medical education research study quality instrument (mersqi)

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A Plea for MERSQI: The Medical Education Research Study Quality Instrument.

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Obstetrics and Gynecology , 01 Oct 2017 , 130(4): 686-690 https://doi.org/10.1097/aog.0000000000002091   PMID: 28885409 

Abstract 

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Read article at publisher's site: https://doi.org/10.1097/aog.0000000000002091

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Update in internal medicine residency education: a review of the literature in 2010 and 2011.

Eaton JE , Reed DA , Aboff BM , Call SA , Chelminski PR , Thanarajasingam U , Post JA , Thomas KG , Dupras DM , Beckman TJ , West CP , Wittich CM , Halvorsen AJ , McDonald FS

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Self-directed learning assessment practices in undergraduate health professions education: a systematic review.

Taylor TAH , Kemp K , Mi M , Lerchenfeldt S

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Publication rates of congress abstracts is associated with abstract quality: Evaluation of Turkish National Medical Education Congresses and Symposia between 2010 and 2014 using MERSQI.

Sarı E , Nteli Chatzioglou G , Aydın ÇY , Sarı F , Tokat T , Gürses İA

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To the Point: Integrating Patient Safety Education Into the Obstetrics and Gynecology Undergraduate Curriculum.

Abbott JF , Pradhan A , Buery-Joyner S , Casey PM , Chuang A , Dugoff L , Dalrymple JL , Forstein DA , Hampton BS , Hueppchen NA , Kaczmarczyk JM , Katz NT , Nuthalapaty FS , Page-Ramsey S , Wolf A , Cullimore AJ , APGO Undergraduate Medical Education Committee

J Patient Saf , 16(1):e39-e45, 01 Mar 2020

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To the Point: The expanding role of simulation in obstetrics and gynecology medical student education.

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A Plea for MERSQI: The Medical Education Research Study Quality Instrument

Affiliation.

• 1 Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida.
• PMID: 28885409
• DOI: 10.1097/AOG.0000000000002091

Objective: To describe the quality of educational scholarship presented at a large national conference of obstetrics and gynecology educators.

Methods: We reviewed Council on Resident Education in Obstetrics and Gynecology-Association of Professors of Gynecology and Obstetrics annual meeting abstracts from 2015 and 2016, published as supplements to Obstetrics & Gynecology. For this uncontrolled observational study, abstracts were reviewed and scored using the Medical Education Research Study Quality Instrument (MERSQI). Comparisons between types of submissions (oral presentations or posters), origin of the report (academic or community), setting (undergraduate, graduate, postgraduate), and focus of the study (tool development or evaluation) were made. Abstracts from award-winning presentations and full manuscripts were compared with the remaining abstracts. One- and two-tailed Student t tests with a two-sample unequal variance (heteroscedastic) test were performed with a significance threshold of P≤.05.

Results: One hundred eighty-six abstracts and articles were available, with 101 posters and 77 oral presentations that could be scored in all six of the MERSQI domains. The average MERSQI score was 9.05 (±1.90) with scores ranging from 5 to 13.5 (median 9). Abstracts from full-text articles scored more than 1 point higher than other abstracts (10.2 compared with 9.0, P<.001, Cohen's d=0.72). Statistically significant smaller magnitude differences were found comparing tool development with evaluation, academic with community studies, and for award with nonaward winners. No differences were found comparing oral and poster presentations.

Conclusion: The quality of educational scholarship presented at a national meeting of obstetrics and gynecology educators falls within the published range for other specialties. The MERSQI scoring system is a useful method for tracking and benchmarking the quality of medical education scholarship in obstetrics and gynecology.

Publication types

• Observational Study
• Biomedical Research / standards*
• Education, Medical / standards*
• Educational Measurement / methods
• Gynecology / education*
• Obstetrics / education*
• Research Report / standards*

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Flipping the Classroom in Graduate Medical Education: A Systematic Review

Associated data.

Flipped classroom (FC) instruction has become increasingly common in graduate medical education (GME).

The purpose of this study was to profile the use of FC in the GME setting and assess the current status of research quality.

We conducted a systematic literature search of major health and social science databases from July 2017 to July 2018. Articles were screened to ensure they described use of the FC method in an Accreditation Council for Graduate Medical Education–accredited residency program and included research outcomes. Resulting articles were analyzed, described, and evaluated for research quality using the Kirkpatrick framework and the Medical Education Research Study Quality Instrument (MERSQI).

