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Clickers: the Use of Audience Response Questions to
Enliven Lectures and Stimulate Teamwork
Frazier Stevenson, M.D.
Medical Education Building (#33), Suite 3101 Email: [email protected]
ABSTRACT

Health science educators are under increasing pressure to reduce traditional lecture time and build more interactive teaching
into curricula. While small group exercises such as problem based learning achieve that aim, they are highly faculty intensive
and difficult to sustain for many faculties. The commercial availability of easy to use audience response systems (ARS)
provides a platform for increasing instructor interaction and engagement with learners. This article details my recent experience
with ARS, and suggests its uses to increase lecture interactivity, build student teamwork, provide formative feedback, and
energize both faculty and students.
INTRODUCTION
4. Providing a template for interactive discussion between students and between students and the Recent medical education trends have emphasized the importance of increasing active learning for health science 5. Providing guidance for the instructor to see if topics students. This trend has been driven by education literature are understood, or require additional time in the emphasizing active learning, application, and analysis, rather than just memorization of facts, and by accreditation bodies1. Most education innovations have focused on adding new interactive techniques to curricula, such as In this paper, I report on both my impressions and problem-based or team-based learning, or use of experience using ARS, and provide student feedback on standardized patients and simulations in small group exercises. Less attention has been given to how the traditional lecture might be enlivened and made more MATERIALS AND METHODS
The ARS system used is the Interwrite PRS System, For the past two years I have used an audience response version 4.4 (Scottsdale, AZ). The system was used in a system (ARS) in my core lectures in a second year second year renal pathophysiology course in 2007 during a required course in renal pathophysiology. My use of it was series of lectures on fluid and electrolyte disorders. Seven based on extensive literature, mostly from the hours of lectures were given, and 20 ARS questions were undergraduate curriculum, touting ARS as a useful and asked during the lectures. Attendance at the sessions stimulating addition to traditional teaching2. Among the ranged from 35-60 students. Questions were delivered in advantages cited by these and other authors, I was most one of two formats. In the first, a multiple choice single best answer or multiple best answer question was shown, and students were given 1-2 minutes to respond 1. Formative assessment that assess students’ individually. After showing the class’ pooled responses graphically, I asked students who answered various 2. Stimulating students to apply and analyze, not just responses to defend their answers, and then elaborated, asked follow up questions, or resumed lecture. In the 3. Posing questions that demonstrate students’ gaps in second protocol, I asked students to discuss the question knowledge and set up subsequent lecture material with nearby students after they saw the initial class response data. This discussion usually lasted 2-3 minutes. IAMSE 2007 Volume17 2 106
Students then re-entered their responses individually modeled my approach to its solution, gave students a without comment from me. I then discussed the answers as framework for success in solving these problems. above. Eight of the 20 ARS questions used in this report used the student discussion protocol, while 12 used ARS in stimulating knowledge application and analysis The lecture has traditionally been the reservoir of facts. Student attitudes about ARS were surveyed in two ways. Most books and presentations on “Powerpoint® Routine end of course surveys were done on overall Technique” emphasize clarity and presentation of bullet assessment of value, and the 54 responses were gathered point slides, on an assumption that data presentation is the by web based surveying by our office of medical main objective of any lecture. Textbooks are usually education. Since class size was 94, this represents 56% of written in the same manner--comprehensive and organized students. It is unknown how many ARS sessions were coverage of facts is the most common structural attended by these respondents. All likely attended at least underpinning of most medical and science texts. But one, since a possible option was “did not attend an ARS should this be the purpose of a lecture for our students? Secondary school teaching typically is far more interactive, even in groups of 30-40. It is only on arrival to In addition, I surveyed students about their preferences of college that we treat the students to the one-way lecture, on ARS learning vs. other modalities, and about their more the assumption that this is somehow preferred for these generalized impressions, by use of ARS surveys done in mature learners. It is certainly efficient. But even mature class at the end of the series of lectures. Depending on learners need to be motivated, stimulated, and challenged attendance and participation that day, these ARS surveys to move beyond the Bloom cognitive process of remembering to that of understanding, analyzing, and applying4. This should be our goal for students entering the RESULTS/DISCUSSION
