Effectiveness of problem-based learning curricula: research and theory

The small group in problem-based learning: more than a cognitive 'learning' experience for first-year medical students in a diverse population

In problem-based learning (PBL) curricula, first-year students need to adapt to a new learning environment and an unfamiliar new pedagogy. The small-group tutorial potentially offers a learning environment where students can become self-directed learners, collaborating with other group members to achieve individual and group learning goals. At the end of the first six-week theme in a relatively new PBL curriculum, new medical students were canvassed about coping with PBL (self-directed learning; content; time management; resources) and the value of the small-group tutorial, the latter of which is currently being reported. Almost 84% of students (n = 178) responded. The benefits of participating in small groups were categorized into three domains-cognitive, affective and social-as identified from student responses. Results were analysed in terms of gender and prior educational experience (secondary school vs. prior tertiary educational experience). For almost 94% of students, the small-group tutorial provided a conducive learning environment that influenced their personal development (i.e. tolerance, patience) and socialization into the faculty. Significantly more males indicated that they had developed social skills, while more school-leavers (matriculants) than mature students felt more receptive to the views of others. More mature students claimed to have made friends. Irrespective of some conflicting opinions in the literature, the present results suggest that the PBL tutorial may be important in facilitating student socialization into a new and unfamiliar academic environment, particularly when the pedagogy differs markedly from their past educational experiences. Through interacting with fellow students from diverse origins who hold different views in the intimate setting of the small group, students felt that they had not only increased their knowledge but had also developed personally and socially. It is proposed that the small group may be useful for integrating a diverse population of students into a new academic environment.

A comparison of problem-based learning and lecture-based learning in an adult health nursing course

PURPOSE

This study aimed to compare the effects of the problem-based learning (PBL) method with the traditional lecture method on learning in the cardiorespiratory nursing section of the Adult Health Nursing course.

METHOD

A pretest-posttest experimental design was used. A total of 71 second-year nursing students in a three-year nursing program in Korea participated: 35 students in the PBL group in the fall semester of 2002, and 36 students in the traditional lecture group in 2003. The seven PBL packages were developed by the authors, based on an analysis of relevant learning content and clinical scenarios.

RESULTS

The level of knowledge in the PBL group was significantly higher than that of students in the lecture group (t=2.007, p=.045). All PBL students with higher and lower grades showed a significant increase in the posttest score. But in the lecture group, only students with higher grades showed a notable increase. No statistically significant difference was found between the PBL and lecture groups in the level of attitude toward learning (t=1.669, p=.100). Learning motivation was significantly higher in the PBL group (t=2.608, p=.012).

CONCLUSION

Students in the PBL group gained more knowledge and had higher motivation toward learning compared to students in the lecture group.

Problem-based learning: a review of current issues relevant to physiotherapy education

This article reviews the development of problem-based learning (PBL) over the past decade within the context of physiotherapy practice. Although there is an emerging literature in physiotherapy, the research is primarily from medical education. Some of the original claims of superiority of PBL in developing problem-solving and self-directed learning skills have not been supported. Results from studies comparing traditional and PBL curricula are inconsistent and have numerous methodological shortcomings. There is no evidence to suggest there is one best way of implementing PBL, however it appears faculty training is required to be most successful. There is a need for physiotherapy specific research; although based on the experiences of our medical colleagues long term studies comparing the outcomes of programs of different curricular designs may not be warranted. PBL may help promote skills important for current practice and remains a viable alternative for those interested in curricular innovation.

Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills

OBJECTIVE

To determine whether full-scale simulation (SIM) is superior to interactive problem-based learning (PBL) for teaching medical students acute care assessment and management skills.

DESIGN

Randomized controlled trial.

SETTING

Simulation center at a U.S. medical school.

SUBJECTS

Thirty-one fourth-year medical students in a week-long acute care course.

INTERVENTIONS

After institutional review board approval and informed consent, eligible students were randomized to either the SIM or PBL group. On day 1, all subjects underwent a simulator-based initial assessment designed to evaluate their critical care skills. Two blinded investigators assessed each student using a standardized checklist. Subsequently, the PBL group learned about dyspnea in a standard PBL format. The SIM group learned about dyspnea using the simulator. To equalize simulator education time, the PBL group learned about acute abdominal pain on the simulator, whereas the SIM group used the PBL format. On day 5, each student was tested on a unique dyspnea scenario.

MEASUREMENTS AND MAIN RESULTS

Mean initial assessment and final assessment checklist scores and their change for the SIM and PBL groups were compared using the Student's t-test. A p < .05 was considered significant. The SIM and PBL groups had similar mean (PBL 0.44, SIM 0.47, p = .64) initial assessment scores (earned score divided by maximum score) and were deemed equivalent. The SIM group performed better than the PBL group on the final assessment (mean, PBL 0.53, SIM 0.72, p < .0001). When each student's change in score (percent correct on final assessment minus percent correct on the initial assessment) was compared, SIM group students performed better (mean improvement, SIM 25 percentage points vs. PBL 8 percentage points, p < .04)

CONCLUSIONS

For fourth-year medical students, simulation-based learning was superior to problem-based learning for the acquisition of critical assessment and management skills.

