Effectiveness of problem-based learning curricula: research and theory

The process of problem-based learning: what works and why

OBJECTIVES

In this review, we portray the process of problem-based learning (PBL) as a cognitive endeavour whereby the learner constructs mental models relevant to problems. Two hypotheses are proposed to explain how learning is driven in PBL; an activation-elaboration hypothesis and a situational interest hypothesis.

METHODS

Research relevant to these hypotheses is discussed. In addition, research studying the effects of various support strategies used in PBL is reviewed. Finally, we summarise a number of recent studies in which a new 'micro-analytical' methodology was used to trace the process of PBL in the natural classroom setting.

CONCLUSIONS

We conclude that there is considerable support for the idea that PBL works because it encourages the activation of prior knowledge in the small-group setting and provides opportunities for elaboration on that knowledge. These activities facilitate the comprehension of new information related to the problem and enhance its long-term memorability. In addition, there is evidence that problems arouse situational interest that drives learning. Flexible scaffolding provided by cognitively and socially congruent tutors also seems to be reasonably effective, as opposed to 'hard' scaffolding represented by, for instance, worksheets or questions added to problems. Small-group work protects against dropout and encourages students to study regularly. Initially, students do not study much beyond the learning issues generated; the development of personal agency in self-study needs time to develop. The extent of learning in PBL results from neither group collaboration only (the social constructivist point of view) nor individual knowledge acquisition only; both activities contribute equally to learning in PBL.

Developing the mental health workforce: review and application of training approaches from multiple disciplines

Strategies specifically designed to facilitate the training of mental health practitioners in evidence-based practices (EBPs) have lagged behind the development of the interventions themselves. The current paper draws from an interdisciplinary literature (including medical training, adult education, and teacher training) to identify useful training and support approaches as well as important conceptual frameworks that may be applied to training in mental health. Theory and research findings are reviewed, which highlight the importance of continued consultation/support following training workshops, congruence between the training content and practitioner experience, and focus on motivational issues. In addition, six individual approaches are presented with careful attention to their empirical foundations and potential applications. Common techniques are highlighted and applications and future directions for mental health workforce training and research are discussed.

Library use by medical students: A comparison of two curricula

This study explored 1) whether there were any differences in the way medical students used library resources under problem-based learning (PBL) and scenario-based learning (SBL) curricula; and 2) what improvements the library could make to facilitate its use by medical students using the different curricula. Twenty medical students selected from two different medical universities in different countries were interviewed in depth. The study found that a) PBL and SBL students used the library significantly differently; b) SBL students presented a wider range of demands and behaviors in seeking information; c) more PBL students preferred using solely electronic resources to solve PBL problems; and d) more SBL students preferred using textbooks in their study and to solve the problems. It is concluded that the characteristics of the two learning approaches affect the medical students in their uses of library resources. The library staff must interact differently with students depending on the curriculum they are following. The study suggests several directions (‘SHELTER’) to the library and recommends it to provide service targeting students’ needs after exploring the following three dimensions of the curriculum: students’ perceptions of the library’s collection related to the curriculum, course requirements for gathering information, and the librarian’s role in the curriculum. When new reforms are initiated it is necessary for the library to undertake a comprehensive review and to gain understanding of the curriculum at the outset.

Active learning on the ward: outcomes from a comparative trial with traditional methods

CONTEXT

Academic activity during internship is essentially practical and ward rounds are traditionally considered the cornerstone of clinical education. However, the efficacy and effectiveness of ward rounds for learning purposes have been under-investigated and it is necessary to assess alternative educational paradigms for this activity.

OBJECTIVES

This study aimed to compare the educational effectiveness of ward rounds conducted with two different learning methodologies.

METHODS

Student subjects were first tested on 30 true/false questions to assess their initial degree of knowledge on pneumonia and diarrhoea. Afterwards, they attended ward rounds conducted using an active and a traditional learning methodology. The participants were submitted to a second test 48hours later in order to assess knowledge acquisition and were asked to answer two questions about self-directed learning and their opinions on the two learning methodologies used.

RESULTS

Seventy-two medical students taking part in a paediatric clinic rotation were enrolled. The active methodology proved to be more effective than the traditional methodology for the three outcomes considered: knowledge acquisition (33 students [45.8%] versus 21 students [29.2%]; p=0.03); self-directed learning (38 students [52.8%] versus 11 students [15.3%]; p<0.001), and student opinion on the methods (61 students [84.7%] versus 38 students [52.8%]; p<0.001).

CONCLUSIONS

The active methodology produced better results than the traditional methodology in a ward-based context. This study seems to be valuable in terms of the new evidence it demonstrates on learning methodologies in the context of the ward round.

Assessing the instructional effectiveness of problem-based management education in Thailand: A longitudinal evaluation

Problem-based learning (PBL) has attracted increased interest in higher education due to claims that it provides a more active and productive learning environment.Yet, to date, most empirical research on the instructional effectiveness of PBL has been conducted in medical education. This article examines the instructional effectiveness of a problem-based curriculum at a business school in Thailand. The quasi-experimental study draws on seven years of student evaluation data to compare the instructional effectiveness of courses offered in a PBL track with other courses taught in the college. The results suggest that students perceived PBL as an effective approach to learning. PBL courses fostered a more active, engaging classroom environment that helped graduate management students understand how to apply theory to practice. The findings offer initial empirical support for the use of PBL in management education and counter the belief that Asian students are not responsive to learner centred approaches to education.

Mixing it but not mixed-up: mixed methods research in medical education (a critical narrative review)

BACKGROUND

Some important research questions in medical education and health services research need 'mixed methods research' (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported.

AIM

The broad search question here, of a disjointed literature, was thus: What is mixed methods research - how should it relate to medical education research?, focused on explicit acknowledgement of 'mixing'.

METHODS

Literature searching focused on Web of Knowledge supplemented by other databases across disciplines.