complex synthesis that characterizes clinical care, and these skills must be rehearsed before intensive clinical care A weakness of traditional lecture is its disengagement The expert teacher must reach many types of learners, from a given class’ and individual learners’ specific needs. including those who first need the facts, as well as those The lecturer often exists in a bubble, delivering the same who want the facts presented conceptually and content regardless of context. Since students may have contextually. ARS can effectively facilitate such a learning varying learning styles, daily curricular schedules, and system. Students can be provided a well written text or degree of fatigue, greater instructor awareness of their syllabus that lays out the facts clearly, and introduces comprehension and attention can lead to more stimulating terminology. Then, the ARS “lecture” can follow up with and focused learning sessions. This sensitivity to learner explanation, explication, and exemplification. Students needs increases learner attention and involvement. often state in course evaluations that they benefit most from these sessions if they have read the facts first, so that ARS questions are very useful here as the punctuation of a they can come to the ARS session ready to extend their lecture segment, in order to assess student comprehension. In order to do so, the questions should be conceptual, asking learners to apply principles given in the lecture The ARS questions, if written to emphasize understanding block, and not simply ask them to recall a specific fact. and application, give students an idea of the level of Such questions are best done in the form of experimental knowledge expected by the instructor and guide their or clinical vignettes, as is now done in USMLE licensing subsequent study away from rote memorization. To do examinations. See Table 1 for examples of this type of this, I feel it is important that the questions be challenging, ARS question. As discussed below, if ARS reveals that so students are motivated to review and learn more after students have not mastered the concept, a lecturer may the session (see Table 1). My ARS questions are a mix of need to spend additional time on it, rather than moving on single best answer and multiple best answer, and the in a fixed schedule. For example, question 1 requires students’ average correct response rates for each type in learners to synthesize the preceding hour of material on 2007 was 63% and 60%, respectively. Beginning or more different types of metabolic acidosis, using the vignette insecure learners might benefit from less difficult and lab values to classify the disorder, and engage in two questions that simply confirm memory of facts, but since I step thinking in identifying a cause of the identified use these ARS sessions primarily to stimulate higher disorder (here, non anion gap metabolic acidosis with cognition, I feel that providing a false sense of mastery hyperkalemia). Many students missed this question, and with easy questions undercuts the goal of motivating further questioning of them revealed many cognitive further study and self directed learning. problems, including focusing on only one value or vignette item, lack of a systematic analysis of the acid base The use of clinical or experimental vignettes, amplified disorder, and reliance on memorized lists rather than with the active learning of clicking on answers in the ARS global analysis. The time spent on this question, in which I format, can reformat the “lecture” into truly interactive IAMSE 2007 Volume17 2 107
Table 1. Sample of ARS Question
1. A 62 year old man has Type 2 diabetes and hypertension. He comes to clinic complaining of diarrhea. He is on lisinopril, Dyazide (hydrochlorthiazide + triamterene) and metformin. Na Serum pH = 7.34 pCO2 = 34 Urine pH = 4.6 Which of the following best explains his acidemia? A. Diabetic ketoacidosis B. Metformin C. Dyazide D. Diarrhea E. Distal RTA F. Lisinopril 2. A 50 year old man with a history of CHF has pulmonary and peripheral edema, and a blood pressure of 100/60. Which of the below is most likely (Select ALL that apply)? A. His extracellular volume is decreased B. His effective circulating volume is decreased C. His total body sodium is increased D. His serum sodium concentration is increased E. His urine sodium concentration is increased learning session in which students extend their factual question. In fact, I frequently do not discuss the correct knowledge into application and analysis, and set the stage answer after showing the response. Instead, I mention that for deeper learning at home. If one therefore reconsiders the upcoming lecture segment will clarify the issue, and what a “lecture” is, then the pressure to cover all the generally return to the question later, either as a lecture factual material disappears. In this model, the lecture is an slide, or as a re-take of the question by the class. To active, energizing supplement to the written syllabus or summarize, ARS provides useful formative feedback for instructors and for students. For students, it joins end-of- syllabus chapter review questions and online exams as ARS for formative feedback (to students and instructor) ways for my students to