Hogg et al.

BMC Medical Education (2020) 20:10

[Link]

RESEARCH ARTICLE Open Access

A non-randomised trial of video and

written educational adjuncts in
undergraduate ophthalmology
H. D. Jeffry Hogg1,2*, Michael Pereira1, Julian Purdy1, Richard J. R. Frearson1,2 and Gordon B. Lau2

Abstract
Background: Provision of relevant pre-learning materials has been shown to increase student engagement and
improve outcomes in medical education. This non-randomised study attempts to quantify the educational gains,
and relative efficacy of video and written pre-learning materials, in ophthalmology undergraduate teaching.
Methods: Ninety-eight final year medical students were contacted prior to their three-day ophthalmology placements at a
British tertiary ophthalmology unit. All participants were sent welcome packs prior to arrival requesting they undertake 90
min of work focusing on a list of specified ophthalmic conditions. One cohort (N = 33) were sent written materials, another
(N = 32) was provided with video materials and a third cohort (N = 33) were not sent any materials. On arrival participants
completed a simple knowledge test, a questionnaire estimating the time they spent preparing for the placement and a self-
reported knowledge score. The teaching on placement was the same for all cohorts. At the conclusion of each placement
participants completed a challenging knowledge test, a clinical skills test and repeated self-reported knowledge scores.
Results: Eighty seven percent of students receiving specified materials claimed to complete pre-placement work compared
to 70% of those receiving learning outcomes alone (p = 0.05). Students receiving learning materials scored higher in the
post-placement tests of knowledge (p < 0.001), 74.8% (72.4–77.2%) vs 63.6% (95%CI 59.3–67.9%) and skills (p = 0.04), 86.9%
(83.9–89.9%) vs 81.3% (77.2–85.4%). Students using video resources outperformed students using written materials in their
visual acuity assessment test (p = 0.03), 90.4% (86.6–94.2%) vs 83.6% (80.1–87.1%) whilst those receiving written
rather than video material performed better in the end of placement knowledge test (p = 0.03), 77.7%
(74.3–81.1%) vs 72.0% (68.9–75.1%).
Conclusion: This study showed that providing pre-placement learning materials improves undergraduates’
commitment and achievement. Written materials better facilitate knowledge acquisition while video materials
preferentially promote skill acquisition. This is a novel demonstration within ophthalmology and can help address the
imbalance between the expectations placed on undergraduates and the resources committed to ensuring they are
met.
Keywords: Undergraduate education, Ophthalmology, Learning resources, Technology enhanced learning, Video
resources

* Correspondence: [Link]@[Link]
1
The University of Newcastle upon Tyne, Newcastle upon Tyne, Tyne and
Wear NE1 7RU, UK
2
The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon
Tyne, Tyne and Wear NE1 7RU, UK

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License ([Link] 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
([Link] applies to the data made available in this article, unless otherwise stated.
Hogg et al. BMC Medical Education (2020) 20:10 Page 2 of 8