FINDINGS

Five main messages emerged: - Thinking quantitative and qualitative, not quantitative versus qualitative - Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods - Using a 'horses for courses' [whatever works] approach to the question, and clarifying the mix - Appreciating how medical education research competes with the 'evidence-based' movement, health services research, and the 'RCT' - Being more explicit about the role of mixed methods in medical education research, and the required expertise

CONCLUSION

Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the 'mixing' (particularly of findings), rather than report separate components.

How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59

Self-determination Theory (SDT), designed by Edward Deci and Richard Ryan, serves among the current major motivational theories in psychology. SDT research has been conducted in many areas, among which are education and health care, but its applications in medical education are rare. The potential of SDT to help understand processes in medical education justifies this Guide. SDT is explained in seven principles, one of which is the distinction of three innate psychological needs of human beings: for competence, for autonomy and for relatedness. Further, SDT elaborates how humans tend to internalise regulation of behaviour that initially has been external, in order to develop autonomous, self-determined behaviour. Implications of SDT for medical education are discussed with reference to preparation and selection, curriculum structure, classroom teaching, assessments and examinations, self-directed learning, clinical teaching, students as teachers and researchers, continuing professional development, faculty development and stress among trainees.

Using problem-based case studies to learn about knowledge translation interventions: an inside perspective

Knowledge translation (KT) interventions can facilitate the successful implementation of best practices by engaging and actively involving various stakeholders in the change process. However, for novices, the design of KT interventions can be overwhelming. In this article, we describe our experience as participants in a problem-based case study on planning a KT intervention and reflect on the use of problem-based learning (PBL) to develop knowledge and skills relevant to the KT process. Participants were six fellows and two faculty members attending the 2009 Canadian Institutes of Health Research KT Summer Institute. Participants received a case study asking them to develop a KT intervention with the goal of implementing a stroke response protocol for hospital inpatients. The group was given 5 hours spread over 2 days to complete the learning task. As the members of the small group reflected on their experience with the case study, 4 themes emerged: (1) balancing engaging stakeholders with moving forward; (2) exploring the research gaps and role of the Knowledge-to-Action Framework; (3) investigating methodological approaches for KT research; and (4) experiencing a supportive training environment. Participation in the problem-based case study allowed participants to expand their individual understanding of KT, while fostering the learning experiences of other group members. In a supportive learning environment, participants were able to identify influential stakeholders for the stroke response protocol implementation, discuss potential barriers by stakeholder group, and consider effective KT interventions. Future training initiatives focusing on strengthening KT capacity and knowledge should consider using small-group problem-based case study to facilitate learning.

Why don't they know enough about anatomy? A narrative review

BACKGROUND

Publications in a variety of journals have described the problem of medical students' decreasing anatomical knowledge. Interestingly, the number of people making this assertion is growing, despite a lack of empirical evidence that today's medical graduates actually know less about anatomy than medical students in the past. Nevertheless, many people are claiming that students' anatomical knowledge is impaired due to negative effects from several factors, including teaching by non-medically qualified teachers, diminished use of cadaver dissection as a teaching tool and neglect of vertical integration of anatomy teaching.

AIM

To find empirical evidence for the factors claimed to have an influence on anatomical knowledge of students.

METHOD

A literature search.

RESULTS

There is a lack of sufficient quantity and quality of information within the existing literature to support any of the claims, but the gathered literature did reveal some fascinating insights which are discussed.

CONCLUSION

Anatomy education should be made as effective as possible, as nobody will deny that medical students cannot do without anatomical knowledge. Because of promising findings in the areas of teaching in context, vertical integration and assessment strategies, it is recommended that future research into anatomy education should focus on these factors.

Effects of comprehensive educational reforms on academic success in a diverse student body

CONTEXT

Calls for medical curriculum reform and increased student diversity in the USA have seen mixed success: performance outcomes following curriculum revisions have been inconsistent and national matriculation of under-represented minority (URM) students has not met aspirations. Published innovations in curricula, academic support and pipeline programmes usually describe isolated interventions that fail to affect curriculum-level outcomes.

METHODS

United States Medical Licensing Examination (USMLE) Step 1 performance and graduation rates were analysed for three classes of medical students before (matriculated 1995-1997, n=517) and after (matriculated 2003-2005, n=597) implementing broad-based reforms in our education system. The changes in pipeline recruitment and preparation programmes, instructional methods, assessment systems, academic support and board preparation were based on sound educational principles and best practices.

RESULTS

Post-reform classes were diverse with respect to ethnicity (25.8% URM students), gender (51.8% female), and Medical College Admissions Test (MCAT) score (range 20-40; 24.1% scored ≤ 25). Mean±standard deviation MCAT scores were minimally changed (from 27.2±4.7 to 27.8±3.6). The Step 1 failure rate decreased by 69.3% and mean score increased by 14.0 points (effect size: d=0.67) overall. Improvements were greater among women (failure rate decreased by 78.9%, mean score increased by 15.6 points; d=0.76) and URM students (failure rate decreased by 76.5%, mean score increased by 14.6 points; d=0.74), especially African-American students (failure rate decreased by 93.6%, mean score increased by 20.8 points; d=1.12). Step 1 scores increased across the entire MCAT range. Four- and 5-year graduation rates increased by 7.1% and 5.8%, respectively.

CONCLUSIONS

The effect sizes in these performance improvements surpassed those previously reported for isolated interventions in curriculum and student support. This success is likely to have resulted from the broad-based, mutually reinforcing nature of reforms in multiple components of the education system. The results suggest that a narrow reductionist view of educational programme reform is less likely to result in improved educational outcomes than a system perspective that addresses the coordinated functioning of multiple aspects of the academic enterprise.

Interactive seminars or small group tutorials in preclinical medical education: results of a randomized controlled trial

BACKGROUND

Learning in small group tutorials is appreciated by students and effective in the acquisition of clinical problem-solving skills but poses financial and resource challenges. Interactive seminars, which accommodate large groups, might be an alternative. This study examines the educational effectiveness of small group tutorials and interactive seminars and students' preferences for and satisfaction with these formats.

