the overall rating of the learning format by students was high (99% of level of satisfaction), despite the higher required commitment. This is explained by the fact that VBLs were perceived as “engaging” by students. Indeed, pleasure in learning is a key concept for e-learning. This concept represents 750 citations in the spontaneous feedback collected by the satisfaction survey in this study. Furthermore, motivation is a fundamental criterion in online education. The absence of interaction with teachers makes it difficult to learn alone remotely, especially for complex courses and requires the establishment of more and longer seminars [50]. In our study, students clearly expressed the increase in their motivation related to VBLs. Motivation due to impending deadlines is important, as seen with the peak in student engagement and video connection peak before the posttest. Indeed, induced motivation results in a more extensive use of VBL by MSs than self-determined motivation [51]. However, further studies with true video engagement quantification will help to better understand students’ expectations.

In this study, there is a clear value in new educational technologies with a blended learning format combining e-learning and a face-to-face classical course, in which students can be in direct interaction with their teachers. Indeed, students improved their results, adhered to the learning concept, and attended to the face-to-face course. In current literature data, there is a lack of extensive and quantitative studies in medical learning in highlighting the real impact of e-learning [52, 53]. Although there are strong pedagogical arguments that favor a blended learning approach, literature on the relative effectiveness of blended versus traditional learning approaches is mixed. Students’ attendance and adherence to BL seem to be higher when compared to a classical format; this type of teaching favors long-term memorization and knowledge assimilation [13‐15, 54, 55], without impact on outcomes [56‐58].

VBLs achieving the highest view counts are those concerning emergency topics (appendicitis and diverticulitis) that may be applicable to a broader range of medical learners. The ability to access the educational content immediately, regardless of location, appears to be a major concern for students. Radiology is becoming increasingly important in the diagnostic and therapeutic management of patients. Indeed, radiology education does not only concern future radiologists but also any future doctors. Medical practitioners need more and more imaging knowledge upon time and technologies [59]. The development of mobile-learning, by the implementation of videos on smartphone applications, makes it possible to overcome this concern while using an innovative learning tool that is appreciated by the students [60‐62].

Educational videos are widely used in educational science as a dissemination tool for web-based training [63]. The effective use of videos as a teaching tool is enhanced when teachers consider how they should manage the cognitive load of videos, maximize student engagement with videos, and promote active learning from video [64]. The choice of using short videos in this work (average length of 5 min 5 s) was based on the fact that engagement is highly associated with video length [65]. The main advantage of the VBL format is time and place flexibility for potentially overwhelmed learners. Our choice of video production style was driven by our main purpose, which was to provide massive real-life imaging examples of both normal and pathological imaging findings in abdominal imaging [66]. Slide presentations with voice over production style showed high engagement in this study (96% of satisfaction).

However, this study has some limitations. First, there is an inclusion bias: 18% of MSs did not perform pre and posttests (80/433) and only 259 students over the 353 included (73.3%) answered the satisfaction survey. This is mainly due to the fact that these tests were not included in the final note that validates the abdominal rotation. In order to reduce the “missing” students’ rates, several reminders were introduced during the entire rotation, in order to encourage the students to perform the whole experience.

Further studies, in which true video engagement quantification is measured, and comparison to classical face-to-face courses will help to better understand students’ needs and behaviors regarding new technologies.

The blended learning format used in this study, combining short video-based lectures, as flipped classroom material, with a face-to-face course and pre and posttests showed high results regarding students’ performance, satisfaction, and engagement. This learning method has allowed students to progress by improving their motivation and pleasure in learning. This study shows that several metrics can be used to measure students’ improvement, and furthermore, the reasons for the success of a specific learning format, in a conceptual manner.