November 12, 2022

Failure to Fail: Why Teachers Are Reluctant to Fail Learners and What We Can Do About It

by Katelyn Miller, PharmD, PGY1 Pharmacy Practice Resident, St. Dominic Hospital

Failure is success in progress. – Albert Einstein

The word “failure” often evokes a negative connotation, but it is a necessary part of learning and growing. However, when it comes time to address an underperforming trainee, student, or resident, many educators and preceptors find it hard to address and document the poor performance of trainees. Reports in medical literature across multiple healthcare disciplines have raised concern about this “failure to fail” phenomenon and its prevalence.1 In one survey, 18% of 1,790 nursing mentors admitted to passing an underachieving student that should have failed.2 Another survey of ten American medical schools found that 74.5% of clinical preceptors indicated it was difficult to accurately assess poorly performing students because they were unwilling to record negative evaluations.3 As health professionals and educators, we have a responsibility to our patients and our professions to accurately evaluate trainees and ensure they become competent members of healthcare teams. To determine if a learner is sufficiently prepared, here is the critical question: Would I let this person take care of my family member? If the answer is no, why is it so hard to act and deliver an accurate evaluation of an underperforming trainee’s performance?

A systematic review article recently published in the Medical Teacher examined both qualitative and quantitative studies relating to evaluators’ willingness and perceived ability to report unsatisfactory performance in health professions education.1 The authors identified six barriers that assessors face when addressing an underperforming trainee:

  1. The Burden and Risks of Failing Someone. Assessors reported that the amount of time and paperwork required to fail a trainee is a deterrent. In the health professions, preceptors and educators often have multiple responsibilities, and student evaluations are often given lower priority. Assessors also express a hesitancy to fail underperforming trainees due to fear of litigation or worries that it would negatively affect the professional reputation of the assessor.1
  2. Guilt and Self-Blame: Assessors reported an emotional toll, including feelings of guilt and self-blame, connected to failing a trainee. These feelings are increased if the assessor has developed a close relationship with the trainee. Assessors often want to avoid conflict with the trainee and feel that failing the trainee could be perceived as uncaring behavior, which is difficult in a profession dedicated to caring for others like healthcare.1
  3. Trainee Considerations. Assessors were reluctant to fail someone based on the trainee’s stage within the program. With trainees who are in the earliest stages in the curriculum, assessors indicated they were reluctant because they believed the learner could improve with time. Ironically, assessors were equally reluctant to fail trainees that were advanced in their training because they had already invested much time and money. Assessors also worried about the negative effect that failing would have on the trainee’s emotional stability, career goals, and self-esteem.1
  4. Questionable Assessments. Assessors reported a lack of confidence in their ability to accurately evaluate trainees due to feeling unprepared, a lack of training, or a lack of experience. As a result, they questioned their judgment and were willing to give underperforming trainees “the benefit of the doubt.” Assessors also reported a lack of confidence in the tools they used to assess trainees. They expressed uncertainty about what the expectations should be for trainees at different stages of training and questioned whether the evaluation tools being used were appropriate or objective.1
  5. Institutional Support. Assessors reported feeling pressured to pass students and feared they would not be supported by the institution if they failed a student. Assessors also considered the loss of financial support for the institution that would result from failing a student.1
  6. Unsatisfactory Remediation. Assessors were reluctant to fail a trainee if there was no remediation available or if they deemed the available remediation unsatisfactory. Assessors also expressed angst about the timeliness of remediation and whether remediation would be long enough to adequately address the performance problems.1

Conversely, the authors also identified three factors that enabled assessors to fail a failing trainee. These include the assessor’s sense of responsibility and duty to the profession, support from the institution, and the availability of remediation for the trainee.1

While this review of literature helps us to understand the “failure to fail” phenomenon, no quick or easy solution exists. Some experts suggest a narrative-based approach is needed in order to help assessors overcome barriers to providing corrective feedback and delivering unsatisfactory evaluations.3 Providing feedback that clearly indicates the specific areas of improvement can help guide underperforming students to address poor skills or knowledge and “shift the focus from evaluating to understanding and teaching” the learner.3 Even with a shift from quantitative to qualitative evaluation methods, several barriers will persist.