practice challenging questions of the type that I will ask on summative exams. Students commonly complain that lecturers assume knowledge that is either more or less advanced than their actual level. Since effective learning occurs best when ARS as a vehicle for student peer interaction built upon a base of preexisting understanding5, the effective lecturer should assess this base regularly. This The most common way in which ARS is used is the can be done in advance by reviewing the students’ prior sequence: lecture Æ ARS question Æ answer Æ instructor curriculum and the specific content of preceding lectures. explanation. While engaging, this still keeps most students However, ARS offers the advantage of real time in a passive role. After reflecting on team-based learning assessment of student preparation and understanding. strategies 6-8, I now often use the ARS system to stimulate Normally this is done by an assessment question at the end student-student interaction. After having students of a lecture segment, ideally spaced about 20 minutes after individually answer the ARS question, I show them the a similar question, in order to minimize student lapses in class distribution of answers, without indicating the correct concentration. However, an ARS question can also be used answer. Then I ask them to discuss their answer with to begin a lecture segment, showing students what they do nearby colleagues for 1-2 minutes, and then individually not know and provoking interest in the upcoming segment. re-enter their answer. Students usually respond more This is especially useful if students have already “covered” accurately after such discussion (improving their correct a topic in a previous course or lecture. The question can response rate by 2-10%), even when the correct answer frame how their knowledge will be extended, not just was initially a minority response. Perhaps additional repeated, in the succeeding minutes. In this use of ARS, it reflection time improves response, or perhaps students is not necessary that students successfully answer the with better understanding are persuasive in the brief IAMSE 2007 Volume17 2 108
interactions with their colleagues. In any case, students gain the satisfaction of benefiting from peer interactions in improving their own understanding. If students self- ARS is not an end in of itself. It is simply a new correct, I frequently offer little additional explanation after technological innovation that, if used well, can achieve the the peer discussions, since the students have gained above aims. I list below several ARS pitfalls that should be understanding on their own. Most students enjoyed the avoided so that ARS does not detract from learning. addition of peer discussion to the ARS sessions, but this is variable: 49% preferred student-student interaction, 27% 1. Overuse: One lecturer recently substituted ARS preferred individual ARS use alone, and 24% were questions en bloc for his traditional lecture slides, without undecided (n = 41). Thus ARS can provide a collegial providing students with preliminary content via readings or learning process that echoes some goals of problem-based other media. While the intent of session interactivity was learning9, 10, but now with a large class. appreciated, the students were made to answer ARS questions with only very limited knowledge, and resented the frustration of not being able to consolidate knowledge appropriately. Students surveyed after my ARS sessions A limitation of the lecture/transmission mode of teaching strongly felt (92%, n=54) that three questions administered is its lack of real time feedback from learners. The lecture per 50 minute lecture was an ideal frequency, with the may have been delivered, but did learning occur? remainder evenly divided between wanting more and Traditional questions posed by the lecturer to the students wanting less. They also felt that ARS works best on a base often prompts more extroverted or knowledgeable students of factual knowledge, allowing them to explore its to respond, but this may not reflect the knowledge or engagement of the group as a whole. ARS provides an ideal medium to improve this student feedback to 2. Overload: ARS cannot be grafted onto an already instructors (a vivid anecdote from a course in embryology loaded slide presentation. Each slide takes 2-3 minutes at teaching gives testimony to the lessons learned when minimum, given the time to answer the question and to student understanding is actually assessed)11. Regular use discuss the results. This often extends to 5 minutes or will tell the instructor whether points made were absorbed more. Obviously, pre-existing slides must be deleted to and understood. Low correct response rates on questions accommodate this, unless the session is lengthened, a prompt the conscientious instructor to rephrase, repeat, or rarity in the current minimalist lecture environment. This exemplify the poorly understood concept, so that learning means that the instructor must prioritize the lecture occurs in the teachable moment. This inevitably “slows content, using ARS to teach fewer concepts more deeply. down” the lecture and may require the instructor to reduce Teaching fewer things with more depth, however, is a goal the number of slides presented. However, if the traditional of most experienced teachers and leads to greater retention