Background initial test scores, in-placement test scores, clinical

The modernisation of undergraduate medical curricula supervisor impression, self-reported scores and end of
has frequently involved a reduction in the course time placement examination skills test scores. We will also
dedicated to ophthalmology across the globe [1–4]. This explore the relative impacts of directing learners toward
is thought to stem from curriculum designers striving to video and textual resources as prior work in under-
cover a growing curriculum and to grant their graduates graduate ophthalmology has suggested a greater efficiency
access to the increasingly disparate careers of primary of learning from video materials [15].
care generalist, specialist and researcher [5]. Interven-
tions such as the establishment of a standardised under- Methods
graduate curriculum and a minimum clinical exposure Ninety-eight final year medical students attended an oph-
time from the International Council of Ophthalmology thalmology department at a tertiary centre for a three-day
have not reversed this long-reported decline [6, 7]. clinical placement between January and May of 2017. Each
There are consequences for patient care in this trend as three-day placement was attended by groups of six or
primary care physicians consistently report low levels of seven students and their placement was an equal mix of
confidence in managing eye conditions with a majority classroom and workplace teaching, alternating between
feeling their undergraduate ophthalmology education the two environments each day over two sessions on the
was inadequate [8–10]. If increasing undergraduate first day and four sessions on the second and third day.
ophthalmology exposure is untenable, then a shift in Classroom sessions were broken down into short lectures
focus towards optimising the efficacy of the limited time and practical role play history and examination exercises.
learners have is likely to be more productive. Workplace sessions were delivered by members of the
The nature and content of a clinical placement is of clinical team through one to one shadowing in the emer-
central importance to learners’ educational outcomes, gency eye department, general ophthalmology clinics and
but is dependent on the host institution’s ability to subspecialty ophthalmology clinics. All placements were
designate appropriate resources. The resources dedicated managed by a single clinical teaching fellow and involved
to undergraduate ophthalmology education are often the same clinics to ensure the content of each placement
minimal and a recent systematic review has called for re- remained constant throughout the study period. As in this
search to focus on improving the efficiency of teaching case, clinical teaching fellows are typically junior doctors
rather than demanding a greater share of teaching time with a mix of clinical and education duties. Typically, they
[11]. The theoretical basis of this goal is to minimise the have completed at least 2 years of postgraduate practice
extrinsic and germane cognitive load that learners ex- and may or may not have committed to a certain specialty.
perience during their placement in order to maximise One week prior to attending each student was emailed a
the progress they can make in the time available [12]. welcome pack composed of an introductory letter, a time-
To achieve this, students need to be made as receptive table for the placement, a list of core conditions and a re-
as possible to the learning outcomes prior to starting a quest that students undertake 90 min of work in
placement. A key contributor to this is the pre-training preparation for a test upon arrival. The students were also
principle; where learners gain more knowledge from a notified of the education research project and asked if they
given learning experience if they have prior exposure to were willing for their anonymised data to be used, this
its content and how to process it [13]. In their meta- written request was repeated verbally at the outset of each
analysis of 128 studies into the impact of pre-training placement. We developed the welcome pack on two occa-
for training systems ranging from typing to police opera- sions over the five-month period, but the 1 week advance
tions, Mesmer-Magnus et al. demonstrated a significant with which students received it remained constant
impact for pre-training on cognitive, skill and affective throughout. Firstly we attached written materials which
learning outcomes [14]. covered core ophthalmology content and subsequently we
To test the relevance of pre-training theory to under- replaced these written materials with links to educational
graduate ophthalmology we present a pragmatic obser- videos covering the same content. These written and video
vational study of final year medical students. We materials are publicly available and similar welcome packs
hypothesise that medical undergraduates demonstrate could easily be replicated at other institutions [16]. No
greater learning over the course of a short ophthalmo- other interventions were made.
logy placement if directed towards relevant learning ma- To remove bias from diffusion of treatment we
terials beforehand. Our primary outcome measure is the collected data from consecutive groups who received the
end of placement test score as it is most representative welcome pack in one of the three stages of development;
of the tools used to assess undergraduate ophthalmology no materials, written materials and video materials. At
competency by medical schools. Secondary outcomes the outset of the placement each student completed a 45
include pre-placement work completion and duration, mark test (one mark per question) covering the basics of
Hogg et al. BMC Medical Education (2020) 20:10 Page 3 of 8

