Use of modified SOAP notes and peer-led small-group discussion in a Medical Physiology course: addressing the hidden curriculum
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《生理学进展》医学期刊
1 Department of Physiology and Neuroscience, St. George's University, St. George's, Grenada
2 Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
Address for reprint requests and other correspondence: J. Kibble, Dept. of Physiology and Neuroscience, St. George's Univ., PO Box 7, St. George's, Grenada (e-mail: jkibble@sgu.edu)
Abstract
Peer leading of small-group discussion of cases; use of modified subjective, objective, assessment of physiology (SOAP) notes; and opportunities for self-assessment were introduced into a Medical Physiology course to increase students' awareness and practice of professional behaviors. These changes arose from faculty members' understanding of the hidden curriculum and their efforts to reveal it to take increased advantage of its educationally beneficial aspects. Faculty members and students observed that the requirement for students to submit SOAP notes before their discussions meant that they were well prepared to participate. Student satisfaction with the protocol was high, with >95% of the students agreeing that discussants were well prepared and that the overall performance of their discussion group was good. A comparison of students' performance on selected exam questions showed that peer leading was equally as effective as a previously used teacher-centered approach. Students agreed that their ability to analyze a clinical case had improved using this protocol, an effect that persisted at least one semester after the end of the course. These approaches were time and cost efficient from a faculty perspective while serving the needs of the students. The use of SOAP notes and peer-led discussion were effective forms of instruction, in which students succeeded in learning medical physiology and in practicing professional behaviors.
Key words: student facilitation; active learning; cooperative learning
THE HIDDEN CURRICULUM comprises what students are learning that is not made explicit to them, learning that may be unrecognized even by teachers. It usually consists of cognitive skills, attitudes, and behaviors–desirable or not–that are acquired because of the way the teacher organizes and conducts the class. The hidden curriculum in medical schools often includes the development of student attitudes and behaviors that are characterized as professional or unprofessional. Indeed, the hidden curriculum has been regarded more generally as part of the process of socialization into medicine (3). Ethics and cultural competency are two areas in which the hidden curriculum has been observed to differ, with undesirable results, from the formal one (3, 13, 14). Medical physiology has a significant hidden curriculum that includes attitudes about the use of animals in teaching and research and about ethical and social aspects of the discipline, and cognitive abilities arising from its experimental basis and integrative nature (4).
The desirable hidden curriculum will be realized more efficiently if it is brought out into the open by expressing it as learning objectives and assessing student achievement of them. It is also essential to incorporate teaching and learning strategies that encourage and aid students' achievement of the desirable aspects. Small-group work is an example of a pedagogical approach shown to promote favorable attitudes toward learning, increased student motivation, and improved academic performance (11). In this study, we introduced a form of small-group learning that emphasized peer facilitation and cooperation into a Medical Physiology course. Peer instruction has been associated with several desirable outcomes, including high degrees of student satisfaction (5), improved cognitive performance (2, 9, 12), and the acquisition of patient-centered interviewing skills (7).
This study also describes the use of modified subjective, objective, assessment, and plan (SOAP) notes as a tool for students to analyze clinical cases with the objective of explaining the physiology related to them. The modification we describe maintains the SOAP acronym but changes the final words to subjective, objective, assessment of physiology. SOAP notes were developed by Lawrence Weed (15, 16) as a structured system for the clinical evaluation of a patient that facilitates a comprehensive analysis of clinical problems and the development of differential diagnoses, culminating in a treatment plan. SOAP notes provide a logical and reproducible framework for generating medical records.
It is usual that some kind of in-training assessment of students' attitudes and behaviors is made during clinical clerkships, and problems in this area of performance are often first noted in the clinical setting. We believe that faculty members who teach in preclinical basic science courses have an obligation to recognize and act on unprofessional and other undesirable behaviors whenever they occur in their courses. This obligation includes helping students understand what professionalism actually means in practice, for example, in a small-group discussion, a laboratory, a lecture, or an exam. Since some students are simply not aware that their behaviors are unprofessional, teachers must make their expectations explicit, i.e., they must reveal this aspect of the hidden curriculum. Portelli (8) has argued that the hidden curriculum always has a moral component and that educators have a responsibility to make it as explicit as possible. In this article, we describe a self-assessment that we developed to help students become more aware of the expected behaviors in their small-group case discussions. At the end of the series of small-group meetings, we invited students to complete an on-line survey that included questions about their own behaviors and those of others in their groups.
The specific questions addressed in this study were as follows: 1) Are the uses of SOAP notes and peer-led discussions an acceptable and effective means of learning medical physiology 2) Did using SOAP notes and peer-led discussion foster desirable professional student behaviors 3) Are SOAP notes a valid tool to measure student performance and 4) Is there any continuing educational benefit for students in learning how to use SOAP notes
METHODS
Background.