METHODS

Students in year three of the Leiden undergraduate medical curriculum, who agreed to participate in a randomized controlled trial (RCT, n = 107), were randomly allocated to small group tutorials (n = 53) or interactive seminars (n = 54). Students who did not agree were free to choose either format (n = 105). Educational effectiveness was measured by comparing the participants' results on the end-of-block test. Data on students' reasons and satisfaction were collected by means of questionnaires. Data was analyzed using student unpaired t test or chi-square test where appropriate.

RESULTS

There were no significant differences between the two educational formats in students' test grades. Retention of knowledge through active participation was the most frequently cited reason for preferring small group tutorials, while a dislike of compulsory course components was mentioned more frequently by students preferring interactive seminars. Small group tutorials led to greater satisfaction.

CONCLUSIONS

We found that small group tutorials leads to greater satisfaction but not to better learning results. Interactive learning in large groups might be might be an effective alternative to small group tutorials in some cases and be offered as an option.

A model for self-directed problem-based learning for renal therapeutics

OBJECTIVE

To introduce a new approach to problem-based learning (PBL) for self-directed learning in renal therapeutics.

DESIGN

This 5-week course, designed for large student cohorts using minimal teaching resources, was based on a series of case studies and subsequent pharmaceutical care plans, followed by intensive and regular feedback from the instructor.

ASSESSMENT

Assessment of achievement of the learning outcomes was based on weekly-graded care plans and peer review assessment, allowing each student to judge the contributions of each group member and their own, along with a written case-study based examination. The pharmaceutical care plan template, designed using a "tick-box" system, significantly reduced staff time for feedback and scoring.

CONCLUSION

The proposed instructional model achieved the desired learning outcomes with appropriate student feedback, while promoting skills that are essential for the students' future careers as health care professionals.

Graduates from a reformed undergraduate medical curriculum based on Tomorrow's Doctors evaluate the effectiveness of their curriculum 6 years after graduation through interviews

BACKGROUND

In 1996 Liverpool reformed its medical curriculum from a traditional lecture based course to a curriculum based on the recommendations in Tomorrow's Doctors. A project has been underway since 2000 to evaluate this change. This paper focuses on the views of graduates from that reformed curriculum 6 years after they had graduated.

METHODS

Between 2007 and 2009 45 interviews took place with doctors from the first two cohorts to graduate from the reformed curriculum.

RESULTS

The interviewees felt like they had been clinically well prepared to work as doctors and in particular had graduated with good clinical and communication skills and had a good knowledge of what the role of doctor entailed. They also felt they had good self directed learning and research skills. They did feel their basic science knowledge level was weaker than traditional graduates and perceived they had to work harder to pass postgraduate exams. Whilst many had enjoyed the curriculum and in particular the clinical skills resource centre and the clinical exposure of the final year including the "shadowing" and A & E attachment they would have liked more "structure" alongside the PBL when learning the basic sciences.

CONCLUSION

According to the graduates themselves many of the aims of curriculum reform have been met by the reformed curriculum and they were well prepared clinically to work as doctors. However, further reforms may be needed to give confidence to science knowledge acquisition.

Can interactive skills-based seminars with standardized patients enhance clinicians' prevention skills? Measuring the impact of a CME program

OBJECTIVE

Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction.

METHODS

Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests.

RESULTS

OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants' patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction.

CONCLUSION

This curriculum improved clinicians' relevant skills and screening behavior.

PRACTICE IMPLICATIONS

Skills-oriented CME can improve clinicians' communication skills and screening and counseling practices.

[Postgraduate training for specialists in psychiatry and psychotherapy. Problem-based learning - evaluation of a pilot project]

Problem-based learning (PBL) emphasizes the student's individual needs, their ability to solve complex clinical problems, and a professional attitude that facilitates communication among colleagues. Thus, PBL appears to provide a perfectly suitable didactic format for postgraduate training of medical specialties. To date, it is only rarely used in this area though. In a pilot project, we implemented PBL into the curriculum of postgraduate training in psychiatry and psychotherapy, and evaluated the program over a period of 12 months, using structured questionnaires. A total of 41 PBL courses were held, with 447 residents participating. Participants as well as tutors assessed 19 of 21 aspects as good or very good (5-point Likert scale, mean value >4). Overall, PBL was rated as highly suitable for advanced training (participants: 4.5±0.8; tutors: 5.0±0.2). The results of this pilot project suggest that PBL might be a useful element of multifaceted advanced training programs, strengthening their practical component and the applicability of knowledge in the daily clinical routine.

Problem-based learning in postgraduate dental education: a qualitative evaluation of students' experience of an orthodontic problem-based postgraduate programme

INTRODUCTION

Problem based learning (PBL) has gained wide acceptance in undergraduate education, but less so in postgraduate education. Qualitative research methodologies can help us gain insight and understanding of the students' experience in undertaking such programmes.

AIM

To evaluate the experiences of postgraduate students undertaking a PBL based postgraduate programme.

METHODS

Focus groups and semi-structured interviews were used to investigate students' experiences. The qualitative data were coded, the codes were grouped into categories and a coding framework developed. From this a construct is proposed to give insight into students' experiences. The validity of this construct was examined by reviewing the literature.

RESULTS

Students entered the programme with high expectations, but soon found they had challenges to overcome. They came to realise that they were on a journey, rather than undertaking a sequence of separate individual learning events. PBL led to significant tensions both within the individuals and the group, caused by the conflict between appreciating PBL as a 'good thing' and yet finding that ;it just doesn't seem to work'. The fear of failure in a high stakes setting only exacerbated these tensions. The literature review revealed an inconsistent approach to the use of PBL and its evaluation in a postgraduate/continuing medical education setting. However it did provide evidence of similar findings in qualitative studies, supporting the construct developed.

CONCLUSION

We have proposed a construct to help in understanding the PBL experience for students undergoing a 'high stakes' orthodontic postgraduate programme with a core of PBL.