lecture is to be transformed into an interactive learning session, this “problem” is a good thing. Our students often complain that instructors may show in excess of 60 slides 3. Poorly written questions: In order for ARS to best in a 50 minute lecture, and one lecturer at my institution provoke and stimulate students, questions should contain has 120 scheduled for such a presentation. The feedback uncertainty, controversy, or analysis/application of provoked by ARS can provide a needed brake on such material. Simple factual recall questions do not do this well. For my second year medical students I use questions similar to, or more advanced than, USMLE Part I questions (Table 1). These are normally based on experimental or clinical vignettes that provoke the students While learning should not be primarily an entertainment, to analyze and apply their knowledge. This approach has enjoyment certainly belongs in any learning session. the additional advantage of preparing students for the more Humor, visual props, colorful slides, and animations are analytic questions ideally used on summative course and frequent lecture props, used by even traditional speakers to enliven the proceedings. However, these still remain mainly one-way, transmission oriented devices, in which 4. Inadequate faculty development: The availability of an the students remain observers, albeit more amused ARS system usually leads to initial administrative and observers. ARS offers a platform for true interaction with student enthusiasm, typically because it is first used by the students within the learning session, and provides a real extroverted “early adaptor” instructor who infuses it with sense that the teacher is interacting with learners, not just excitement 13. Once the glowing initial reviews come in, talking to them. This human contact allows a more other instructors may use it, but sometimes without any personal interaction, even with a large group of students, real preparation or orientation other than on the technical and is a strong attractant for students who value the human aspects of building the session. This often leads to the interaction as key to learning (e.g. students with strong F above listed mistakes, or a stylistic discontinuity in which domain in the Myers Briggs type indicator)12. Such a lecturer uses ARS questions but does not really engage students are often most put off by traditional lectures. the students verbally or emotionally. Students may then pan the entire technique. To avoid this drawback, our IAMSE 2007 Volume17 2 109
school provides regular lunchtime seminars for interested of sample questions for students to use, so this is not instructors in which experienced ARS users share tips and demonstrate effective practice. In addition, we have begun demonstrating ARS to entire departments at their faculty meetings so that all instructors can learn about ARS, thus CONCLUSION
enlivening a departmental course lecture curriculum systematically. Several initially reluctant instructors have While no technology serves as a panacea for indifferent or told me that ARS helped them emerge from behind the poorly prepared instructors, appropriate use of ARS podium and better engage the class, and improved their increases interactivity in large group learning sessions. It lecture technique generally. In these cases the technology joins team-based learning as another formal option for facilitated a change in instructor behavior. instructors who feel that their sessions need to become more interactive. The reduction of formal lecture time has been encouraged by many accrediting bodies such as LCME, but should not be done for that reason alone. These second year medical students rated the educational Declining student attendance at lectures nationwide shows value of ARS questions highly (6.8 out of a 7 point score, that students are increasingly needing a rationale for n=54). More affective responses are quantitated in Table 2. attendance, and if not given one, will choose a distance Post course comments indicated that individual students learning strategy. In my view, given the wealth of current Table 2. Students answering “yes” to various descriptors of ARS sessions (n=44)
valued different types/uses of ARS questions: online and written resources for students, this is a justifiable view. Any time used for whole class The audience response system is great for gauging presentations should have a clear rationale beyond simple our comprehension of materials just presented, and presentation of facts, which can be done effectively at helps to further cement our newly acquired knowledge home. Is a lecture that duplicates preexisting written by making us recall and actively apply it to complex materials worth the time? Audience response systems is one means of taking a large group session to a more stimulating, interactive level, and provides a format for (The instructor) uses it the way it was meant to be professional faculty to re-engage with students and return used. He goes over the concepts and then puts a little to the art of teaching, not just lecturing. twist into a question and then we can discuss it. I liked that he didn't give us a question about REFERENCES
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Source: http://www.med.wright.edu/sites/default/files/aa/facdev/Events/2008info/ARSQuestions_Enliven_Lectures.pdf