Red cell indexes made easy using an interactive animation: do ...

Adv Physiol Educ 42: 50–55, 2018; doi:10.1152/advan.00142.2017.

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Red cell indexes made easy using an interactive animation: do students and their scores concur? Upasana Kachroo,1 Elizabeth Vinod,1 Sivakumar Balasubramanian,2 Jesi W.,1 and Neetu Prince1 1

Department of Physiology, Christian Medical College, Vellore, India; and 2Department of Bioengineering, Christian Medical College, Vellore, India Submitted 20 September 2017; accepted in final form 27 November 2017

Kachroo U, Vinod E, Balasubramanian S, W. J, Prince N. Red cell indexes made easy using an interactive animation: do students and their scores concur? Adv Physiol Educ 42: 50 –55, 2018; doi:10.1152/ advan.00142.2017.—A good understanding of red cell indexes can aid medical students in a considerable manner, serving as a basis to unravel both concepts in red cell physiology and abnormalities associated with the same. In this study, we tried to assess whether an interactive animation was helpful in improving student comprehension and understanding of red cell indexes compared with conventional classroom teaching. Eighty-eight first-year MBBS students participated, of which 44 were assigned to group A and 44 were assigned to group B after randomization. After further creation of smaller groups, students were provided with 45 min to revise red cell indexes, after which they were required to complete a multimodal questionnaire. Group A subgroups used written material for revision, whereas group B subgroups had access to an interactive animation. After completion of the questionnaire, group A students also used the animation after which feedback was collected from all students. Efficacy of the animation to improve learning and retention was demonstrated, as group B students scored significantly higher than group A students on the questionnaire (P ⫽ 0.0003). A clear majority of the students agreed/strongly agreed that the animation was easy to operate, conveyed important concepts efficiently, and improved their knowledge of related clinical aspects as well. From the results and feedback, we found that the animation was a simple, well-received model, which, by significantly improving student performance, corroborated our hypothesis that inclusion of interactive animation into student curriculum can advance their academic attainment, compared with didactic teaching alone. red cell indexes; interactive animation; medical education; physiology

Assessing the results of MCV, MCH, and MCHC provides a reliable index of the average size, mean amount of Hb, and mean concentration of Hb per cell, respectively, serving both as a teaching guide and clinical adjunct of considerable importance to uncover the underlying nature of red cell abnormality (3). As part of the hematology practical curriculum, Bachelor of Medicine and Bachelor of Surgery (MBBS) students in the first professional year are taught about red cell indexes, with more stress on their derivation and calculation. This helps them to understand normal blood physiology, as concepts learned can be correlated with clinical scenarios. Although conventional teaching (theory lectures and interpretation of values during practicals) aims at improving comprehension and applicability in clinical years, the lacunae faced are due to the textual approach and limited student compliance. This calls for the need to integrate interactive media with conventional teaching methods to pique student interest and enhance their learning experience. Since students are adept at using and learning via such interfaces, it would be prudent to explore avenues involving animation and other multimedia to teach basic concepts to them (2, 4). This would be an easily usable tool that would immensely help in improving the knowledge of students and also help them appreciate the importance of basic physiological concepts and their clinical implications. The purpose of this study was to assess the effectiveness of a newly developed interactive animation for improving student comprehension and understanding of red cell indexes compared with conventional classroom teaching. METHODOLOGY

INTRODUCTION

In the year 1929, Dr. Maxwell Myer Wintrobe utilized the three cardinal red cell parameters, namely hemoglobin (Hb), red blood cell or RBC count, and hematocrit (5), to arithmetically derive mean corpuscular volume (MCV), mean corpuscular Hb (MCH), and mean corpuscular Hb concentration (MCHC) and hence introduced to us erythrocyte or red cell indexes. As Wintrobe was successful in postulating the relation between red cell morphology and etiology of anemias, these indexes, also known as Wintrobe’s indexes, could be used clinically, if precise measurements of cell count, hematocrit, and Hb were made (1). Address for reprint requests and other correspondence: J. W., Dept. of Physiology, Christian Medical College, Bagayam, Vellore, Tamil Nadu 632002, India (e-mail: [email protected]). 50

