The results of the present study indicate that a Computer Supported Collaborative Learning environment can effectively support medical students to learn collaboratively during clinical clerkships. By the execution of an authentic task such as a critical appraisal of a relevant clinical problem, students are stimulated to critically discuss and revise their critical appraisal paper. Students’ paper revision seems to be associated with an increased activity during discussions with peers, and to be related to higher task-focussed discussion activity as well as a more intense discussion of critical appraisal topics.
The discussion of students who revise their CAT paper substantially differs from that of students who do not revise. Revised paper discussions are more extensive, social and task-focussed, reflecting both low and higher levels of knowledge construction. These results findings are consistent with results obtained with CSCL in university classroom environments and medical workplace, showing that both social interaction and task-orientation are typical for an active discussion leading to higher levels of knowledge construction
Furthermore, students who revise their CAT paper after discussing its content with peers in a CSCL environment show more discussion activity on critical appraisal topics, with a strong focus on the CAT task elements: strategy of the literature search, and appraisal of the study population. Other elements identified under discussion in the majority of revised papers were: ‘preparation for executing literature search’; ‘study design’, and ‘relevant clinical conclusion regarding clinical problem’. A study among undergraduate medical students showed no differences in critical appraisal skills between students who received a computer-based learning session and students who attended classroom lectures
]. However, two studies on medical students’ individual learning in on-line critical appraisal modules during clinical clerkships showed positive outcomes in favour of on-line learning. One study measured medical students’ pre-and post-test scores on an individual pre-determined critical appraisal task, and showed improvement in executing a search strategy and in appraise a study design
], while another study compared the critical appraisal skills of medical students after on-line learning with those of students without intervention, and reported a higher quality of the literature search after on-line learning
]. In the above-mentioned studies as well as in present study, students worked individually on a critical appraisal task. However, in present study students worked on a self-selected clinical problem extended with a collaborative discussion on their paper with peers. These differences in study design could have influenced the finding in present study that not only identical CAT task elements were identified, but moreover, even more critical appraisal elements were found.
A limitation of present study is the challenge to control all variables in an on-line collaborative discussion. By the design of a structured discussion task a certain control of variables is achieved. Despite of this structured discussion, it can not be excluded that students’ performance in course may have influenced them to revise their paper. However, this phenomenon likely has played a minor role since it concerned last year medical students with a comparable knowledge level. Moreover, all students participating in the present study performed several critical appraisals during the previous four years of the medical curriculum, and thus can be considered to be experienced in writing a CAT paper. Therefore, it was expected that participants may not have felt great urgency to discuss the task. It thus is remarkable that, even after intensive training the skill in performing a CAT, 51% of the students revised their paper after collaborative online discussion. Therefore, students can profit by a peer discussion of their papers, irrespective whether they revise or not revise their paper
]. Besides the effect of discussion with peers, other factors could have influenced students to revise the CAT paper. First, since students participated voluntarily in this study they were probably highly motivated to discuss with peers. Secondly, it can be emphasized that motivation for discussion is high because this critical appraisal task was related to a self-selected, authentic clinical problem. Even though it cannot be excluded that the discussion itself could stimulate students to discuss.
Another limitation is that the content analysis was performed by one researcher. Since the analysis was conducted according to a structured and validated analysis system
], it seemed safe to assume that the analysis was well executed.
Furthermore, it cannot be denied that the sample of participants was relatively small. However, high effect sizes reveal a high effect on the students’ activity in discussion on two levels of knowledge construction and on two critical appraisal topics of the discussion.
In CSCL research, much attention has been given to measuring outcomes in terms of cognition, skills, critical thinking and problem solving, but research on what influences student learning during discussions is scant. Further research on a larger scale could be useful to clarify the learning processes during discussions and to what extent these processes affect the interaction among students and knowledge construction in CSCL. A controlled study comparing students interaction between an intense and limited discussion could be an interesting intervention for further research. Furthermore, it could be interesting to further research the question whether implementing an on-line discussion could be applied as a framework to support students’ learning in existing courses.