St. George's University offers a 4-yr medical program in which basic medical sciences are taught during the first 2 yr. The Medical Physiology course is taught twice a year to cohorts of 350+ students. It is a 5-credit hour course, delivered over 18 consecutive weeks, consisting of 75 lecture hours and 12 h of formal small-group teaching. The curricular content is based on the American Physiology Society Medical Physiology Objectives Project. The course runs during the second academic semester, concurrently with the Neuroscience, Genetics, Immunology, and Medical Parasitology courses. The Medical Physiology course follows the Anatomy and Biochemistry course and precedes courses that include Pathology, Pharmacology, and Pathophysiology. Medical Physiology students are assessed using the aggregate score from a summative multiple-choice examination after 9 wk and another after 18 wk. Formative assessment is provided using quizzes available online via the ANGEL course management system. Self-assessment quizzes are also available via printed course materials. This study addressed changes to the small-group teaching program, which required significantly higher student responsibility for learning. Before the changes described in this study were introduced, there were two important differences in the organization of small-group case discussions: 1) community physicians and physiologists acted as discussion facilitators rather than students and 2) students were not required to complete a SOAP notes worksheet before small-group discussions. The major pedagogic problem with this previous approach was poor preparation by students, which inhibited meaningful discussion, often resulting in case discussion becoming didactic teacher-centered sessions. This sometimes defeated our goals of having small-group discussions in which students were able to set some learning agendas and achieve learning objectives through independent study and discussion. In this context, running small groups with a small faculty and over 350 students was also problematic, with too much variance in the quality of teaching from one group to another.
Learning materials and student orientation.
At the start of the spring 2005 semester, students were provided with five paper clinical case histories, which, in each instance, included a description of signs and symptoms together with laboratory findings. Students were given a 50-min orientation period en masse in their lecture theater about how to organize and analyze a case using a SOAP notes worksheet. During the orientation, students worked through a model case and were guided about how to define relevant subjective and objective findings. The emphasis was then on documenting the physiological reasoning for clinical findings. Students were required to complete a SOAP notes worksheet and submit it electronically via the ANGEL course management system before they attended a formal small-group discussion. The use of internet searching was strongly encouraged, and several useful websites were posted as links via the Physiology course website to assist students in finding definitions for unfamiliar terms and researching normal values and pathophysiology. Students were further oriented about the conduct of peer-facilitated small-group discussion.
Groups of 8–10 students met for 90 min to discuss a case. Students selected a peer facilitator, who was charged with developing a discussion that analyzed and synthesized ideas about the relevant physiology, culminating in collective suggestions for differential diagnoses. Each group was accompanied by a faculty member who did not participate in the discussion unless asked directly by the student facilitator for brief clarification. During the final 5 min of the discussion, faculty tutors provided general feedback on group dynamics and on any misconceptions about physiology that had arisen during the session. Students were provided with a questionnaire (Table 1) at the start of the program and were asked to perform regular self-assessments in relation to their academic and professional performance.
Evaluation of SOAP notes and peer-led discussions.
Several approaches were used to evaluate the stated goals of the study. Students were asked to complete the questionnaire shown in Table 2 just before the final examination. Questions were devised in four areas: perceptions about discussion group performance (questions 1–5), perceptions about individual performance (questions 6–11), assessment of the educational value of peer-led discussions (questions 12–14), and perceived value of self-assessment in the development of professional behaviors (questions 15 and 16).
An assessment of how well students learned the physiology associated with clinical cases was made by comparing the examination performance against previous student cohorts using questions specifically related to the clinical case content. Every semester, summative multiple-choice examinations include two questions from each clinical case. As part of a general question validation procedure, approximately two-thirds of questions included on summative examinations have been used previously and have statistical history; approximately one-third are new questions. In spring 2005, 7 of 10 examination questions included for clinical cases had historical data derived from students taking the course before the present peer-led discussion format was adopted. For these seven questions, a paired analysis of student performance was made for spring 2005 versus history. A Wilcoxon's paired-rank test was applied, assuming a 5% significance level.