Twenty-two articles were identified, all of which were recently published. Five were only indirectly related to FC methods. Most studies reported Kirkpatrick-level outcomes. Studies involving resident learner opinions were generally positive. Pre-posttest studies resulted in large positive improvements in knowledge or skills attainment. Control group study results ranged from large positive (1.56) to negative effects (–0.51). Average MERSQI scores of 12.1 (range, 8.5–15.5) were comparable to GME research norms.

Conclusions

Varying methods for implementing and studying the FC in GME has led to variable results. While residents expressed a positive attitude toward FC learning, shortcomings were reported. Approximately half of the studies comparing the flipped to the traditional classroom reported better achievement under the FC design. As indicated by the MERSQI score, studies captured by this review, on average, were as rigorous as typical research on residency education.

Introduction

Medical education has been shifting from traditional, lecture-based teaching to approaches that promote higher-order thinking and active learning. 1 One particular approach, the flipped classroom (FC), has become increasingly popular in higher education, including medical education. 2 In this educational pedagogy, foundational content materials are studied by the learner independently through preclassroom activities, such as reading an article or textbook chapter, watching a multimedia presentation, or listening to a lecture in advance of classroom time. The classroom is reserved for applying foundational content knowledge in small group discussions involving clinical cases or more generic problem-solving. Conversely, in the traditional classroom, foundational content material is transmitted to learners through lectures that require review and reinforcement through study after class. 3 , 4

Advances in technology and the search for more effective approaches to teaching seem to be driving the shift to FC. 5 Active, self-directed learning—a necessary component of the FC learning model—is consistent with the needs of resident learners. 4 Additionally, this model is consistent with social, behavioral, and constructivist learning theories. 6 , 7 Group collaboration encourages modeling, scaffolding, and feedback that engage learners and facilitate the integration of new knowledge with old knowledge. 8 Compared to the traditional lecture, the FC promotes higher levels of cognitive processing as defined by Bloom's taxonomy. 8 – 10 As a result, increasing numbers of educators have adopted the FC across a variety of educational settings. 11 – 19

Literature on the FC has proliferated rapidly across health sciences education since its inception in 2007. 20 Numerous articles originated from pharmacy, nursing, or veterinary medicine education programs. 3 , 7 , 12 , 21 – 29 Both a recent systematic review and a meta-analysis covering the FC in medical education yielded very few articles on graduate medical education (GME). 3 , 30

The GME setting is more challenging than the undergraduate medical education (UME) setting. Resident learners may be less motivated by grades and more motivated by learning that facilitates patient care. Additionally, the GME learner's primary role is care provider while the UME learner's primary role is student. Given the marked differences in learning environments between UME and GME, and the FC's increasing popularity with residency programs, 19 a review specific to the effectiveness of the FC method in GME was needed. The goal of this systematic review is to profile the use of and assess the quality of the research literature on FC methods used in GME.

This study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and was performed in accordance with best practice guidelines. 31

A health sciences librarian (S.J.S.) performed comprehensive searches of multiple databases, including PubMed, CINAHL Plus, Embase, Web of Science Core Collection, and ERIC, on July 27, 2017. Search alerts were used to gather new records through July 27, 2018. Major search terms and strategies are provided as online supplemental material. To identify additional manuscripts, we also searched MedEdPORTAL and reviewed bibliographies of included studies.

Inclusion and Exclusion Criteria

All articles published through July 2018 involving the use of FC in Accreditation Council for Graduate Medical Education (ACGME)–accredited residency programs were screened. We included articles that pertained to residents in any year of training from any medical specialty. Other inclusion criteria involved peer-reviewed, full-text articles that described some form of research or evaluation. We excluded articles that involved FC in non–medical education settings and at other levels of medical education, including UME, continuing medical education, or fellowship. We also excluded published abstracts. We did include articles that involved research or evaluation about preclassroom learning activities associated with FC. These activities are designed to introduce new knowledge to prepare learners for the classroom session, where they will apply the new knowledge from presession activities.