To ensure patient safety and the quality of care delivered by future health professionals, I believe all schools should institute standardized, formal training of preceptors, educators, and anyone who will be evaluating trainees. Institutions should require new assessors to complete training that teaches them how to accurately use evaluation tools, how to articulate concerns, and how to deliver difficult messages. The training program should make clear the remediation opportunities available to address performance problems and emphasize a competency-based approach to teaching and learning. Institutions should make it explicitly clear what resources are available, including the support systems available to address the assessor’s negative emotions and the mental toll that comes with failing a trainee.

I believe a mental shift in healthcare education is needed. We should acknowledge that competency is the primary goal and that everyone progresses at different paces. Not everyone will graduate at the same time, and that is okay! It is important for educators to accept their responsibility to future patients and the potential harm that could result from failing to fail underperforming trainees. 


  1. Yepes-Rios M, Dudek N, Duboyce R, Curtis J, Allard RJ, Varpio L. The failure to fail underperforming trainees in health professions education: A BEME systematic review: BEME Guide No. 42. Medical Teacher. 2016;38(11):1092-1099.
  2. Brown L, Douglas V, Garrity J, Shepard CK. What influences mentors to pass or fail students. Nursing Management. 2012;19(5)16–21.
  3. McConnell M, Harms S, Saperson K. Meaningful Feedback in Medical Education: Challenging the “Failure to Fail” Using Narrative Methodology. Acad Psychiatry. 2016;40(2):377-379.

November 7, 2022

Gamification to Motivate Students

by Antoniya R. Holloway, PharmD, PGY1 Community Pharmacy Practice Resident, Mississippi State Department of Health

Ask anyone in my pharmacy school graduating class, and I believe they would tell you that the most anticipated part of a long therapeutics lecture was the sound of the Kahoot! theme song. Despite how glazed-over our eyes became during medicinal chemistry discussions, my classmates and I always seemed to perk up at the mention of a fun, competitive opportunity to demonstrate what we had learned. More educators are using games and other competitive activities to fuel student engagement and motivation during instruction.1 This instructional design method is termed “gamification.”

Gamifying education, aka gamification, is described in one of two ways: (1) the act of rewarding learners with gameplay after a tedious lesson, or (2) the act of infusing game elements into a lesson to make it more enjoyable.2Although using incentives to motivate learners is not a new concept, gamification of classrooms was ignited in the era of e-Learning.1 The Smithsonian Science Education Center lists five prominent benefits of gamification:2

  1. Increased level of learner engagement in classrooms
  2. Increased accessibility for students diagnosed with autism
  3. Improved cognitive development in adolescents
  4. Improved physical development in adolescents
  5. Increased opportunities for learning outside of classrooms

The question is not whether there are theoretical benefits in gamifying education, but whether there are long-term educational benefits to learners.  And whether there are specific methodological approaches to gamifying education that can be standardized and implemented in a similar fashion.

The International Journal of Educational Technology in Higher Education published a systematic review in 2017 examining 63 papers to evaluate research studies and emerging gamification trends and to identify patterns, educational contexts, and game elements.1 The results were stratified into 5 categories: educational level, academic subject, learning activity, game elements, and study outcome.

Education level

Educators must understand that although gamification can be implemented at any grade level, more sophisticated platforms that require higher levels of technique may be too complicated for younger learners to navigate. Most papers included in this review were conducted at the university level (44 papers), while fewer (seven papers) were conducted at the K-12 level. Authors propose that this disproportion is because college professors have more control over their courses than teachers following state-mandated curricula and because college students have better-developed computer skills.

Academic subjects

The systematic review included gamification studies related to over 32 academic subjects in six categories. Many papers (39%) targeted computer science/information technology (CS/IT) and multimedia and communication (12%). Although the results are inconclusive, it could be speculated that gamification is more suitable for CS/IT courses compared to other subjects.

Types of Learning Activities 

A mix of instructional activities was used in 16 studies instead of the sole activity. Half were online courses, and the other half had a web-based learning component (aka hybrid courses that included both face-to-face and online instruction). This supports the conclusion that even though some courses are traditional in nature, educators could modernize courses by incorporating an online gaming component.

