Effectiveness of problem-based learning curricula: research and theory

Effects of conventional and problem-based learning on clinical and general competencies and career development

OBJECTIVE

To test hypotheses regarding the longitudinal effects of problem-based learning (PBL) and conventional learning relating to students' appreciation of the curriculum, self-assessment of general competencies, summative assessment of clinical competence and indicators of career development.

METHODS

The study group included 2 complete cohorts of graduates who were admitted to the medical curriculum in 1992 (conventional curriculum, n = 175) and 1993 (PBL curriculum, n = 169) at the Faculty of Medicine, University of Groningen, the Netherlands. Data were obtained from student records, graduates' self-ratings and a literature search. Gender and secondary school grade point average (GPA) scores were included as moderator variables. Data were analysed by a stepwise multiple and logistic regression analysis.

RESULTS

Graduates of the PBL curriculum scored higher on self-rated competencies. Contrary to expectations, graduates of the PBL curriculum did not show more appreciation of their curriculum than graduates of the conventional curriculum and no differences were found on clinical competence. Graduates of the conventional curriculum needed less time to find a postgraduate training place. No differences were found for scientific activities such as reading scientific articles and publishing in peer- reviewed journals. Women performed better on clinical competence than did men. Grade point average did not affect any of the variables.

CONCLUSIONS

The results suggest that PBL affects self-rated competencies. These outcomes confirm earlier findings. However, clinical competence measures did not support this finding.

Patient-centered education: applying learner-centered concepts to asthma education

OBJECTIVE

To review studies of patient-centered asthma education.

METHOD

CINAHL, Medline, Psycinfo, Eric, PsycARTICLES, and web of science databases were searched. RESULTS Asthma education programs are often based on health behavior theories. Many studies lack rigor in the assessment of the program's efficacy and effectiveness. Asthma education that promotes self-management primarily uses a problem-based approach. Few studies have examined the way educators teach and patients learn. Patient-centered approaches to education have mainly focused on communication between the patient and the health professional. Decision making as part of shared responsibility may vary with every patient. Patient-centered care shares similarities with the Self-Determination Theory as a learner-centered approach to education.

CONCLUSIONS

Many asthma education studies have been completed with varying levels of efficacy and effectiveness reported. Most programs focus on changing behavior with few studies examining educator behavior and/or the patient's learning styles. With a patient-centered approach being the preferred model of care, the incorporation of learner-centered approaches to patient education may prove useful in the future.

The semi-structured triple jump--a new assessment tool reflects qualifications of tutors in a PBL course on basic pharmacology

In spite of major efforts, there are only a few assessment tools reflecting learning outcomes particularly attributed to problem-based learning (PBL). We aimed to design a more appropriate assessment method by merging elements of the key features and the triple-jump approach. In a prospective, two-phase study, we designed and validated a new assessment tool, called the semi-structured triple jump (sTJ). At the end of a course on basic medical pharmacology, it was performed in addition to a final exam composed of multiple-choice questions. Since in a previous study we had shown tutor expertise to influence students' perception of the learning process, we examined the effect of tutor expertise on results obtained with these assessment tools. We newly developed a questionnaire for student evaluation of the PBL learning process that was validated and tested for reliability. Our aim was to answer two major questions: (1) Does our newly designed assessment tool come up with methodical claims like validity, objectivity and reliability? (2) Does our newly designed assessment tool reflect differences in tutors' expertise? The semi-structured triple jump turned out to be a valid and highly objective assessment tool showing a moderate reliability as found with other triple-jump modifications before. Interestingly, several steps of the sTJ showed a significant correlation to either tutors' subject- or method-matter expertise, respectively. Our data support the approach of supplementing the assessment by structured case-based tools to make it more appropriate for PBL.

The effects of problem-based learning during medical school on physician competency: a systematic review

BACKGROUND

Systematic reviews on the effects of problem-based learning have been limited to knowledge competency either during medical school or postgraduate training. We conducted a systematic review of evidence of the effects that problem-based learning during medical school had on physician competencies after graduation.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Databases, and the tables of contents of 5 major medical education journals from earliest available date through Oct. 31, 2006. We included studies in our review if they met the following criteria: problem-based learning was a teaching method in medical school, physician competencies were assessed after graduation and a control group of graduates of traditional curricula was used. We developed a scoring system to assess the quality of the studies, categorized competencies into 8 thematic dimensions and used a second system to determine the level of evidence for each competency assessed.

RESULTS

Our search yielded 102 articles, of which 15 met inclusion criteria after full text review. Only 13 studies entered final systematic analysis because 2 studies reported their findings in 2 articles. According to self-assessments, 8 of 37 competencies had strong evidence in support of problem-based learning. Observed assessments had 7 competencies with strong evidence. In both groups, most of these competencies were in the social and cognitive dimensions. Only 4 competencies had moderate to strong levels of evidence in support of problem-based learning for both self-and observed assessments: coping with uncertainty (strong), appreciation of legal and ethical aspects of health care (strong), communication skills (moderate and strong respectively) and self-directed continuing learning (moderate).

