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Thesis submitted to obtain the degree of

Doctor in Medical Sciences

Proefschrift voorgedragen tot het bekomen van de graad van Doctor in de Medische Wetenschappen Elena Vladimirovna Kourdioukova ____________________________________________________________________________________________________

PhD Dissertation Elena Vladimirovna Kourdioukova Ghent, 2010


This dissertation was submitted to fulfill the requirements for the degree of Doctor in Medical Sciences Promoters Prof. dr. K. Verstraete, Faculty of Medicine and Health Sciences Prof. dr. M. Valcke, Faculty of Psychology and Educational Sciences

Members of the Examining Committee:

Prof. dr. Th. J. ten Cate, UMC Utrecht Prof. dr. M. Maas, University of Amsterdam Prof. dr. J. De Maeseneer, University of Ghent Prof. dr. M. Van Winckel, University of Ghent Prof. dr. G. Vanderstraeten, University of Ghent Prof. dr. K. D'Herde, University of Ghent

Supervisory Board:

Prof. Dr. H. P. A. Boshuizen, Open Universiteit Nederland Prof. Dr. A. Derese, University of Ghent ISBN 978-90-9025749-5 Copyright © 2010 Ryhove Plot-it All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, or any information storage and retrieval system, without in writing from the publisher.


PhD Dissertation Elena Vladimirovna Kourdioukova Ghent, 2010



List of abbreviations


General introduction


The current state of radiology education

The innovative radiological curriculum model of Ghent University

Research objectives

Overview of the studies in this dissertation


Original research

Part 1: Evaluation of the radiology teaching system in the international context.................. 22 Chapter 1.1: Analysis of radiology education in undergraduate MD training in Europe.... 23 Part 2 : Evaluation of the innovating approach of radiology teaching in medical curriculum at Ghent University

Chapter 2.1: The perceived long-term impact of the radiological curriculum innovation in the MD training at Ghent University

Chapter 2.2: Radiological clerkships as a critical curriculum component in radiology education

Chapter 2.3: The quality and impact of computer supported collaborative learning (GSCL) in radiology case-based learning

General discussion

Research focus of this dissertation

Overview of the research objectives and the related research results

General discussion and conclusions

Strengths and limitations of the different studies

Implications of the research findings for educational practice

Directions for future research


Summary in Dutch- Samenvatting (NL)

Summary in Russian – Pезюме (RUS)

Acknowledgement – Dankwoord

Curriculum Vitae

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AGFI Adjusted Goodness-of-Fit-Index ANOVA Analysis of Variance CMC Conventional Medical Curriculum CSCL Computer Supported Collaborative Learning ERTeCS Evaluation Radiology Teaching Concept Scale ESR European Society of Radiology GFI Goodness-of-Fit-Index

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SUMMARY Aim The general research problem of the current dissertation centers on (1) an international benchmarking of radiology curricula in Europe, and (2) the evaluation of the innovative radiology curriculum as implemented at Ghent University (UGent). Four research objectives (RO) were put


RO 1: To describe how undergraduate radiology teaching is organized in Europe and to identify important characteristics of undergraduate radiology curricula.

RO 2: To investigate how do students perceive the innovative undergraduate radiology curriculum at Ghent University, and what explains differences in student perception.

RO 3: To explore the perceived value of clinical clerkships in the radiology curriculum as well as the impact of radiology clerkship on students’ beliefs about the radiology profession and radiology as a career.

RO 4: To explore whether case-based learning within a computer supported collaborative learning (CSCL) setting results in student satisfaction and helps to develop and improve radiologic problem-solving abilities of medical students.

Methods In view of this dissertation, two specific questionnaires were developed. To map radiology undergraduate curricula in an international context, the “ESR (European Society of Radiology) questionnaire on undergraduate radiology teaching” was developed. In view of evaluating the UGent innovative radiology curriculum, a questionnaire “Evaluation Radiology Teaching Concept Scale” (ERTeCS) was designed. A qualitative and quantitative analysis of online collaborative learning discussions was performed to investigate radiology case based learning in a CSCL setting.

Results The descriptive results of the ESR questionnaire show large differences in the organization of undergraduate radiology curricula in Europe. The results from the evaluation of the UGent innovative radiology curriculum show that students -both during pre-clinical and clinical years appreciate particular curriculum components such as ex-cathedra lessons with syllabus, Elearning, E-testing, the use of E-cases, etc. During clinical years when students are oriented to the application of knowledge and skills, a high appreciation is expressed for practice linked curriculum components. The results show that students highly appreciate the radiology clerkship to learn to order and to interpret imaging studies. The clerkship provides students a unique possibility to attend various radiological examinations and to get access to a variety of radiology software systems. They develop a better understanding of radiology and improve their image interpretation skills. The clerkship experiences affect positively student perceptions about radiology as a profession. The results about case-based learning via computer supported collaborative learning groups show that this approach is effective in terms of process and learning performance. Critical is the role of scripting. The CSCL approach proves to be useful for students of different grade levels in view of developing their radiology diagnostic skills and problem solving abilities.