ocular anatomy, retinopathy, visual pathway, red eye and no materials to those receiving video or written mate-
visual loss. Students also completed hard copies of five- rials. To address our secondary hypothesis that the effi-
point Likert scale questionnaires with only numerical cacy of video and written materials differ we then went
extremes marked by text (5 positive, 1 negative) marked. on to perform a direct comparison between written and
These indicated their perception of their own ophthal- video materials for variables that had proved significant
mology knowledge and their interest to pursue it as a in the first analysis. To test correlations, Pearson r and
career. During the placement ten-point Likert scales Spearman’s rho were used for parametric and non-
were emailed to consultants who had provided individ- parametric data respectively.
ual teaching in clinics to gain their impression of student
knowledge and engagement, again only numerical ex- Results
tremes were translated to text (10 positive, 1 negative). Pre-placement learning materials
These consultant supervisors were blinded to pre- Ninety five percent of students (N = 93) volunteered
material allocation. As an objective measure of perform- whether or not they had done pre-placement work
ance during the placement, groups were also tested on (Table 1). Students who had been given specified written
the content of seminars at their conclusion using Turn- or video materials were more likely (p = 0.05) to prepare
ing Point™ (Turning Technologies™, Ohio, USA). These for the placement (87%) than those who had not (70%).
took the form of 24 five-choice multiple choice ques- Whether these resources were video or written had no
tions delivered over four classroom sessions (one mark significant impact on the likelihood that they would be
per question). At the conclusion of the placement each used (p = 0.11). Of the 33 students not sent specified
student completed a more challenging exam with 22 resources 61% (N = 20) identified and read their own
four-choice multiple choice questions covering the core written materials and 9% (N = 3) identified and viewed
conditions stated in their welcome pack (one mark per video materials. In an as-treated analysis students identi-
question). They were also asked to rate their own oph- fying their own written resources performed worse in
thalmology knowledge and career interest again using both initial and final knowledge tests compared to
the same Likert scale from the initial assessment. Each students receiving specified written resources (Fig. 1).
student was then tested on their ability to assess visual Of the students claiming completion of pre-placement
acuity with a simulated patient using an objective struc- work the time spent was not significantly affected by
tured clinical examination (OSCE). At the conclusion of having had resources specified to them (Table 2). For
the final placement all 98 students were invited to this comparison students denying completion of pre-
complete a hard copy of a ten-point Likert questionnaire placement work were assigned a time of zero minutes.
on their perceived efficacy of different learning strategies The difference in score on the initial knowledge test was
for the acquisition of knowledge and skill. As before, also not significantly different between the two groups
only numerical extremes were translated to text. At this (p = 0.15). However, a five point agreement Likert scale
point all students had been made aware of the written with the statement ‘my knowledge of ophthalmology is
and video learning materials used over the 5 months adequate to pass my finals examination’ showed stu-
through their online learning management system. dents’ perception of their own knowledge was improved
A prospective power calculation was not performed as by pre-placement materials (p = 0.005). Final knowledge
the study was built around the host ophthalmology and skills test scores, final self-reported knowledge
teaching programme and so cohort size was limited to a ratings and supervisor reported knowledge were all found
single final year group. Data were analysed using SPSS to be significantly higher in students who had received
v.24 (IBM Corporation, New York, USA) comparing the specified pre-placement learning materials (Table 2).
performance of students given specified pre-materials However, no significant differences were found in know-
with those who were not. An intention-to-treat approach ledge retention immediately after seminars. Supervisor
was used for comparative tests as the study aimed to reported student engagement levels were also found
produce pragmatic data reflecting the impact of the to be equivalent between groups (p = 0.78).
intervention. In some settings additional insights were
gained from as-treated analysis, these comparisons are Video versus written pre-placement learning materials
specified. The impact of written and video pre-materials Of the 33 students receiving written pre-placement learning
was also compared. When comparing two groups, two- materials 82% (N = 27) used them whereas 69% (N = 22) of
tailed student t-tests or Mann-Whitney u-tests were the 32 students receiving video materials made use of them.
used for parametric and non-parametric data respect- Of the five parameters found to be significantly impacted by
ively. As the primary hypothesis this study aimed to test specifying learning resources of some kind, only the end of
was whether or not pre-placement materials of any kind placement knowledge test score was significant when com-
were beneficial, we initially compared students receiving paring video and written pre-materials(Table 3). Students
Hogg et al. BMC Medical Education (2020) 20:10 Page 4 of 8

Table 1 Table showing student resource allocation and distribution of student-reported pre-placement work completed
No specified materials Written materials received Video materials received Total
N = 33 N = 33 N = 32 N = 98
Declined comment 0 (0%) 2 (6%) 3 (9%) 5 (5%)
No work done 10 (30%) 2 (6%) 6 (19%) 18 (18%)
Written materials used 20 (61%) 26 (79%) 1 (3%) 47 (48%)
Video materials used 1 (3%) 0 (0%) 19 (59%) 20 (20%)
Audio materials used 1 (3%) 2 (6%) 0 (0%) 3 (3%)
Both video and written materials used 1 (3%) 1 (3%) 3 (9%) 5 (5%)