INTERPRETATION

Problem-based learning during medical school has positive effects on physician competency after graduation, mainly in social and cognitive dimensions.

Models of medical education in Australia, Europe and North America

BACKGROUND

The universal goal of medical education is to train excellent physicians, able to maintain the health of individuals and communities. The route to achieving this goal has shifted over time. This paper describes the absolutes and ambiguities of philosophical vision, responsiveness to stakeholders, curriculum content and delivery, and assessment of trainees and training programs across much of the developed world.

DESCRIPTION

Traditional medical education is content focused and organized by organ systems. Newer curricula, informed by current learning theories, emphasize a competencies based approach, with clinical scenarios at the centre of teaching and assessment of students. Associated with this is a shift from the in-depth knowledge of the specialist to a 'what must a generalist know' approach. These models are explored as are options for curriculum delivery, input from governments, students, the public and faculty, and methods and importance of accreditation.

CONCLUSION

The goals and the process of training physicians to achieve these exhibit numerous commonalities across time and place throughout the developed world while still allowing for cultural or national adaptations. All models and content aim for minimum basic knowledge, while emphasizing communication skills, cultural awareness and professionalism amongst future physicians.

The potential of the inventory of learning styles to study students' learning patterns in three types of medical curricula

BACKGROUND

Introducing innovative curricular designs can be evaluating by scrutinizing the learning patterns students use.

AIM

Studying the potential of Vermunt's Inventory of Learning Styles (ILS) in detecting differences in student learning patterns in different medical curricula.

METHODS

Cross-sectional between-subjects comparison of ILS-scores in third-year medical students in a conventional, an integrated contextual and a PBL-curriculum using one-way post hoc ANOVA.

RESULTS

Response rate was 85%: 197 conventional, 130 integrated contextual and 301 PBL students. The results show a differential impact from the three curricula. In relation to processing strategies, the students in the problem-based curriculum showed less rote learning and rehearsing, greater variety in sources of knowledge used and less ability to express study content in a personal manner than did the students in the conventional curriculum. The students of the integrated contextual curriculum showed more structuring of subject matter by integrating different aspects into a whole. In relation to regulation strategies, the students in the problem-based curriculum showed significantly more self-regulation of learning content and the students in the integrated contextual curriculum showed lower levels of regulation. As to learning orientations, the students in the problem-based curriculum showed less ambivalence and the students of the conventional curriculum were less vocationally oriented.

CONCLUSION

The study provides empirical support for expected effects of traditional and innovative curricula which thus far were not well supported by empirical studies.

Problem-based learning: where are we now?

The definition of problem-based learning (PBL) as an educational concept is as elusive in 2008 as it has been since the concept was first expressed over forty years ago. A definitive guide to the practice of PBL is equally elusive. Like all worthwhile educational ideas, PBL has proved attractive to those teachers who seek improvements for their courses. Its appeal has transcended the traditional boundaries in formal education so that there are examples of PBL from primary to tertiary education, and across many disciplines within these. Dissemination, however, has wrought confusion in understanding and practice, and consequent difficulties for researchers in evaluating its efficacy, and lack of clear advice for those who would like to adopt PBL. Rather than attempting to be definitive, this Guide explores the various interpretations and practices that claim the label PBL, and critiques these against the original concept and practice. The primary aim is to provide insight into the causes of the confusion about PBL in 2008. The second aim is to point a feasible way forward so that, where appropriate, the potential of PBL as a whole-of-curriculum concept may be realised; and, where it is not possible to implement the whole concept, worthwhile educational principles that have been associated more or less with PBL may be recognised as such and given value in their own right.

Part II: directions and objectives of curriculum structure at veterinary medical and other health professions schools

This article surveys reports on various models and methods of curriculum structure and directions of health professions schools in North America over the past 20 years, with particular emphasis on veterinary and allopathic medical schools. The importance of administrative and faculty leadership, a clear sense of vision, recognition that curricula must change to meet societal needs, and continual, extensive communication and collaboration are discussed as important keys to successfully navigating curriculum reform. The advantages of central versus departmental management of the curriculum are noted with respect to implementing curricular change. Investment in faculty development is essential to ensure sustained cultural and curricular change. As instructional methodology changes, new and better methods of assessing student performance must be developed, with timely and appropriate feedback. Barriers to curriculum change are inevitable; effective strategies must be designed and implemented to navigate these barriers. The future of education in the health professions is clearly in the hands of the educators who prepare future health professionals.

Problem-based learning in veterinary education

Problem-based learning (PBL) replicates life experiences to stimulate learning, the integration of knowledge, and lifelong learning skills, all of which are requirements for veterinary medical education. As the curricular content of veterinary schools expands to immense proportions following advances in medical knowledge and biotechnology, it becomes impracticable to ensure that all students at the beginning of their careers have such a wide knowledge base. Students who are faced with vast amounts of information to learn by rote, much of which may seem irrelevant to their prospective career, may become disillusioned with their chosen course, hence the temptation to convert to a PBL curriculum. The PBL strategy of teaching is becoming increasingly popular in veterinary faculties worldwide, encompassing both curriculum content and a process of learning. In PBL, clinical cases are carefully selected to provoke deep student learning by the acquisition of both basic scientific and clinical knowledge critical to the case; cultivate problem-solving abilities; and encourage the development of team-building, self-directed learning, communication, and self- and peer-assessment skills. Problem-solving skills, understanding of the basic sciences, and clinical performance are all improved by the PBL process. The aim of this paper is to review a decade of literature pertaining to the inclusion of PBL in veterinary and medical curricula.

