Robles et al. BMC Medical Education (2019) 19:70 https://doi.org/10.1186/s12909-019-1494-1 RESEARCH ARTICLE Open Access Different ways to present clinical cases in a classroom: video projection versus live representation of a simulated clinical scene with actors M. J. Robles1,2*†, Ramón Miralles1,2†, Ascension Esperanza3† and Mercedes Riera1† Abstract Background: Use of the video digital format in the classroom is a common way to present clinical cases to stimulate discussion and increase learning. A simulated live performance with actors, also in the classroom, could be an alternative way to present cases that may be more attractive to arouse students’ interest and attention. The aim of the present study was to compare the learning process between a group of students who saw a clinical case as a simulated live scene in the classroom and others seeing the same clinical case projected by video. Method: One hundred and thirty-one students (69 from physiotherapy and 62 from medicine) attended an interactive seminar on delirium in older people. Each group was subdivided into two groups: one saw the clinical case as a theatrical performance in the classroom (scene group; n = 68), while the other saw the same case projected on video (video group; n = 63). Before and after attending the seminar, students answered a questionnaire [four questions on theoretical knowledge of delirium (score 0–7) and two on subjective learning perception (linear scale: 0–10) (score 0–20)]. At the end, a further question was included on the usefulness of the scene or a video in the learning process (linear scale: 0–10). Results: Students in both groups (live scene and video) significantly improved in all questionnaire scores after the seminar (p = 0.001) with a large Effect Size (ES > 0.80). Students of the scene group obtained higher scores on theoretical delirium knowledge [6.41 ± 0.73 vs 5.93 ± 1.31 (p = 0.05)], subjective learning perception questions (what they thought they knew about delirium) (16.28 ± 3.51 versus 15.92 ± 2.47 (p = 0.072)], and the overall questionnaire (22.45 ± 4.15 versus 21.48 ± 2.94 (p = 0.027)] than the video group. Students of the scene group opined that live scene was very useful for learning with a mean score of 9.04 ± 1.16 (range 0–10), and opinion in the student’s video group scored 8.21 ± 1.22 (p = 0.001). Conclusions: All students improved significantly their knowledge but those who saw the theatrical performance obtained slightly better results, which suggest that this form of clinical case presentation in the classroom may be an alternative at least as effective as traditional video projections. Background theoretical lessons and lectures presented in the class- The use of images recorded in video format is wide- room. Moreover, it is well known that clinical cases spread in the field of training and teaching in health sci- filmed in video digital format can be a key tool to learn- ence [1]. Modern digital cameras and the possibility to ing and illustrating real life problems from that encour- recording videos easily with a mobile phone have facili- age discussion on clinically significant aspects and tated the use of images and videos that often accompany improve reflective approaches concerning values, atti- tudes and beliefs [1, 2]. However, in recent years, the * Correspondence: 91737@parcdesalutmar.cat overuse of video may have become in itself overly rou- † All authors are equally contributed to this work. tine with a less incentive capacity to maintain students’ 1 Geriatric Department Consorcio Parc de Salut Mar de Barcelona, Paseo attention. To show in the classroom the same case that Marítimo, 25-29, 08003 Barcelona, Spain 2 Faculty of Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain could be projected in video, in the form of a live simu- Full list of author information is available at the end of the article lated scene with actors as a theatrical performance, can © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), 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 (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Robles et al. BMC Medical Education (2019) 19:70 Page 2 of 6 also be an attractive way to present a clinical situation The seminar was performed four times, two in the form of for discussion. The use of simulated patients has proved a simulated live scene in the classroom with actors (one for to be a useful learning method in health science educa- the physiotherapy students and the other for the medicine tion. Its value as a teaching tool usually requires stu- students) (scene group; n = 68), and two with the projection dents to face the simulated patient individually and of the case recorded on video which had been filmed previ- undertake an activity (e.g. a medical history aimed at a ously (the same case and the same actors) (video group; n = problem or a physical examination) [3]. This model is 63) (for both groups of students, respectively). Students from complex to organise and difficult to carry out in the the video group watched the pre-recorded scene all together context of routine academic activity. in the classroom in order to preserve the same conditions as Some authors have suggested that students can also in the other group of students who saw the live performance. learn by watching the simulation without participating At the beginning of the seminar, students were informed of actively in it −the concept of learning by observing− what was happen. They were provided with a written sum- which has become popular in the international literature mary of the case to be simulated and answered a question- under the term “vicarious learning” or “learning by see- naire with four theoretical questions related to delirium in ing others” [4, 5]. This concept offers a theoretical and the elderly, and two questions on students’ subjective learn- practical basis for carrying out simulation techniques in ing perception with regard to what they thought they knew conventional classrooms, which, has the advantage that about