Imperatives in medical education and training in response to demands for a sustainable workforce

Factors to be considered in planning our medical workforce to meet future needs include: Need for outcomes-based curricular designs in medical schools and postgraduate training. Shortening the length of medical training. Improving career flexibility to permit professional re-invention. Developing awareness within the profession about how innovation happens.

Problem-based learning and the medical school: another case of the emperor's new clothes?

For almost four decades, problem-based learning (PBL) has been the stated cornerstone of learning in many medical schools. Proponents of PBL cite the open nature of the learning experience where students are free to study in depth, unencumbered by the burdens of broad courses based on the memorization of facts; detractors, on the other hand, cite the lack of breadth and factual knowledge required for professional qualification. Both points of view have merit. Professional schools have a different set of needs and requirements, and it is these that drive the curriculum and learning philosophies. The constraints of the professional school are so different from those of the purely academic environment that PBL, while admirably suited to the latter, is just problem solving in the former.

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

OBJECTIVE

To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students.

DESIGN

Postal questionnaire.

SUBJECTS AND SETTING

A total of 308 acute hospital trust consultants working in 4 'new' and 4 'established' teaching hospitals in the West Midlands metropolitan area, and involved in the delivery of clinical teaching to Year 3 medical students at the University of Birmingham Medical School during 2002-03.

MAIN OUTCOME MEASURE(S)

The questionnaire explored contractual requirements, actual teaching commitments and perceptions of medical students' knowledge and attitudes. Responses from doctors and surgeons and from respondents working in established and new teaching hospitals were compared.

RESULTS

A total of 249 responses were received (response rate 80.8%). Although many consultants enjoy teaching students, their enjoyment and their ability to deliver high standards of teaching are compromised by time and resource constraints. For many the situation is aggravated by the perceived inappropriate organisation of the clinical teaching curriculum and the inadequate preparation of students for clinical practice. Linking these themes is the overarching perception among teachers that neither service nor educational establishments afford teaching the levels of recognition and reward associated with clinical work or research.

CONCLUSION

To overcome barriers to teaching requires more reciprocal links between hospital staff and medical schools, opportunities for consultants to understand and to comment on curricular and timetable developments, and, perhaps most importantly, recognition (in contractual, financial, managerial and personal terms) of the importance of undergraduate teaching in the competing triad of service, research and education.

Problem-based learning and learning approach: is there a relationship?

AIM

To assess the influence of a graduate-entry PBL curriculum on individual learning style; and to investigate the relationship between learning style, academic achievement and clinical reasoning skill.

METHOD

Subjects were first-year medical students completed the Study Process Questionnaire at the commencement, and again, at the end of the academic year when they also completed the Diagnostic Thinking Inventory, a measure of clinical reasoning skill. Subjects were classified on the basis of their predominant learning approach, and this was correlated with examination results and DTI score.

RESULTS

There was a net shift in predominant learning approach away from deep learning towards a more surface approach over the period of the study, as well as a significant decrease in deep-learning scores. There was a statistically significant association between deep learning score and clinical reasoning skill as shown by total DTI score as well as on the structure of knowledge subscale. No correlation was found between learning approach and examination results.

CONCLUSION

Although these results suggest that a deep learning approach may be beneficial in the development of clinical reasoning skill through its potential to enhance the development of knowledge representations, the substantial shift towards a surface learning approach brings into question previous conclusions that PBL curricula foster a deep approach to learning, and suggests that other factors, such as work load may be more determinants of learning approach than curriculum type. Taken together, these findings emphasise the context-dependent nature of learning approach as well as the importance of assessment as a driver of student learning and strongly suggest that further work to determine precisely the factors which influence learning approach in medical students is urgently needed.

Effect of a community oriented problem based learning curriculum on quality of primary care delivered by graduates: historical cohort comparison study

OBJECTIVE

To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease.

DESIGN

Historical cohort comparison study.

SETTING

Sherbrooke University and three traditional medical schools in Quebec, Canada.

PARTICIPANTS

751 doctors from four graduation cohorts (1988-91); three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151).

OUTCOME MEASURES

Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice.

RESULTS

After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition.

CONCLUSION

Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.

Comparison of directed and self-directed learning in evidence-based medicine: a randomised controlled trial

OBJECTIVES

To compare 2 educational programmes for teaching evidence-based medicine (EBM).

DESIGN

Prospective randomised controlled trial accompanied by a qualitative evaluation.

SETTING

University of Oslo, Norway, 2002-03.

PARTICIPANTS

A total of 175 students entered the study. All tenth semester medical students from 3 semesters were eligible for inclusion if they completed baseline assessment and consent forms and either attended teaching on the first day of the semester or gave reasons for their absence on the first day in advance. Interventions One intervention was based on computer-assisted, self-directed learning (self-directed intervention), whilst the other was organised as workshops based on social learning theory (directed intervention). Both educational interventions consisted of 5 half-day sessions.