The fuzzy world of problem based learning

The AMEE Guide by Taylor & Miflin (2008) in this issue of Medical Teacher offers an excellent critical review on PBL as it is understood and implemented in 2008, reflecting the experience, understanding and position of the authors. As an advocate of PBL and with personal experience of working for 30 years in three medical schools adopting integrated PBL curricula-The Suez Canal University, Egypt, Arabian Gulf University, College of Medicine, Bahrain and the University of Sharjah, College of Medicine, U.A.E. - I have witnessed its evolution and implementation in different contexts and cultures. While keeping an open mind about variabilities in its implementation, and without being entrenched in the orthodoxy of the original philosophy, perhaps I may be able to reflect on some aspects of this controversial and challenging educational strategy.

Problem-based learning, critical thinking and concept mapping in speech-language pathology education: A review

Despite speech-language pathology (SLP) education undergoing many innovative changes over the years, there has been little research about learning or outcomes in SLP programs. Critical thinking in clinical decision-making, however, has been identified as a critical skill in SLP. Several recent studies have shown that concept mapping can be used to assess, and perhaps enhance, critical thinking. Problem-based learning (PBL) is reported to be one way to encourage critical thinking and life-long learning. Here we review the literature in PBL, concept mapping, and critical thinking, focusing on the education of SLP students. The review illustrates the close and complex interactions amongst problem-based learning, critical thinking and concept mapping. The aim of the review is to provide a better understanding of the mechanism of PBL, and to increase understanding regarding why the employment of PBL in SLP programs may facilitate critically-thinking graduate clinicians. The evidence indicates that PBL allows more meaningful learning that promotes better integration between theory and clinical practice.

[Experience with new teaching methods and testing in psychiatric training]

In 1999, the Charité Medical University in Berlin, Germany, implemented a reformed medical study course (RMSC) along with traditional undergraduate medical education. The RMSC is characterized by problem-based learning (PBL), training in communication skills with "simulated patients", and interdisciplinary seminars. The curriculum is organized into blocks according to organ system and age (period od life). In a new intensive 4-week psychiatric block, 4th-year students get practical experience in psychiatric wards. Furthermore, PBL groups and workshops are offered that focus on frequent psychiatric disorders. By providing interactive courses with simulated patients, students are intensively trained in taking psychiatric histories and in generating psychopathological findings. Defined learning objectives are tested using multiple-choice items and objectively structured clinical examinations at semester end. First positive results indicate that this course represents an appropriate and practicable curriculum for teaching psychiatry in Germany.

Problem based learning and the case method--medical students change preferences during clerkship

BACKGROUND

The Case Method (Case) and Problem Based Learning (PBL) are two student active methods, increasingly used in medical education.

AIM

The aim of this study was to compare medical student satisfaction with the two different active methods of learning and to see if there was any variation in preference between two stages in medical training.

METHODS

A short questionnaire was given out to 254 students during the eighth and eleventh term of medical training. Answers were obtained from 221 students. The results were computer analysed.

RESULTS

Students in the eighth term rated both methods high, while students in the eleventh term rated Case even higher while PBL decreased in popularity. Traditional lectures were given constant neutral rating. Case was rated better for problem solving.

CONCLUSIONS

It seems that Case is more suitable than PBL for the later stages of medical training when clinical problem-solving skills need to be honed.

A Study on the Personal Traits and Knowledge Base of Taiwanese Medical Students Following Problem-based Learning Instructions

Introduction: Problem-based learning (PBL), a pedagogic concept using a student-centred approach and problem-solving through small group discussions, has been adopted in varying degrees for years at all 11 medical institutes in Taiwan. Much evidence has shown that a number of factors can seriously affect student performance in PBL courses, such as the design of PBL scenarios, the tutors’ character and students’ attitudes and efforts. Materials and Methods: The aim of this study was to examine how the personal characters or knowledge base of Taiwanese medical students influence their performance in a hybrid-PBL curriculum. A total of 309 (234 male, 75 female) high-school entry undergraduate medical students participated in this survey. Self-assessed personal traits were presented in a 44-item questionnaire with a Big Five factor structure. Knowledge base was assessed by students’ score point average (SPA) based on their previous 4-year education in medical school. Peer-assessed performance of students in the PBL curriculum was carried out using a well-developed, reliable and validated evaluation form. Results: Each student’s peer-evaluated PBL performance can be divided into 5 principal components, which included control-lead, assist-coordinate, written organisation and compromise-comply (Eigen value >1). The consistency and reliability of the Big Five questionnaire on personal traits was analysed and discordant items were deleted (Cronbach’s alpha = 0.72 to 0.86 after deletion). The relationship between the personal traits, knowledge base and PBL performance, as analysed by simple regression, showed that “extraversion” and “openness to experience” were positively related to the “assist-coordinate” characteristic in PBL performance, and “conscientiousness” was positively related to the “control-lead” characteristic in PBL performance. The SPA was positively related to the “assist-coordinate” or “control-lead” characteristic in PBL performance. The “agreeableness” was negatively correlated with the “control-lead” characteristic in PBL performance. After stepwise regression between the Big Five and each component of PBL performance, only the correlation between conscientiousness and control/lead, and between extraversion and assist/coordinate remained significant. Conclusion: Knowledge and personality characteristics appear to be associated with student performance in a hybrid-PBL curriculum. The implications of this study on the future development and application of this assessment tool in medical schools are presented. Key words: Big-Five, Performance, Score point average

