During the three tests, a total of six different written patient problems concerning pain were presented to the students of both study and control groups (Table 2). Problem A was presented in each of the three tests in order to measure the retention effect Patient problems B and C were new cases, presented at T2 and T3 respectively in order to measure the transfer effect. The patient data on history, physical examinations and relevant laboratory and X-ray data were provided. Students were requested to provide a complete therapeutic action plan within 15 minutes, using the open question: “Describe step by step what you are going to do from this moment on (the moment of determining the diagnosis) until you finish the consultation”. Students were allowed to use any reference material, with exception of the WHO manual.

In addition to the open questions and after the answers to these questions had been collected, at each test one structured question was given. In this question the students were guided in the reasoning process by detailed questions such as “What is the patient’s problem”, “What is your therapeutic goal”, etc. These questions were included to determine whether a possible increase in score for questions A, B or C was due to an increase in knowledge about drug treatment of pain, rather than to improved skills in problem solving.

Table 2 Patient problems used in tests

T1 = pre-test; T2 = post-test; T3 = 6 months post-test