MAIN OUTCOME MEASURES

The primary outcomes were knowledge about EBM and skills in critical appraisal. A secondary outcome measured attitudes to EBM. Outcomes were compared on an intention-to-treat basis using a stratified Wilcoxon rank-sum test.

RESULTS

There were no differences in outcomes for the 2 study groups in terms of EBM knowledge (mean deviation 0.0 [95% confidence interval - 1.0, 1.0], P = 0.8), critical appraisal skills (MD 0.1 [95% CI - 0.9, 1.1], P = 0.5), or attitudes to EBM (MD - 0.3 [95% CI - 1.4, 0.8], P = 0.5). Follow-up rates were 96%, 97% and 63%, respectively.

CONCLUSIONS

This trial and its accompanying qualitative evaluation suggest that self-directed, computer-assisted learning may be an alternative format for teaching EBM. However, further research is needed to confirm this and investigate alternative educational models.

The Effect of Problem-Based Learning on Nursing Students' Perceptions of Empowerment

This study tested Kanter's structural empowerment theory within a university nursing student population. Differences in perceptions of empowerment among nursing students enrolled in either a problem-based learning (PBL) or a conventional lecture learning (CLL) program were examined, as well as the relationship between perceptions of structural empowerment in the learning environment and feelings of psychological empowerment. Participants completed measures of structural and psychological empowerment adapted to educational settings, as well as measures related to exposure to various learning strategies in their programs and clinical problem-solving abilities. Students in the PBL program (n = 41) had significantly higher perceptions of structural and psychological empowerment than students in the CLL program (n = 67). Regardless of academic program, structural empowerment was strongly positively related to psychological empowerment. The results of this study are the first to support the applicability of Kanter's theory to nursing education settings.

Problem‐based learning: a dissemination success story?

The demand to implement clinical and educational strategies based on evidence has increased in the past two decades. Over a similar time frame, the problem-based learning (PBL) approach has been widely adopted by undergraduate medical schools, in spite of empirical reviews suggesting that its effectiveness may be limited. Students claim that PBL provides a more satisfying learning experience than traditional methods. While such an outcome is desirable, it is substantively less than the original promise of the approach. We hypothesise that the widespread adoption of PBL may be more a consequence of the approach meeting criteria for successful dissemination than of demonstrable positive educational outcomes. We suggest that greater effort should be taken to articulate and measure important undergraduate educational outcomes. Alternatives to the PBL approach should be actively considered.

The introduction of large class problem-based learning into an undergraduate medical curriculum: an evaluation

When considering implementing integrated curriculum models, such as problem-based learning (PBL), concerns may be expressed about the need for increased staff resources required to deliver tutor-led small group PBL. Less staff intensive ways of supporting PBL need to be explored. We compared the outcomes of a PBL module conducted in a large class format within a lecture theatre with a module having the same defined learning outcomes delivered in small group PBL format, both supported by e-learning resources. The pre-existing 27 small groups within the whole class (n = 246) of first year students undertaking a cardiovascular basic science module at Sheffield undergraduate medical school, UK, were randomized to 22 groups undertaking the large class Integrated Learning Activity (ILA) and 5 groups to traditional small group facilitated PBL sessions. Outcome measures were: a pre-post knowledge based test, a student educational effectiveness questionnaire, and assessment of student group work and presentations. There seemed to be no significant differences in learning outcomes between the methods although it is recognized that students would prefer the small group teaching format. Within institutions where resources to support small group PBL are limited, the large group ILA format supported with e-learning techniques may be a useful alternative approach.

PBL in undergraduate medical education: a qualitative study of the views of Canadian residents

BACKGROUND AND OBJECTIVES

At McMaster University, the birthplace of problem-based learning (PBL), administrators and curriculum planners have begun the process of renewing the undergraduate MD curriculum. One step has been to conduct an environmental scan that includes input from medical residents.

METHODS

Individual interviews with 17 medical residents and fellows currently enrolled at McMaster University and are graduates of six Canadian medical schools.

RESULTS

PBL appears to be well known even by graduates of non-PBL Canadian medical schools. Tutors are key to a successful PBL program, should be knowledgeable about the content area under study and able to effectively facilitate groups. Tutorial problems should be realistic, up-to-date, and challenge students to investigate more than the medical aspects of the case in question. Students need to be prepared, willing to participate in peer teaching, and supportive of the group learning process. PBL programs can be improved if they incorporate elements of traditional medical programs (e.g., mini-lectures, clear learning objectives, and unbiased evaluation of student progress) while retaining the essence of student-generated learning.

CONCLUSIONS

Medical residents are an underutilized source of information about undergraduate medical programs. According to our participants, more emphasis on faculty development and upgrading health care problems will improve PBL-based undergraduate medical education.

Problem-based learning: future challenges for educational practice and research

CONTEXT

Problem-based learning (PBL) is widely used in higher education. There is evidence available that students and faculty are highly satisfied with PBL. Nevertheless, in educational practice problems are often encountered, such as tutors who are too directive, problems that are too well-structured, and dysfunctional tutorial groups.