What kind of curriculum can better address community needs? Problems arisen by hypothetical-deductive reasoning

The aim of this study was to identify problems arisen by conventional curricula, the guidelines for development of an appropriate educational model for 21st century, and the advantages and disadvantages of the last two curricular models. The medical education literature published from 1995 through 2002 of four reputable journals in medical education were searched (Academic Medicine, Teaching and Learning in Medicine, Medical Education, and Medical Teacher). First the possibly best articles were identified. During the second screening process 76 of 180 articles were found to be highly relevant to our questions. A review of the chosen articles revealed a concept map which starts from currently applied hypothetical-deductive reasoning (HDR)-based curricula in many medical schools all around the world. Results revelaed that continuing cyclical process might be time consuming, enhance burden of faculty and might be stressful for students involved. Current issues in health care system are possibly attributable to current HDR-based curricular models including PBL. Advantages of reiterative PBL theory can not be denied, but it appears that its limited application should be mainly seen in some academic classes to develop some generic transferable skills simultaneously with other teaching methods. Therefore vast application of HDR in clinical settings is not recommended according to our study. However the relationships demonstrated between factors and outcomes mentioned in the concept map can be used to run some new studies to test some hypotheses.

Performance of academically at-risk medical students in a problem-based learning programme: a preliminary report

INTRODUCTION

Racially segregated schooling, a legacy of Apartheid policies, continues to hamper education in South Africa. Students entering university from suboptimal circumstances are at significant risk of demonstrating poor academic performance and dropping out of their programmes. Attempts to address the educational needs of these students have included the introduction of extended medical programmes at several universities. Such a programme, the Academic Development Programme (ADP), was implemented at the University of Cape Town in 1991. Over the past decade the programme has graduated more than 100 students. Upon implementation of a new problem-based learning (PBL) programme in 2002, the ADP was discontinued and all students were entered directly into the new PBL programme. Students who demonstrate a need for additional academic support by the end of the first semester enter the Intervention Programme for 1 year before proceeding to the second semester of the PBL programme. An interim analysis was performed to compare the retention rates and academic performance of academically at-risk students in the new PBL programme and the ADP.

METHODS

The records of all academically at-risk students entering the ADP (1991-2000) and the new PBL programme (2002) were reviewed. Retention rates for all years of study, and academic performance in the fourth year clerkship courses of the respective programmes were compared.

RESULTS

A total of 239 academically at-risk students in the ADP and 43 at-risk students in the new PBL programme were studied. The median retention rates, per year of study, for at-risk students in the PBL programme was significantly better than for at-risk students in the ADP (p<0.02). Academic performance of the at-risk students in all the fourth year clinical clerkship courses of the PBL programme was significantly better than the mean performance over 10 years for at-risk students in the same fourth year courses in the ADP.

CONCLUSION

The introduction of PBL at the University of Cape Town has not had a deleterious effect on the performance of academically at-risk medical students. Interim analysis suggests that retention rates and academic performance in the PBL programme are better than those achieved in the extended traditional programme.

Viewpoint: leaving the "empty glass" of problem-based learning behind: new assumptions and a revised model for case study in preclinical medical education

The popularity of problem-based learning (PBL) reflects medical educators' recognition that case study can enhance the preclinical medical school curriculum. However, the PBL method itself has features, particularly its reliance on small-group work with tutor-facilitators, that are expensive to implement and that limit the potential educational value of case study. The author systematically analyzes specific aspects of the PBL methodology and concludes that the PBL approach misuses the faculty, tends to compromise the authenticity of cases, and results in an unnecessarily varied and impoverished educational experience for students. Approaches to case study with different assumptions need to be devised. A model is proposed that shifts the goal of case study from development of problem-solving skills to development of ideas that allow meaningful engagement in sophisticated discussions of medicine. In this model, the method shifts from self-directed learning to independent study guided by the expertise of the faculty. One possible approach to case study based on this model is briefly described. It consists of reading published cases from the medical literature, with analysis and discussion of the cases led by faculty experts in large-group format. The approach immerses students in an authentic, state-of-the-art discussion of medicine and is easily incorporated into any curriculum structure at limited cost. The author argues that, contrary to the claims of proponents, the glass is "mostly empty" for PBL and that we can generate the higher-level discussion that case study merits only by moving away from PBL's extraneous assumptions.

