Table 4 Examples of students’ utterances on how they perceived their cognitive engagement during the in-class session

Active (A)

“We learned a lot of practical things because we once had to scrutinize the radiologic images ourselves. This method makes that one is more involved. It irritates when one overlooks a broken rib. But the next time one will scan all the ribs systematically.”

“You quickly lose attention when you are only listening. It is good that we can first experiment”

Constructive (C)

“Before (this session) I thought I could discern features in images quite well. But it is another story when one has to start from zero, without suggestions. In such a situation it can feel like an unending and sometimes confusing endeavor. With this task I have, like in real practice, to start from zero and pay close attention to it all.”

“Till now (this session) I am merely trained to solve cases by selecting from given answers. Learning was more a preparation for the assessments (multiple choice) than for being a physician.”

Interactive (I)

“The discussion with the overview of all the answers given was a good thing (many expressed accordance). It was a relief that the answers were anonymous. When I logged in at the start I feared for another procedure. It was interesting to see the frequency of all answers. Does one follow the majority or are my answers to some question different from the group? This is effective because it stimulates me to restudy such a subject in more detail.”