Adv Physiol Educ 30: 230 –236, 2006;
doi:10.1152/advan.00038.2006.
Teaching With Problems and Cases
Use of modified SOAP notes and peer-led small-group discussion in a
Medical Physiology course: addressing the hidden curriculum
Jonathan Kibble,1 Penelope A. Hansen,2 and Loren Nelson1
1
Department of Physiology and Neuroscience, St. George’s University, St. George’s, Grenada;
and 2Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
Submitted 18 May 2006; accepted in final form 29 August 2006
student facilitation; active learning; cooperative learning
comprises what students are learning
that is not made explicit to them, learning that may be unrecognized even by teachers. It usually consists of cognitive skills,
attitudes, and behaviors– desirable or not–that are acquired
because of the way the teacher organizes and conducts the
class. The hidden curriculum in medical schools often includes
the development of student attitudes and behaviors that are
characterized as professional or unprofessional. Indeed, the
hidden curriculum has been regarded more generally as part of
the process of socialization into medicine (3). Ethics and
cultural competency are two areas in which the hidden curriculum has been observed to differ, with undesirable results,
from the formal one (3, 13, 14). Medical physiology has a
significant hidden curriculum that includes attitudes about the
use of animals in teaching and research and about ethical and
social aspects of the discipline, and cognitive abilities arising
from its experimental basis and integrative nature (4).
THE HIDDEN CURRICULUM
Address for reprint requests and other correspondence: J. Kibble, Dept. of
Physiology and Neuroscience, St. George’s Univ., PO Box 7, St. George’s,
Grenada (e-mail: [email protected]).
230
The desirable hidden curriculum will be realized more efficiently if it is brought out into the open by expressing it as learning
objectives and assessing student achievement of them. It is also
essential to incorporate teaching and learning strategies that encourage and aid students’ achievement of the desirable aspects.
Small-group work is an example of a pedagogical approach
shown to promote favorable attitudes toward learning, increased
student motivation, and improved academic performance (11). In
this study, we introduced a form of small-group learning that
emphasized peer facilitation and cooperation into a Medical Physiology course. Peer instruction has been associated with several
desirable outcomes, including high degrees of student satisfaction
(5), improved cognitive performance (2, 9, 12), and the acquisition of patient-centered interviewing skills (7).
This study also describes the use of modified subjective,
objective, assessment, and plan (SOAP) notes as a tool for
students to analyze clinical cases with the objective of explaining the physiology related to them. The modification we
describe maintains the SOAP acronym but changes the final
words to subjective, objective, assessment of physiology.
SOAP notes were developed by Lawrence Weed (15, 16) as a
structured system for the clinical evaluation of a patient that
facilitates a comprehensive analysis of clinical problems and
the development of differential diagnoses, culminating in a
treatment plan. SOAP notes provide a logical and reproducible
framework for generating medical records.
It is usual that some kind of in-training assessment of
students’ attitudes and behaviors is made during clinical clerkships, and problems in this area of performance are often first
noted in the clinical setting. We believe that faculty members
who teach in preclinical basic science courses have an obligation to recognize and act on unprofessional and other undesirable behaviors whenever they occur in their courses. This
obligation includes helping students understand what professionalism actually means in practice, for example, in a smallgroup discussion, a laboratory, a lecture, or an exam. Since
some students are simply not aware that their behaviors are
unprofessional, teachers must make their expectations explicit,
i.e., they must reveal this aspect of the hidden curriculum.
Portelli (8) has argued that the hidden curriculum always has a
moral component and that educators have a responsibility to
make it as explicit as possible. In this article, we describe a
self-assessment that we developed to help students become
more aware of the expected behaviors in their small-group case
discussions. At the end of the series of small-group meetings,
we invited students to complete an on-line survey that included
questions about their own behaviors and those of others in their
groups.