PURPOSE

The aim of this paper is to demonstrate that PBL has the potential to prepare students more effectively for future learning because it is based on four modern insights into learning: constructive, self-directed, collaborative and contextual. These four learning principles are described and it is explained how they apply to PBL. In addition, available research is reviewed and the current debate in research on PBL is described.

DISCUSSION

It is argued that problems encountered in educational practice usually stem from poor implementation of PBL. In many cases the way in which PBL is implemented is not consistent with the current insights on learning. Furthermore, it is argued that research on PBL should contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances. Examples of studies are given to illustrate this issue.

Beyond 'tomorrow's doctors': a review of basic medical education in the UK

Basic medical education in the UK has been radically reshaped in the past 15 years, prompted by the General Medical Council who drove, supported and monitored the changes. Central aims of the reform included a reduction in curricular factual content, greater prominence of skills acquisition, eradication of the pre-clinical/clinical divide and a higher profile for community-based teaching and learning. Some of the major developments are outlined, although change continues in other areas. Consequences of the initiative include greater choice in the courses now offered to applicants to medical school, the growth of medical education units within medical schools and greater interest in medical education generally.

O enfoque problematizador na formação de profissionais da saúde

OBJETIVO: Discutir o enfoque problematizador para formação de profissionais de saúde que possam atuar tanto na docência como nas práticas educativas nos serviços e comunidade. MÉTODOS: Descrição analítica de experiência formativa problematizadora em nível de especialização desenvolvida em instituição de ensino superior no campo da saúde, focalizando-se três perspectivas de análise: a construção do curso, o aluno como centro do processo de aprendizagem e o papel docente. RESULTADO: O enfoque problematizador mobilizou os especializandos em seus processos de aprendizagem, estabelecendo-se movimentos de motivação, desenvolvimento de lideranças e trabalho em grupo, traduzidos em trabalhos escritos, seminários e elaboração de portfólio. O processo avaliativo dessas experiências pressupõe práticas fundadas que articulem os olhares dos sujeitos envolvidos: auto-avaliação e heteroavaliação. O impacto dessa metodologia, no que se refere às práticas docentes, demanda aprofundamento sobre teorias educacionais que respaldem os princípios da aprendizagem significativa, da função docente mediadora e da pesquisa como princípio educativo. CONCLUSÕES: O enfoque problematizador apresenta-se como resposta inovadora frente a desafios presentes na formação de profissionais da saúde. Seu potencial é reconhecido, ressaltando que inovações educacionais se caracterizam por provocar rupturas com o consolidado e instauram modos distintos de responder às demandas que se apresentam num determinado momento. Foram identificados os nós críticos, destacando-se o risco de tomá-las como instrumentos técnicos, desvinculados de um projeto político-pedagógico. Experiências e análises inspiradas nos pressupostos problematizadores precisam ser partilhadas, viabilizando a produção de um conhecimento que fortaleça a transformação das práticas educativas em saúde.

Problem-based learning improves the academic performance of medical students in South Africa

OBJECTIVES

To compare the academic performance of students on the previous, classical, discipline- and lecture-based, traditional curriculum with that of subsequent students who followed an innovative, problem- and community-based curriculum.

METHODS

This was a retrospective study that analysed the records of students who enrolled on the doctor training programme between 1985 and 1995, and the records of students who graduated from the programme between 1989 and 2002.

OUTCOMES

The educational outcomes assessed were the attrition and graduation rates on the traditional curriculum and those on the innovative curriculum.

RESULTS

A total of 149 students on the traditional curriculum and 145 students on the innovative curriculum were studied. Overall, 23% of the traditional cohort as opposed to 10.3% of the innovative cohort dropped out of the course (P = 0.0041) and 55% of the traditional cohort as opposed to 67% of the innovative cohort graduated within the minimum period of 6 years (P < 0.001). The mean throughput period was 6.71 (0.09) years in the traditional cohort and 6.44 (0.07) years in the innovative cohort (P = 0.014)

CONCLUSION

The introduction of the problem-based learning/community-based education (PBL/CBE) curriculum coincided with improved academic performance. The PBL/CBE approach to medical education may have contributed to this improvement.

[Problem-based learning in urology training. The Faculty of Medicine of the Universidad de Castilla-La Mancha model]

Ongoing changes in the social, economic, technological and scientific realms have generated new needs and led various organizations to suggest that educational institutions should reorient their educational strategies toward developing effective professionals with the skills to meet these needs. These "modern" strategies include problem-based learning, in which the student seeks and selects information, analyzes the data obtained, integrates both prior and newly acquired knowledge, and, finally, offers diagnostic and therapeutic options to resolve the problem posed, as would occur in professional practice. With this approach, prior skills and practical experience form the foundation of learning. Problem-based learning incorporates some aspects of cognitive psychology, a model that mainly centers on the nature of the knowledge structures found in active memory, the processes involved in information storage and retrieval and the various factors that activate these processes. At the Faculty of Medicine of the Universidad de Castilla-La Mancha, urology is part of a core subject (Medical and Surgical Pathology II) taught in the fifth year of coursework together with nephrology. Each course includes approximately 75 students, divided into five groups. The rotation lasts six weeks, with students spending a mean of two hours a day on theory (nephrology and/or urology) and the remaining time on rotations in the various activities: three weeks in nephrology and three weeks in urology. Upon completion of the rotation, the students write a combined theoretical examination with 100 multiple-choice questions (50 on urology) and take a practical skills examination. At the end of the course, another practical test consisting of an objective, structured clinical examination is taken, in which standard patients are used and the professor directly assesses the level of skills acquired with a "real" case.