receiving written materials scored a mean of 77.7% compared perception of video and written materials for knowledge
to 72.0% among students receiving video materials (p = 0.03). acquisition. However, video materials were considered
With an as-treated analysis, students that went on to use significantly better for skill acquisition (Table 4).
video materials had a mean OSCE score of 90.4% (95% CI:
86.4–90.4%) compared to 83.6% (95% CI: 80.1–87.1%) for
students who went on to use written materials (p = 0.03). Student performance prediction
This suggestion of video materials’ superiority for skill There was a significant positive correlation (r = 0.316)
acquisition was supported by student perception of the between the time students claimed they had worked
relative value of these modalities. Fifty-three students prior to their placement and their performance at the
(54%) completed 10-point Likert questionnaires demon- end of placement knowledge test (p = 0.003). When ap-
strating their agreement with four statements; ‘video/ plying an as-treated analysis to these data separately for
written learning materials are most effective for know- video and written resources, the correlation coefficients
ledge/skill acquisition’. Using a paired sign test, on ac- were 0.455 (p = 0.06) and 0.239 (p = 0.13) respectively
count of the non-parametric and skewed nature of the (Fig. 2). There was also a positive but non-significant re-
data, there was no significant difference in student lationship between supervisor impression of student

Fig. 1 Chart displaying an as-treated analysis of student performance on two different ophthalmology knowledge tests at the outset of the placement
and at its conclusion. Chart shows means with 95% confidence intervals, p values calculated with Mann-Whitney u-tests
Hogg et al. BMC Medical Education (2020) 20:10 Page 5 of 8

Table 2 Table showing differences in performance between students who received specified pre-placement learning materials and
those who did not
No PPR 95% CI Specified PPR 95% CI p value
Mean time on pre-placement work (mins) 51 43.3–58.7 61.9 39.0–84.8 0.15
Mean initial knowledge test score (%) 56 52.3–59.7 60.4 56.8–64.0 0.12
Mean initial self-reported knowledge rating/5 1.7 1.4–2.0 2.3 2.1–2.5 0.005*
Mean supervisor knowledge rating/10 6.4 5.7–7.1 7.5 7.0–8.0 0.006*
Mean supervisor engagement rating/10 8.6 8.2–9 8.5 8.1–8.9 0.78
Mean post-seminar interactive test score (%) 70.4 61.6–79.2 74.5 70.5–78.5 0.89
Mean final knowledge test score (%) 63.6 59.3–67.9 74.8 72.4–77.2 < 0.001*
Mean final self-reported knowledge rating/5 3.8 3.5–4.1 4.3 4.1–4.5 0.001*
Mean OSCE score (%) 81.3 77.2–85.4 86.9 83.9–89.9 0.04*
p values calculated using two-tailed t-tests for parametric data and Mann-Whitney u-tests for non-parametric data. OSCE Objective structured clinical examination.
CI Confidence interval. PPR Pre-placement resources. * = statistical significance defined as p < 0.05

knowledge and performance in the end of placement ophthalmology undergraduate education from Steedman
knowledge test (p = 0.13). et al. which demonstrated equivalent test results follow-
ing a shorter work duration from students using multi-
Discussion media learning compared to textual materials alone [15].
This pragmatic single centre study shows that the Whilst intention-to-treat analysis did not find a signifi-
provision of learning materials prior to undergraduate cant difference in OSCE performance between recipients
ophthalmology clinical placements significantly im- of video and written materials, a comparison based on
proved subjective and objective measures of knowledge what materials individuals actually went on to use did
and skill performance. This effect is likely due to both suggest an objective advantage in clinic skill learning for
the demonstrated increased engagement with pre- video materials. This is also supported by subjective data
training by students when materials were specified and that video materials are more effective than written ma-
also the higher efficacy of teacher selected materials rela- terials in helping learners acquire skills (Table 4). These
tive to student selected materials. As few students in our findings are consistent with work in endocrinology
study independently sourced video materials we were showing improvement in undergraduate clinical skill
unable to evaluate the efficacy of student sourced video performance with the availability of specified video
materials. However, evidence from ophthalmology and materials [19].
other areas of healthcare suggest that clinical skills The proof of our hypothesis that pre-placement ma-
videos selected to meet student needs are also more terials improve learning efficiency on an undergraduate
effective than video materials that students source ophthalmology placement is informative but not un-
independently [17, 18]. Our data suggest that written expected. The real value of the outcome is the reprodu-
materials yield better results on knowledge tests than cibility of the means by which it was achieved. To
video materials if student time is unlimited. However, if minimise barriers to teachers implementing similar ap-
students are only willing or able to commit a short proaches both the welcome pack and learning resources
period of time to self-directed learning it seems that used are publicly available (Additional files 1, 2 and 3)
video materials may have a greater yield (Fig. 2). This is [16]. In considering feasibility of the distribution of pre-
consistent with a randomised controlled trial (RCT) in placement materials at any given institution it is also