1043-4046/06 $8.00 Copyright © 2006 The American Physiological Society
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Kibble, Jonathan, Penelope A. Hansen, and Loren Nelson. Use
of modified SOAP notes and peer-led small-group discussion in a
Medical Physiology course: addressing the hidden curriculum. Adv
Physiol Educ 30: 230 –236, 2006; doi:10.1152/advan.00038.2006.—
Peer leading of small-group discussion of cases; use of modified
subjective, objective, assessment of physiology (SOAP) notes; and
opportunities for self-assessment were introduced into a Medical
Physiology course to increase students’ awareness and practice of
professional behaviors. These changes arose from faculty members’ understanding of the hidden curriculum and their efforts to
reveal it to take increased advantage of its educationally beneficial
aspects. Faculty members and students observed that the requirement for students to submit SOAP notes before their discussions
meant that they were well prepared to participate. Student satisfaction with the protocol was high, with ⬎95% of the students
agreeing that discussants were well prepared and that the overall
performance of their discussion group was good. A comparison of
students’ performance on selected exam questions showed that
peer leading was equally as effective as a previously used teachercentered approach. Students agreed that their ability to analyze a
clinical case had improved using this protocol, an effect that
persisted at least one semester after the end of the course. These
approaches were time and cost efficient from a faculty perspective
while serving the needs of the students. The use of SOAP notes and
peer-led discussion were effective forms of instruction, in which
students succeeded in learning medical physiology and in practicing professional behaviors.
Teaching With Problems and Cases
LEARNING MEDICAL PHYSIOLOGY AND DEVELOPING PROFESSIONALISM
The specific questions addressed in this study were as
follows: 1) Are the uses of SOAP notes and peer-led discussions an acceptable and effective means of learning medical
physiology? 2) Did using SOAP notes and peer-led discussion
foster desirable professional student behaviors? 3) Are SOAP
notes a valid tool to measure student performance? and 4) Is
there any continuing educational benefit for students in learning how to use SOAP notes?
METHODS
worksheet and submit it electronically via the ANGEL
course management system before they attended a formal
small-group discussion. The use of internet searching was
strongly encouraged, and several useful websites were
posted as links via the Physiology course website to assist
students in finding definitions for unfamiliar terms and
researching normal values and pathophysiology. Students
were further oriented about the conduct of peer-facilitated
small-group discussion.
Groups of 8 –10 students met for 90 min to discuss a case.
Students selected a peer facilitator, who was charged with
developing a discussion that analyzed and synthesized ideas
about the relevant physiology, culminating in collective suggestions for differential diagnoses. Each group was accompanied by a faculty member who did not participate in the
discussion unless asked directly by the student facilitator for
brief clarification. During the final 5 min of the discussion,
faculty tutors provided general feedback on group dynamics
and on any misconceptions about physiology that had arisen
during the session. Students were provided with a questionnaire (Table 1) at the start of the program and were asked to
perform regular self-assessments in relation to their academic
and professional performance.
Evaluation of SOAP notes and peer-led discussions. Several approaches were used to evaluate the stated goals of the
study. Students were asked to complete the questionnaire
shown in Table 2 just before the final examination. Questions
were devised in four areas: perceptions about discussion group
performance (questions 1–5), perceptions about individual performance (questions 6 –11), assessment of the educational
value of peer-led discussions (questions 12–14), and perceived
value of self-assessment in the development of professional
behaviors (questions 15 and 16).
An assessment of how well students learned the physiology associated with clinical cases was made by comparing
the examination performance against previous student cohorts using questions specifically related to the clinical case
content. Every semester, summative multiple-choice examinations include two questions from each clinical case. As
part of a general question validation procedure, approximately two-thirds of questions included on summative examinations have been used previously and have statistical
history; approximately one-third are new questions. In
spring 2005, 7 of 10 examination questions included for
clinical cases had historical data derived from students
taking the course before the present peer-led discussion
format was adopted. For these seven questions, a paired
analysis of student performance was made for spring 2005
versus history. A Wilcoxon’s paired-rank test was applied,
assuming a 5% significance level.