A faculty development program to train tutors to be discussion leaders rather than facilitators

PURPOSE

During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made.

METHOD

During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students' overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05.

RESULTS

In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002.

CONCLUSIONS

The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam's mean score.

Early patient contact in undergraduate dental education in Germany--'The Greifswald Model'

Revised regulations in Germany have allowed new curricular concepts to be introduced into the undergraduate dental curriculum. In the first 2 years of the dental curriculum at the University of Greifswald, a new teaching concept which is based on the interactions between Community Medicine and Dentistry has been introduced. It emphasises the importance of early patient contact in providing experience for students. The course consists of three principal elements: student-patient contacts in the patient's home; problem-based learning tutorials to discuss patient cases; and special training in communication skills. The aim of the course is to give students an insight into the patient's view of the illness and treatment, and the effect of their condition on his or her lifestyle. The students also learn about the communal perspective (health survey, intervention planning and implementation in a community). The first four courses were evaluated by questionnaires from the students before and after the 2-year course to assess the concept from the students' perspective. The results indicate that it is possible to provide considerable improvement of the medical/dental education as regards communication skills and understanding of the patients' perceptions, by letting the student establish contact with patients at the very beginning of the curriculum.

Problem-based learning in dental education: what's the evidence for and against … and is it worth the effort?

All Australian dental schools have introduced problem-based learning (PBL) approaches to their programmes over the past decade, although the nature of the innovations has varied from school to school. Before one can ask whether PBL is better than the conventional style of education, one needs to consider three key issues. Firstly, we need to agree on what is meant by the term PBL; secondly, we need to decide what "better" means when comparing educational approaches; and thirdly, we must look carefully at how PBL is implemented in given situations. It is argued that PBL fulfils, at least in theory, some important principles relating to the development of new knowledge. It also represents a change in focus from teachers and teaching in conventional programmes to learners and learning. Generally, students enjoy PBL programmes more than conventional programmes and feel they are more nurturing. There is also some evidence of an improvement in clinical and diagnostic reasoning ability associated with PBL curricula. The main negative points raised about PBL are the costs involved and mixed reports of insufficient grounding of students in the basic sciences. Financial restraints will probably preclude the introduction of pure or fully integrated PBL programmes in Australian dental schools. However, our research and experience, as well as other published literature, indicate that well-planned hybrid PBL programmes, with matching methods of assessment, can foster development of the types of knowledge, skills and attributes that oral health professionals will need in the future.

Revival of the case method: a way to retain student-centred learning in a post-PBL era

BACKGROUND

In current renewal of medical education, problem-based learning (PBL) is the predominant approach. PBL is afflicted with limitations, which cause uncertainness about its future. A profoundly different approach is the case method, developed a century ago and today attracting much less interest in developmental work than PBL.

AIM

To compare the characteristics of PBL and the case method and ask the question of whether the case method may serve as an alternative approach to student-centred learning.

METHOD

The comparison was literature-based.

RESULTS

PBL implicates fostering of self-directed learning and its prospects deal with depth and retention of knowledge and clinical reasoning skills. Problems are used to define learning goals and to stimulate students' interest in various aspects of an item, rather than just for problem-solving. In the small-group tutorials of a PBL curriculum, the teacher is assigned to facilitate the process of self-directed learning and needs not necessarily be a subject-matter expert. In spite of its exciting philosophy and an increased input of students' and teachers' time, the superiority of PBL as a mode of learning has not been convincingly demonstrated, either in terms of acquisition of knowledge or in clinical performance. Moreover, dysfunction is a well-recognized phenomenon. In some PBL tutorials, indifference towards the group discussion is encountered, including individual quietness or dominant behaviour and incomplete attendance. To cope with dysfunctional problems, efforts are recommended aiming to increase PBL tutors' and students' understanding of the group process. As opposed to PBL, the case method relies strongly on teacher-directed learning. Students are placed in a dilemma or a problem to be solved. After preparatory work, they meet for a discussion, lead by a subject-matter expert, who preferably has experienced the case in reality. As a chairperson, the teacher is supposed to stimulate the discussion and detect gaps and misunderstandings. Due to its teacher-dependent approach to learning, the case method is less susceptible to group dysfunction. The case method is also less resource consuming, primarily because it can be practised in groups several times larger than those of PBL.

CONCLUSION

A revival of the case method seems warranted as an alternative means of interactive learning, which is simpler, easier to realize and less time-consuming with regard to both institutions and students.

Developing a psychopathology curriculum during child and adolescent psychiatry residency training: general principles and a problem-based approach

Psychopathology is one of the core elements in a curriculum on child and adolescent psychiatry. Because there is no best-evidence model described for teaching this topic, an approach must be developed in each program that meets the standards set out by the Residency Review Committee and fully prepares its graduates to be competent child and adolescent psychiatrists. Methods used for teaching psychopathology may vary widely among programs and should be based on a sound educational rationale and adult learning principles that emphasize life-long, self-directed learning. This article describes an overall approach to curriculum design and expands on the use of problem-based learning as an educational method for teaching psychopathology in a child and adolescent psychiatry residency program.

