Physiology teaching constitutes an essential part of medical and other health science training programmes. This matter is currently experiencing important reforms in most European countries regarding its curriculum design in order to meet the Bologna Declaration [¹,²]. The Bologna process aims to create an European Higher Education Area by 2010 in order to make studies compatible and comparable amongst countries and to increase competitiveness and quality. Such calls for reforms are mirrored worldwide towards active learning approaches aimed to more actively involve students in the learning process [³].

Traditionally, physiology has been taught through classical lectures and laboratory practices with little focus on strengthening specific competencies and interdisciplinary interaction. For physiology teaching, these reforms are focused in adopting an integrated curriculum drawn along the lines of student-centered approaches aimed to assimilate the different physiological systems into a unified view [^4-7]. This involves using non-traditional methods, including problem-based learning, team-working and several other active learning techniques [^7-9], and new evaluation systems that successfully measure all the aspects of knowledge [^10-13]. Such an approach seems essential nowadays to equip students with the competences required for their social and professional integration in the modern knowledge-based society.

Several studies have investigated the impact of class attendance on the academic performance [¹⁴,¹⁵]. Most of these studies were focused in traditional teaching methods and have reported that lecture attendance levels have an impact that ranges from moderate [¹⁶,¹⁷] to significant on academic performance [¹⁸]. However, there is a fundamental difference in knowledge delivery between traditional and non-traditional teaching, that could make academic performance more sensible to class attendance when active and student-based methodologies are in use.

Here we aimed to look at the impact of attendance on integrated non-traditional physiology teaching. We report the results of a comparative study between a control group receiving information through traditional methods and an experimental group submitted to new methodologies that meet the new European standards. Our results suggest a fundamental effect of attendance on academic performance when new methodologies are used.

This study was approved by the ethics committee of the Universidad Europea de Madrid in compliance with the Helsinki Declaration. Academic scores were recorded blindly and personal data were not included, except for gender information. Students were informed on the purpose of the study at the beginning of the academic course and their consent was waived.

We first compared the examination scores between the control and the experimental group. We found no difference between the final examination scores from both groups (Table 1, ANOVA, p = 0.510), neither for the partial exam scores with the only exception of the 2nd partial exam score which was different between groups at p = 0.034. However, a different picture emerged when class attendance was considered. We looked at the effect of class attendance by reorganizing data according to four categories: never, poor, mean and frequent (see Methods). There was no difference between attendance levels in the control versus the experimental group (Mann-Whitney, p = 0.685)

Tables 2 and 3 summarize examination results in the control and experimental group according to this scale. In both groups exam scores significantly increased from the 1st exam for students that never attend to the last exams for attending students (P < 0.001; Tables 1 and 2), suggesting that class attendance has a similar beneficial effect over the scores for both groups. However, we found a largest impact of attendance on performance in the experimental versus the control group when comparing the score evolution of attending students versus their peers. In the experimental group, scores were not different between the 1st and the 2nd exams (p = 0.429) nor between the 2nd and the 3rd exams (p = 0.225) for students that poorly attend classes, in contrast to the control group where there was evolution (p < 0.001). This suggests that absentees poorly improve performance along the academic course in the experimental group. Indeed, the score difference between attending students versus their peers was maximal in the experimental compared with the control group all along the different exams and in the final score. This suggests that class attendance is critical for learning using non-traditional methods.

We have compared the impact of class attendance on academic performance depending on the use of traditional (control group) or non-traditional methods (experimental group) in Physiology teaching. We found that in the experimental group there was significant difference in exam scores between attending students and those who poorly attend classes. Moreover, a statistically significant increase of performance across different exams is present in the control but not in the experimental group for absentees. This supports the idea that students that poorly attend classes hardly compensate their performance when non-traditional methods are used and points towards the importance of class attendance in such a teaching modality. One may argue that there are similar beneficial effects of attendance in both groups since poor attendees improve more than attending students in the control and experimental groups when the first and the last exam scores are compared. This merely reflects that knowledge is effectively acquired over the course of learning using both teaching approaches. What is fundamentally different between the groups is that students that never or poorly attend classes performed worse when non-traditional methods are used because they do not improve exam scores longitudinally, in contrast with the control group.

Previous studies have demonstrated the impact of attendance on academic performance for traditional teaching [^14-16]. In lecture-based physiology teaching, regular attendance was found to be helpful but not decisive [¹⁷]. Traditional methods for physiology teaching mostly include academic lectures, tutorials and laboratory practices. This teaching modality is easily followed by personal work as most available text books deal adequately with the material discussed in lectures. Therefore, students could easily compensate their absenteeism. In contrast, using new methodologies in Physiology teaching include several active-learning techniques and an integrated approach to gain a comprehensive understanding of all the physiological systems. Our data suggest that teacher supervision appears to be instrumental in order to achieve good academic performance in non-traditional teaching.

We suggest that class attendance is critical when non-traditional active-learning methods are in use in Physiology teaching.

The authors declare that they have no competing interests.

BG, IB and CG conceived the study. BG and CG compiled the data. IB performed the statistical analysis. BG prepared and reviewed the manuscript. All authors read and approved the final manuscript

This project was funded by grants from the Universidad Europea de Madrid (OTRI 2005/UEM04, and UEM 16/2008).