Game Elements

Game design elements described in this systematic review were classified by the game dynamics, mechanics, and components. Game “dynamics” prioritize emotions and relationships while “mechanics” prioritize competition, feedback, and reward. Components are the basic levels of dynamics and mechanics using leaderboards, points, and badges. All of the studies used one or more gaming elements, but there were no standardized gaming elements nor standardized definitions of gaming elements used across all studies.

Study Outcomes

Specific learning and behavioral outcomes were also stratified into categories: knowledge acquisition, perception, behavior, engagement, motivation, and social. Because of the diversity of studies, outcome results were further stratified as (A) affective, (B) behavioral, or (C) cognitive. Educators should note that different game elements (or combinations of elements) and individual factors (personal or motivational factors) influence the outcomes of gamification.  Thus, what works for one learner may not work for others.

The authors of the included studies in the systematic review concluded that gamification produced learning gains (performance, motivation, retention, and engagement) and that learners appreciated the gamification features,1 but the validity and reliability of these claims are questionable. For example, twenty studies either had too small a sample size or too short an evaluation period. Using performance as an outcome is inconclusive, as performance can be influenced by other non-motivational factors like mental capability and prior knowledge.

Theoretical Perspective

Several papers conclude that focusing on game elements like points and rewards rather than an individual’s desire to play is not a fail-proof way to change learning outcomes. A “user-centered" approach may be more conducive as educators develop gamified content due to the wide variety of personal factors.3 One study suggested shifting from the introduction of game elements into course lessons and, instead, developing a “gameful” experience throughout the course.4 The authors of the systematic review conclude that there is insufficient understanding of the motivational mechanisms of gamification. A theoretical framework is necessary to standardize how gamification is implemented and to differentiate which mechanisms create successful outcomes.

This systematic review reinforces the observation that learners generally “like” gamified education and that gamification of learning content increases learner motivation. But it does not provide a concrete answer as to whether gamification leads to long-term improvements in outcomes. I believe educators should consider implementing gamification to increase participation and engagement for health professional students, especially during the foundational years of their professional curricula. However, educators must be aware that the lack of a standardized approach to gamification and individual learner preferences will yield variable outcomes.


  1. Dichev C, Dicheva D. Gamifying education: What is Known, What is Believed and What Remains Uncertain: A Critical Review. Int J Educ Technol High Educ 2017; 14 (9).
  2. Mandell B, Deese A. STEMvisions Blog. Five Benefits of Gamification. Washington, DC: Smithsonian Science Education Center. 2016 March 10 [cited 2022 Oct 10].
  3. Hansch A, Newman C, Schildhauer T. Fostering Engagement with Gamification: Review of Current Practices on Online Learning Platforms. HIIG Discussion Paper Series [Internet]. HIIG Discussion Paper Series No. 2015-4 [cited 2022 October 10].
  4. Songer RW, Miyata K. A Playful Affordances Model for Gameful Learning [Internet]. TEEM '14: Proceedings of the Second International Conference on Technological Ecosystems for Enhancing Multiculturality; 2014 October [cited 2022 October 10].

October 10, 2022

Cultivating Cultural Humility

by Amy Ly-Ha, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

Growing up in the Vietnamese culture, whenever I had a minor illness, my parents engaged in the practice of cạo gió, also known as coining. The intent of the practice is to dispel negative energy from a sick individual.  Coining involves spreading medicated oil onto the skin and rubbing a coin over this area until a red abrasion mark forms. To those who are unfamiliar with the practice, these marks may look frightening and can be mistaken as abuse. As a child, I did not pay much attention to these marks on my body. Once, I came home from school feeling feverish. My mother performed coining and brought me to the doctor’s office the next day. Upon conducting a physical examination, the physician noticed the red stripes on my back. Rather than making accusations of abuse, the physician skillfully interviewed my mother and listened to her explanation. Looking back, I now recognize the significance of this encounter. Not only did the physician display a willingness to listen to my parents, but she also demonstrated an openness to my family’s cultural traditions. This physician modeled cultural humility, a concept that I believe all healthcare professionals should possess to create an environment conducive to optimal patient care.