Conclusions The differences between the radiology curricula in medical training in Europe introduces a focus on standardization of curricula in view of credit transfer between countries and different medical programs. This comparative study can be extended further by focusing on the analysis of instructional practices, internships, rewards systems, etc.

Also the positive findings about the UGent curriculum innovation induce a further reflection. Next to the implementation of qualitative studies about the curriculum innovation and the adoption of a true longitudinal perspective, it also seems critical to center on the teaching staff that is responsible for the curriculum implementation. Only when a continuous critical evaluation perspective is adopted, we will be able to attain and maintain the potential benefits of the curriculum innovation.


PhD Dissertation Elena Vladimirovna Kourdioukova Ghent 2010 ~ ii ~


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Introduction The current state of radiology education Radiological curriculum model of innovating teaching at Ghent University Central research objectives Overview of the studies in the dissertation References

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Introduction The topic of this dissertation is the evaluation of an innovative radiology teaching system within the context of the medical school curriculum. In addition, an international perspective is adopted to position the local innovation within a broader frame of references. Depending on a particular medical school, educational programs and in particular the undergraduate training of radiology are different in terms of the curricular content, instructional formats (teaching approach, course design, evaluation approaches) and available human resources.

Considering the influence of good teaching on learning performance, student satisfaction and future career choice1-2, a better understanding of the content and nature of traditional and innovative instructional formats used in radiology is expected to be helpful to direct the current and future design of adequate learning and teaching environments and appropriate, state-of-the-art curricula.

This introductory chapter presents an overview of earlier research in the field of the radiology curriculum as it is related to the medical curriculum. This overview will provide a rich background to ground the central research problem of this dissertation. The chapter therefore starts with an overview of literature about the current status of radiology education. Next, a descriptive perspective will be adopted to analyze critical features of the radiology curriculum at Ghent University.

This will help to state the main research objectives and to develop an advance organizer about the different studies, conducted in the context of this dissertation to address the research problem.

The current state of radiology education

In the medical literature reviewing the status and innovation of medical education in Canadian and US medical schools, the main focus is on changes in organizational structures, staffing patterns, and educational approaches. The specific position of undergraduate radiology education in these educational programs is not clear. Mostly radiology is presented as an elective course, only a few medical schools include radiology as a requirement3-4. Though the situation in Europe is more varied, we again observe that radiology is hardly a part of the formal undergraduate medical curriculum5-8. In addition, thorough information about the current status of radiology teaching in Europe is lacking and also a comprehensive educational strategy to make radiology qualifications transferrable within Europe is not available. The latter is peculiar since recommendations for an innovative radiology curriculum design are on hand9.

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Despite a lack of standards related to good educational practices in undergraduate radiology education, currently, a lot of research has been carried out regarding reorientations in the content and instructional design of the radiology teaching and learning experiences. Some clear trends can be derived from the related literature.

• Several authors explain why radiology should play a vital role in the medical school curriculum10 and advocate the need to improve undergraduate education in field of radiology 11. Educational research stresses to move away from a focus on single and/or isolated radiology learning experiences towards a stronger emphasis in on radiology in the undergraduate radiology curriculum12 and/or towards a fully integrated approach of radiology education13-16.

• The current literature emphasizes the adoption of evidence-based approaches in the field of radiology education 17-18. Research additionally emphasizes the psycho-social aspects of learning and teaching in medical education. The particular interest is the role of Gestalt principles related to visual perception in radiology practices and education. Research acknowledged that Gestalt theory conceptions such as the figure–ground relationship and a variety of “grouping principles” (the laws of closure, proximity, similarity, common region, continuity, and symmetry) are underappreciated, but invaluable in radiology training. Applying these conceptions can help students to better understand and interpret radiology images19. Research also centers on broad conceptions of learning as advocated in the medical education literature: “the ultimate goal of education is not to teach well, but for learners to learn well” 20. This stresses the importance of learning subdomains such as the cognitive (what we think and believe), the affective (what we feel and experience), and the psychomotor (what we do) subdomain in medical education 21. The affective learning domain is not to be underestimated in relation to clinical competences and clinical performance22. Affective attitudes as reflected in emotional responses and personal experiences are sensitive to personal feelings and the context23. As a result, instructional research increasingly focuses on the design24-26 and innovative features of learning environments as reflected inaction learning and group work 27, the interactivity of the learning environment 28, the expansive use of multimedia 29-31, and the adoption of e-learning 30, 32-38. The latter results in the implementation of

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“blended” learning approach in which face-to-face instruction is mixed with e-learning, resulting higher efficiency, better learner achievement and higher learner satisfaction31, 39. In this context, a large body of research evidence emphasizes that these innovations are only beneficial when they are perceived as such by the students40-41.

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