Study Design

In this study, we used a within-subject educational intervention study that associates the use of infographics and social media threads with the results in a final MCQ exam. This study was conducted over three consecutive academic years (2022–2023, 2023–2024, 2024–2025), involving three cohorts of students enrolled in the MMSP course. The course is offered annually between September and December (Fig. 1).

Fig. 1

The MMSP includes two main differentiate subjects: rheumatology and traumatology. All students were required to study both subjects as part of the course curriculum.

The study intervention was focused on the rheumatology and included two tools:

(a)

Infographics: Most of the infographics created for this project were used as clinical summaries to illustrate the key features of rheumatologic diseases through clinical vignettes; additional infographics served as diagnostic schemas, guideline-based decision trees, or visual aids to reinforce key associations (e.g., tobacco use and rheumatoid arthritis), facilitating learning and exam preparation (see example in Fig. 2 and link to all the infographics in this interactive infographic link https://uvadoc.uva.es/handle/10324/68119). The infographics were made available to students as PDF files uploaded to the university’s online campus platform, integrated into classroom teaching sessions, archived in the institutional repository (https://uvadoc.uva.es/), and, in some cases, disseminated through social media platforms.

(b)

Social media threads featuring clinical vignettes for various rheumatologic conditions (X/Twitter® during 2022–2023 and 2023–2024 or Instagram® during 2024–2025) (further information is available in Appendix 1).

Fig. 2

Example of infographic to summarize the main signs and symptoms of Systemic Lupus Erythematosus (SLE), organized by frequency. The infographic presents the organ systems commonly affected in SLE, accompanied by representative visual icons (e.g., malar erythema, oral ulcers, photosensitivity, alopecia for skin involvement). Each system is labeled with the approximate percentage of patients affected, based on published epidemiological data. The manifestations are arranged in descending order of frequency to provide a visual summary of the typical clinical spectrum of the disease

The educational tools were provided to the students during the first half of the course.

In contrast, no additional educational tools, such as infographics or social media threads, were offered for the traumatology part of the course. This difference in educational support formed the basis for comparison.

To assess the frequency of use of infographics and social media threads by students and to know their perceptions of the interest and usefulness of these tools in facilitating their study of rheumatology, we conducted a survey at the end of September.

At the end of the semester, students completed a final exam comprising 100 MCQs: 25 questions on rheumatology and 75 on traumatology. Although the exam was administered simultaneously, scores for rheumatology and traumatology were calculated and graded independently.

Ethical Approval

This project has been approved by the Institutional Review Board of the University of Valladolid.

Setting and Participants

The study was conducted within the Medical Degree Program at the University of Valladolid, specifically during the fifth year of the program, which includes the MMSP course. The fifth year of medical school in Spain is the penultimate year of training and includes a range of clinical subjects with a strong practical focus, such as Preventive Medicine and Public Health, Radiology, Clinical Pharmacology, Geriatrics, Emergency Medicine, and Musculoskeletal Medical and Surgical Pathology, among others. All students enrolled in the MMSP course were invited to participate in the survey.

Survey Characteristics

The survey consisted of the following questions:

Tool Evaluation

Students rated, on a scale from 1 (worst) to 5 (best), their assessment of five learning tools: (I) in-person lectures; (II) patient participation in lectures, where individuals shared their clinical histories with the students; (III) live-polls conducted in class using Ahaslides® or Wooclap®; (IV) infographics summarizing rheumatologic diseases; (V) social media threads featuring clinical vignettes.

Additional Likert questions assess (I) the frequency of use of infographics and social media threads; (II) whether infographics or social media threads aided their studying; (III) whether these tools increased their interest in the subject; (IV) whether they would recommend the use of these tools to future students.

Rationale for Selecting Within-Subject Educational Intervention Study Design

The selection of this study design was guided by the need to minimize bias when assessing the effectiveness of an educational intervention. Specifically, we aimed to avoid a scenario where the observed benefits of the intervention (infographics and social media threads) might be attributed to the characteristics of the students who chose to use them, such as higher motivation or greater academic ability, rather than the intrinsic value of the tools themselves.

To address this concern in our study, each student taking the rheumatology exam after the exposition to the infographics and social media threads serves as their own control in the traumatology exam where they are not being exposed to infographics or social media threads. Since all students were required to study both rheumatology and traumatology as part of the same course, this design allowed for a within-subject comparison of outcomes for the same individual under different conditions, reducing the likelihood that differences in outcomes were driven by individual student characteristics (e.g., differences in prior knowledge, motivation, or learning styles) rather than the intervention itself.

Data Analysis

Survey data were collected through live polls conducted during class, while MCQ exam data were obtained from offline tests included in the Moodle platform. Individual responses on the use of infographics and social media were linked to each student’s final exam performance. This linkage enabled the within-subject analysis crucial to our study design. All data were managed confidentially in accordance with institutional data protection protocols and were used solely for research purposes.

Data were expressed as mean ± standard deviation (SD) for normally distributed variables or as median and interquartile range (IQR) for non-normally distributed variables, based on the results of the Kolmogorov–Smirnov test for normality.

Since most data series did not follow a normal distribution, non-parametric tests were employed to analyze differences. We used Mann–Whitney U test for independent samples to compare continuous variables differences between men and women. We used the Kruskal–Wallis test (KWt) to assess differences in categorical variables (e.g., exam performance based on the frequency of use of infographics or social media threads (divided in five ordinal categories: never, almost never, occasionally, almost always, and always)). When significant differences were identified (p < 0.005), the Jonckheere-Terpstra test (JTt) was performed to evaluate specific directional trends across the ordered categories. When the KWt was significant but there is no apparent trend in JTt, we assessed post hoc pairwise comparisons (Dunn’s test with Bonferroni correction) to identify the specific group differences.

Due to differences in the difficulty and grading scales of the exams in the rheumatology and traumatology MCQ exams during the three different academic courses, we decided to standardize the grades by using Z-scores. This method adjusts each grade based on the mean and standard deviation of its respective course, using the formula Z = (X − μ)/σ, where X is the grade, μ is the course mean, and σ is the standard deviation. Z-scores standardize grades to a scale with a mean of 0 and a standard deviation of 1, allowing for direct comparison between courses regardless of differences in grading scales or variability. This standardization allows for a fair comparison of student performance across the two subject areas, independent of inherent disparities in exam structure or scoring.

A significance level of 0.005 was set for all analyses, and data processing was conducted using SPSS version 21.