The validity of SOAP notes as a tool for measuring student
learning in physiology was evaluated by devising a scoring
system for SOAP notes and comparing the outcome with
summative examination scores in a sample of students. An
example of the SOAP notes grading form used by faculty
members is shown in Table 3. The form describes a six-point
scale designed to emphasize physiological reasoning. This was
shown to students during their orientation lecture to emphasize
the expected qualities of a good SOAP notes submission.
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Background. St. George’s University offers a 4-yr medical
program in which basic medical sciences are taught during the
first 2 yr. The Medical Physiology course is taught twice a year
to cohorts of 350⫹ students. It is a 5-credit hour course,
delivered over 18 consecutive weeks, consisting of 75 lecture
hours and 12 h of formal small-group teaching. The curricular
content is based on the American Physiology Society Medical
Physiology Objectives Project. The course runs during the
second academic semester, concurrently with the Neuroscience, Genetics, Immunology, and Medical Parasitology
courses. The Medical Physiology course follows the Anatomy
and Biochemistry course and precedes courses that include
Pathology, Pharmacology, and Pathophysiology. Medical
Physiology students are assessed using the aggregate score
from a summative multiple-choice examination after 9 wk and
another after 18 wk. Formative assessment is provided using
quizzes available online via the ANGEL course management
system. Self-assessment quizzes are also available via printed
course materials. This study addressed changes to the smallgroup teaching program, which required significantly higher
student responsibility for learning. Before the changes described in this study were introduced, there were two important
differences in the organization of small-group case discussions:
1) community physicians and physiologists acted as discussion
facilitators rather than students and 2) students were not required to complete a SOAP notes worksheet before smallgroup discussions. The major pedagogic problem with this
previous approach was poor preparation by students, which
inhibited meaningful discussion, often resulting in case discussion becoming didactic teacher-centered sessions. This sometimes defeated our goals of having small-group discussions in
which students were able to set some learning agendas and
achieve learning objectives through independent study and
discussion. In this context, running small groups with a small
faculty and over 350 students was also problematic, with too
much variance in the quality of teaching from one group to
another.
Learning materials and student orientation. At the start of
the spring 2005 semester, students were provided with five
paper clinical case histories, which, in each instance, included a description of signs and symptoms together with
laboratory findings. Students were given a 50-min orientation period en masse in their lecture theater about how to
organize and analyze a case using a SOAP notes worksheet.
During the orientation, students worked through a model
case and were guided about how to define relevant subjective and objective findings. The emphasis was then on
documenting the physiological reasoning for clinical findings. Students were required to complete a SOAP notes
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LEARNING MEDICAL PHYSIOLOGY AND DEVELOPING PROFESSIONALISM
Table 1. Self-assessment chart indicating faculty expectations of students with respect to academic and professional
performance during the conduct of small-group discussions
My Performance Meets
Expectations (Goal)
My Performance Needs Improvement
My knowledge of
physiology
related to the
case
My case analysis
skills
My professional
relationships
My attendance
and preparation
I have difficulty identifying and
organizing key information related
to the case.
I am occasionally discourteous or
uncooperative with my classmates
or tutor. Sometimes my behavior
interferes with the work of my
group.
I answer questions but don’t
volunteer, and I rarely contribute
to discussion. Occasionally I overor under-estimate my abilities.
Sometimes I am absent or late
without explaining why. I am
often unprepared for discussion.
My Performance Exceeds Expectations
I demonstrate comprehension
of physiology facts and
concepts at the level of
course materials.
I identify major topics and
organize information
logically.
I am always cooperative and
courteous.
I show outstanding knowledge and
understanding of facts and concepts at
textbook or greater level.
I participate well in
discussions. I accept
criticism well and have
insight into my strengths
and deficiencies.
I attend all sessions on time
and am almost always
prepared for the session.
My participation is excellent. I stimulate
the discussion process with appropriate
questions. I am eager to learn and be
evaluated and have good insight into
my abilities.