Problem-based learning in academic health education. A systematic literature review

Problem based learning (PBL) arguably represents the most significant development in education over the past five decades. It has been promoted as the curriculum of choice, and since its introduction in the 1960's, has been widely adopted by many medical and dental schools. PBL has been the subject of much published literature but ironically, very little high quality evidence exists to advocate its efficacy and subsequently justify the widespread curriculum change. The purpose of this review is to classify and interpret the available evidence and extract relevant conclusions. In addition, it is the intent to propose recommendations regarding the relative benefits of PBL compared with conventional teaching. The literature was searched using PubMed, ERIC and PsycLIT. Further articles were retrieved from the reference lists of selected papers. Articles were chosen and included according to specific selection criteria. Studies were further classified as randomised controlled trials (RCTs) or comparative studies. These studies were then analysed according to intervention type: whole curricula comparisons and single educational interventions of shorter duration. At the level of RCTs and comparative studies (whole curricula), no clear difference was observed between PBL and conventional teaching. Paradoxically, it was only comparative studies of single PBL intervention in a traditional curriculum that yielded results that were consistently in favour of PBL. Further research is needed to investigate the possibility that multiple PBL interventions in a traditional curriculum could be more effective than an exclusively PBL programme. In addition, it is important to address the potential benefits of PBL in relation to life-long learning of health care professionals.

Job requirements compared to medical school education: differences between graduates from problem-based learning and conventional curricula

BACKGROUND

Problem-based Learning (PBL) has been suggested as a key educational method of knowledge acquisition to improve medical education. We sought to evaluate the differences in medical school education between graduates from PBL-based and conventional curricula and to what extent these curricula fit job requirements.

METHODS

Graduates from all German medical schools who graduated between 1996 and 2002 were eligible for this study. Graduates self-assessed nine competencies as required at their day-to-day work and as taught in medical school on a 6-point Likert scale. Results were compared between graduates from a PBL-based curriculum (University Witten/Herdecke) and conventional curricula.

RESULTS

Three schools were excluded because of low response rates. Baseline demographics between graduates of the PBL-based curriculum (n = 101, 49% female) and the conventional curricula (n = 4720, 49% female) were similar. No major differences were observed regarding job requirements with priorities for "Independent learning/working" and "Practical medical skills". All competencies were rated to be better taught in PBL-based curriculum compared to the conventional curricula (all p < 0.001), except for "Medical knowledge" and "Research competence". Comparing competencies required at work and taught in medical school, PBL was associated with benefits in "Interdisciplinary thinking" (Delta + 0.88), "Independent learning/working" (Delta + 0.57), "Psycho-social competence" (Delta + 0.56), "Teamwork" (Delta + 0.39) and "Problem-solving skills" (Delta + 0.36), whereas "Research competence" (Delta--1.23) and "Business competence" (Delta--1.44) in the PBL-based curriculum needed improvement.

CONCLUSION

Among medical graduates in Germany, PBL demonstrated benefits with regard to competencies which were highly required in the job of physicians. Research and business competence deserve closer attention in future curricular development.

Using team-based learning to prepare medical students for future problem-based learning

BACKGROUND

The original concept of problem-based learning (PBL) was built upon an acceptance that its participants would be of a more mature age, and with personal and potential qualities that would equip them for problem solving as part of their learning process. However, despite global acceptance for the use of PBL in medical and health sciences education, and knowledge of the diverse background of students about to embark upon PBL, structured programs preparing medical students for such an educational activity are not common.

AIM

The primary aim of this study is to describe the experience in adopting and adapting an educational approach analogous to PBL, team-based learning (TBL), in preparing medical students to later study in a PBL environment and secondarily, to measure the students' reaction to this experience.

METHODS

At the University of Sharjah, 363 students were enrolled over four semesters in the 'Introduction to Medical Sciences Education (IMSE)' course. They were divided into groups of 25-27 students per class, where their learning was facilitated through a TBL approach. The course was evaluated both quantitatively and qualitatively and appropriate statistical analysis was applied to their responses.

RESULTS

Out of 363 students, 304 (84%) responded to a 28-item closed-ended questionnaire. Their mean scores and consensus measurements indicated a high degree of students' satisfaction. Eighty-two students (65%) responded to the open-ended questions providing 139 comments. Content analysis of the responses supported the quantitative results.

CONCLUSION

This study demonstrated a high degree of students' satisfaction from the course in acquiring skills preparing them for future PBL. Although this represents an evaluation of the TBL effects upon the early exposures to PBL, TBL was considered to be a feasible, efficient and cost-effective educational approach in preparing the students for their new educational experience.

Problem-based learning in pre-clinical medical education: 22 years of outcome research

PURPOSE

To conduct a systematic review of problem-based learning (PBL) in undergraduate, pre-clinical medical education.

METHODS

A research librarian developed comprehensive search strategies for MEDLINE, PSYCINFO, and ERIC (1985-2007). Two reviewers independently screened search results and applied inclusion criteria. Studies were included if they had a comparison group and reported primary data for evaluative outcomes. One reviewer extracted data and a second reviewer checked data for accuracy. Two reviewers independently assessed methodological quality. Quantitative synthesis was not performed due to heterogeneity. A qualitative review with detailed evidence tables is provided.

RESULTS

Thirty unique studies were included. Knowledge acquisition measured by exam scores was the most frequent outcome reported; 12 of 15 studies found no significant differences. Individual studies demonstrated either improved clerkship (N = 3) or residency (N = 1) performance, or benefits on some clinical competencies during internships for PBL (N = 1). Three of four studies found some benefits for PBL when evaluating diagnostic accuracy. Three studies found few differences of clinical (or practical) importance on the impact of PBL on practicing physicians.

CONCLUSIONS

Twenty-two years of research shows that PBL does not impact knowledge acquisition; evidence for other outcomes does not provide unequivocal support for enhanced learning. Work is needed to determine the most appropriate outcome measures to capture and quantify the effects of PBL. General conclusions are limited by methodological weaknesses and heterogeneity across studies. The critical appraisal of previous studies, conducted as part of this review, provides direction for future research in this area.