Two authors (A.M.K. and M.G.) independently screened titles and abstracts of retrieved articles, and subsequently selected articles for full-text review. Discrepancies were resolved by a third reviewer (J.M.). Two authors (J.M. and T.D.) independently reviewed the full-text articles and made the determination for inclusion in the final quality review. A third author (D.P.W.) adjudicated discrepancies at this stage.

Data Extraction

We extracted the following variables for each study: authors, publication year, medical specialty, level of trainees, education topic, FC method, specific intervention, number of FC participants, study design, and study outcomes. Research design terms used for classifying study design were derived from Campbell and Stanley. 32 Originally, 2 authors (J.M. and T.D.) independently performed data extraction using a worksheet to guide the process. Differences were adjudicated by a third reviewer (M.G.). Data from articles added later in the process were extracted by 2 other authors (A.M.K. and D.P.W.).

Quality Assessment

We used the modified Kirkpatrick framework to classify study outcomes of educational interventions according to impact level. 33 The modified Kirkpatrick classification levels are 1, measures of learner perceptions; 2a, self-reported changes in learner opinions; 2b, changes in knowledge or skills; 3, changes in learner behavior; 4a, change in professional practice; and 4b, change in patient's condition. When not provided, we also attempted to extract information needed to calculate associated Cohen's d effect sizes for each outcome. 34 , 35

Finally, we used the Medical Education Research Study Quality Instrument (MERSQI) to assess the quality of selected studies. 36 , 37 This 10-item scale provides a measure of methodological quality across 6 domains: study design, sampling, type of data, validity evidence, data analysis, and outcomes. Total MERSQI scores range from 2 (low-quality research) to 18 (high-quality research). Two authors (A.M.K. and J.M.) independently scored each article. An educational researcher (D.P.W.) adjudicated discrepancies in MERSQI scoring and Kirkpatrick level assignment.

Search Strategy

The Figure illustrates the systematic review process. The initial search yielded 2562 articles. After removing duplicates, 2123 studies were screened using titles and abstracts. Articles were excluded based on criteria outlined earlier, which resulted in 116 articles for full-text review. Of these 116, an additional 94 were excluded because they did not meet criteria. The final list of articles that met criteria for quality review included 22 articles. 8 , 38 – 58

PRISMA Diagram Illustrating Selection and Review Process of Articles Related to Flipped Classroom in Graduate Medical Education

Education Content

The 22 studies included in the final analysis are presented in Tables 1 and ​ and2. 2 . All were published in the past 5 years (2014–2018), most (86%) in the past 3 years. Across all studies, approximately 985 learners were involved with a flipped classroom intervention. Thirteen medical specialties were represented, including anesthesiology, 46 , 49 , 50 , 57 emergency medicine, 8 , 38 , 44 , 52 , 58 internal medicine, 39 internal medicine–pediatrics, 43 neurology, 47 neurological surgery, 41 obstetrics and gynecology, 55 , 56 pathology, 42 pediatrics, 40 , 43 , 51 psychiatry, 45 radiology, 53 thoracic surgery, 48 and surgical intensive care. 54 All study designs were quantitative; however, a few gathered feedback through open-ended survey items.

Flipped Classroom (FC) Methodology in Graduate Medical Education

Abbreviations: PGY, postgraduate year; MK, medical knowledge; TBL, team-based learning; ACLS, advanced cardiovascular life support; PEM, pediatric emergency medicine; SICU, surgical intensive care unit; EEG, electroencephalogram.

Note: Dark shading indicates studies that focus predominantly on pre-class methods rather than the FC method.

Summary of Study Outcomes and Analysis

Abbreviations: MERSQI, Medical Education Research Study Quality Instrument; NA, not available; FC, flipped classroom; QIKAT, Quality Improvement Knowledge Application Tool; TBL, team-based learning; NR, not reported; QI, quality improvement; ADHD, Attention-Deficit/Hyperactivity Disorder.

Note: Dark shading indicates studies that focus predominantly on preclass methods rather than the FC method.