I attend all sessions on time. I am
consistently very well prepared for
discussion.
Students were encouraged to discuss any aspect of the clinical
cases with study partners but were required to prepare and
submit their own SOAP note worksheets. Course examinations
consisted of multiple-choice questions designed to assess cognitive achievement at the levels of knowledge, comprehension,
and application. Examinations were sequestered and took place
under closed, proctored conditions to prevent student collaboration. After the summative final examination was completed
and course grades had been assigned, 10 students were selected
at random from each of the 4 possible course grade categories
(A, B, C, and F) that are applied at our medical school. SOAP
notes submissions from these 40 students were assembled for
grading by a single faculty member in a blinded fashion. SOAP
notes were given to a moderator to check for grading consistency. A discussion between the grader and moderator was
used to reach a consensus score in cases of disagreement. A
I identify and put major and minor topics
in perspective and organize
information logically.
I work very well with others. I am
consistently courteous and cooperative
and have the respect of my classmates.
cumulative SOAP notes score for each student was obtained by
adding together scores from each of the five clinical cases,
providing a maximum cumulative SOAP score of 30 points.
Cumulative SOAP notes scores were compared with summative multiple-choice examination scores. Linear regression
analysis was used, applying ANOVA, and assuming a 5%
significance level.
The extent to which learning to use SOAP notes could
benefit student learning later in the basic science curriculum
was evaluated using the followup survey shown in Table 4.
This questionnaire was designed to start with questions directly
related to the original purpose of using SOAP notes, as a
clinical case analysis tool, and then progressing to more generic learning issues. The followup survey was administered 6
mo later after the Medical Physiology course, toward the end
of the Pathology course.
Table 2. Student questionnaire evaluating the performance of peer-led discussion groups
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Question
Mean Score
1. All students seem to be prepared for discussion of the cases.
2. All students were able to participate in discussion most of the time.
3. On the whole, our group worked well using student facilitators.
4. Our group was usually able to have a full and complete discussion.
5. The overall performance of our group was good.
6. I was on time for the sessions.
7. I came prepared with my SOAP notes sheet filled out.
8. I was comforable participating in the discussion.
9. I was able to demonstrate that I understood the topics that were discussed.
10. I feel that my contributions were effective.
11. I actively listened to contributions from my peers.
12. I improved my ability to analyze a case by participating in the discussion.
13. I learned a significant amount of physiology during the discussion.
14. The benefits of preparing for and attending the case discussions were worth the time it took.
15. I feel that honest self-assessment gives me insight into my behavior as a student.
16. The self-assessment table in the handout raised my awareness of the professional behavior that is expected of me.
1.5
1.5
1.4
1.4
1.4
1.2
1.2
1.3
1.5
1.5
1.2
1.4
1.5
1.4
1.5
1.8
n ⫽ 361 students total enrolled in the Medical Physiology course; 7 studends withdrew, and 312 of 354 students that completed the course (88%) responded
to the survey shown. Questions were scored using a Likert scale where 1 is strongly agree, 2 is agree, 3 is disagree, and 4 is strongly disagree. SOAP, subjective,
objective, assessment of physiology.
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My educational
attitudes
I demonstrate minimal knowledge of
physiology facts and concepts.
Teaching With Problems and Cases
LEARNING MEDICAL PHYSIOLOGY AND DEVELOPING PROFESSIONALISM
233
Table 3. The SOAP notes grading sheet
SOAP NOTES GRADING SHEET
Clinical Case Title:
Student Name:
Grading Category
Grading Criteria
1. Subjective and Objective Information
Complete and accurate
Inadequate
Mechanisms given and correct
Mechanisms given and partially correct
Mechanisms given, several errors
Descriptive and correct
Descriptive and partially correct
Lack of reasoning
Sufficient, relevant and justified
Insufficient, not relevant or reasoned
2. Physiological Reasoning
3. Differential Diagnosis
Possible
Score
Score
Awarded
1
A 6-point grading scale was used, in which points could be earned in the 3 grading categories shown. 0 –1 points were available for the ability to identify and
differentiate between subjective and objective case findings; 0 – 4 points were available for the quality of physiological reasoning; and 0 –1 points were available
for suggesting differential diagnoses. The number of points awarded in each category was based on meeting the criteria listed. The score from each category was
added to give a total score out of a maximum of 6 points.