Cooperative learning in industrial-sized biology classes

This study examined the impact of cooperative learning activities on student achievement and attitudes in large-enrollment (>250) introductory biology classes. We found that students taught using a cooperative learning approach showed greater improvement in their knowledge of course material compared with students taught using a traditional lecture format. In addition, students viewed cooperative learning activities highly favorably. These findings suggest that encouraging students to work in small groups and improving feedback between the instructor and the students can help to improve student outcomes even in very large classes. These results should be viewed cautiously, however, until this experiment can be replicated with additional faculty. Strategies for potentially improving the impact of cooperative learning on student achievement in large courses are discussed.

Anatomical dissection as a teaching method in medical school: a review of the evidence

CONTEXT

Discussions about dissection as a teaching method in gross anatomy are characterised by a lack of objective evidence.

METHODS

A search for such evidence in the literature produced 14 relevant papers. These were reviewed for objective data on the effect of cadaver dissection on cognitive learning outcomes.

RESULTS

All reviewed studies compared groups of students exposed to different teaching approaches, including active dissection, learning on prosected material, or a combination with computerised teaching aids. Study and course designs varied substantially and student groups compared were not always homogeneous. In all studies, compared learning experiences differed in more than 1 variable, and assessment of anatomical knowledge was not standardised.

DISCUSSION

It is difficult to interpret and generalise from the results of the reviewed studies. Considering the bias that must be assumed for teachers who develop new course designs and compare these with traditional ones, the review shows a slight advantage for traditional dissection over prosection.

CONCLUSIONS

More sophisticated research designs may be necessary to solve the general problem of the small measurable impact of educational interventions and to come to scientifically sound conclusions about the best way to teach gross anatomy. Such research will have to include sufficient sample sizes, the use of validated assessment instruments, and a discussion of the educational significance of measured differences. More educational research in anatomy is necessary to counterbalance emotional arguments about dissection with scientific evidence. Anatomical knowledge is too important to future doctors to leave its teaching to the educational fashion of the day.

Student learning strategies, mental models and learning outcomes in problem-based and traditional curricula in medicine

Kelson and Distlehorst (2000) state the PBL outcomes should be discussed on a broad basis including a useable knowledge base, skills in problem solving, self-directed learning and collaboration. The present research compares students in a PBL programme and in a traditional program on learning strategies, mental models and outcomes. Learning strategies and metal models of learning were measured for two student groups in 2001 using an adaptation of Vermunt's (1994) "Inventory of learning styles". Learning outcomes were measured for the same groups in 2002 using a test of medical knowledge. PBL-students showed significantly more self-regulated learning and more constructive conceptions of learning. No significant differences in learning outcomes were found between the two groups. Students in the PBL-programme perceived students as more active contributors to group learning process and made use of a broader range of resources than students in the traditional programme. The findings confirm effects of educational programmes on student learning strategies (Vermetten 1999) and also confirm lack of significant differences in medical knowledge (Albanese 2000, Colliver 2000, Norman & Schmidt 2000, Wiers-Jensen & Aasland 2004). The curricular influence on students' learning strategies challenges educators to design approaches that promote lifelong learning skills as well as disciplinary knowledge.

A Problem-Based Learning Approach to Incorporating Nutrition into the Medical Curriculum

Problem Based Learning (PBL) provides a unique opportunity for medical students to learn nutrition principles in the context of evidence-based clinical cases. At the University of Texas Medical School at Houston (UTMSH), PBL is a major component during the second year of the four year undergraduate medical curriculum. A recent review of forty-two clinical cases has shown that over half of the cases include nutrition-specific objectives related to diagnosis, therapy, prognosis, or disease prevention. Thus, these PBL cases provide students the opportunity to study a broad range of nutrition topics in a clinically relevant context. The students' nutrition knowledge is evaluated using clinically-oriented, multiple-choice questions. In order for students to develop fully their competency in clinical nutrition topics, they are also provided a foundation in basic nutrition principles. This report describes a comprehensive approach through a case-based curriculum to help prepare students in their pre-clinical years for the nutritional care of patients in their clerkships, residency, and as practicing physicians.

Introduction to the special issue on innovations in problem-based learning

This special issue on Innovations in Problem-Based Learning is based on a symposium that was organized during the 11th biennial meeting of the European Association for Research on Learning and Instruction (EARLI) in Nicosia (Cyprus). Most papers in this special issue were presented at this symposium. The aim of this special issue in Advances in Health Sciences Education is to provide an overview of the state of the art in PBL research, and to discuss implications of these recent developments for educational practice. This introductory paper presents a short overview of all contributions to the special issue.

Innovations in problem-based learning: what can we learn from recent studies?