The validity of SOAP notes as a tool for measuring student learning in physiology was evaluated by devising a scoring system for SOAP notes and comparing the outcome with summative examination scores in a sample of students. An example of the SOAP notes grading form used by faculty members is shown in Table 3. The form describes a six-point scale designed to emphasize physiological reasoning. This was shown to students during their orientation lecture to emphasize the expected qualities of a good SOAP notes submission. Students were encouraged to discuss any aspect of the clinical cases with study partners but were required to prepare and submit their own SOAP note worksheets. Course examinations consisted of multiple-choice questions designed to assess cognitive achievement at the levels of knowledge, comprehension, and application. Examinations were sequestered and took place under closed, proctored conditions to prevent student collaboration. After the summative final examination was completed and course grades had been assigned, 10 students were selected at random from each of the 4 possible course grade categories (A, B, C, and F) that are applied at our medical school. SOAP notes submissions from these 40 students were assembled for grading by a single faculty member in a blinded fashion. SOAP notes were given to a moderator to check for grading consistency. A discussion between the grader and moderator was used to reach a consensus score in cases of disagreement. A cumulative SOAP notes score for each student was obtained by adding together scores from each of the five clinical cases, providing a maximum cumulative SOAP score of 30 points. Cumulative SOAP notes scores were compared with summative multiple-choice examination scores. Linear regression analysis was used, applying ANOVA, and assuming a 5% significance level.
The extent to which learning to use SOAP notes could benefit student learning later in the basic science curriculum was evaluated using the followup survey shown in Table 4. This questionnaire was designed to start with questions directly related to the original purpose of using SOAP notes, as a clinical case analysis tool, and then progressing to more generic learning issues. The followup survey was administered 6 mo later after the Medical Physiology course, toward the end of the Pathology course.
RESULTS
Acceptability and effectiveness of the new approach to clinical case discussions.
Student acceptance was high based on the overall level of agreement with statements in the end of course survey (Fig. 1 and Table 2). Of particular relevance to student acceptance were the following: students agreed that the overall discussion group performance was good, that they felt comfortable in participating in the group discussion, that their personal contributions were effective, that they learned a significant amount of physiology, and that the benefits of preparing SOAP notes and attending discussions were worth the time it took.
Student performance on seven summative examination questions directly related to the physiology covered in clinical cases was unchanged compared with cumulative historical examination performance (Fig. 2). These data suggested that the new approach to clinical cases was equally as effective as the previous more teacher-centered approach. The effectiveness of SOAP note preparation and peer-led discussions in terms of learning physiology was also supported by student agreement that understanding of the topics covered was demonstrated during discussions and that a significant amount of physiology was learned (Fig. 1 and Table 2).
Student behaviors.
Attendance at the small-group discussion and submission of SOAP notes was an expected part of the course, and 99% of all SOAP notes worksheets were submitted. The attendance rate at the small-group discussions was 95%.
Students were made clearly aware of the performance expectations during orientation (Table 1). Several responses in the end of course survey indicated that students exhibited a high degree of professionalism. Students not only reported strong agreement that they were personally well prepared with the SOAP notes filled out before their discussion group met but that the other student discussants in the group were too. On a personal level, students agreed that their contributions in discussion were effective and that they actively listened to their peers. Strong agreement that all students were able to participate, that group discussions were full and complete, and that the groups worked well with student facilitators suggested that a successful cooperative learning environment was created by students.
Validity of using SOAP notes for assessments.
The relationship between cumulative SOAP notes score for all five clinical cases added together and the aggregate summative examination score is shown in Fig. 3. Despite the fact that students were allowed to discuss the cases freely and to use any external information sources, a significant relationship was observed between the SOAP notes score and examination score. These data suggested that the attainment of knowledge and comprehension and application of physiology tested in summative examinations was also reflected in the ability to compose a good SOAP notes record.
Educational benefits.
At the end of the course, students strongly agreed that their ability to analyze a clinical case had improved (Fig. 1 and Table 2). In a followup survey one semester later, albeit from a smaller sample size (131 compared with 312 respondents), students agreed their ability to organize clinical findings was improved and their depth of analysis was more comprehensive by having learned to use SOAP notes in the Medical Physiology course (Fig. 4 and Table 4). SOAP notes were initially presented to students as part of a small-group learning initiative. One semester later, students agreed that learning to use SOAP notes had been useful, in general, when learning in the setting of small-group discussions. Moving further away from the original context of SOAP notes to analyze a clinical case in preparation for group discussion, students reported that SOAP notes were sometimes useful in general terms for prioritizing high-yield concepts and in identifying misconceptions but were more rarely used as a tool to help review for examinations.
DISCUSSION
We made changes to our clinical case-based instruction to enhance student engagement in learning medical physiology and to give students an opportunity to master learning objectives through independent study and discussion. By making our expectations about student behavior explicit and through devising SOAP notes as a precursor to peer-led discussion, we aimed to illuminate aspects of the hidden curriculum. These interventions were judged to be a success overall, based on the positive student responses about individual and group performances related to both learning and behaviors. The modified SOAP notes tool was judged to be valid, based on a comparison of student scores for graded SOAP notes and summative examination scores. The process of using SOAP notes to precede peer-led discussion was also judged to be useful, based on the comparable summative examination performance between students using SOAP notes and previous cohorts of students who experienced more teacher-centered tutorials. The survey data suggested that some educational benefits of learning to use SOAP notes persisted 6 mo after the Medical Physiology course ended.