RESULTS
Acceptability and effectiveness of the new approach to
clinical case discussions. Student acceptance was high based
on the overall level of agreement with statements in the end of
course survey (Fig. 1 and Table 2). Of particular relevance to
student acceptance were the following: students agreed that the
overall discussion group performance was good, that they felt
comfortable in participating in the group discussion, that their
personal contributions were effective, that they learned a significant amount of physiology, and that the benefits of preparing SOAP notes and attending discussions were worth the time
it took.
Student performance on seven summative examination questions directly related to the physiology covered in clinical cases
was unchanged compared with cumulative historical examinaTable 4. Student questionnaire evaluating the potential
continuing educational benefits of learning how to apply
SOAP notes during a first-year Medical Physiology course
Mean
Score
Question
Question 1. Being familiar with SOAP notes has improved my
ability to organize findings in a clinical case history.
Question 2. Being familiar with SOAP notes has made my
analysis of case findings more comprehensive.
Question 3. Being familiar with SOAP notes has increased the
depth to which I try to explain clinical findings.
Question 4. Being familiar with SOAP notes has helped me to
model the clinical reasoning process.
Question 5. Being familiar with SOAP notes has been a useful
during informal small-group discussions.
Question 6. Being familiar with SOAP notes has helped me to
prioritize high-yield concepts.
Question 7. Being familiar with SOAP notes has helped me to
identify personal misconceptions.
Question 8. Being familiar with SOAP notes has been a useful
review tool before examinations.
1.8
1.7
1.7
1.6
1.9
2.0
2.2
2.5
n ⫽ 131 of 354 students (37%) who responded to this followup survey.
Questions were scored using a Likert scale where 1 is often, 2 is sometimes,
3 is rarely, and 4 is never.
tion performance (Fig. 2). These data suggested that the new
approach to clinical cases was equally as effective as the
previous more teacher-centered approach. The effectiveness of
SOAP note preparation and peer-led discussions in terms of
learning physiology was also supported by student agreement
that understanding of the topics covered was demonstrated
during discussions and that a significant amount of physiology
was learned (Fig. 1 and Table 2).
Student behaviors. Attendance at the small-group discussion and submission of SOAP notes was an expected part of the
course, and 99% of all SOAP notes worksheets were submitted. The attendance rate at the small-group discussions
was 95%.
Students were made clearly aware of the performance expectations during orientation (Table 1). Several responses in
the end of course survey indicated that students exhibited a
high degree of professionalism. Students not only reported
strong agreement that they were personally well prepared with
the SOAP notes filled out before their discussion group met but
that the other student discussants in the group were too. On a
personal level, students agreed that their contributions in discussion were effective and that they actively listened to their
peers. Strong agreement that all students were able to participate, that group discussions were full and complete, and that
the groups worked well with student facilitators suggested that
a successful cooperative learning environment was created by
students.
Validity of using SOAP notes for assessments. The relationship between cumulative SOAP notes score for all five
clinical cases added together and the aggregate summative
examination score is shown in Fig. 3. Despite the fact that
students were allowed to discuss the cases freely and to use any
external information sources, a significant relationship was
observed between the SOAP notes score and examination
score. These data suggested that the attainment of knowledge
and comprehension and application of physiology tested in
summative examinations was also reflected in the ability to
compose a good SOAP notes record.
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4
3
2
2
1
0
1
0
TOTAL
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LEARNING MEDICAL PHYSIOLOGY AND DEVELOPING PROFESSIONALISM
discussions. Moving further away from the original context of
SOAP notes to analyze a clinical case in preparation for group
discussion, students reported that SOAP notes were sometimes
useful in general terms for prioritizing high-yield concepts and
in identifying misconceptions but were more rarely used as a
tool to help review for examinations.