The study involved students from the MBBS first professional year. It took place at a time point at which the theory and practical sessions pertaining to red cell indexes had already taken place, as per the physiology curriculum, by means of large and small group lectures. Institutional review board approval was obtained before the study was initiated. Study design. A total of 88 students were divided into two groups: group A (n ⫽ 44) and group B (n ⫽ 44). Randomization was achieved by lot picks. Each group was further randomized and divided into smaller groups of three by picking numbered lots. The subgroups within group A were provided with printed material containing details of red cell indexes and were asked to study/revise the material for 45 min, after which they were required to complete a test in the form of a multimodal questionnaire. Similarly, group B subgroup students were provided with a computer/laptop containing the newly developed interactive animation called PhysioAnime. They were also provided with 45 min to study/revise the topic of red cell indexes by using the PhysioAnime, after which they were also required to

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RED CELL INDEXES MADE EASY USING PhysioAnime

answer the same questionnaire. During the 45-min period, the subgroups were allowed time for discussion, but the tests were individually attempted and scored. After completion of the questionnaire, group B students were asked to provide their feedback by means of a form based on a Likert scale template. Group A students were allowed to access PhysioAnime after completing the questionnaire, after which feedback was collected from them as well (Fig. 1). The identity of all of the students was kept anonymous by providing each student with a unique identification. Investigators analyzing the data were not involved in the administration of the questionnaire and collection of feedback to reduce bias. The results obtained from the questionnaire completed by group A and group B students were compared using unpaired t-test, and a P value of ⬍0.05 was considered significant. Interactive animation model. The animation software, called PhysioAnime, was developed to visually demonstrate concepts in red cell physiology. The animation was developed using Unity Game Engine, a popular game development environment for two- and three-dimensional games. It was built to run on a web browser, thus making it

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suitable for easy deployment across the institutional computer network [link to PhysioAnime:https://drive.google.com/drive/folders/ 0B356KFCMYtDmdmh5RjAxQTl3MDQ?usp⫽sharing. This is a link to access the HTML file to use the animation (to be opened using Mozilla Firefox) as well as the software (unity web player) required to run it.] In brief, the computer-animated interactive model included options to select a red cell indexes parameter. Any selected page contained the definition of the specific index, followed by the formula with options for entering values to obtain a result. The unit for the index could also be seen next to where the result was displayed. The resulting value was linked to a scroll bar, which also displayed the normal range for the index. Values were also linked to animating RBCs, which depicted corresponding changes. In addition, the scroll bar was user regulated and had additional pointers appear when and where necessary, i.e., the scroll bar could be moved independently after initial entry of values, and, when moved to abnormally low or high values for that index, it was coupled with examples of conditions and changes in animating red cells appearing next to it for that value. For reference (Fig. 2,

Fig. 1. Diagrammatic algorithm of the study design.

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RED CELL INDEXES MADE EASY USING PhysioAnime

A–C), the screenshot of PhysioAnime showing the values and corresponding red cell changes for the parameter MCHC have been shown. Questionnaire and feedback (Likert scale). To assess understanding of red cell indexes following access to either handouts or interactive animation, both of the groups were provided with a questionnaire. The questionnaire was structured to determine cognitive and recall memory knowledge on the topic (see Supplemental Information, Test Questionnaire; supplemental material for this article is available online at the Journal website). It also tested the students’ conceptual understanding, as it required them to analyze the information learned and apply it to the clinical scenario presented in the questionnaire. Questions included were varied and composed of the following types: multiple choice, numerical, true-false, open ended, and distractors. To assess student compliance and qualitative superiority of the teachinglearning method, feedback was collected from the students after conclusion of the test (see Supplemental Information, Feedback Form). RESULTS