One limitation of the study is the exclusive use of student perceptions to explore the value and quality of peer-led discussion and student professionalism. In our setting, with an adverse faculty member-to-student ratio, it is difficult for a given faculty member to consistently observe a given group. This presented difficulty in recording objective faculty observations of student behaviors, although faculty members anecdotally reported satisfaction with the level of student preparation and behaviors in small-group meetings. It should be noted, however, that student responses related to group performance (Table 1) showed a very high degree of internal consistency, which has also been noted by others using peer evaluation of group performance (10). Another possible limitation of our study design was that it did not apply a prospective randomized approach but sought to report the findings of an intervention applied equally to all students. Therefore, our ability to make firm conclusions about the efficacy of SOAP notes and peer-led discussion with respect to cognitive performance is limited.
It is generally held that small-group learning experiences promote favorable attitudes toward learning (11). Student acceptance of our peer-led discussion format was high based on the consistently positive responses shown in Table 1. Anecdotally, our faculty members reported high levels of satisfaction with student motivation, participation, and enthusiasm. Other studies (2, 5) have noted similarly favorable student endorsements using peer-led small-group learning. The attendance rate at the peer-led discussions was high, with only 86 recorded absences of 1,770 individual attendance records over the course. This is consistent with the strong agreement by students that the benefits of preparing for and attending the sessions were worth the time it took.
The SOAP notes format allowed students to study what they identified as important points in a case history, providing a higher degree of student ownership and responsibility for learning. Examination performance using this format was comparable with a previous teacher-centered instructional approach, indicating that student performance was unaffected by reducing the emphasis on the teacher. Using a randomized crossover design, Kolars et al. (6) compared the effects of student and teacher-led small-group learning in a class of second-year medical students and reported comparable performance on knowledge-based assessments. Nestel and Kidd (7) also reported that peer-led instruction had comparable effectiveness to teacher-led instruction in the area of patient interviewing skills.
The construction of SOAP notes required students to take an organized and systematic approach to case analysis. Based on the sample of SOAP notes used for grading, most students mastered the ability to define all major subjective and objective findings in a case. In the followup survey, students broadly agreed that using SOAP notes had improved their ability to organize case findings. Students were then required to make suggestions for the physiological basis of every finding, encouraging a comprehensive approach. In the followup survey, students indicated that learning to use SOAP notes had made them analyze case findings more comprehensively and in greater depth.
The use of SOAP notes allowed students to construct physiological knowledge and understanding in a usable manner, which has relevance to their studies in clinical skills and in preparation for clerkship. The importance of embedding learning in the context of the practice of a discipline has been emphasized (1). In the present study, students agreed that using SOAP notes models the clinical reasoning process, which may contribute to their satisfaction using this learning tool.
A comparison of scores for graded SOAP notes with those obtained in multiple-choice examinations showed a significant positive correlation (Fig. 3). Bearing in mind that students devised their SOAP notes outside of examination conditions, the persistence of a clear relationship with examination scores indicates that SOAP notes measure attributes similar to summative examinations. SOAP notes may, therefore, be a valid tool to measure student performance. Our primary goal was to use SOAP notes as a means of enhancing the quality of student preparation for discussions. However, SOAP notes have the potential to be useful in formative assessment, summative assessment, as feedback to teachers about where misconceptions may lie, and perhaps as a diagnostic tool to identify students in academic difficulty.
Discussion sessions were very well attended, despite the fact that students had already studied the case in some detail to complete SOAP notes. Since there was no explicit penalty or reward for attendance, this alone suggested that discussion sessions were highly regarded by students. Faculty expectations for performance were made explicit, and, according to the student survey, the groups met these expectations well. The discussions were intended to help address aspects of the hidden curriculum. Students were engaged in activities such as asking questions, explaining concepts to each other, and actively listening to each other, all of which contribute to the development of communication skills. Students reported feeling comfortable participating in their discussion groups. This was an opportunity to develop teamwork skills in a supportive environment of cooperation and respect. Simple indicators of "professionalism" such as timeliness and level of preparation were also very positive.
The small-group program we devised served 350 students using 3 full-time faculty members supported by 4 clinical tutors on case discussion days. It is self-evident, therefore, that the program was very time and cost efficient from a faculty perspective while serving the needs of the students. Future work on our use of SOAP notes and peer discussion will focus more on the effectiveness of this intervention. A prospective randomized study would be useful to establish the effects on cognitive performance. The perceptions of student facilitators and faculty members would also be useful to gauge the quality of group discussions.
In conclusion, the use of SOAP notes and peer-led discussion was an effective form of instruction, in which students succeeded in learning medical physiology and in practicing professional behaviors.