Interdisciplinary curriculum to train internal medicine and obstetrics-gynecology residents in ambulatory women's health: adapting problem-based learning to residency education

OBJECTIVE

Although residents in internal medicine (IM) and obstetrics-gynecology (OG) must provide primary care for women, studies indicate that both groups require more skills and training in women's health. Our goals were to assess the needs of residents at our academic medical center and to design an interdisciplinary curriculum that addresses these needs utilizing a modified problem-based learning (PBL) format. The aim of this article is to report on the development, logistics, and successful implementation of our innovative curriculum.

METHODS

Based on results from a targeted needs-assessment, we designed a curriculum for both IM and OG residents to address curricular deficiencies in an efficient and effective manner. Procurement of support was achieved by reviewing overlapping competency requirements and results of the needs-assessment with the program directors. The curriculum consists of six ambulatory clinical cases which lead residents through a discussion of screening, diagnosis, prevention, and management within a modified PBL format. Residents select one learning objective each week which allows them to serve as content experts during case discussions, applying what they learned from their literature review to guide the group as they decide upon the next step for the case. This format helps accommodate different experience levels of learners, encourages discussion from less-vocal residents, and utilizes theories of adult learning.

RESULTS

Sixty-five residents have participated in the curriculum since it was successfully implemented. IM residents report that the cases were their first opportunity to discuss the health concerns of younger women; OG residents felt similarly about cases related to older women. Implementation challenges included resident accountability. Residents identified the timing of the sessions and clinical coverage requirements as barriers to conference attendance.

CONCLUSIONS

Interdisciplinary modified PBL conferences focusing on shared curricular needs in ambulatory women's health are well-received by both IM and OG residents. This format utilizes theories of adult learning and maximizes limited time and resources by teaching IM and OG residents concurrently, and can be successfully implemented at a large academic medical center.

Using innovative group-work activities to enhance the problem-based learning experience for dental students

Problem-based learning (PBL) in medical and dental curricula is now well established, as such courses are seen to equip students with valuable transferable skills (e.g. problem-solving or team-working abilities), in addition to knowledge acquisition. However, it is often assumed that students improve in such skills without actually providing direct opportunity for practice, and without giving students feedback on their performance. 'The Manchester Dental Programme' (TMDP) was developed at The University of Manchester, UK as a 5-year, integrated enquiry-led curriculum. The existing PBL course was redesigned to include a unique, additional PBL session ('Session 4') that incorporated an activity for the group to complete, based on the subject material covered during student self-study. A summative mark was awarded for each activity that reflected the teamwork, organisational and overall capabilities of the groups. This paper describes the different types of activities developed for the Session 4 and presents an analysis of the perceptions of the students and staff involved. The student response to the Session 4 activities, obtained via questionnaires, was extremely positive, with the majority finding them fun, yet challenging, and 'worthwhile'. The activities were perceived to enhance subject understanding; develop students' problem-solving skills; allow the application of knowledge to new situations, and helped to identify gaps in knowledge to direct further study. Staff found the activities innovative and exciting learning tools for the students. The Session 4 activities described here are useful educational resources that could be adapted for other PBL courses in a wide variety of subject areas.

Supervisor and self-ratings of graduates from a medical school with a problem-based learning and standard curriculum track

BACKGROUND

Medical schools recognize the importance of following up on graduates to evaluate performance during residency. Such performance is of particular interest for schools with problem-based learning (PBL) and conventional curriculum tracks.

PURPOSES

Our purposes were to determine any differences in ratings of resident performance in 3 competency areas compared across two different curriculum tracks, 1st and 3rd postgraduate years, and self versus supervisor.

METHODS

Performance ratings by residents and their supervisors for the 9 years during which 2 curriculum tracks were operative were analyzed using t tests. Effect sizes for statistically significant results were calculated.

RESULTS

Several comparisons found differences, although effect sizes were almost uniformly small. The exception was the rating of self-directed learning habits, in which graduates from the problem-based track rated themselves higher than graduates from the standard curriculum (both Years 1 and 3) and higher than their supervisors in Year 3.

CONCLUSIONS

Ratings by supervisors for both groups and both rating times are above average in the rating scale. Supervisors differentiated between the curricula tracks in postgraduate year 3 (PGY-3), rating Standard Curriculum graduates higher than PBL graduates in 5 of 6 noncognitive items and in two of three general ratings. Supervisor ratings increased between PGY-1 and PGY-3 for Standard Curriculum graduates in 9 of the competencies, whereas there were no changes for PBL graduates. In conclusion, performance differences and effect sizes are minimal, and it is possible to conclude that graduates from the 2 curricular tracks achieve at similar levels during their residency programs.

A comparison of course-related stressors in undergraduate problem-based learning (PBL) versus non-PBL medical programmes

BACKGROUND

Medical students report high levels of stress related to their medical training as well as to other personal and financial factors. The aim of this study is to investigate whether there are differences in course-related stressors reported by medical students on undergraduate problem-based learning (PBL) and non-PBL programmes in the UK.

METHOD

A cross-sectional study of second-year medical students in two UK medical schools (one PBL and one non-PBL programme) was conducted. A 16-question self-report questionnaire, derived from the Perceived Medical Student Stress Scale and the Higher Education Stress Inventory, was used to measure course-related stressors. Following univariate analysis of each stressor between groups, multivariate logistic regression was used to determine which stressors were the best predictors of each course type, while controlling for socio-demographic differences between the groups.

RESULTS

A total of 280 students responded. Compared to the non-PBL students (N = 197), the PBL students (N = 83) were significantly more likely to agree that: they did not know what the faculty expected of them (Odds Ratio (OR) = 0.38, p = 0.03); there were too many small group sessions facilitated only by students resulting in an unclear curriculum (OR = 0.04, p < 0.0001); and that there was a lack of opportunity to explore academic subjects of interest (OR = 0.40, p = 0.02). They were significantly more likely to disagree that: there was a lack of encouragement from teachers (OR = 3.11, p = 0.02); and that the medical course fostered a sense of anonymity and feelings of isolation amongst students (OR = 3.42, p = 0.008).