delirium (see footnote of Table 1). The scene was then all students can observe the simulation at the same time simulated live in the classroom as a theatrical performance with the appropriate feedback and discussion (debrief- for the scene group while the case was projected on a wall ing). Vicarious learning occurs both if the clinical case is screen for the video group, after which open questions on seen by students in the form of a video projection or as the case were asked and discussed (debriefing). The students a live simulated scene with actors (as if they were thea- were divided into groups and encouraged to give their an- tregoers). Video has the advantage that it can be swers; the teacher then provided the correct answers using a re-played as many times as necessary, while repeating powerpoint presentation (learning feedback). Students the scene “live” is more complicated and requires actors watched the scene or the video in the same classroom where having to return to the classroom. Such difficulties could lectures are usually given. The clinical problem represented be recompensed if the impact of seeing the scene “live” was entitled “What’s wrong with my father?” and involved leads to better learning. Previous experience performed three actors. A brief summary of the clinical case and the in our setting showed that the use of actors in the class- two different ways in which it was performed are shown in room to simulate a clinical scenario may per se be a Fig. 1. At the end of the seminar, students again answered powerful stimulus to arouse students’ interest and atten- the same questionnaire as at the beginning, but with a new tion and break the monotony of the classroom [6]. question added on their opinion of the usefulness of the The aim of the present study was to ascertain whether scene or video (depending on the case) for learning [Do you differences existed in learning between the group of stu- think the simulated patient scene or video as teaching tools dents who saw a simulated clinical scene with actors in were useful for understanding and treating the delirium syn- the classroom (theatrical performance) and the other drome? (range 0–10)]. An overall diagram of the seminar who saw the same case in a video projection. and details of the teaching activity are shown in Fig. 2. Ques- tionnaires were later corrected by experts in geriatrics blinded to which group they belonged (scene or video). Cor- Methods rection criteria of theoretical questions had been previously A teaching seminar was conducted at the Parc Salut Mar, agreed. According to what was considered important, an ar- a university hospital in Barcelona (Spain). Sixty-nine stu- bitrary score was assigned to each of the possible answers to dents from physiotherapy and sixty-two from medicine, the theoretical questions (see footnote in Table 1). from two universities (Universidad Autónoma de Barce- lona and Universidad Pompeu Fabra) attended the sem- Assessment of results and statistical analysis inar. This seminar was based on the approach to a clinical Students’ results (both on theoretical and subjective know- problem in the form of a simulated live scene with actors ledge) and their opinions on teaching activity were collected in the classroom or projected by video; this was followed from the questionnaires in the form of numerical scores. by an interactive presentation in the same classroom, These were treated as quantitative variables (ordinals) and which was the same for both options. The students of their results are expressed as mean and standard deviation. each program attended the seminar separately in different Student’s t-test or Mann-Whitney U test were used to com- days; the students of each program were divided into re- pare scores on the questionnaires (mean comparison of dif- duced groups chosen at random (the students from both ferent groups), depending on whether the variables followed programs were they kept separate). a normal distribution. In the case of comparison of means in Robles et al. BMC Medical Education (2019) 19:70 Page 3 of 6 Table 1 Comparison of scores obtained on the questionnaires of knowledge about delirium before and after the seminar in both groups and between groups Scene group Video group Differences between groups (n = 68) (n = 63) (p value) Total theoretical question scorea (range 0–7)* Before (mean ± SD) 3.51 ± 1.47 2.95 ± 1.50 0.036 After (mean ± SD) 6.41 ± 0.73 5.93 ± 1.31 0.050 Differences (mean ± SD)Ɨ 2.90 ± 1.15 2.98 ± 1.43 0.439 p. value (before vs after) 0.001 0.001 Effect size (before vs after)ƗƗ 1.97 1.98 a Total subjective learning perception question score (range 0–20)** Before (mean ± SD) 10.54 ± 3.59 9.40 ± 3.70 0.108 After (mean ± SD) 16.28 ± 3.51 15.92 ± 2.47 0.072 Differences (mean ± SD)Ɨ 5.74 ± 4.61 6.51 ± 3.27 0.503 p. value (before vs after) 0.001 0.001 Effect size (before vs after)ƗƗ 1.59 1.76 a Total score (sum of all questions from 1 to 6) (range: 0–27 points) Before (mean ± SD) 14.05 ± 4.38 12.35 ± 4.56 0.044 After (mean ± SD) 22.45 ± 4.15 21.48 ± 2.94 0.027 Differences (mean ± SD)Ɨ 8.40 ± 4.86 9.48 ± 5.03 0.682 p. value (before vs after) 0.001 0.001 Effect size (before vs after)ƗƗ 1.91 2.08 *Four theoretical questions about delirium; definition (range 0–2 points), describe predisposing factors (range 0–1 point), describe precipitating factors (range 0–2 points) and make a list of measures to improve and prevent progression of delirium (range 0–2 points) **Two subjective learning perception questions [to what degree would you be able to detect the risk of a confusional syndrome? (Linear scale from 0 to 10 points) and to what degree would you be able to advise a plan of interventions to prevent delirium in an elderly patient? (Linear scale from 0 to 10 points)] a Complete questionnaire can be obtained in the supplementary appendix S1 of a previous publication [6] Ɨ Average increase in questionnaire score after the seminar ƗƗ > 0.80 signifies large change the same group (before and after), Student’s t-test was used and the