Online vs live methods for teaching difficult airway management to anesthesiology residents

OBJECTIVE

To compare the effectiveness of traditional and online teaching methods for educating anesthesiology residents in the principles and practice of difficult airway management.

DESIGN

Prospective, randomized, controlled trial.

SETTING

University hospital.

PARTICIPANTS

Two randomly selected groups, each containing 28 physicians enrolled from among residents in Anesthesiology and Intensive Care Medicine in Italy.

INTERVENTIONS

Residents in Group 1 took a traditional 5-h course on the principles and practice of airway management, which included lectures, slide projection, and dummy demonstrations. The same material was presented to Group 2 in an exclusively online format, which could be individually accessed for a period of 36 h. In the online course, student-instructor interaction was provided through threaded discussion forums during three 30-min real-time question-and-answer sessions.

MEASUREMENTS AND RESULTS

Differences in baseline and post-course scores on written tests and practical skills tests were measured. Knowledge gains in Group 2 were slightly, but not significantly, greater compared with Group 1 both in written (P=0.228) and practical skills (P=0.376) tests. Semi-quantitative ratings of learner satisfaction were significantly higher in the online group (P=0.014). Almost all online students (93%) were logged in for at least 45 of the 90 min of real-time question-and-answer sessions. The four instructors spent an average of 144+/-10 min preparing answers and interacting with online students.

CONCLUSIONS

Online teaching formats may be a valid alternative for teaching residents the principles and practice of difficult airway management. Interaction with instructors seems to be an important element, but it may require substantial time commitments by instructors.

Problem based learning in a junior doctor teaching programme

BACKGROUND

Problem based learning (PBL) is used increasingly in undergraduate medical education, but there are few postgraduate medical studies.

AIM

To compare SHO learning outcomes for a PBL course with a traditional didactic course.

METHODS

As part of their protected teaching programme, 14 senior house officers (SHOs) were taught about paediatric dermatology using a traditional didactic course. Six months later, the new SHOs received a PBL course including small group teaching and a study guide. Both the traditional and the PBL group were assessed using multiple choice questions (MCQs), an objective structured clinical examination (OSCE), and pre- and post-course self-assessment sheets. SHOs completed course evaluation sheets.

RESULTS

There was no significant difference in learning outcome between the traditional and PBL courses as assessed by the MCQs, OSCE, and self-assessment sheets. The PBL course was well appreciated by SHOs who liked variety in the teaching programme.

CONCLUSIONS

The PBL and traditional course had equivalent learning outcomes. PBL adds variety to junior doctor protected teaching programmes and can be a useful tool for doctors working shift patterns.

Problem based learning

Problem based learning (PBL) has been the subject of considerable interest and debate in medical undergraduate and, increasingly, postgraduate education in recent years. Its supporters maintain that PBL enhances learning by providing a highly motivational environment for acquisition of knowledge, which is well received by those who take part in it. Critics argue that PBL is a time consuming exercise, often undertaken by people with a limited appreciation of its complexities, and the lack of evidence that PBL translates into better clinical competence brings into question the relevance of such intensive learning methods in everyday practice. This article outlines the background to PBL, explains its mechanics in action, and considers the potential disadvantages of its use as a clinical learning tool in the emergency department.

A comparison of in-class learner engagement across lecture, problem-based learning, and team learning using the STROBE classroom observation tool

BACKGROUND

Having recently introduced team learning into the preclinical medical curriculum, evidence of the relative impact of this instructional method on in-class learner engagement was sought.

PURPOSE

To compare patterns of engagement behaviors among learners in class sessions across 3 distinct instructional methods: lecture, problem-based learning (PBL), and team learning.

METHODS

Trained observers used the STROBE classroom observation tool to measure learner engagement in 7 lecture, 4 PBL, and 3 team learning classrooms over a 12-month period. Proportions of different types of engagement behaviors were compared using chi-square.

RESULTS

In PBL and team learning, the amount of learner-to-learner engagement was similar and much greater than in lecture, where most engagement was of the learner-to-instructor and self-engagement types. Also, learner-to-instructor engagement appeared greater in team learning than in PBL.

CONCLUSIONS

Observed engagement behaviors confirm the potential of team learning to foster engagement similar to PBL, but with greater faculty input.

Assessing the impact of a comprehensive sexually transmitted disease curriculum on learning outcomes

OBJECTIVE

Our purpose was to assess the impact of a curriculum designed to improve third-year medical students' knowledge of sexually transmitted diseases, measured by sexually transmitted disease-related items from the National Board of Medical Examiners subject examination and by a locally developed sexually transmitted disease test.