This article aims at discussing the six papers included in this special issue on innovations in Problem-based learning (PBL). The papers address different aspects related to the implementation and the development of PBL. This discussion article highlights the relevance of the theme explored by each of the papers, the contributions emerging from the study to what is already known about that topic, and its limitations, particularly those that suggest directions for future research. Emphasis is given to new insights brought by the papers for better understanding tutorial group processes and self-study phase in PBL. The contributions provided by the papers are discussed in the light of pertinent literature and also in relation to their companion articles in this issue when indicated.

Do student-defined learning issues increase quality and quantity of individual study?

An experiment was conducted in the context of a problem-based learning course to investigate the influence of a learning-goal-free problem scenario on the quality and quantity of individual study. In half of the tutorial groups, the problem scenario was constructed in such a way that it provided useful learning issues (goal-specified condition), whereas in the other half of the tutorial groups, the problem scenario did not provide learning issues (goal-free condition). It was demonstrated that students in the goal-free condition read more articles, studied longer, and spent more time reporting the studied literature than their peers in the goal-specified condition. These findings suggest that the use of goal-free problems has a positive effect on the students' individual study and the extensiveness of the tutorial group meeting.

Fitness for purpose evaluation in problem based learning should consider the requirements for establishing descriptive causation

Debate continues about what existing evaluations of the impact of Problem Based Learning tell us and about how future evaluations should be designed. This paper argues that establishing descriptive causation should be an important goal of such evaluations. Minimizing threats to internal validity is of key importance to establishing descriptive causation. It is argued that whilst not a panacea randomized experiments offer particular advantages in this respect. This is illustrated through comparison of examples of evaluations of Problem Based Learning that have used different types of study design.

Integrated problem-based learning in the neuroscience curriculum--the SUNY Downstate experience

BACKGROUND

This paper reports the author's initial experience as Block Director in converting a Conventional Curriculum into a problem-based learning model (PBL) for teaching Psychopathology. As part of a wide initiative in curriculum reform, Psychopathology, which was a six-week course in the second-year medical school curriculum, became integrated into a combined Neuroscience block. The study compares curriculum conversion at State University of New York (SUNY), Downstate, with the experiences at other medical centres that have instituted similar curricula reform.

METHODS

Student satisfaction with the Conventional and PBL components of the Neuroscience curriculum was compared using questionnaires and formal discussions between faculty and a body of elected students. The PBL experience in Psychopathology was also compared with that of the rest of the Neuroscience Block, which used large student groups and expert facilitators, while the Psychopathology track was limited to small groups using mentors differing widely in levels of expertise.

RESULTS

Students appeared to indicate a preference toward conventional lectures and large PBL groups using expert facilitators in contrast to small group mentors who were not experts. Small PBL groups with expert mentors in the Psychopathology track were also rated favorably.

CONCLUSION

The study reviews the advantages and pitfalls of the PBL system when applied to a Neuroscience curriculum on early career development. At SUNY, conversion from a Conventional model to a PBL model diverged from that proposed by Howard S. Barrows where student groups define the learning objectives and problem-solving strategies. In our model, the learning objectives were faculty-driven. The critical issue for the students appeared to be the level of faculty expertise rather than group size. Expert mentors were rated more favorably by students in fulfilling the philosophical objectives of PBL. The author, by citing the experience at other major Medical Faculties, makes a cautious attempt to address the challenges involved in the conversion of a Psychopathology curriculum into a PBL dominated format.

An innovative outcomes-based medical education program built on adult learning principles

An innovative medical curriculum at the University of New South Wales (UNSW) has been developed through a highly collaborative process aimed at building faculty ownership and ongoing sustainability. The result is a novel capability-based program that features early clinical experience and small-group teaching, which offers students considerable flexibility and achieves a high degree of alignment between graduate outcomes, learning activities and assessments. Graduate capabilities that focus student learning on generic outcomes are described (critical evaluation, reflection, communication and teamwork) along with traditional outcomes in biomedical science, social aspects, clinical performance and ethics. Each two-year phase promotes a distinctive learning process to support and develop autonomous learning across six years. The approaches emphasize important adult education themes: student autonomy; learning from experience; collaborative learning; and adult teacher-learner relationships. Teaching in each phase draws on stages of the human life cycle to provide an explicit organization for the vertical integration of knowledge and skills. A learning environment that values the social nature of learning is fostered through the program's design and assessment system, which supports interdisciplinary integration and rewards students who exhibit self-direction. Assessment incorporates criterion referencing, interdisciplinary examinations, a balance between continuous and barrier assessments, peer feedback and performance assessments of clinical competence. A portfolio examination in each phase, in which students submit evidence of reflection and achievement for each capability, ensures overall alignment.

Preparation for practice: how can medical schools better prepare PRHOs?

There is growing evidence that new PRHOs feel unprepared for their first post. This study compared three cohorts of graduates, the first from a traditional systems-based curriculum, the second from the same systems-based curriculum, who had also taken an intercalated degree, and the third from a PBL curriculum who had not intercalated. Subjective reports of confidence in clinical skills, anxiety and feelings of preparedness for practice were assessed using a previously published instrument. Graduates from the PBL curriculum who had not intercalated felt significantly better prepared, less anxious and more confident than equivalent graduates from the systems-based curriculum. Systems-based curriculum graduates who had taken an additional intercalated degree scored as highly in these criteria as the PBL graduates who had not intercalated. Despite these improvements, absolute levels of anxiety remained high and feelings of preparedness and confidence in clinical skills remained poor.