The widespread implementation of cultural diversity training in various health professions education aligns with the growing diversity of our patient populations. There are many aspects to cultural diversity training. Commonly taught in health professions degree programs today, cultural competency embodies the ability to provide care to people with diverse values, beliefs, and behaviors.1 Cultural competency requires several skills, including recognizing the unique needs of every patient, realizing that culture impacts health beliefs, and respecting cultural differences. A culturally competent healthcare professional is able to negotiate and restructure therapeutic plans in response to a patient’s cultural beliefs and behaviors.2 And while cultural diversity training is clearly important, health professionals must also demonstrate cultural humility.

Cultural humility, a term first coined in 1988, is a lifelong process of ongoing self-reflection and self-critique.3 It emphasizes awareness of one’s possible biases and a willingness to be taught by patients. Unlike cultural competency, the goal of cultural humility involves “relinquish[ing] a provider’s role as a cultural expert and adopt[ing] patient-centered interviewing to create a mutual therapeutic alliance.”2 One barrier to teaching cultural humility includes the difficulty of assessing students’ growth in this area. Despite this, I recommend that educators implement the following elements to foster cultural humility in their students.

Element 1: Develop Culturally Relevant Curricula

A culturally relevant curriculum incorporates aspects of culture throughout a curriculum, thus valuing various cultures and encouraging intercultural understanding.4 Introducing students to different cultures throughout their education, in and outside the classroom, enables students to learn how to navigate through diversity. By embedding cultural diversity training at strategic times throughout a curriculum, educators can include reflective exercises intended to build cultural humility. 

When developing and implementing a culturally relevant curriculum, one must be aware of the potential to introduce unconscious bias in lessons and assessments. For example, a recently published research study investigated the presence of unconscious bias in student assessments at a Doctor of Pharmacy program.5 Assessing questions from the academic year of 2018 to 2019 for first-, second-, and third-year pharmacy classes, the investigators examined 3,621 questions. Only a small fraction of these questions referenced race (N=40); however, race was relevant to only two questions. The study also found that specific races were more often associated with specific health conditions. For example, in the analyzed set, the researchers found that all questions related to human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) were associated with African-Americans. Thus, as this study documents, the routine use of race as a descriptor in instances where it lacks significance may propagate racial bias.5 Therefore, providing culturally relevant curricula requires educators to acknowledge their own biases, mitigate them, and display intentionality as they develop and implement instructional materials.

Element 2: Create Opportunities for Cultural Socialization

Cultural socialization is the process in which individuals learn about the customs and values of other cultures. Within the classroom, instructors can create simulations that foster cultural humility. For example, scenarios that prompt students to confront challenging situations and recognize their own biases can help facilitate cultural humility. Furthermore, instructors can create discussion boards to encourage students to share their cultural practices, values, and beliefs.

Immersive experiences outside of the classroom can reinforce direct instruction. These opportunities include community outreach events, introductory and advanced practice-based experiences, and international service trips. Placing students in these environments encourages students to go outside their comfort zone and strengthen their confidence. By creating and introducing experiences for cultural socialization, educators can broaden their students’ perspectives.

Element 3: Promote the Practice of Self-Reflection

The emphasis on introspection sets cultural humility apart from cultural competency. Instructors should encourage students to regularly reflect on and learn from their experiences. Activities that promote reflective practices include journaling and meditation. Online resources like the Implicit Association Tests can also serve as tools to help students recognize their unconscious biases.6 By encouraging reflection and providing opportunities to talk about experiences, educators are developing the habits of mind needed for learners to continue this practice throughout their careers.

Implementing the three elements can promote cultural humility within students. Fostering cultural humility and incorporating cultural competency training in health professions education is critical to achieving accessible and comprehensive healthcare for all.



  1. American Hospital Association [Internet]. Becoming a Culturally Competent Health Care Organization. AHA; 2016 Jun [cited 2022 Sep 16].
  2. Rockich-Winston N, Wyatt TR. The Case for Culturally Responsive Teaching in Pharmacy Curricula. Am J Pharm Educ 2019; 83(8): Article 7425.
  3. Tervalon M, Murray-García J. Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. J Health Care Poor Underserved 1998; 9(2):117-25.
  4. International Bureau of Education [Internet]. Culturally Responsive Curriculum; [cited 2022 Sep 16].
  5. Rizzolo D, Kalabalik-Hoganson J, Sandifer C, Lowy N. Focusing on Cultural Humility in Pharmacy Assessment Tools. Curr Pharm Teach Learn 2022;14(6):747-50.
  6. Project Implicit [Internet]. Select a Test; [cited 2022 Sep 30].