STUDY DESIGN

All students (n = 108) were exposed to a new sexually transmitted disease curriculum: a 2-hour laboratory module, lectures, syllabus, and locally developed pretest/posttest with review of the test prior to taking the National Board of Medical Examiners subject examination. Students were randomized to a attend sexually transmitted disease clinic (n = 47) versus no sexually transmitted disease clinic (n = 61).

RESULTS

Students performed equal to or better than the national average on 85% of the National Board of Medical Examiners sexually transmitted disease-related items after curriculum institution, compared with 56% of the test items prior ( P < .001). Magnitude of improvement was dependent on clerkship timing, with greater improvement in students taking the obstetrics-gynecology clerkship earlier in the third year. Mean postcurriculum test scores of sexually transmitted disease improved significantly ( P < .001), independent of clinic site and clerkship timing.

CONCLUSION

The curriculum for sexually transmitted disease produced significant improvement in third-year medical students' knowledge of sexually transmitted disease. This might have an impact on future prevention and control of sexually transmitted diseases in communities in which these students practice.

Assessing the relationship of learning approaches to workplace climate in clerkship and residency

PURPOSE

To determine what approaches to learning are adopted by clinical clerks and residents and whether these approaches are associated with demographic factors, specialty, level of training, and perceptions of the workplace climate.

METHOD

In 2001-02, medical clerks (n = 532) and residents (n = 2,939) at five medical schools in Ontario, Canada, were mailed the Workplace Learning Questionnaire. The correlation between the approaches to learning at work and perceived workplace climate and the influence of gender, age, location, residency program and level of training on outcomes were measured.

RESULTS

A total of 1,642 clerks and residents responded (47%). The factor structure and reliability of the Workplace Learning Questionnaire were confirmed for these respondents. A surface-disorganized approach to learning was correlated with perception of heavy workload (r = .401, p < .001). The deep approach to learning was correlated with perception of choice-independence in the workplace and a supportive-receptive workplace (r = .32, p < .001; r = .23, p < .001). The climate factors, perception of choice-independence and supportive-receptive workplace, were correlated (r = .60, p < .001). There were significant differences among the mean scores for scales based on residency, year of training, and location of training.

CONCLUSIONS

Perception of the workplace climate was associated with the approach to learning in the workplace of clerks and residents. Perception of heavy workload was associated with less effective approaches to learning. These associations varied with the residency program and the level of training.

The patient as text: a challenge for problem-based learning

OBJECTIVES

To explore the values and assumptions underlying problem-based learning (PBL) cases through narrative analysis, in order to consider the ways by which paper cases may affect student attitudes and values.

METHODS

Randomly chosen PBL cases from the first year curriculum at Dalhousie University medical school (n = 10) were coded by 3 independent reviewers attending to narrative components.

RESULTS

The cases generally used spare, objective language, used the passive voice, eliminated agency, and employed linguistic markers to encode scepticism about patient reports. There was almost no sense of the presence of the patient as person in these cases in terms of their words, feelings, or their social and cultural context. The almost complete exclusion of the preferences and priorities of the patient was striking.

CONCLUSION

The sample is small, the results only suggestive. Yet it appears that the cases used in PBL may unnecessarily, even unintentionally, encourage student detachment from the messiness of real patients' lives and emotions. Positioning a particular way of seeing - the doctor's gaze - as normative renders less visible the choices that are being made whenever an account is constructed. Including multiple voices in a case would complicate that tidy reduction of choices. Ongoing attempts to enrich the case format should be encouraged. At the same time, students may benefit from being taught the skills for critical analysis of the case itself.

Small groups and problem-based learning: are we singing from the same hymn sheet?

Recently, commented that there is a need for better ways of looking at how teaching and learning work in the PBL approach before it is banished to the wilderness of other educational innovations. The premise of this paper is that better ways of looking at how PBL works are dependent on better ways of understanding PBL. The recent exchange of views in the literature about the value of the small-group learning environment in PBL suggests that there is a variety of perspectives on the role and purpose of the small group. The debaters will have difficulty settling their differences or even understanding each other's point of view if they are not 'singing from the same hymn sheet'. In pursuit of clarifying the issue and contributing to an enhanced understanding of PBL, this paper critiques published views of the small-group learning environment against a way of looking at PBL as a whole approach to learning medicine.

Small-Group Discussion Versus Lecture Format for Third-Year Students in Obstetrics and Gynecology

OBJECTIVE

To compare lecture and small-group discussion for third-year medical students in obstetrics and gynecology.

METHODS

Over a 2-year period, 91 third-year medical students in the obstetrics and gynecology clerkships were given educational sessions on diabetes and hypertension in pregnancy by a single instructor, either in a traditional lecture format or in a small-group discussion. After the instructional sessions, students anonymously completed a 20-question multiple-choice examination on the covered topics. They also completed an evaluation form on the instructional format, using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). At the completion of each clerkship, students repeated the same multiple-choice examination.