Table 3 Comparison of the impact of specifying video and written pre-placement learning materials in parameters where specifying
written or video learning materials was found to have a significant impact
Video LRS 95% CI Written LRS 95% CI p value
Mean initial self-reported knowledge rating/5 2.4 2.1–2.7 2.1 1.8–2.4 0.14
Mean supervisor knowledge rating/10 7.5 6.9–8.1 7.6 6.9–8.3 0.70
Mean final knowledge test score (%) 72.0 68.9–75.1 77.7 74.3–81.1 0.03*
Mean final self-reported knowledge rating/5 4.2 3.9–4.5 4.4 4.2–4.6 0.47
Mean OSCE score (%) 88.1 84.0–92.2 86.0 81.6–90.4 0.53
p values calculated using two-tailed t-tests for parametric data and Mann-Whitney u-tests for non-parametric data. OSCE Objective structured clinical examination.
CI Confidence interval. LRS Learning resources specified. * = statistical significance defined as p < 0.05
Hogg et al. BMC Medical Education (2020) 20:10 Page 6 of 8

Table 4 Student reported perception of video and written materials claimed to have spent compared to the 90 min
learning material efficacy for knowledge and skill acquisition requested of them suggest these attempts were at least
Knowledge Skill in part successful. Student feedback placed great value
Mean 95% CI p value Mean 95% CI p value on the welcome pack that had been sent 1 week prior to
Written materials 5.4 4.9–5.9 0.12 4.8 4.3–5.4 < 0.001 attending the placement, as it gave them an early sense
Video materials 5.8 5.3–6.3 6.6 6.2–7.1
that their learning had been carefully considered. This
helped to persuade them into committing their own
Data are taken from ten-point Likert scales with a higher score representing
greater perceived efficacy. p values are calculated with paired sign tests time. It may be that a more refined pre-placement wel-
come pack could win even greater time commitments
important to address the barriers to success from the from student and elicit further learning benefits.
learner perspective. Reid et al. recently performed However, student engagement may not be so readily
thematic analysis on interviews with Irish medical un- won if pre-placement materials become ubiquitous for
dergraduates regarding a year of self-led e-learning [20]. all medical student placements. If this proves to be the
The three major themes of barriers to engagement were case it may be best to prioritise areas of the curriculum
a sense of being cheated out of higher quality traditional where student exposure is limited.
teaching methods, the ease with which attention could In considering the application of these data it is import-
fail to be paid to audio and video materials and a sense ant to appreciate that the specialty of ophthalmology is
of being overwhelmed at a large bank of seemingly un- just one of many areas in the undergraduate medical cur-
structured materials [20]. We attempted to address these riculum where student exposure is limited. Plastic surgery,
barriers by making our learning materials an adjuvant neurosurgery, otolaryngology and cardiothoracic surgery
rather than an alternative to traditional teaching and by are all examples of specialties with little presence in timet-
requesting a short period of commitment from learners. abled teaching where students could benefit from an in-
The mean of 62 min (median = 55, interquartile range crease of teaching efficiency if not quantity [21–24].
10–90) that students who received pre-placement Another transferrable theme that was frequently voiced by