other with the projection of the same case in a digital for paired data and also Wilcoxon’s t-test depending on the video) are shown in Table 1. In both groups, all questionnaire type of variable distribution. Standard categorisation of effect scores showed a statistically-significant increase after the size (ES) was applied to ascertain the magnitude of change seminar with a large ES (> 0.80). Students who attended the scores on the questionnaires before and after the seminar, ac- seminar in the scene group obtained higher scores on theor- cording to the formula of Cohen in which ES is equal to the etical delirium knowledge, subjective learning perception difference between mean scores on a question at the begin- questions (what they thought they knew about delirium) and ning and end of the seminar, divided by the standard devi- the overall questionnaire than the video group. The differ- ation of the mean of scores obtained at baseline. This ence was only statistically significant in the latter. Students in calculation converts the change score into a standard unit of the scene group returned a mean score on the question of measurement which evaluates whether the difference be- opinion of 9.04 ± 1.16 (in this question, the student assessed tween the mean score of a question before and after the sem- the usefulness of the simulated clinical scene or the video inar is small or large depending on the number of standard projection) (see Methods). This score was 8.21 ± 1.22 in the deviations separating them. The guidelines define an ES of video group (p = 0.001). 0.20 as small, 0.50 as moderate and 0.80 as large [7, 8]. Fi- nally, a statistically-significant difference was considered Discussion when p value was < 0.05. The present study shows that all students both the scene group and the video group significantly improved their Results knowledge of the main topic. This change was signifi- The mean scores obtained by students on the questionnaires cant from a practical point of view (large ES > 0.80). on understanding of delirium before and after the seminars Thus, we can affirm that the seminar was effective in in both groups (one with the simulated clinical live scene both groups of students. Robles et al. BMC Medical Education (2019) 19:70 Page 4 of 6 understand the topic [9]. We found few studies in the literature in which both forms of clinical case presenta- tion were compared in conditions similar to ours. There- fore, it is difficult to contrast our results with other published experiences. Hernandez et at [11], used med- ical simulation to help teaching basic pharmacology in a manner that can more easily integrate with clinical sci- ences; the simulation involved the use of both pre-recorded and live streaming simulated scenes in a clinical vignette format. Alqahtani et al. conducted a study which aimed to assess the efficacy of procedural video compared to a live demonstration in transferring skills to four-year undergraduate dental students during a laboratory session. The authors concluded that proced- ural video was equally as effective as a live demonstra- tion [12]. Aghababaeian et al. studied 144 emergency personnel randomly classified in two groups: the first group used an educational video method and the second a role-playing method to learn and perform medical emergencies. Those authors observed that no significant difference existed between the two training methods in performance and immediate knowledge, as in our study; however a statistical advantage was observed for the role-playing method in lasting performance when the same students were re-evaluated after 15 days, suggest- ing that the latter method encouraged longer and more lasting learning [13]. The experience of those authors and the fact that in our study the results of the clinical Fig. 1 (The drawings depicted have been created on behalf of the scene group were slightly better at the end of seminar authors, and copyright have been paid, and written permission to use suggest that the simulated “live performance” could fa- it in a medical journal has also been given by the artist (Ferreiro cilitate better learning. This could be explained by the Iglesias Studio SL, Igualada, Barcelona) a. The pre-recorded scene was displayed on a screen wall using the usual projector that was fact that the live scene would provide an element of already installed in the classroom. b. Image that shows the live greater authenticity (the theatre brings an element of simulation in the centre of the classroom surrounded by realism that renders it unique in itself ), ensuring that the students learning takes place in a more attractive context than the video format and enabling the students to retain the Similarly, in this study, a tendency towards slightly knowledge more effectively. Although this idea seems at- better results was observed in students who saw the live tractive, our results do not permit us to affirm that the scene in the classroom than in those who saw the case learning in one group was better than in the other be- by video projection. The format of the seminar and the cause the differences between the groups are small; thus, questions discussed on the clinical case (debriefing) and both forms of clinical case presentation are useful and the information provided by the powerpoint were the each method has its own advantages and limitations. same in both groups (scene and video); this suggests that Definitely both the live scene and pre-recorded simulation the small difference observed could be attributed to the case required a lot more preparation. But if the case is different format in which the clinical case was presented. presented as a theatrical performance, the dramatization These results could be in line with those of other au- of a clinical vignette by faculty lets the audience experi- thors who published positive teaching experiences utilis- ence and appreciate the case from a different perspective ing actors to represent a clinical scene in the classroom and in some instances theatre