Group B students achieved a higher score than group A students in 9 of the 12 questions, one of which was statistically significant (P ⫽ 0.00003). Group A scored higher than group B in one question (P ⫽ 0.54) and obtained an equal score in the remaining two questions (Fig. 3A). Significant difference was observed in the total score obtained by group B (746.5), which was higher than that of group A (644.5), having a P value of 0.0003 (Fig. 3B). General impression. The majority of the students in both groups showed agreement/strong agreement toward liking PhysioAnime (group A ⫽ 88.63%, group B ⫽ 68.17%) and its ease of operation (group A ⫽ 95.45%, group B ⫽ 88.63%). There was agreement/strong agreement from both groups that PhysioAnime helped them better their conceptual understanding of red cell indexes (group A ⫽ 79.53%, group B ⫽ 68.17%) and allowed them to appreciate the importance of erythrocyte indexes in diagnosing anemias (group A ⫽ 79.54%, group B ⫽ 77.27%). When asked whether they were likely to use the animation for the purpose of revision (group A ⫽ 72.72%, group B ⫽ 61.36%) or recommending to a peer for the same (group A ⫽ 86.36%, group B ⫽ 79.54%), most students gave a positive response. Although a very small percentage of students did have a less than enthusiastic approach toward the interactive animation (group A ⫽ 2.27%, group B ⫽ 9.09%), none of the students reported any challenges regarding the use of PhysioAnime (group A ⫽ 0%, group B ⫽ 0%). Also, a very low percentage of students gave a languid response when questioned about better learning via the animation (group A ⫽ 2.27%, group B ⫽ 9.08%) and using it as a tool for revision (group A ⫽ 2.27%, group B ⫽ 11.25%) and voluntarily recommending its use (group A ⫽ 4.54%, group B ⫽ 6.81%) (Fig. 4). Preference for teaching-learning method and student recommendations. Although there was a small number of students (group A ⫽ 4.54%, group B ⫽ 13.63%) who leaned toward printed notes only as a means of study/revision, a greater majority in both of the groups (group A ⫽ 81.80%, group B ⫽ 75.10%) felt that the combination of handouts and PhysioAnime would be their preferred option when it came to learning and understanding red cell indexes. It was also interesting to see that there was a small portion of students who professed that they would like to use only the animation as

their preferred learning tool (group A ⫽ 13.63%, group B ⫽ 11.36%) (Fig. 5). Some of the students who chose written material specifically expressed that they would like the animation to contain more text and information than what it already had, whereas others were satisfied with the handouts and regular didactic teaching, as it made structuring and choosing relevant information easier for the student, thus making it convenient for them to study the topic and revise it on a later date. The students who chose either animation only or a combination of animation and written material revealed that they found PhysioAnime to be more effortless and entertaining to go through while learning about an academic topic, since it diagrammatically represented the formula as well, making it easier to visually learn the concept, something that was not being achieved by the handout alone. When asked about the advantages of the animation and its shortcomings, most students appreciated the easy navigation and straightforward style. Some students found the animated version of the formula to be easier to understand and reproduce. They even expressed their wish to have such animations made for other concepts and topics in physiology and even requested audio to be added to PhysioAnime to make it more engaging and user friendly. On the other hand, a few students did not approve of the simplicity of presentation and wanted PhysioAnime to provide them with a lot more information pertaining to red cell physiology. DISCUSSION

Although comparison of question-wise score between group A and group B did not show significant difference, except in one question, where group B scored higher than group A (question 12: P ⫽ 0.00003), the total scores attained by both groups tell a different story. We found that group B scored significantly higher than group A when the total scores were compared (P ⫽ 0.0003), which leads us to believe that using PhysioAnime to learn about red cell indexes played a role in improvement of student test performance compared with written material alone. Better performance of group B in item 12 on the posttest also adds merit to the hypothesis that knowledge acquisition and retention were better while using the animation than written material, as this item dealt with calculations based on remembering correct formulas and units. It is also worth noting that part of student feedback was that PhysioAnime made learning the topic more enjoyable and easier to understand due to inclusion of animation. This begs the question whether improvement in retention and hence higher scores were a result of visual learning acting as a stepping stone for superior recall. We also found while collecting feedback that there was agreement/strong agreement from the majority of students with regard to the fluid use of animation, ease of understanding the concept, as well as applying acquired knowledge to clinical scenarios. Most students also agreed/strongly agreed that they would use PhysioAnime as a means of revising red cell indexes and also recommend it to their peer group. It was illuminating to find out that a majority of students found it ideal to have a combination of interactive animation and written material as opposed to either mode of learning by itself. The choice of this teaching-learning method by the students may also suggest that

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RED CELL INDEXES MADE EASY USING PhysioAnime

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Fig. 2. A: screen shot of the interactive animation showing normal MCHC. The scroll bar (linked to results) is seen within the normal range. B: screen shot of the interactive animation showing low MCHC. C: screen shot of the interactive animation showing high MCHC.