Cooperative learning: a new application of problem-based learning in mental health training

Interaction in problem-based learning (PBL) tutorials is not necessarily cooperative, which may account for variation in learning outcomes. Therefore, a cooperative assessment structure was introduced in a PBL course and the difference examined between this method and individual, lecture-based learning in mental health training. Experimental student groups gained more knowledge between pre- and post-test than did control groups, and the experimental students who scored low on the pre-test made the greatest gains. Groups that reported greater cooperation tended to have higher achievement scores. Experimental students felt that cooperation helped them learn but it also took more time and was sometimes chaotic.

Modeling the problem-based learning preferences of McMaster University undergraduate medical students using a discrete choice conjoint experiment

OBJECTIVES

To use methods from the field of marketing research to involve students in the redesign of McMaster University's small group, problem-based undergraduate medical education program.

METHODS

We used themes from a focus group conducted in an electronic decision support lab to compose 14 four-level educational attributes. Undergraduate medical students completed a discrete choice experiment composed of 15 web-administered, partial-profile, conjoint-choice tasks.

RESULTS

Latent class analysis revealed two segments with different preferences. Segment 1, (86% of students), preferred a problem-based approach with more small group tutorial sessions led by expert tutors who facilitated the tutorial process without teaching didactically. Segment 2, (14% of students), preferred more large group lectures, explicit learning objectives, expert tutors who taught didactically, and streaming options based on learning preferences. Although Segment 1 preferred smaller tutorial groups, simulations predicted these students would trade increases in tutorial group size for a conceptually integrated program that included tutorial problems based on core curriculum concepts, greater integration of the content of clinical skills training sessions and the tutorial curriculum, and a link between clerkship patient selection and the program's curriculum. A majority of both segments would accept a more conceptually integrated program if the savings associated with increases in tutorial group size was reinvested in web-enhanced tutorial processes and computer-simulated health care problems.

CONCLUSIONS

Most students preferred a small group, web-supported, problem-based learning approach led by content experts who facilitated group process. Students favored a program in which tutorial group problems, clinical skills training sessions and the patients selected for clerkship activities were more closely linked to core curriculum concepts.

Problem-based learning: Concept, theories, effectiveness and application to radiology teaching

Australian and New Zealand medical schools are partly or entirely incorporating problem-based learning (PBL) in their medical school curricula. As this change moves forwards and gathers momentum, radiologists are called upon to facilitate or to contribute to PBL tutorials. This study explains the concept and the theories of PBL and discusses its application to radiology teaching.

Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia School of Medicine

PURPOSE

To add to a previous publication from the University of Missouri-Columbia School of Medicine (UMCSOM) on students' improvement in United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores after the implementation of a problem-based learning (PBL) curriculum by studying the performance of ten PBL class cohorts at the UMCSOM.

METHOD

Characteristics of graduating classes matriculating in both traditional and PBL curricula, 1993-2006, were compared for Medical College Admission Test component scores, undergraduate grade point averages, performance on the USMLE Step 1 and Step 2 exams, faculty contact hours, and residency directors' evaluations of UMCSOM graduates' performance in the first year of residency.

RESULTS

Mean scores of six of the ten comparisons for USMLE Step 1 and six of nine comparisons for USMLE Step 2 are significantly higher (p < .01) for UMCSOM PBL students than for first-time examinees nationally. These differences cannot be accounted for by preselection of academically advantaged students, increased time on task, or reduced class size. Gains in performance continue into residency, as evidenced by program directors' perceptions of superior performance of UMCSOM PBL graduates.

CONCLUSIONS

The PBL curricular changes implemented with the graduating class of 1997 resulted in higher performances on USMLEs and improved evaluations from residency program directors. These changes better prepare graduates with knowledge and skills needed to practice within a complex health care system. Outcomes reported here support the investment of financial and human resources in our PBL curriculum.

A software framework for the development of Web-based medical education using learning object classes

A software framework for the development of Web-based medical education is proposed. The objective is to optimize the development process by introducing Learning Objects (LO) and Learning Object Classes (LO Classes) so that the content preparation can be separated from the educational issues, ergonomic design, and technical realization. Based on the concept of case-based, problem-oriented education, different learning scenarios were analysed and then modelled as different LOs. These LOs can be further abstracted in several reusable LO Classes that represent certain patterns of content structure, pedagogical concept, and user interface. With the help of LO input templates, the educational material can be prepared by the authors in the authoring process easily and appropriately. An LO content management system was developed to store and maintain different LOs and to generate the Web-presentation of LOs adaptively and dynamically in the tutoring process. This software framework has been applied to the exemplary development of an interactive course in orthopaedics. The LOs and LO Classes also help to maintain consistency of the course representation to users. As a result, more efficiency in the development phase and good usability and quality of the end products can be achieved.