CONCLUSION

There are significant differences in the perceived course-related stressors affecting medical students on PBL and non-PBL programmes. Course designers and student support services should therefore tailor their work to minimise, or help students cope with, the specific stressors on each course type to ensure optimum learning and wellbeing among our future doctors.

Development of basic medical sciences in a new medical school with an integrated curriculum: the ANU experience

BACKGROUND

The development of a basic medical science curriculum in a new medical school with a problem-based focus in Australia has been subject to a number of constraints. We describe the process and early evaluation.

AIM

To describe the development of a basic medical science curriculum in an Australian medical school with a problem-based curriculum.

METHODS

We describe the process we used for curriculum development and the benefits and constraints that arose from pre-existing strong biomedical science on the Australian National University (ANU) campus. We outline methods we used to inform our curriculum content and report on accreditation and early internal evaluation.

RESULTS

Australian medical schools design their curriculum within a relatively restrictive framework put forward by a national accreditation system. The curriculum achieved accreditation from the external accrediting agency, but early student evaluation has been mixed.

CONCLUSION

Although our internal faculty evaluation and external review by the accrediting agency has supported the view that this aspect of the curriculum has performed reasonably well, student feedback is mixed and further evaluation is needed and adjustments probably warranted.

The replacement of 'paper' cases by interactive online virtual patients in problem-based learning

St George's University of London (SGUL) has a Problem-Based Learning (PBL) curriculum for its undergraduate medicine course, using traditional paper-based patient cases. To counter the limitation that paper cases are linear and do not allow students to explore the consequences of decisions, interactive online virtual patients (VPs) were developed which allowed students to consider options as the cases unfold, and allow students to explore the consequences of their actions. A PBL module was converted to VPs, and delivered to 72 students in 10 tutorial groups, with 5 groups each week receiving VPs with options and consequences, and 5 groups receiving online VPs but without options. A comprehensive evaluation was carried out, using questionnaires, and interviews.Both tutors and students believed that the ability to explore options and consequences created a more engaging experience and encouraged students to explore their learning. They regretted the loss of paper and neither group could see any value in putting cases online without the options. SGUL is now adapting its transitional year between the early campus years and the clinical attachment years. This will include the integration of all technology-based resources with face-to-face learning and create a more adaptive, personalised, competency-based style of learning.

Team-based learning in intensive course format for first-year medical students

AIM

To examine the impact of team-based learning (TBL) on educational outcomes in the first year of the curriculum of the Medical University of Vienna.

METHODS

TBL was first offered to students as a single-group exercise to illustrate the value and dynamics of a learning team. In a second step, TBL was provided in an intensive course format with six 2-hour sessions over a 3-day period as an elective course covering the material of a critical teaching block. Students' responses to the program and the impact on the final exam were analyzed.

RESULTS

Out of 1417 eligible students, 386 participated in 8 parallel courses offered in the TBL block. The reaction of students to TBL was highly positive. Using the final exam as an outcome measure, 220 students who completed the intensive courses had a 25.3% higher score (non-TBL vs TBL students: 22+/-9 vs 28+/-9 points) in the TBL block. They also had a 16.5% higher score (non-TBL vs TBL students: 94+/-29 vs 109+/-26 points) in the remaining 5 non-TBL blocks of the year.

CONCLUSIONS

TBL in an intensive course format seems to be especially attractive for the best students of the year, making them even more successful in the key exam. Even the students who usually learned alone highly appreciated learning in teams, thereby developing the understanding and skills needed to work productively in task-groups.

Impact of the transition from a conventional to an integrated contextual medical curriculum on students' learning patterns: a longitudinal study

BACKGROUND

Until now, most research studying the impact of curriculum innovations on student learning patterns was restricted to short term or cross-sectional research.

AIM

Studying longitudinal changes in student learning patterns parallel to the implementation of a curriculum innovation from a discipline based to an integrated contextual medical curriculum (ICMC).

METHODS

A post hoc study applying General Linear Model ANOVA one-way repeated-measures. The inventory of learning styles(126-item version) is used to determine changes in student learning patterns.

RESULTS

Though not all hypotheses could be accepted, the results suggest a significant impact of the ICMC on learning processing strategies; regulation strategies; and on learning orientations. The clear build-up of the curriculum and vertical and horizontal integration of subject knowledge seem to have significantly reduced lack of regulation and promoted at an earlier stage structuring, relating, critical processing and vocational-orientation. The effect on use of sources of knowledge, self-regulation of learning content and certificate-orientation was less important than expected. It was yet not possible to confirm the hypothesis that ICMC students become better in translating study topics into their own phrasing or expressions; and neither the expected impact on vocation-orientation could be confirmed.

CONCLUSIONS

There is little doubt that the present results are important to curriculum (re)designers and those interested in the evaluation of curriculum reforms.

Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment

Simulation-based teaching (SBT) is increasingly used in medical education. As an alternative to other teaching methods there is a lack of evidence concerning its efficacy. The aim of this study was to evaluate the potency of SBT in anesthesia in comparison to problem-based discussion (PBD) with students in a randomized controlled setting. Thirty-three fourth-year medical students attending a curricular anesthesiology course were randomly allocated to either a session of SBT or a session of PBD on an emergency induction method. Ten days later all students underwent examination in a simulator. The performance of each student was evaluated by weighted tasks, established according to a modified Delphi process. Confidence and a multiple-choice questionnaire were additionally performed pre- and post-intervention. A total of 32 students completed the study. Participants in the SBT group presented with significantly higher self-assessment scores after the intervention than students in the PBD group. However, students in the SBT group achieved only slightly and statistically insignificantly higher scores in the theoretical and simulator examination (p > 0.05) with only a moderate effect size of d = 0.52. The current study demonstrates that both PBD and SBT lead to comparable short-term outcomes in theoretical knowledge and clinical skills. However, undesirably, SBT students overrated their anticipated clinical abilities and knowledge improvement.