RESULTS

There was a significantly higher level of enjoyment (median value 5 versus 4, P <.001) and sense of educational stimulation (median value 5 versus 4, P <.001) in the discussion group, and students in the discussion group were less desirous of the alternate instructional format than those in the lecture group (median value 2 versus 3, P <.001). However, there were no differences in the test scores, either immediately after the instructional sessions or at the end of the clerkships. There was a 90% power to detect a 15% difference in postinstructional test scores.

CONCLUSION

Third-year medical students learning about hypertension and diabetes in pregnancy during their obstetrics and gynecology clerkship strongly preferred small-group discussions over traditional lectures. However, this preference did not lead to improved test scores on these subjects.

The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry

OBJECTIVES

A change from traditional to problem-based learning (PBL) methods in a psychiatry attachment was evaluated by comparing the learning styles, attitudes to psychiatry and examination performance of 2 cohorts of students. It was hypothesised that the PBL curriculum would result in increased deep learning, decreased surface learning, more favourable attitudes to psychiatry and improved examination performance. It was predicted that students' examination success would be related to the use of deep and strategic learning and favourable attitudes.

METHODS

Consecutive cohorts of Year 2 clinical students taught using a traditional psychiatry curriculum (n = 188) and a PBL curriculum (n = 191) were compared. Students completed the Study Process Questionnaire to assess their learning styles and the Attitudes to Psychiatry Scale at the beginning and end of the attachment. Students completed 2 end-of-attachment examinations, a multiple-choice paper and a viva.

RESULTS

The PBL curriculum resulted in significantly better examination performance than did the traditional teaching curriculum, both for multiple-choice questions and the viva. No differences in learning styles or attitudes to psychiatry were found between the curricula. Students were significantly more successful in the examinations if they had received the PBL curriculum, were female, and used strategic learning.

CONCLUSIONS

Examination performance indicated that the PBL curriculum was more successful than the previous course, but that this improvement was not due to students using more effective learning styles or having more favourable attitudes towards psychiatry. It is possible that students learned more effectively during the teaching sessions in the PBL curriculum, but did not change their preferred learning styles.

An Unfolding Case with a Linked Objective Structured Clinical Examination (OSCE): A Curriculum in Inpatient Geriatric Medicine

As the percentage of time devoted to the care of older adults by internists continues to rise, the need for these physicians to be skilled at their care becomes even more critical. In fact, the Education Committee of the American Geriatrics Society has recommended the development of structured educational curricula to teach the principles of geriatric care. This article describes a comprehensive, evidence-based curriculum for internal medicine house staff in inpatient geriatric medicine. The intervention encompasses a novel instructional method, defined skill and behavioral goals, and a competency-based effectiveness evaluation. Moreover, the principles in this curricular model are those that may affect any hospitalized older adult and so will be important for all house staff taking care of inpatient geriatric patients, regardless of their future subspecialty choice.

Prospective randomised comparison of traditional, personal bedside and problem-oriented practical dermatology courses

PURPOSE

This paper reports a prospective, randomised study comparing a problem-oriented practical (POP) course based on paper cases to a personal bedside teaching (PBT) practical course and a standard practical course.

METHODS

During 2 consecutive terms, students were randomly allocated to either 2 POP groups/term (n = 10/group), 2 PBT groups/term (n = 10/group) or the standard practical course, which consisted of a rotating system of lectures and bedside teaching with randomly appointed tutors. Each course was evaluated with the same 12-item questionnaire and multiple-choice test administered at the beginning and end of the course.

RESULTS

The numbers of students evaluated were 36 for the POP groups, 37 for the PBT groups, and 155 for the standard course. The PBT and POP courses were rated significantly better (P < 0.001) than the standard course for all items. Aggregate marks (mean +/- SD) were: 1.59 +/- 0.8 for the POP course; 1.69 +/- 0.68 for the PBT course, and 2.71 +/- 0.98 for the standard course. There were no significant differences between the POP and PBT courses. Significantly better learning rates as indicated by an increase in the number of correctly answered questions were observed in students attending the POP and PBT courses.

CONCLUSION

This prospective study demonstrated that there was no difference in the rating of a POP course and a bedside teaching course by students randomly assigned to 1 of 3 different pedagogical approaches. Furthermore, both alternative options achieved better ratings than the standard course, which is current teaching practice in our medical school. The PBT and POP approaches provided superior learning success and POP helped solve the problems of standardisation and patient recruitment.

[Discovery-based teaching and learning strategies in health: problematization and problem-based learning]

Considering the changes in teaching in the health field and the demand for new ways of dealing with knowledge in higher learning, the article discusses two innovative methodological approaches: problem-based learning (PBL) and problematization. Describing the two methods' theoretical roots, the article attempts to identify their main foundations. As distinct proposals, both contribute to a review of the teaching and learning process: problematization, focused on knowledge construction in the context of the formation of a critical awareness; PBL, focused on cognitive aspects in the construction of concepts and appropriation of basic mechanisms in science. Both problematization and PBL lead to breaks with the traditional way of teaching and learning, stimulating participatory management by actors in the experience and reorganization of the relationship between theory and practice. The critique of each proposal's possibilities and limits using the analysis of their theoretical and methodological foundations leads us to conclude that pedagogical experiences based on PBL and/or problematization can represent an innovative trend in the context of health education, fostering breaks and more sweeping changes.