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Weed L. Medical records that guide and teach continued. N Engl J Med 278: 652–657, 1968.(Jonathan Kibble1, Penelope A. Hansen2 an)
2 Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
Address for reprint requests and other correspondence: J. Kibble, Dept. of Physiology and Neuroscience, St. George's Univ., PO Box 7, St. George's, Grenada (e-mail: jkibble@sgu.edu)
Abstract
Peer leading of small-group discussion of cases; use of modified subjective, objective, assessment of physiology (SOAP) notes; and opportunities for self-assessment were introduced into a Medical Physiology course to increase students' awareness and practice of professional behaviors. These changes arose from faculty members' understanding of the hidden curriculum and their efforts to reveal it to take increased advantage of its educationally beneficial aspects. Faculty members and students observed that the requirement for students to submit SOAP notes before their discussions meant that they were well prepared to participate. Student satisfaction with the protocol was high, with >95% of the students agreeing that discussants were well prepared and that the overall performance of their discussion group was good. A comparison of students' performance on selected exam questions showed that peer leading was equally as effective as a previously used teacher-centered approach. Students agreed that their ability to analyze a clinical case had improved using this protocol, an effect that persisted at least one semester after the end of the course. These approaches were time and cost efficient from a faculty perspective while serving the needs of the students. The use of SOAP notes and peer-led discussion were effective forms of instruction, in which students succeeded in learning medical physiology and in practicing professional behaviors.
Key words: student facilitation; active learning; cooperative learning
THE HIDDEN CURRICULUM comprises what students are learning that is not made explicit to them, learning that may be unrecognized even by teachers. It usually consists of cognitive skills, attitudes, and behaviors–desirable or not–that are acquired because of the way the teacher organizes and conducts the class. The hidden curriculum in medical schools often includes the development of student attitudes and behaviors that are characterized as professional or unprofessional. Indeed, the hidden curriculum has been regarded more generally as part of the process of socialization into medicine (3). Ethics and cultural competency are two areas in which the hidden curriculum has been observed to differ, with undesirable results, from the formal one (3, 13, 14). Medical physiology has a significant hidden curriculum that includes attitudes about the use of animals in teaching and research and about ethical and social aspects of the discipline, and cognitive abilities arising from its experimental basis and integrative nature (4).
The desirable hidden curriculum will be realized more efficiently if it is brought out into the open by expressing it as learning objectives and assessing student achievement of them. It is also essential to incorporate teaching and learning strategies that encourage and aid students' achievement of the desirable aspects. Small-group work is an example of a pedagogical approach shown to promote favorable attitudes toward learning, increased student motivation, and improved academic performance (11). In this study, we introduced a form of small-group learning that emphasized peer facilitation and cooperation into a Medical Physiology course. Peer instruction has been associated with several desirable outcomes, including high degrees of student satisfaction (5), improved cognitive performance (2, 9, 12), and the acquisition of patient-centered interviewing skills (7).
This study also describes the use of modified subjective, objective, assessment, and plan (SOAP) notes as a tool for students to analyze clinical cases with the objective of explaining the physiology related to them. The modification we describe maintains the SOAP acronym but changes the final words to subjective, objective, assessment of physiology. SOAP notes were developed by Lawrence Weed (15, 16) as a structured system for the clinical evaluation of a patient that facilitates a comprehensive analysis of clinical problems and the development of differential diagnoses, culminating in a treatment plan. SOAP notes provide a logical and reproducible framework for generating medical records.
It is usual that some kind of in-training assessment of students' attitudes and behaviors is made during clinical clerkships, and problems in this area of performance are often first noted in the clinical setting. We believe that faculty members who teach in preclinical basic science courses have an obligation to recognize and act on unprofessional and other undesirable behaviors whenever they occur in their courses. This obligation includes helping students understand what professionalism actually means in practice, for example, in a small-group discussion, a laboratory, a lecture, or an exam. Since some students are simply not aware that their behaviors are unprofessional, teachers must make their expectations explicit, i.e., they must reveal this aspect of the hidden curriculum. Portelli (8) has argued that the hidden curriculum always has a moral component and that educators have a responsibility to make it as explicit as possible. In this article, we describe a self-assessment that we developed to help students become more aware of the expected behaviors in their small-group case discussions. At the end of the series of small-group meetings, we invited students to complete an on-line survey that included questions about their own behaviors and those of others in their groups.
The specific questions addressed in this study were as follows: 1) Are the uses of SOAP notes and peer-led discussions an acceptable and effective means of learning medical physiology 2) Did using SOAP notes and peer-led discussion foster desirable professional student behaviors 3) Are SOAP notes a valid tool to measure student performance and 4) Is there any continuing educational benefit for students in learning how to use SOAP notes
METHODS
Background.