Fig. 2 Scatter plot of the time students claimed to have spent on pre-placement work and their final knowledge test score with trend lines.
Students using video resources are represented by crosses whilst those using written resources are represented by circles
Hogg et al. BMC Medical Education (2020) 20:10 Page 7 of 8

students in open space feedback through this study was and quality of pre-placement work each student per-
the perceived benefit of the provision of a clinical member formed would be technically and ethically challenging and
of staff dedicated to their teaching. These student com- would impose bias from the Hawthorn effect. For self and
ments are consistent with UK student surveys on clinical supervisor reported knowledge outcomes, it is true that
teaching fellows who are perceived to deliver higher qual- they do not hold the same objectivity as test scores but
ity teaching, be more punctual and have a clearer under- student confidence and esteem is also an important
standing of students’ learning needs compared to full time outcome of education and these outcomes complement
clinicians [25, 26]. In our experience the service provision rather than duplicate the test scores reported. When
capacity of the department was also improved by the considering the analysis some of the significance demon-
introduction of a teaching fellow as more experienced strated is not maintained following Bonferroni correction.
clinical staff, who have previously shared teaching respon- The risk of type 1 error should be borne in mind but
sibilities, were no longer required to be withdrawn from amongst many others our primary outcome of final test
clinical duties. If the teaching demands on a department score remains significantly dependent on pre-placement
are great enough, as in this case, the consequent increase material provision following Bonferroni correction.
in clinical capacity can offset the cost of employing a full
or part time teaching fellow. Disruption to service Conclusion
provision can be reduced while teaching quality is This pragmatic comparative study found that the
improved at little or no cost. provision of specified learning materials prior to a short
The study was limited by its design as a longitudinal ophthalmology clinical placement augmented student per-
quality improvement project. This was chosen over a formance at its conclusion. Written learning materials
RCT as it would not have been feasible to stop students improved knowledge test performance to a greater extent
sharing learning materials with peers in different groups; than video materials, whilst video materials were superior
a recognised limitation of RCT in medical education for clinical skill development. Judicious selection of an
research [27]. Our approach also meant that the whole appropriate learning material format for given learning
year group was able to access learning resources as our outcomes can optimise the educational efficiency of
links to learning resources were developed, albeit at teacher time expenditure.
varying time points relative to their placement. The
study design also prohibited any control over the cohort Supplementary information
size as it was built around an established annual teaching Supplementary information accompanies this paper at [Link]
programme. Any attempt to extend beyond a year would 1186/s12909-019-1923-1.

have raised issues of bias as the teaching fellow deliver-

Additional file 1. Welcome pack sent to the first cohort of students
ing the course changes annually and would also intro- who did not receive any prescribed pre-placement materials.
duce ethical issues, as learning materials with proven Additional file 2. Welcome pack sent to the second cohort of students
efficacy would be withheld from students in the second who received links to specified written materials.
year. This limits the external validity of the study as only Additional file 3. Welcome pack sent to the third cohort of students
statistically significant differences are reported rather who received links to specified video materials
than prospectively defined ‘clinical’ significance.
The reader should also consider the discrepancy be- Abbreviations
CI: Confidence Interval; OSCE: Objective Structured Clinical Examination;
tween what learning materials were sent to students and RCT: Randomised Controlled Trial
which materials they went on to use. We chose to analyse
the variable within the control of the education staff, Acknowledgements
namely the materials sent to the students, in order to Not applicable.

maximise the external validity of our data. It is also true Authors’ contributions
that the self-reported outcomes, such as material type All authors have approved the submitted version and agree to be personally
used, time spent working and perceived knowledge levels accountable for their own contributions. HH: Contributed to study design,
data collection, data analysis, drafting and revision. JP: Contributed to data
cannot be assumed to be accurate. This limitation is likely collection. MP: Contributed to data collection. RF: Contributed to study
to be greatest for the claims students made of how much design, drafting and revision. GL: Contributed to study design, drafting and
time they worked, as this is likely to be influenced by other revision
factors such as student confidence and the degree to Funding
which they did not want to disappoint teaching staff. This study had no financial support.
Whilst this may limit the accuracy of the measure, these
confounding factors ought to have been distributed ran- Availability of data and materials
The datasets generated and/or analysed during the current study are not
domly between the three groups so should not bias the publicly available as data sharing was not consented for or included in the
outcome. An objective means of measuring the quantity protocol reviewed by local ethics boards.
Hogg et al. BMC Medical Education (2020) 20:10 Page 8 of 8

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