Authors of reviewed studies offered numerous reasons for incorporating the FC into their residency programs. Some suggested that using the FC was a solution to scheduling issues—either saving time in already saturated didactic schedules or providing schedule flexibility. 38 , 39 , 41 , 48 , 52 , 53 , 56 Others suggested that the FC method was selected to improve didactic instruction, motivate or engage learners, promote active learning, or prepare for more advanced levels of content material. 38 – 42 , 44 , 46 , 47 , 49 , 54

Residency programs adopted the FC method in 1 of 3 ways. Most commonly, authors described “occasional” use of the FC for a single lesson, usually to emphasize an important topic such as quality improvement, 39 , 43 resident-as-teacher skills, 40 using clinical guidelines, 51 echocardiography or electro-encephalograph interpretation, 47 , 54 , 57 or pediatric advanced life-support. 52 Other programs have replaced their entire didactic curriculum with FC sessions. 41 , 44 , 48 , 50 , 55 Three articles describe the use of FC for portions of their didactic curriculum: intern orientation, 38 , 49 , 53 reinforcement of important basic science principles, 42 , 45 , 46 and weekly didactics during 1- or 2-month rotations. 39 , 47 , 54 , 55 As proof-of-concept projects, Haspel and Lockhart designed FC instruction for delivery at national conferences. 42 , 45

Concerns about the FC surfaced in some of the literature, particularly around learner compliance with self-directed learning. Rose and colleagues discovered that residents did not accurately report time spent viewing video lectures in preparation for FC activities. 52 Residents in the Young et al study suggested that time for preclass preparation was a weakness of the FC format. 58 Without adequate preclass preparation, learners are unable to effectively participate in applying content knowledge during the in-class meeting. Consequently, several studies involved the production of innovative methods for delivering preclass content such as podcast lectures, interactive electronic modules, or multimedia textbooks. These materials were designed specifically to persuade learners into completing the self-directed learning required for constructive participation during in-class activities. 41 , 45 , 47 , 49 , 50 , 52 , 57

Study Outcomes

Five of the selected articles focused more on preclass methods and less about the FC method itself. Lockhart and colleagues assessed the implementation of a small, private, online course. 45 Moeller et al and Vasilopoulos et al studied the effectiveness of podcast lectures. 47 , 57 Rose and colleagues studied the impact of embedding multiple-choice questions into instructional videos, 52 and Ortega et al evaluated a multimedia, interactive textbook. 50 Since none of these studies reported outcomes related to both preclass and in-class FC methods, they were not subject to Kirkpatrick classification.

Level 1 Outcomes–Perception:

Most of the 7 studies that evaluated Kirkpatrick Level 1 outcomes were not designed for control group comparisons or change over time. 41 – 44 , 48 , 51 , 58 Accordingly, effect sizes were not appropriate for Level 1 articles. An exception was the article by King and colleagues that compared ratings of curriculum components before and after the program switched from lecture-based to FC methods. 44 Residents rated all components higher under the FC model, but only 2 (adult and pediatric case conferences) were deemed significantly higher in quality and value, which yielded large effect sizes (d = 1.19 and 1.10, respectively). 44

Level 2a Outcomes–Change in Opinion:

Almost a third of the articles reported changes in learner opinions about the FC, the content taught, or the learners themselves. 38 – 40 , 43 , 46 , 49 , 53 , 54 Changes in opinion about the FC method were observed in a control group study and a pre-post study, both yielding large effect sizes of 1.1 and 0.95, respectively. 39 , 46 Residents improved their opinions about teaching in a pre-post study of resident-as-teacher skills, which also yielded a large effect (0.95). 40 Studies that reported changes in self-efficacy, confidence, comfort, or anxiety yielded smaller effect sizes, ranging from 0.32–0.84. 39 , 49 An exception was the Bonnes resident-as-teacher study, which generated a large 1.68 effect size for change in self-assessment of resident teaching skills. 39 Effect sizes could not be calculated for the remaining articles reporting Level 2a outcomes. 38 , 43 , 53 , 54

Level 2b Outcomes–Change in Knowledge or Skills:

A third of the articles reported changes in knowledge or skills that came from controlled studies involving either parallel or historic control groups. 8 , 39 , 41 , 44 , 46 , 51 , 55 , 56 Effect sizes for these studies ranged from large (1.56) to negative (–0.51). An additional 5 articles reported changes in knowledge or skills that came from pre-posttest studies, 2 of which had associated effect size that were either large (0.81) 40 or very large (2.73). 38 Effect sizes could not be calculated for the other 3 articles. 43 , 53 , 54

Level 3 Outcomes–Change in Behaviors:

Only 2 studies reported changes in behaviors: one involving increases in self-directed learning outside of class, 44 and the other reporting inflated, self-reported, preclass preparation times when compared to actual preparation times. 52 The effect size for the first was large (0.85), 44 but the effect size for the second could not be calculated. 52

Study Quality

Cook and Reed provided a table of normative data for interpreting MERSQI scores. 36 A mean score of 10 (range, 5–16) was generated through a review of 210 articles covering medical education. 36 For the specific topic of residency education, the mean MERSQI of 12.9 (range, 9–15.6) was generated through a review of 97 articles. This is considerably higher than the mean MERSQI score of 10.9 we observed for the 22 articles reviewed (range, 4–15.5, SD = 3.08). By dropping 4 pilot or proof-of-concept studies, which had only Level 1 outcomes from our analysis, 45 , 47 , 50 , 58 the average MERSQI score would be more comparable to the normative data reported by Cook and Reed (M = 12.1; range, 8.5–15.5; SD = 1.93). 36

Looking at individual MERSQI items suggests that research on the FC in GME is still in its infancy. The literature review included numerous articles that were considered pilot or proof-of-concept studies. Some specifically targeted investigations into developing content delivery methods for preclass preparation such as video lectures, 43 , 46 podcasts, 41 , 51 or a multimedia interactive textbook. 44 Only half of the articles reviewed used experimental or quasi-experimental designs with control groups (either a control arm or historical controls). 8 , 39 , 41 , 44 , 46 , 48 , 49 , 51 , 55 , 56 The other half were pre-experimental, involving only 1 group pre-posttest or posttest-only designs. 38 , 40 , 42 , 43 , 45 , 47 , 49 , 52 – 54 , 57 , 58 Only 5 studies involved cross-institutional collaborations. 8 , 36 , 39 , 46 , 47 While almost three-quarters used objective measures, very few articles provided validity evidence in the form of construct or content validity. Furthermore, articles investigating the relationship between relevant variables were limited. However, more than three-quarters (77%, 17 of 22) of the studies used appropriate analyses and almost 70% (15 of 22) implemented inferential statistics to analyze outcome variables such as knowledge or skills.

This systematic review of FC application in GME yielded several important findings. While still in its early stages, research on the FC in GME has increased substantially over the past 5 years, with 17 of 22 articles being published since 2016. We discovered use of the FC in at least 13 types of residency programs, suggesting that the teaching method can be broadly adopted across a variety of GME settings. Reasons for using the FC and specific techniques on how it was applied vary greatly across programs, suggesting that it is not a one-method-fits-all intervention. We found that the FC has been applied to entire residency programs or, on a more limited scale, within rotations or to cover specific topics. The method has also been used across institutions to prepare learners for specialized topics, or to capitalize on educator expertise.

We attribute the rise of interest in the FC in GME to medical educators' desire to find better teaching methods, recognizing that this method is suitable for residents and can be adapted to the GME setting. The self-directed learning component gives residents more control, allowing them to learn content at their own pace and during times outside of their clinical responsibilities. Consistent with social learning theory, the FC provides a venue for collaborative learning where learners publicly demonstrate their application of knowledge during small group discussion of patient cases and problems. 7 , 8 Learner enthusiasm for the FC method and documented improvements in knowledge and skills make the FC an attractive alternative to the traditional lecture-based education model.

Medical educators have suggested that their interest in the FC is associated with making more effective use of instructional time, providing more structure for self-directed learning outside of class, or motivating residents to spend more time outside of clinical responsibilities engaged in study. The FC requires learners to complete self-directed learning activities to participate during in-class sessions. This was a concern among graduate medical educators because residents have clinical responsibilities that compete for their time. We believe many studies created more interesting methods for delivering preclassroom content because of this concern.

F. Chen and colleagues' earlier systematic review of the FC approach in medical education found that the “majority of literature has been carried out in UME.” 3 Additionally, their review suggested that research up to that point “lacked strong evidence for the effectiveness of FCs.” 3 A subsequent comprehensive meta-analysis by K.S. Chen et al covered a relatively small number of studies involving medical education and only one that involved residency education. 30 This group of authors tentatively suggested an advantage of the FC over lecture-based methods; however, they expressed concern about this interpretation due to extreme diversity in methods. Our systematic review focused solely on the use of the FC in ACGME-accredited residency programs. Like K.S. Chen, we confronted diversity in research methods, but also diversity in how the FC was applied and the content covered. In contrast with F. Chen, and comparable to K.S. Chen, we found that learners generally find the FC approach acceptable and evidence supports that the FC is as good as a traditional didactic approach (introducing topics through lecture or during a face-to-face meeting followed by readings and study of educational materials).