St. George's University offers a 4-yr medical program in which basic medical sciences are taught during the first 2 yr. The Medical Physiology course is taught twice a year to cohorts of 350+ students. It is a 5-credit hour course, delivered over 18 consecutive weeks, consisting of 75 lecture hours and 12 h of formal small-group teaching. The curricular content is based on the American Physiology Society Medical Physiology Objectives Project. The course runs during the second academic semester, concurrently with the Neuroscience, Genetics, Immunology, and Medical Parasitology courses. The Medical Physiology course follows the Anatomy and Biochemistry course and precedes courses that include Pathology, Pharmacology, and Pathophysiology. Medical Physiology students are assessed using the aggregate score from a summative multiple-choice examination after 9 wk and another after 18 wk. Formative assessment is provided using quizzes available online via the ANGEL course management system. Self-assessment quizzes are also available via printed course materials. This study addressed changes to the small-group teaching program, which required significantly higher student responsibility for learning. Before the changes described in this study were introduced, there were two important differences in the organization of small-group case discussions: 1) community physicians and physiologists acted as discussion facilitators rather than students and 2) students were not required to complete a SOAP notes worksheet before small-group discussions. The major pedagogic problem with this previous approach was poor preparation by students, which inhibited meaningful discussion, often resulting in case discussion becoming didactic teacher-centered sessions. This sometimes defeated our goals of having small-group discussions in which students were able to set some learning agendas and achieve learning objectives through independent study and discussion. In this context, running small groups with a small faculty and over 350 students was also problematic, with too much variance in the quality of teaching from one group to another.
Learning materials and student orientation.
At the start of the spring 2005 semester, students were provided with five paper clinical case histories, which, in each instance, included a description of signs and symptoms together with laboratory findings. Students were given a 50-min orientation period en masse in their lecture theater about how to organize and analyze a case using a SOAP notes worksheet. During the orientation, students worked through a model case and were guided about how to define relevant subjective and objective findings. The emphasis was then on documenting the physiological reasoning for clinical findings. Students were required to complete a SOAP notes worksheet and submit it electronically via the ANGEL course management system before they attended a formal small-group discussion. The use of internet searching was strongly encouraged, and several useful websites were posted as links via the Physiology course website to assist students in finding definitions for unfamiliar terms and researching normal values and pathophysiology. Students were further oriented about the conduct of peer-facilitated small-group discussion.
Groups of 8–10 students met for 90 min to discuss a case. Students selected a peer facilitator, who was charged with developing a discussion that analyzed and synthesized ideas about the relevant physiology, culminating in collective suggestions for differential diagnoses. Each group was accompanied by a faculty member who did not participate in the discussion unless asked directly by the student facilitator for brief clarification. During the final 5 min of the discussion, faculty tutors provided general feedback on group dynamics and on any misconceptions about physiology that had arisen during the session. Students were provided with a questionnaire (Table 1) at the start of the program and were asked to perform regular self-assessments in relation to their academic and professional performance.
Evaluation of SOAP notes and peer-led discussions.
Several approaches were used to evaluate the stated goals of the study. Students were asked to complete the questionnaire shown in Table 2 just before the final examination. Questions were devised in four areas: perceptions about discussion group performance (questions 1–5), perceptions about individual performance (questions 6–11), assessment of the educational value of peer-led discussions (questions 12–14), and perceived value of self-assessment in the development of professional behaviors (questions 15 and 16).
An assessment of how well students learned the physiology associated with clinical cases was made by comparing the examination performance against previous student cohorts using questions specifically related to the clinical case content. Every semester, summative multiple-choice examinations include two questions from each clinical case. As part of a general question validation procedure, approximately two-thirds of questions included on summative examinations have been used previously and have statistical history; approximately one-third are new questions. In spring 2005, 7 of 10 examination questions included for clinical cases had historical data derived from students taking the course before the present peer-led discussion format was adopted. For these seven questions, a paired analysis of student performance was made for spring 2005 versus history. A Wilcoxon's paired-rank test was applied, assuming a 5% significance level.