Midwives’ reflections on their educational programme: a traditional or problem-based learning approach?

OBJECTIVE

to explore the longer-term effect of a problem-based learning (PBL) programme on midwives in practice.

DESIGN

qualitative study. Graduates involved in an earlier study of the implementation of a PBL programme were interviewed between 5 and 6 years after graduating to explore the possible longer-term effect of a PBL programme on their practice as midwives.

SETTING

Thames Valley University with graduates who had completed an 18-month programme on one of two campuses on a variety of clinical sites.

PARTICIPANTS

interviews were held with four graduates who had completed their programme before the implementation of PBL and five who had completed a PBL programme. Key themes were identified and compared cross-sectionally.

FINDINGS

midwives who had graduated from a PBL programme found that the approach was valuable in enabling them to access information and to develop a critical questioning approach. Some felt anxious at the beginning of their programme and said that they would have benefited from more direction and feedback from the facilitator early on in the programme. The focus on individual presentations sometimes inhibited the students learning from others in the group. The success of the PBL approach was felt to be dependent on the way in which the group worked together. The quality of the clinical placement, and the support of mentors and link teachers in the clinical setting, was a key factor in learning for students from both programmes.

CONCLUSIONS

PBL has been incorporated into some programmes because it is thought to benefit practice disciplines, especially in a world of uncertain and changing evidence. However, no clear picture has emerged about the benefits of a PBL programme for midwifery education.

IMPLICATIONS FOR PRACTICE

our findings have implications for curriculum development to ensure the potential benefits of PBL are realised in practice. This may include providing further guidance and feedback to students, particularly at the start of their programme. Further research using innovative methodologies is needed to critically assess the longer-term effect of this approach to education.

Impact of problem-based, active learning on graduation rates for 10 generations of Dutch medical students

OBJECTIVES

We aimed to study the effects of active-learning curricula on graduation rates of students and on the length of time needed to graduate.

METHODS

Graduation rates for 10 generations of students enrolling in the eight Dutch medical schools between 1989 and 1998 were analysed. In addition, time needed to graduate was recorded. Three of the eight schools had curricula emphasising active learning, small-group instruction and limited numbers of lectures; the other five had conventional curricula to varying degrees.

RESULTS

Overall, the active-learning curricula graduated on average 8% more students per year, and these students graduated on average 5 months earlier than their colleagues from conventional curricula.

CONCLUSIONS

Four hypotheses potentially explaining the effect of active learning on graduation rate and study duration were considered: (i) active-learning curricula promote the social and academic integration of students; (ii) active-learning curricula attract brighter students; (iii) active-learning curricula retain more poor students, and (iv) the active engagement of students with their study required by active-learning curricula induces better academic performance and, hence, lower dropout rates. The first three hypotheses had to be rejected. It was concluded that the better-learning hypothesis provides the most parsimonious account for the data.

Speech-language pathology students' approaches to learning in a problem-based learning curriculum

Problem-based learning (PBL) is hypothesized to enhance the development of deep learning. Most previous studies, however, have focused on outcomes (knowledge and skills) rather than students' approaches to learning, or how learning approach correlates with learning outcomes. Undergraduates in a speech-language pathology program (n = 114) completed the revised 2-factor Study Process Questionnaire (R-SPQ-2F) twice in an academic year to identify their approaches to learning and to compare these results with academic outcomes. Two findings emerged. Although the mean of scores for the deep approach (DA) to learning was consistently higher than the mean of scores for the surface approach (SA) to learning, exposure to PBL led to significant increase in DA and SA to learning during an academic year for students in Years 1 to 3. Students who did well in a PBL examination showed a much stronger DA than SA to learning, while students who performed less well showed a smaller difference between DA and SA to learning. Possible explanations for these findings are evaluated and implications for further studies are discussed.

Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education

Theoretical and methodological advances in the cognitive and learning sciences can greatly inform curriculum and instruction in biomedicine and also educational programs in biomedical informatics. It does so by addressing issues such as the processes related to comprehension of medical information, clinical problem-solving and decision-making, and the role of technology. This paper reviews these theories and methods from the cognitive and learning sciences and their role in addressing current and future needs in designing curricula, largely using illustrative examples drawn from medical education. The lessons of this past work are also applicable, however, to biomedical and health professional curricula in general, and to biomedical informatics training, in particular. We summarize empirical studies conducted over two decades on the role of memory, knowledge organization and reasoning as well as studies of problem-solving and decision-making in medical areas that inform curricular design. The results of this research contribute to the design of more informed curricula based on empirical findings about how people learn and think, and more specifically, how expertise is developed. Similarly, the study of practice can also help to shape theories of human performance, technology-based learning, and scientific and professional collaboration that extend beyond the domain of medicine. Just as biomedical science has revolutionized health care practice, research in the cognitive and learning sciences provides a scientific foundation for education in biomedicine, the health professions, and biomedical informatics.

The effects of problem-based learning integration in a course on rational drug use: a comparative study between two Croatian medical schools

PURPOSE

Young doctors write prescriptions regularly from their first day of practice. We investigated final-semester students' perceptions of their training in relation to prescribing in two Croatian medical schools with different clinical pharmacology (CPT) teaching styles (Zagreb: problem-based and Rijeka: lecture-based course).

METHODS

A total of 315 students (220 in Zagreb, 95 in Rijeka) underwent a 4-week-long course in CPT in the academic year 2006/2007. We compared the impact of different educational methods on student performance using an MCQ assessment. After the training, students completed a paper questionnaire on prescribing skills and knowledge of pharmacotherapy.

RESULTS

Students in Rijeka were significantly more satisfied with their traditional lecture-based course. Only 56% of Zagreb students and 54% of students from Rijeka felt confident about their prescription-writing skills. Only 8% of Zagreb and none of Rijeka students had written more than six prescriptions during their entire medical curriculum. There was no difference in the participants' levels of factual knowledge of rational pharmacotherapy.