June 25, 2022

Should Feedback be Given Verbally or in Writing?

by Mariam M Philip, PharmD, PGY1 Community Pharmacy Practice Resident, Walgreens Pharmacy

Learners thrive in a safe environment where they can freely express their thoughts and opinions. At the heart of learning is feedback.1 Feedback is critical in the classroom, in clinic, at work … indeed, anywhere learning occurs. It is crucial to knowledge acquisition, patient care, personal development, and growth. As educators, it's critically important to strive to give effective feedback.  Many agree it gets easier to provide over time. Feedback received is not always predicted, positive, effectively delivered, or correctly interpreted. Generally, the feedback provided should be based on direct observations and understood by the learner. Feedback should be provided in a safe environment where learners can discuss the feedback, express their concerns, and participate in developing an action plan.

Feedback is different from an evaluation, and it should be delivered in a conversational yet descriptive manner. When it’s done effectively and periodically, the formal evaluation (which typically occurs at the end of the course or experience) should not be a surprise.1 Evaluations are more formal and done to determine the learner’s grade (or, in the case of employees, pay raises or promotion decisions).

Feedback can take two forms: verbal or written.  Is one delivery method better than another?  The goal of feedback is to influence the learner and either motivate the continuation of their good work or point out what needs improvement, or both. One of the advantages of verbal feedback is that can lead to a “real-time” discussion and provides an opportunity for both the educator and student to elaborate more with examples. On the other hand, written feedback is often clearer, can be referenced later (e.g. when constructing the final evaluation), and (perhaps) reduces the chance of miscommunication or misinterpretation.

In 2017, a randomized controlled trial that enrolled 44 nursing students assessed the effectiveness of oral and written feedback.  The students were divided equally into two groups. The students filled out a questionnaire after the feedback to determine their reactions, perceptions, and responses to the different forms of feedback. The questionnaire showed no statistical differences between the two groups, and the results were similar. Although there was no statistical significance between the groups, the study might have been underpowered due to the small sample size. Nonetheless, the authors offer some interesting points of view.2

Based on the students’ responses to the questionnaire, 21.3% of the oral feedback group experienced negative reactions; 75.8% were classified as mild, and 24.2% were classified as severe reactions. Conversely, only 14.4% of the students in the written feedback group had a negative reaction; most were classified (92.3%) as mild and 7.7% were severe. While the difference was statically significant, the oral feedback group had a higher percentage of students who experienced negative responses such as arguing, crying, insulting, denying, and inattention. The written feedback group had a higher rate of intimidation, undue self-defensiveness, and confrontation. The satisfaction rate was higher (but not significantly so) in the written feedback group (77.1% indicated high satisfaction with the feedback vs. 50% in the oral group). Lastly, when the delivery of the feedback was assessed, the students in the oral feedback group gave it a higher delivery score.2

Additional studies conducted with medical students who received “well done” feedback showed similar satisfaction from both oral and written methods of communication.3 A similar study was conducted with medical residents from two university-based clinics. To diversify the participants and results, the residents that participated were assigned to medical clinics of various specialties. Sixty-eight internal medicine residents were randomly assigned to receive either written or “face-to-face” feedback. They were then given a questionnaire to assess their overall clinic experience, in which eight of the 19 questions asked about feedback. Six five residents completed the questionnaire. The results showed no differences in the residents’ perceptions of oral and written feedback.3

Both forms of feedback are acceptable and can be effective when delivered following best practice principles. There are advantages to each method of communication when providing feedback. Oral feedback is often less formal and more conversational, which will allow the student to feel safer expressing their concerns or participating in planning for the future. While less efficient, written feedback often promotes deeper reflection. The student can reflect on the given feedback and refer to it periodically. Thus, a teacher should focus on the quality and frequency of the feedback rather than the delivery method.4

I believe health professional students benefit from written and oral feedback in both the didactic and experiential settings. Both delivery methods serve a purpose that is important to students’ growth. The thoroughly thought-of written feedback will allow the student to digest the feedback and reflect on their own time. This will increase autonomy and promote self-assessment and planning. Meanwhile, oral feedback allows students to explain themself, ask questions, and brainstorm with the preceptor on the next steps.