The validity of SOAP notes as a tool for measuring student learning in physiology was evaluated by devising a scoring system for SOAP notes and comparing the outcome with summative examination scores in a sample of students. An example of the SOAP notes grading form used by faculty members is shown in Table 3. The form describes a six-point scale designed to emphasize physiological reasoning. This was shown to students during their orientation lecture to emphasize the expected qualities of a good SOAP notes submission. Students were encouraged to discuss any aspect of the clinical cases with study partners but were required to prepare and submit their own SOAP note worksheets. Course examinations consisted of multiple-choice questions designed to assess cognitive achievement at the levels of knowledge, comprehension, and application. Examinations were sequestered and took place under closed, proctored conditions to prevent student collaboration. After the summative final examination was completed and course grades had been assigned, 10 students were selected at random from each of the 4 possible course grade categories (A, B, C, and F) that are applied at our medical school. SOAP notes submissions from these 40 students were assembled for grading by a single faculty member in a blinded fashion. SOAP notes were given to a moderator to check for grading consistency. A discussion between the grader and moderator was used to reach a consensus score in cases of disagreement. A cumulative SOAP notes score for each student was obtained by adding together scores from each of the five clinical cases, providing a maximum cumulative SOAP score of 30 points. Cumulative SOAP notes scores were compared with summative multiple-choice examination scores. Linear regression analysis was used, applying ANOVA, and assuming a 5% significance level.
The extent to which learning to use SOAP notes could benefit student learning later in the basic science curriculum was evaluated using the followup survey shown in Table 4. This questionnaire was designed to start with questions directly related to the original purpose of using SOAP notes, as a clinical case analysis tool, and then progressing to more generic learning issues. The followup survey was administered 6 mo later after the Medical Physiology course, toward the end of the Pathology course.
RESULTS
Acceptability and effectiveness of the new approach to clinical case discussions.
Student acceptance was high based on the overall level of agreement with statements in the end of course survey (Fig. 1 and Table 2). Of particular relevance to student acceptance were the following: students agreed that the overall discussion group performance was good, that they felt comfortable in participating in the group discussion, that their personal contributions were effective, that they learned a significant amount of physiology, and that the benefits of preparing SOAP notes and attending discussions were worth the time it took.
Student performance on seven summative examination questions directly related to the physiology covered in clinical cases was unchanged compared with cumulative historical examination performance (Fig. 2). These data suggested that the new approach to clinical cases was equally as effective as the previous more teacher-centered approach. The effectiveness of SOAP note preparation and peer-led discussions in terms of learning physiology was also supported by student agreement that understanding of the topics covered was demonstrated during discussions and that a significant amount of physiology was learned (Fig. 1 and Table 2).
Student behaviors.
Attendance at the small-group discussion and submission of SOAP notes was an expected part of the course, and 99% of all SOAP notes worksheets were submitted. The attendance rate at the small-group discussions was 95%.
Students were made clearly aware of the performance expectations during orientation (Table 1). Several responses in the end of course survey indicated that students exhibited a high degree of professionalism. Students not only reported strong agreement that they were personally well prepared with the SOAP notes filled out before their discussion group met but that the other student discussants in the group were too. On a personal level, students agreed that their contributions in discussion were effective and that they actively listened to their peers. Strong agreement that all students were able to participate, that group discussions were full and complete, and that the groups worked well with student facilitators suggested that a successful cooperative learning environment was created by students.
Validity of using SOAP notes for assessments.
The relationship between cumulative SOAP notes score for all five clinical cases added together and the aggregate summative examination score is shown in Fig. 3. Despite the fact that students were allowed to discuss the cases freely and to use any external information sources, a significant relationship was observed between the SOAP notes score and examination score. These data suggested that the attainment of knowledge and comprehension and application of physiology tested in summative examinations was also reflected in the ability to compose a good SOAP notes record.
Educational benefits.
At the end of the course, students strongly agreed that their ability to analyze a clinical case had improved (Fig. 1 and Table 2). In a followup survey one semester later, albeit from a smaller sample size (131 compared with 312 respondents), students agreed their ability to organize clinical findings was improved and their depth of analysis was more comprehensive by having learned to use SOAP notes in the Medical Physiology course (Fig. 4 and Table 4). SOAP notes were initially presented to students as part of a small-group learning initiative. One semester later, students agreed that learning to use SOAP notes had been useful, in general, when learning in the setting of small-group discussions. Moving further away from the original context of SOAP notes to analyze a clinical case in preparation for group discussion, students reported that SOAP notes were sometimes useful in general terms for prioritizing high-yield concepts and in identifying misconceptions but were more rarely used as a tool to help review for examinations.
DISCUSSION
We made changes to our clinical case-based instruction to enhance student engagement in learning medical physiology and to give students an opportunity to master learning objectives through independent study and discussion. By making our expectations about student behavior explicit and through devising SOAP notes as a precursor to peer-led discussion, we aimed to illuminate aspects of the hidden curriculum. These interventions were judged to be a success overall, based on the positive student responses about individual and group performances related to both learning and behaviors. The modified SOAP notes tool was judged to be valid, based on a comparison of student scores for graded SOAP notes and summative examination scores. The process of using SOAP notes to precede peer-led discussion was also judged to be useful, based on the comparable summative examination performance between students using SOAP notes and previous cohorts of students who experienced more teacher-centered tutorials. The survey data suggested that some educational benefits of learning to use SOAP notes persisted 6 mo after the Medical Physiology course ended.