This systematic review of the FC literature has some limitations. While we employed what we think is a comprehensive search strategy with the help of an experienced medical librarian, it is possible that we did not include more esoteric terms that refer to methods associated with FCs. For example, we did not use the term “problem-based learning,” which is a method that typically describes a comprehensive approach to education, but could be associated with the FC format on a more limited basis. In addition, we made the decision to exclude non-ACGME residency programs and US fellowship programs. This decision was based on the variability of education structures found outside the United States and variability in size and purpose of fellowships. These decisions may have restricted the generalizability of our findings.

The assessment of higher-level outcomes, such as changes in learner behaviors or patient outcomes, remains a challenge in medical education. 36 These outcomes are difficult to assess because they rarely can be attributed to a single educational intervention. Despite these challenges, we were heartened to find an increasing number of studies that generated Kirkpatrick levels 2a, 2b, and 3 outcomes, many studies that employed objective measures, and an increasing number of studies that employed more rigorous research designs. Future research on the FC in GME should focus on higher-level outcomes such as changes in behaviors, clinical practice, and patient outcomes. 33

The FC pedagogical approach in GME has been implemented in a variety of ways and studied with a variety of methods, which has yielded variable results. Using MERSQI scores, studies evaluating the efficacy of the FC were somewhat less rigorous than typical medical education research studies; however, if pilot and proof-of-concept studies are eliminated, the average MERSQI score was comparable to that of other medical education research studies. The studies that evaluated resident satisfaction or efficacy concluded that residents held generally positive opinions about the FC. For studies that evaluated learning outcomes, the results were mixed: slightly more than half of the studies using a control group for comparison found positive learning results. Future studies of FC in GME should include higher-level outcomes (changes in knowledge, behaviors, or patient outcomes) and assessment of preclassroom assignment completion.

Supplementary Material

Educational endoscopic videos improve teaching of middle ear anatomy

• Published: 20 April 2024

Cite this article

• Valentino Caputo   ORCID: orcid.org/0009-0006-3635-6035 1 ,
• Françoise Denoyelle   ORCID: orcid.org/0000-0003-4338-9258 1 &
• François Simon   ORCID: orcid.org/0000-0003-0082-538X 1  

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Videos and images are becoming an educational tool in every domain. The objective was to assess the contribution of short educational endoscopic videos in learning the complex anatomy of the tympanic cavity.

We conducted a prospective study amongst all the otolaryngology residents in 2021 in the greater Paris area ( n  = 74), from the first year to fifth year. We divided the residents into two groups who had the same 30-min anatomy class based on anatomical drawings. The second group had a 4-min endoscopic educational video at the end, whereas the first group did not. A video test of 10 surgical situations with each time 5 anatomic structures to identify was created. All the residents took the test just after the class, and 1 month later to assess long-term memory. The MERSQI score (design to assess the quality of educational studies) applied to our study was calculated.

The two groups were comparable in terms of training. The “video” group had significantly better results in the first test, mean score 24.40/50 (± 11.7) versus 16.74/50 (± 11.1) (p = 0.005) and also at 1 month, mean score 23.25/50 (± 12.3) versus 18.01/50 (± 11.3) (p = 0.035). The score in each group, and the difference between both groups, increased with resident seniority. The MERSQI score of our study was 14.5/18.

This study highlights the educational value of videos to help memorise complex 3D anatomy such as in the tympanic cavity.

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Valentino Caputo, Françoise Denoyelle & François Simon

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Caputo, V., Denoyelle, F. & Simon, F. Educational endoscopic videos improve teaching of middle ear anatomy. Eur Arch Otorhinolaryngol (2024). https://doi.org/10.1007/s00405-024-08658-1

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Received : 18 February 2024

Accepted : 03 April 2024

Published : 20 April 2024

DOI : https://doi.org/10.1007/s00405-024-08658-1

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