CONCLUSION

The style of learning about medicines did not affect students' factual knowledge. Only half of the student cohort felt confident about their ability to prescribe medicines, and few had practiced this skill during their medical training.

Student experiences of problem-based learning in pharmacy: conceptions of learning, approaches to learning and the integration of face-to-face and on-line activities

This study investigates fourth-year pharmacy students' experiences of problem-based learning (PBL). It adopts a phenomenographic approach to the evaluation of problem-based learning, to shed light on the ways in which different groups of students conceive of, and approach, PBL. The study focuses on the way students approach solving problem scenarios in class, and using professional pharmacy databases on-line. Qualitative variations in student approaches to solving problem scenarios in both learning situations are identified. These turn out to be associated with qualitatively different conceptions of PBL and also with levels of achievement. Conceptions and approaches that emphasis learning for understanding correlate with attaining higher course marks. The outcomes of the study reinforce arguments that we need to know more about how students interpret the requirements of study in a PBL context if we are to unravel the complex web of influences upon study activities, academic achievement and longer-term professional competence. Such knowledge is crucial to any theoretical model of PBL and has direct practical implications for the design of learning tasks and the induction of students into a PBL environment.

Meta-analysis of quasi-experimental research: are systematic narrative reviews indicated?

CONTEXT

Meta-analyses are commonly performed on quasi-experimental studies in medical education and other applied field settings, with little or no apparent concern for biases and confounds present in the studies synthesised. The implicit assumption is that the biases and confounds are randomly distributed across the studies and are averaged or cancelled out by the synthesis.

OBJECTIVES

We set out to consider the possibility that the results and conclusions of meta-analyses in medical education are subject to biases and confounds and to illustrate this possibility with a re-examination of the studies synthesised in an important, recently published meta-analysis of problem-based learning.

METHODS

We carefully re-examined the studies in the meta-analysis. Our aims were to identify obvious biases and confounds that provided plausible alternative explanations of each study's results and to determine whether these threats to validity were considered and convincingly ruled out as plausible rival hypotheses.

RESULTS

Ten of the 11 studies in the meta-analysis used quasi-experimental designs; all 10 were subject to constant biases and confounds that favoured the intervention condition. Threats to validity were not ruled out in the individual studies, nor in the meta-analysis itself.

CONCLUSIONS

Our re-examination of the results and conclusions of the meta-analysis illustrates our concerns about the validity of meta-analyses based primarily on quasi-experimental studies. Our tentative conclusion is that the field of medical education might be better served in most instances by systematic narrative reviews that describe and critically evaluate individual studies and their results in light of threats to their validity.

Proposed model of case based learning for training undergraduate medical student in surgery

BACKGROUND

Systematic surveys of undergraduate medical education have cautiously supported the outcomes of Problem Based Learning (PBL) compared with traditional learning. This article provides a critical overview of PBL, its limitations in the developing country scenario and our proposed model of PBL triggered by Real cases, to address these limitations.

AIM

Our hypothesis was to see whether the proposed CBL model would work in Indian set up in comparison with traditional teaching

METHODS

We followed a modified Barrow's Model. A tutor selected a real case and created a problem scenario which was progressively disclosed to students, and learning issues were raised. In session 2 students presented self studied learning issues. The process was evaluated throughout with feedback from students and faculty.

RESULTS

We were successful in establishing CBL. Study group (n=57) students scored better in SAQ((short Answer question) and EMQ((extended matching question)) assessment, (Mean study 21.15+/- 4.0565, control 18.5357+/-3.8632, n=56, p value 0.01.) Students appreciated it as good learning activity STATISTICAL DESIGN: SAQ and EMQ, are compared in study vs. control groups by unpaired 't' test & also by equivalent non-parametric Mann-Whitney test

CONCLUSION

The training of doctors is too important an activity for bold experiments to be conducted without discovery what really happens. We had success in establishing Case based learning with faculty of almost all departments participating in the project as Resources. Although size of sample is small, CBL is found to be an effective modality of imparting medical education with effective integration of all departments.

Problem-based learning and larger student groups: mutually exclusive or compatible concepts - a pilot study

BACKGROUND

Problem-based learning is recognised as promoting integration of knowledge and fostering a deeper approach to life-long learning, but is associated with significant resource implications. In order to encourage second year undergraduate medical students to integrate their pharmacological knowledge in a professionally relevant clinical context, with limited staff resources, we developed a novel clustered PBL approach. This paper utilises preliminary data from both the facilitator and student viewpoint to determine whether the use of this novel methodology is feasible with large groups of students.

METHODS

Students were divided into 16 groups (20-21 students/group) and were allocated a PBL facilitator. Each group was then divided into seven subgroups, or clusters, of 2 or 3 students wh each cluster being allocated a specific case. Each cluster was then provided with more detailed clinical information and studied an individual and distinct case-study. An electronic questionnaire was used to evaluate both student and facilitator perception of this clustered PBL format, with each being asked to rate the content, structure, facilitator effectiveness, and their personal view of the wider learning experience.

RESULTS

Despite initial misgivings, facilitators managed this more complex clustered PBL methodology effectively within the time restraints and reported that they enjoyed the process. They felt that the cases effectively illustrated medical concepts and fitted and reinforced the students' pharmacological knowledge, but were less convinced that the scenario motivated students to use additional resources or stimulated their interest in pharmacology. Student feedback was broadly similar to that of the facilitators; although they were more positive about the scenario stimulating the use of additional resources and an interest in pharmacology.

CONCLUSION

This clustered PBL methodology can be successfully used with larger groups of students. The key to success lies with challenging and well situated clinically relevant cases together with enthusiastic facilitators. Facilitator enjoyment of the PBL process may be related to adequate training and previous PBL experience, rather than academic background. The smaller number of facilitators required using this clustered PBL approach allows for facilitators with 'a belief in the philosophy of PBL' to volunteer which would again impact on the success of the process.