One limitation of the study is the exclusive use of student perceptions to explore the value and quality of peer-led discussion and student professionalism. In our setting, with an adverse faculty member-to-student ratio, it is difficult for a given faculty member to consistently observe a given group. This presented difficulty in recording objective faculty observations of student behaviors, although faculty members anecdotally reported satisfaction with the level of student preparation and behaviors in small-group meetings. It should be noted, however, that student responses related to group performance (Table 1) showed a very high degree of internal consistency, which has also been noted by others using peer evaluation of group performance (10). Another possible limitation of our study design was that it did not apply a prospective randomized approach but sought to report the findings of an intervention applied equally to all students. Therefore, our ability to make firm conclusions about the efficacy of SOAP notes and peer-led discussion with respect to cognitive performance is limited.
It is generally held that small-group learning experiences promote favorable attitudes toward learning (11). Student acceptance of our peer-led discussion format was high based on the consistently positive responses shown in Table 1. Anecdotally, our faculty members reported high levels of satisfaction with student motivation, participation, and enthusiasm. Other studies (2, 5) have noted similarly favorable student endorsements using peer-led small-group learning. The attendance rate at the peer-led discussions was high, with only 86 recorded absences of 1,770 individual attendance records over the course. This is consistent with the strong agreement by students that the benefits of preparing for and attending the sessions were worth the time it took.
The SOAP notes format allowed students to study what they identified as important points in a case history, providing a higher degree of student ownership and responsibility for learning. Examination performance using this format was comparable with a previous teacher-centered instructional approach, indicating that student performance was unaffected by reducing the emphasis on the teacher. Using a randomized crossover design, Kolars et al. (6) compared the effects of student and teacher-led small-group learning in a class of second-year medical students and reported comparable performance on knowledge-based assessments. Nestel and Kidd (7) also reported that peer-led instruction had comparable effectiveness to teacher-led instruction in the area of patient interviewing skills.
The construction of SOAP notes required students to take an organized and systematic approach to case analysis. Based on the sample of SOAP notes used for grading, most students mastered the ability to define all major subjective and objective findings in a case. In the followup survey, students broadly agreed that using SOAP notes had improved their ability to organize case findings. Students were then required to make suggestions for the physiological basis of every finding, encouraging a comprehensive approach. In the followup survey, students indicated that learning to use SOAP notes had made them analyze case findings more comprehensively and in greater depth.
The use of SOAP notes allowed students to construct physiological knowledge and understanding in a usable manner, which has relevance to their studies in clinical skills and in preparation for clerkship. The importance of embedding learning in the context of the practice of a discipline has been emphasized (1). In the present study, students agreed that using SOAP notes models the clinical reasoning process, which may contribute to their satisfaction using this learning tool.
A comparison of scores for graded SOAP notes with those obtained in multiple-choice examinations showed a significant positive correlation (Fig. 3). Bearing in mind that students devised their SOAP notes outside of examination conditions, the persistence of a clear relationship with examination scores indicates that SOAP notes measure attributes similar to summative examinations. SOAP notes may, therefore, be a valid tool to measure student performance. Our primary goal was to use SOAP notes as a means of enhancing the quality of student preparation for discussions. However, SOAP notes have the potential to be useful in formative assessment, summative assessment, as feedback to teachers about where misconceptions may lie, and perhaps as a diagnostic tool to identify students in academic difficulty.
Discussion sessions were very well attended, despite the fact that students had already studied the case in some detail to complete SOAP notes. Since there was no explicit penalty or reward for attendance, this alone suggested that discussion sessions were highly regarded by students. Faculty expectations for performance were made explicit, and, according to the student survey, the groups met these expectations well. The discussions were intended to help address aspects of the hidden curriculum. Students were engaged in activities such as asking questions, explaining concepts to each other, and actively listening to each other, all of which contribute to the development of communication skills. Students reported feeling comfortable participating in their discussion groups. This was an opportunity to develop teamwork skills in a supportive environment of cooperation and respect. Simple indicators of "professionalism" such as timeliness and level of preparation were also very positive.
The small-group program we devised served 350 students using 3 full-time faculty members supported by 4 clinical tutors on case discussion days. It is self-evident, therefore, that the program was very time and cost efficient from a faculty perspective while serving the needs of the students. Future work on our use of SOAP notes and peer discussion will focus more on the effectiveness of this intervention. A prospective randomized study would be useful to establish the effects on cognitive performance. The perceptions of student facilitators and faculty members would also be useful to gauge the quality of group discussions.
In conclusion, the use of SOAP notes and peer-led discussion was an effective form of instruction, in which students succeeded in learning medical physiology and in practicing professional behaviors.
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