A healthy balance between verbal and written feedback should exist between the two forms of communication.  Both should be used to help the student grow. I find oral informal feedback more engaging, which helps build the teacher-learner relationship. It can help shift the “formal meeting” nerves to a mentorship mindset. Periodic written feedback can reinforce verbal discussions and make constructing the end-of-course evaluations easier.


  1. Jug R, Jiang X, Bean Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine 2019; 143 (2): 244–250.
  2. Tayebi V, Armat MR, Ghouchani HT, et al. Oral versus written feedback delivery to nursing students in clinical education: A randomized controlled trial. Electron Physician. 2017;9(8):5008-5014. Published 2017 Aug 25. doi:10.19082/5008
  3. Elnicki DM, Layne RD, Ogden PE, et al. Oral Versus Written Feedback in Medical Clinic. J Gen Intern Med. 1998;13(3):155-158. doi:10.1046/j.1525-1497.1998.00049.x
  4. Dobbie A, Tysinger JW. Evidence-based strategies that help office-based teachers give effective feedback. Fam Med. 2005;37(9):617-619.

May 23, 2022

"Blended Learning” Models and Their Effectiveness

by Hannah Black, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Health-North Mississippi

Many of us are familiar with the term, “blended learning.” While it is easy to assume that this teaching model simply involves a combination of in-class and online instruction, there are lots of different ways of accomplishing it. Although blended learning models are now commonplace (thank you COVID-19), there has been a lot of research published in medical education journals over the last 4 decades.1 Many studies have documented the effectiveness of blended learning in health professions education but given that blended learning methods vary very substantially, what strategies are most effective?

The Journal of Medical Internet Research published a systematic review and meta-analysis examining the effectiveness of blended learning compared to traditional learning in health professions education.1 Blended learning was stratified into different types of learning support, defined as follows:

  • Offline Learning - the use of personal computers to assist in delivering stand-alone multimedia materials without the need for internet.
    • Videos and audio-visual learning materials (as long as the learning activities did not rely on internet connection)
  • Online Support – all online materials used in learning courses.
    • Educational platforms (learning management system, LMS like Blackboard)
  • Digital Education – a wide range of teaching and learning strategies exclusively based on the use of electronic media and devices
    • Facilitates remote learning for training purposes
  • Computer-Assisted Instruction – the use of audio-visual material to augment instruction.
    • Multimedia presentations, live synchronous virtual sessions via a web-based learning platform, synchronous or asynchronous discussion forums
  • Virtual Patients – interactive computers simulations of real-life clinical scenarios

The primary outcome of this study was to evaluate the effectiveness of blended learning to achieve knowledge outcomes compared with traditional teaching strategies.1 Of the 3,389 articles identified in MEDLINE, 56 studies met the inclusion criteria with a total of 9,943 participants. Most of the participants were students in medical schools. Other participant subgroups included nursing, pharmacy, physiotherapy, dentistry, and interprofessional education.

Offline Blended Learning vs Traditional Learning

Some benefits of offline learning have been suggested, such as unrestricted knowledge transfer and enhanced accessibility. This type of learning gives students more flexibility to learn at a convenient pace, place, and time, which can improve retention of content. However, this study showed no significant difference in knowledge outcomes when compared to traditional teaching methods. It was noted that the majority of studies in this group were in nursing. These results were consistent with a previous meta-analysis on offline digital instruction.2

Online Blended Learning vs Traditional Learning

Online blended learning gives students more experience building competency in things that require repeated practice, such as EKG and imaging interpretation. The internet has provided students with an abundance of resources that can be used with the click of a button, so why not use it to the learner’s advantage? As expected, this study did show a significant advantage in knowledge outcomes of online blended learning versus traditional learning alone. Using the internet to deliver instruction does not come without challenges. Learning is highly dependent on the student’s ability to cope with technical difficulties and comfort using computers and navigating the internet.