could help to teach em- as if it were a theatre [9, 10]. Ünalan et al. demonstrated pathy [11]. Some limitations in the live scene could be that that a theatrical performance on a lecture about head- actors must rehearse and be prepared for the unexpected ache followed by debriefing about the symptoms, signs that can go wrong when it is done live. and differential diagnosis was very useful for students’ Even though the pre-recorded simulation case is also learning. In that experience, the authors stated that over more dependent on technology and bandwidth strength 90% of students opined that the theatre made it easier to needed for transmission of good quality visual and Robles et al. BMC Medical Education (2019) 19:70 Page 5 of 6 Fig. 2 Diagrammatic representation of the seminar on delirium with a simulated clinical scenario in the classroom or with video projection (duration: 2 h). Groups attended the seminar separately sound, after having the technology problems resolved, it topic, but the fact that the results of the clinical scene can be an excellent tool to minimize the risk of some- group were slightly better at the end of seminar suggest thing going wrong in the live scene, it allows watching that the simulated “live performance” could facilitate the scene as many times as one wants, pause rewind, better learning providing an element of greater authenti- etc. Finally, in making decisions for which method to city, ensuring that learning takes place in a more attract- use other factors can be taken into account such as cost, ive context than the video format and enabling the feasibility and teacher preference among other things. students to retain the knowledge more effectively. Lec- The present study had the limitations that the students tures supported by clinical case presentation as a theatri- were not randomised individually for their group assign- cal performance in a classroom appears to be an ment. The groups were distributed following the com- attractive alternative to the traditional format and as ef- mon university method (alphabetical order, compatibility fective as a video projection. of timetables and shifts, etc.), which may account for Abbreviations both groups not being similar in basal conditions. Before AE: Ascensión Esperanza; ES: Effect Size; MJR: María José Robles; the seminar, students in the clinical scene group had MR: Mercedes Riera; RM: Ramón MIralles; VS: versus better scores on the theoretical questionnaire than the Acknowledgements video group. Although this difference was slight, it could The authors would like to thank Maria Pi-Figueras for technical support with have influenced the higher score obtained by this group videotaping the workshop and theatrical performance. at the end of the seminar. The authors are grateful to Christine O’Hara for assistance with the English revision of the manuscript. On the other hand, we believe the results in learning of the clinical scene group would have been better if the Funding live performance had been interactive, allowing the stu- “No funding was obtained for this study”. dents to be involved at some point of the live perform- Availability of data and materials ance by interacting with the actors, as in the experiences The datasets used and/or analysed during the current study available from of other authors [10]. the corresponding author on reasonable request. Finally, from our experience, lectures supported by clinical Author’ contributions case presentation as a theatrical performance in a classroom MJR and RM made substantial contributions to the design of the study, data appears to be an attractive alternative to the traditional for- collection, analysis and interpretation of the data as well as drafting the mat and as effective as a video projection. We advocated manuscript and revising it critically for intellectual content. AE and MR helped with data analysis, drafting the manuscript, and revised it critically for carrying out further similar experiences in the future to intellectual content. All authors read and approved the final manuscript. widen this learning practice for it to be better evaluated. Ethics approval and consent to participate Conclusions The use of simulated patients is common in our university. Students are accustomed and it is not perceived as something new or experimental. All students both the scene group and the video group Because the research does not directly involve persons, material of human significantly improved their knowledge of the main origin or experimental animals, ethical approval for the study was not Robles et al. BMC Medical Education (2019) 19:70 Page 6 of 6 required according to the current regulations at our university [14]. For this playing and educational video on the knowledge and performance of reason ethical approval for research relating to this seminar was not sought. emergency medical service staffs in Iran. Prehosp Disaster Med. 2013;28:1–5. At the beginning of seminar, all students were informed about the 14. Universitat Autònoma de Barcelona. Codi de bones pràctiques en la recerca. methodology and contents. An oral consent was given by all of them. [Disponible en : https://www.uab.cat/doc/codibonespractiques_recerca Participation in the seminar was performed in the context of the normal (accedido el 29 de diciembre 2018)]. academic course. Also the fact of attending to one seminar group or another was not disadvantage from the academic point of view. When the study was finished, the live scene was repeated and all students of the video group went also to see the scene. In this way all students felt in equal conditions. The data and results of the students were treated following their normal course in the academic activity of the university, but in the study data of the students were used anonymously”. Consent for publication “Not Applicable”. Competing interests The authors declare that they have no competing interests. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 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