DISCUSSION
Educational benefits. At the end of the course, students
strongly agreed that their ability to analyze a clinical case had
improved (Fig. 1 and Table 2). In a followup survey one
semester later, albeit from a smaller sample size (131 compared with 312 respondents), students agreed their ability to
organize clinical findings was improved and their depth of
analysis was more comprehensive by having learned to use
SOAP notes in the Medical Physiology course (Fig. 4 and
Table 4). SOAP notes were initially presented to students as
part of a small-group learning initiative. One semester later,
students agreed that learning to use SOAP notes had been
useful, in general, when learning in the setting of small-group
Fig. 2. Comparison of summative examination performance on 7 previously
validated clinical case test items for the spring 2005 cohort versus the
cumulative history. Wilcoxon’s paired-rank test applied to the mean item score
showed no significant difference between groups.
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Fig. 1. Student responses to the questionnaire shown in Table 2. A: student
evaluation of group performance. B: evaluation of personal performance. C:
perceptions on the educational value of peer-led discussions. D: perceived
value of self-assessment to the development of professional behaviors. Q1–
Q16, questions 1–16. Three hundred sixty-one students enrolled in the Medical
Physiology course; 7 students withdrew, and 312 of 354 students completing
the course (88%) responded to the survey shown.
We made changes to our clinical case-based instruction to
enhance student engagement in learning medical physiology
and to give students an opportunity to master learning objectives through independent study and discussion. By making our
expectations about student behavior explicit and through devising SOAP notes as a precursor to peer-led discussion, we
aimed to illuminate aspects of the hidden curriculum. These
interventions were judged to be a success overall, based on the
positive student responses about individual and group performances related to both learning and behaviors. The modified
SOAP notes tool was judged to be valid, based on a comparison of student scores for graded SOAP notes and summative
examination scores. The process of using SOAP notes to
precede peer-led discussion was also judged to be useful, based
on the comparable summative examination performance between students using SOAP notes and previous cohorts of
students who experienced more teacher-centered tutorials. The
survey data suggested that some educational benefits of learning to use SOAP notes persisted 6 mo after the Medical
Physiology course ended.
One limitation of the study is the exclusive use of student
perceptions to explore the value and quality of peer-led discussion and student professionalism. In our setting, with an
adverse faculty member-to-student ratio, it is difficult for a
given faculty member to consistently observe a given group.
This presented difficulty in recording objective faculty observations of student behaviors, although faculty members anecdotally reported satisfaction with the level of student preparation and behaviors in small-group meetings. It should be noted,
however, that student responses related to group performance
(Table 1) showed a very high degree of internal consistency,
which has also been noted by others using peer evaluation of
group performance (10). Another possible limitation of our
study design was that it did not apply a prospective randomized
approach but sought to report the findings of an intervention
applied equally to all students. Therefore, our ability to make
Teaching With Problems and Cases
LEARNING MEDICAL PHYSIOLOGY AND DEVELOPING PROFESSIONALISM
firm conclusions about the efficacy of SOAP notes and peer-led
discussion with respect to cognitive performance is limited.
It is generally held that small-group learning experiences
promote favorable attitudes toward learning (11). Student acceptance of our peer-led discussion format was high based on
the consistently positive responses shown in Table 1. Anecdotally, our faculty members reported high levels of satisfaction with student motivation, participation, and enthusiasm.
Other studies (2, 5) have noted similarly favorable student
endorsements using peer-led small-group learning. The attendance rate at the peer-led discussions was high, with only 86
recorded absences of 1,770 individual attendance records over
the course. This is consistent with the strong agreement by
students that the benefits of preparing for and attending the
sessions were worth the time it took.