Digital Learning vs Traditional Learning

Digital learning, or “eLearning,” is being used increasingly in health professional education for improvement of access to training and communication.3 However, the pooled effect for knowledge outcomes in this study suggests no significant difference.1 This study was broken into subgroups, and the medicine subgroup showed digital learning had a positive effect when compared to the control group.1 I feel this concept is not one to ignore because it facilitates remote learning, which could help in addressing the shortage of health professionals in settings with limited resources.1

Computer-Assisted Instruction Blended Learning vs Traditional Learning

Computer-assisted instruction can provide students with innovative methods of instruction for things like physical examination techniques.8 The pooled effect for knowledge outcomes in this study suggested a significant improvement. Participants in one study reported difficulties accessing the course due to problems with the university’s internet, so the online discussion board was not used to its full potential.5 One could argue that similar problems could have emerged even in the traditional learning setting where students may choose not to or feel intimidated to engage in discussion. 

Virtual Patient Blended Learning vs Traditional Learning

Virtual patients are widely used in simulation-based instruction. These simulations can be used as a precursor to bedside learning, or to be used when direct patient contact is not possible. The groups with supplementary virtual patient learning support showed a significant improvement in knowledge outcomes compared to traditional learning.1 These results reinforce the results found in a similar meta-analysis, showing that virtual patients have a positive impact in terms of skill development and problem solving.3

When combining all 56 studies, the pooled effect size reflected a significantly positive effect on knowledge acquisition in favor of blended learning versus traditional learning in health professions education.1 A possible explanation could be that blended learning allows students to review materials at their own pace and as often as necessary. This reinforces the belief that the outcomes of blended learning is most dependent on student characteristics and motivation, rather than the instructional deliver method.

In my opinion, one of the most interesting findings from this study comes from the subgroup analysis. For the top 3 subgroups, the pooled effect difference in the medicine subgroup was 0.91, nursing studies was 0.75, and dentistry studies was 0.35.1 This reiterates that the effectiveness of blended learning is complex and dependent on the learner characteristics and needs of the student population. One tool that can be used to develop and implement a personalized blended learning curriculum is the six step Kern cycle6, described below:

  1. Problem identification – The first step begins with the identification and analysis of a specific healthcare need or group of needs. It could relate to the needs of the provider, or the needs of society in general.
  2. Targeted needs assessment – The second step involves assessing the needs of your group of health professional students, which may differ from the needs of providers or society in general.
  3. Formulating goals and learning objectives – Once the needs have been clearly identified, goals and objectives should be written starting with broad goals, then moving to specific, measurable objectives.
  4. Selecting educational strategies – After objectives have been finalized, the content and methods can be selected that will help to achieve the educational objectives.
  5. Implementation – In this step the finalized curriculum is implemented.
  6. Evaluation and feedback – This final step is important to help continuously improve the curriculum and gain support to drive the ongoing learning of participants.

 Overall, this meta-analysis reinforces the notion that blended learning has a positive effect on knowledge outcomes in healthcare education. However, it also indicates that different methods of conducting blended courses could demonstrate differing effectiveness based on the student population, their needs, and the learning objectives.1 When strategically developed and implemented, I believe blended learning enhances outcomes.


  1. Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning compared to traditional learning in medical education: Systematic Review and meta-analysis. Journal of Medical Internet Research. 2020;22(8): e16504.
  2. Posadzki P, Bala MM, Kyaw BM, et al. Offline Digital Education for Postregistration Health Professions: Systematic review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(4): e20316.
  3. Kononowicz AA, Woodham LA, Edelbring S, et al. Virtual patient simulations in Health Professions Education: Systematic Review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(7): e14676.
  4. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: Student perceptions of useful and challenging characteristics. The Internet and Higher Education. 2004;7(1):59–70.
  5. Al-Riyami S, Moles DR, Leeson R, Cunningham SJ. Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar. British Dental Journal. 2010;209(11):571–6.
  6. Kern D. Curriculum Development for Medical Education: A Six-step Approach. Baltimore, MD: Johns Hopkins University Press, 2022.
  7. George PP, Papachristou N, Belisario JM, et al. Online elearning for undergraduates in Health Professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction. Journal of Global Health. 2014;4(1).
  8. Tomesko J, Touger-Decker R, Dreker M, Zelig R, Parrott JS. The effectiveness of computer-assisted instruction to teach physical examination to students and trainees in the Health Sciences Professions: A systematic review and meta-analysis. Journal of Medical Education and Curricular Development. 2017 Jul 14;4:2382120517720428