PURPOSE: To determine the effect of self-assessment questions on learners' knowledge and format preference in a Web-based course, and investigate associations between learning styles and outcomes. METHOD: The authors conducted a randomized, controlled, crossover trial in the continuity clinics of the Mayo-Rochester internal medicine residency program during the 2003-04 academic year. Case-based self-assessment questions were added to Web-based modules covering topics in ambulatory internal medicine. Participants completed two modules with questions and two modules without questions, with sequence randomly assigned. Outcomes included knowledge assessed after each module, format preference, and learning style assessed using the Index of Learning Styles. RESULTS: A total of 121 of 146 residents (83%) consented. Residents had higher test scores when using the question format (mean ± standard error, 78.9% ± 1.0) than when using the standard format (76.2% ± 1.0, p = .006). Residents preferring the question format scored higher (79.7% ± 1.1) than those preferring standard (69.5% ± 2.3, p < .001). Learning styles did not affect scores except that visual-verbal "intermediate" learners (80.6% ± 1.4) and visual learners (77.5% ± 1.3) did better than verbal learners (70.9% ± 3.0, p = .003 and p = .033, respectively). Sixty-five of 78 residents (83.3%, 95% CI 73.2-90.8%) preferred the question format. Learning styles were not associated with preference (p > .384). Although the question format took longer than the standard format (60.4 ± 3.6 versus 44.3 ± 3.3 minutes, p < .001), 55 of 77 residents (71.4%, 60.0-81.2%) reported that it was more efficient. CONCLUSIONS: Instructional methods that actively engage learners improve learning outcomes. These findings hold implications for both Web-based learning and "traditional" educational activities. Future research, in both Web-based learning and other teaching modalities, should focus on further defining the effectiveness of selected instructional methods in specific learning contexts.
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