A student learning perspective on teaching and learning, with implications for problem-based learning

Over the last 20 years or so, there has been a substantial development in our understanding of how and what university students learn in their courses (here meaning a component of a programme) and programmes of study. This research has shown that rather than there being a direct connection between the way teachers teach and design their courses, and the quality of their students' learning outcomes, the relationship is indirect. The way students perceive and understand their learning context and the way they approach their learning in relationship to these perceptions have been found to be major intervening factors between teachers' teaching and students' learning outcomes. Their perceptions are, in turn, constituted in relation to their prior experiences of teaching and learning and what is designed for them to learn. In this paper, some of the key findings of this research and how it can be related to a problem-based learning (PBL) perspective in higher education are outlined. In particular, it is argued that the variation in students' perceptions and understanding of what PBL is about is fundamental to the way they approach their studies and to their learning outcomes.

Computer assisted learning in medicine: a long-term evaluation of the 'Practical Training Programme Dermatology 2000'

In recent years, numerous computer assisted learning (CAL) programmes based on new teaching methods, as for example the principles of cognitive apprenticeship and problem based learning, have euphorically been developed for various medical fields. However, many of these programmes failed due to either low acceptance, economic inefficiency, or, most seriously, problems with the implementation and evaluation in medical curricula. In 1999, the practical training course 'Dermatology 2000', an interactive multimedia programme for dermatological education, was developed and completely integrated into the regular dermatological curriculum of five German medical schools. The formative evaluation of an implemented relational database revealed contemporary information about the programme's quantity of use. So far, 3050 students have participated in 6557 lessons. The evaluation of two online questionnaires showed a high learner acceptance regarding the programme's instructional design, ergonomics, and didactical presentation and, after completion of Dermatology 2000, an increased interest in medical education software. A comparison of the objective learning outcome illustrated that Dermatology 2000 students (n = 31) not only outperformed non-participants (n = 7) but also showed a (10%) lower rate of errors in a conventional knowledge test. Additionally, single-case studies demonstrated the increased ability of participating students to apply the acquired knowledge to diagnostic problems. We conclude that the implementation of CAL in present medical curricula can contribute to reformations of medical education. The instructional design of Dermatology 2000 is well accepted and suitable to provide both theoretic biomedical knowledge and clinical skills.

Randomized trial of problem-based versus didactic seminars for disseminating evidence-based guidelines on asthma management to primary care physicians

INTRODUCTION

This randomized controlled trial (RCT) investigated the effectiveness of and satisfaction with small-group problem-based learning (PBL) versus a didactic lecture approach to guideline dissemination in asthma management controlling for confounders common in comparative educational interventions.

METHODS

Sites were selected as either lecture or PBL using simple randomization. All participants were exposed to similar educational resources to ensure treatment equivalency. Instruments included standardized program/speaker evaluation forms and a validated case-based questionnaire with a visual analogue scale measuring the level of confidence of responses. The latter was presented immediately pre- and post-intervention and 3 months later. The statistician was blinded to intervention groups.

RESULTS

Overall, 52 family physicians agreed to participate, 23 in the PBL sessions (mean 4.6 per group) and 29 in the didactic lecture sessions (mean 7.25). There was no significant difference between the groups with respect to the knowledge gained at each test administration. Participants rated the lecturer or facilitator equally well as having established a positive learning environment. PBL participants rated the perceived educational value of the program higher than did lecture participants (4.36 vs. 3.93; p = .04). Both groups experienced a significant increase in asthma-related knowledge post-intervention. Attrition rates for the 3-month post-test were 14% for PBL participants versus 32% for lecture-based participants.

DISCUSSION

PBL was as effective in knowledge uptake and retention as lecture-based continuing medical education (CME) programs. Further study is warranted to investigate whether the assessment of higher educational value or an increase in response rate to delayed testing is replicable in other RCTs addressing common confounders and if these factors influence future CME participation, changes in physician clinical behavior, or patient health outcomes.

Influence of type of curriculum on students' perceptions of the medical course: a compilation of results from the Cognitive Behavior Survey, Attitudes Toward Social Issues In Medicine survey, and Learning Environment Questionnaire

BACKGROUND

This study administered selected scales from the Cognitive Behavior Survey, Attitudes Toward Social Issues in Medicine survey, and the Learning Environment Questionnaire. Data were gathered from other medical schools to put results into context.

PURPOSE

To present results on these scales from other medical schools and to compare the effects of type of curriculum on the results.

METHODS

Articles that had cited the articles that originally presented the scales used were searched for. Results were organized by type of curriculum and effect sizes were calculated where possible.

RESULTS

Within the limits of small numbers of studies so far, problem-based learning (PBL) curricula appear to have much more positive effects on students' reported cognitive behaviors than do hybrid curricula. Both have substantial positive effects on students' perceptions of the learning environment (PBL medium to large; hybrid small to medium). Neither appears to have much effect on students' attitudes toward social issues in medicine.

CONCLUSION

These data provide a starting point for further study of some of the effects of curricular interventions.