Course directors often note that medical science classes struggle with beginning medical courses when the material introduces novel concepts and terminology or requires recall of previously learned material. Pre-class quizzes induce students to review past courses and pre-read before the class is initiated, fostering easier entry into the subject matter.
Students in professional schools are often challenged to apply previously learned, as well as some novel material, in required professional courses. Based on their understanding of the objectives of prerequisite courses, instructors often assume that students have understood prior concepts. However, this assumption is often incorrect. The earlier courses may not have taught what was assumed, or students may have learned material superficially for a summative exam, but never internalized it for later application. Frequently, there is a long time lag between the prerequisite course and the new one. These mistaken assumptions may continue within a course—the instructor assumes learning of initial material prior to moving on with more advanced content, but students may not have done so. Students may not pre-read the required texts and may then struggle as the course quickly moves on into even more complex ideas and material. These challenges were met at two professional schools by using online pre-quizzes at the start of required courses in Microbiology/Immunology (University of Louisville School of Medicine, U of L) and Nephrology (University of California Davis School of Medicine, UCD). Online quizzes have been used in several curricula to stimulate review or provide formative feedback1-10. Those described pre-quizzes differed from those in this manuscript because ours are given at the beginning of major courses.
At UCD a 30 question online quiz was distributed 3 days before the start of the year 2 Nephrology course. The quiz covered normal renal histology and physiology that had been taught one year earlier in required year 1 courses and was designed to reflect the key concepts needed for success in understanding renal pathophysiology. Students had 2 weeks to complete it, taking it at most once per day and keeping their best score. WebCT software was used for administration. Questions were scrambled on each administration to prevent students generating a standard key. The quiz was open book, but students were asked to complete it independently. Questions were a mix of factual recall and short vignettes requiring understanding or application of knowledge (sample questions are shown in Table 1 with correct answers bolded).
The quiz counted 13% of the final course grade, more than normally used for a formative quiz. However, the multiple attempts allowed and the score provided at the end of each attempt allowed the student to use it formatively to stimulate additional learning. Specifically, over the two years the pre-quiz has been given, students took the quiz a mean of 3.9 times (range 1-11, n = 192), with a mean final correct score of 94.3% (n = 192). Assessment of the value of the exercise by students has been positive (Table 2), both regarding its value in reviewing the one year distant course material, and in its value in understanding current Nephrology concepts.
At U of L the 10 question electronic quiz (sample questions shown in Table 3; correct answers bolded) covering the first two chapters of the required text was sent to the class the week before class started in Microbiology and Immunology. Since immunology is the first course subject and is complex in both nomenclature and concepts, it was communicated to the students that the answers could be readily found in the first two chapters of the required book and that the quiz represented 0.5% of their total grade in the course. We also indicated that the quiz is open book but must be done independently. The native curiosity of medical students to do questions correctly, the possibility of getting some positive credit before the course started, and the fact that they would ultimately get it all correct yielded 100% response from the class of 146 two years in a row. An analysis of both years showed that 60% did it correctly the first time, while it took 23% 2 tries, 12 % 3 tries, and 5% more than that to get all the answers correct. No formal survey of the class has been taken regarding the value of the quiz, but anecdotal evidence suggests that the class enjoys this exercise and appreciates the credit points. Instructors report far fewer elementary questions and apparent confusion in the introductory lectures. Similar instructor feedback was obtained anecdotally from UCD Nephrology discussion leaders, who reported increased student precision in vocabulary and in application of physiology principles during the initial discussion sections on electrolyte disorders.
In summary, self-paced pre-quizzes given during the initial phase of these courses stimulated learner review of past material, focused them on concepts essential to understanding the upcoming course, and provided formative feedback of their understanding and retention of past curricular content. They were also useful for course instructors to assess the variability of retention from prerequisite courses. While the quizzes at the two institutions differed in length (30 questions UCD vs. 10 U of L), in weight towards the final grade (13% vs. 0.5%) and in how many times the quiz could be taken (12 vs variable) student and faculty acceptance was similarly positive. At UCD the pulmonary and neurology pathophysiology courses are now using similar pre-quizzes based on the success of the exercise in nephrology. While online quizzes are now widely endorsed for assessment during the progress of conventional and electronic curricula2-7, 9, 10, we additionally endorse such quizzes for motivating students to succeed early in courses and to integrate course content with previously learned material.