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RED CELL INDEXES MADE EASY USING PhysioAnime

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Fig. 3. A: comparison of question-specific scores between group A (handouts) and group B (interactive animated model). B: total score obtained by group A and group B students. ***P ⬍ 0.001.

learners in this age group do not restrict themselves to a particular way of academic attainment and generally rely on multimodal learning practices. While addressing the amount of information provided in the animation, most students were satisfied by the simple and straightforward approach of PhysioAnime, while a few did add that they would have liked more content to be added, especially with regard to applied physiology. Suggestions for improvement included use of audio to make the animation livelier and thereby increase user compliance. One of the aspects that we would have liked to look at is long-term retention by doing a follow-up assessment, which was not possible in the current setup of the study. In the end, judging by the feedback and certain volunteered comments, it was seen that the majority of the students welcomed the concept of including PhysioAnime into their regular hematology curriculum, with some going so far as to request similar animations for other concepts in physiology as well. Conclusion. The results and feedback obtained from students participating in this study suggest that PhysioAnime is a simple, easy-to-use learning tool, which effectively translates concepts needed for better understanding of red cell indexes and related red cell abnormalities. As this model was well received by students and also keeping in mind their preference, if PhysioAnime and other such animations are included in the practical curriculum, then students will have the liberty to

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Fig. 4. Comparison of percentage of student feedback to questions based on Likert scale template between group A and group B. The questions are as follows. Q1, I liked the interactive animation. Q2, The interactive animation was easy to operate. Q3, The interactive animation helped me understand the red cell indexes better. Q4, The interactive animation helped me appreciate the importance of red cell indexes in diagnosing the type of anemia. Q5, I would use this interactive animation before my exams for revision. Q6, I am likely to recommend this interactive animation to other medical students.

self-learn and discuss a topic in small groups. This kind of engaging practical session, followed by a discussion with the tutor to consolidate concepts and resolve doubts, will help create an efficient learning environment. DISCLOSURES No conflicts of interest, financial or otherwise, are declared by the authors.

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Advances in Physiology Education • doi:10.1152/advan.00142.2017 • http://advan.physiology.org Downloaded from www.physiology.org/journal/advances by ${individualUser.givenNames} ${individualUser.surname} (220.225.126.138) on January 23, 2018. Copyright © 2018 American Physiological Society. All rights reserved.

RED CELL INDEXES MADE EASY USING PhysioAnime AUTHOR CONTRIBUTIONS U.K., E.V., S.B., J.W., and N.P. conceived and designed research; U.K., E.V., J.W., and N.P. performed experiments; U.K., E.V., S.B., J.W., and N.P. analyzed data; U.K., E.V., S.B., J.W., and N.P. interpreted results of experiments; U.K., E.V., J.W., and N.P. prepared figures; U.K., E.V., S.B., J.W., and N.P. drafted manuscript; U.K., E.V., S.B., J.W., and N.P. edited and revised manuscript; U.K., E.V., S.B., J.W., and N.P. approved final version of manuscript. REFERENCES 1. Brugnara C, Mohandas N. Red cell indices in classification and treatment of anemias: from M. M. Wintrobes’s original 1934 classification to

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the third millennium. Curr Opin Hematol 20: 222–230, 2013. doi: 10.1097/MOH.0b013e32835f5933. Davis MJ. Basic principles of synaptic physiology illustrated by a computer model. Adv Physiol Educ 25: 1–12, 2001. Firkin F, Chesterman C, Rush B, Pennigton D. De Gruchy’s Clinical Haematology in Medical Practice. Hoboken, NJ: Wiley, 2008. Gookin JL, McWhorter D, Vaden S, Posner L. Outcome assessment of a computer-animated model for learning about the regulation of glomerular filtration rate. Adv Physiol Educ 34: 97–105, 2010. doi:10.1152/ advan.00012.2010. Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston, MA: Butterworth, 1990.

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