The SOAP notes format allowed students to study what they
identified as important points in a case history, providing a
higher degree of student ownership and responsibility for
learning. Examination performance using this format was comparable with a previous teacher-centered instructional approach, indicating that student performance was unaffected by
reducing the emphasis on the teacher. Using a randomized
crossover design, Kolars et al. (6) compared the effects of
student and teacher-led small-group learning in a class of
second-year medical students and reported comparable performance on knowledge-based assessments. Nestel and Kidd (7)
also reported that peer-led instruction had comparable effectiveness to teacher-led instruction in the area of patient interviewing skills.
The construction of SOAP notes required students to take an
organized and systematic approach to case analysis. Based on
the sample of SOAP notes used for grading, most students
mastered the ability to define all major subjective and objective
findings in a case. In the followup survey, students broadly
agreed that using SOAP notes had improved their ability to
organize case findings. Students were then required to make
suggestions for the physiological basis of every finding, encouraging a comprehensive approach. In the followup survey,
students indicated that learning to use SOAP notes had made
them analyze case findings more comprehensively and in
greater depth.
The use of SOAP notes allowed students to construct physiological knowledge and understanding in a usable manner,
which has relevance to their studies in clinical skills and in
preparation for clerkship. The importance of embedding learning in the context of the practice of a discipline has been
emphasized (1). In the present study, students agreed that using
SOAP notes models the clinical reasoning process, which may
contribute to their satisfaction using this learning tool.
A comparison of scores for graded SOAP notes with those
obtained in multiple-choice examinations showed a significant
positive correlation (Fig. 3). Bearing in mind that students
devised their SOAP notes outside of examination conditions,
the persistence of a clear relationship with examination scores
indicates that SOAP notes measure attributes similar to summative examinations. SOAP notes may, therefore, be a valid
tool to measure student performance. Our primary goal was to
use SOAP notes as a means of enhancing the quality of student
preparation for discussions. However, SOAP notes have the
potential to be useful in formative assessment, summative
assessment, as feedback to teachers about where misconceptions may lie, and perhaps as a diagnostic tool to identify
students in academic difficulty.
Fig. 4. Patterns of student responses to the questionnaire
shown in Table 3, evaluating the potential continuing benefits
of learning about SOAP notes during the Medical Physiology
course. One hundred thirty-one of 354 students (37%) responded to this followup survey.
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Fig. 3. Validation of the SOAP notes grade as a tool to measure performance
in physiology. Regression analysis of the SOAP notes score versus the
summative multiple-choice examination score indicated a significant positive
correlation (r ⫽ 0.6, n ⫽ 40, P ⬍ 0.05 by ANOVA).
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Discussion sessions were very well attended, despite the fact
that students had already studied the case in some detail to
complete SOAP notes. Since there was no explicit penalty or
reward for attendance, this alone suggested that discussion
sessions were highly regarded by students. Faculty expectations for performance were made explicit, and, according to the
student survey, the groups met these expectations well. The
discussions were intended to help address aspects of the hidden
curriculum. Students were engaged in activities such as asking
questions, explaining concepts to each other, and actively
listening to each other, all of which contribute to the development of communication skills. Students reported feeling comfortable participating in their discussion groups. This was an
opportunity to develop teamwork skills in a supportive environment of cooperation and respect. Simple indicators of
“professionalism” such as timeliness and level of preparation
were also very positive.
The small-group program we devised served 350 students
using 3 full-time faculty members supported by 4 clinical
tutors on case discussion days. It is self-evident, therefore, that
the program was very time and cost efficient from a faculty
perspective while serving the needs of the students. Future
work on our use of SOAP notes and peer discussion will focus
more on the effectiveness of this intervention. A prospective
randomized study would be useful to establish the effects on
cognitive performance. The perceptions of student facilitators
and faculty members would also be useful to gauge the quality
of group discussions.
In conclusion, the use of SOAP notes and peer-led discussion was an effective form of instruction, in which students
succeeded in learning medical physiology and in practicing
professional behaviors.