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

Case-Informed Learning in Medical Education: A Call for Ontological Fidelity

Case-informed learning is an umbrella term we use to classify pedagogical approaches that use text-based cases for learning. Examples include Problem-Based, Case-Based, and Team-Based approaches, amongst others. We contend that the cases at the heart of case-informed learning are philosophical artefacts that reveal traditional positivist orientations of medical education and medicine, more broadly, through their centering scientific knowledge and objective fact. This positivist orientation, however, leads to an absence of the human experience of medicine in most cases. One of the rationales for using cases is that they allow for learning in context, representing aspects of real-life medical practice in controlled environments. Cases are, therefore, a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation literature, have yet to enter discussions of case-informed learning. We propose the concept of ontological fidelity as a way to approach ontological questions (i.e., questions regarding what we assume to be real), so that they might centre narrative and experiential elements of medicine. Ontological fidelity can help medical educators grapple with what information should be included in a case by encouraging an exploration of the philosophical questions: What is real? Which (and whose) reality do we want to simulate through cases? What are the essential elements of a case that make it feel real? What is the clinical story we want to reproduce in case format? In this Eye-Opener, we explore what it would mean to create cases from a position of ontological fidelity and provide suggestions for how to do this in everyday medical education.

Students integrate knowledge acquisition and practical work in the laboratory

The aim of the present work was to transfer a wider concept of teamwork and self-learning to the laboratory, encouraging students' capabilities when seeking, acquiring, and processing knowledge. This educational innovation was carried out with a total of 38 students (fourth year of degree in Biology) in the area of physiology (Advances in Reproduction course) at University of Córdoba in Córdoba, Spain. The design of the project's application methodology consisted of establishing a way in which problems would be tackled in the practical classes. For this purpose, the different tasks were set up so that students could relate them to the concepts learned in the theory classes. On the first day of class, the project was presented to the students. Groups of two to three students worked in the laboratory and set up an outline of the protocol of the practical work that they had done. This outline was performed individually and sent to the lecturers through a learning management system (Moodle). The teachers gave feedback and assessed student submissions. Upon finishing the course, students completed a survey. The project-based learning method promotes practical self-learning on the part of students. This methodology demonstrated to us that it stimulates a critical and self-critical capacity in students, both individually and in groups, and that writing didactic practical material helped students to enhance their theory knowledge. The experiment was a success in view of the scores obtained upon finishing the subject.

The perceived effects of faculty presence vs. absence on small-group learning and group dynamics: a quasi-experimental study

BACKGROUND

Medical education increasingly relies on small-group learning. Small group learning provides more active learning, better retention, higher satisfaction, and facilitates development of problem-solving and team-working abilities. However, less is known about student experience and preference for different small groups teaching models. We evaluated group educational dynamics and group learning process in medical school clerkship small group case-based settings, with a faculty member present versus absent.

METHODS

Students completed surveys after cases when the faculty was present ("in") or absent ("out") for the bulk of the discussion. 228 paired surveys (114 pairs) were available for paired analysis, assessing group dynamics, group learning process, student preference, and participation through self-report and self-rating of group behaviors tied to learning and discussion quality.

RESULTS

Ratings of group dynamics and group learning process were significantly higher with the faculty absent vs. present (p range <0.001 to 0.015). Students also reported higher levels of participation when the faculty member was absent (p = 0.03). Students were more likely to express a preference for having the faculty member present after "in" case vs. "out" case discussions. (p < 0.001). There was no difference in reported success of the case discussion after "in" vs. "out" cases (p = 0.67).

CONCLUSIONS

Student groups without faculty present reported better group dynamics, group learning processes, and participation with faculty absent. Students reported that they feel somewhat dependent on faculty, especially when the faculty is present, though there was no significant difference in students reporting that they obtained the most they could from the discussion of the case after both "in" and "out" cases.

Learning in the tutorial group: a balance between individual freedom and institutional control

The study investigates factors in problem-based learning tutorial groups which promote or inhibit learning. The informants were tutors and students from speech-language pathology and physiotherapy programmes. Semi-structured focus-group interviews and individual interviews were used. Results revealed three themes: Responsibility. Time and Support. Under responsibility, the delicate balance between individual and institutional responsibility and control was shown. Time included short and long-term perspectives on learning. Under support, supporting documents, activities and personnel resources were mentioned. In summary, an increased control by the program and tutors decreases student's motivation to assume responsibility for learning. Support in tutorial groups needs to adapt to student progression and to be well aligned to tutorial work to have the intended effect. A lifelong learning perspective may help students develop a meta-awareness regarding learning that could make tutorial work more meaningful.

Creating a virtual pharmacology curriculum in a problem-based learning environment: one medical school's experience

Integrating pharmacology education into a problem-based learning (PBL) curriculum has proven challenging for many medical schools, including the Pennsylvania State University College of Medicine (Penn State COM). In response to pharmacology content gaps in its PBL-intensive curriculum, Penn State COM in 2003 hired a director of medical pharmacology instruction to oversee efforts to improve the structure of pharmacology education in the absence of a stand-alone course. In this article, the authors describe the ongoing development of the virtual pharmacology curriculum, which weaves pharmacology instruction through the entire medical school curriculum with particular emphasis on the organ-based second year. Pharmacology is taught in a spiraling manner designed to add to and build upon students' knowledge and competency. Key aspects of the virtual curriculum (as of 2011) include clearly stated and behaviorally oriented pharmacology learning objectives, pharmacology study guides that correspond to each PBL case, pharmacology review sessions that feature discussions of United States Medical Licensing Examination (USMLE)-type questions, and pharmacology questions for each PBL case on course examinations to increase student accountability. The authors report a trend toward improved USMLE Step 1 scores since these initiatives were introduced. Furthermore, graduates' ratings of their pharmacology education have improved on the Medical School Graduation Questionnaire. The authors suggest that the initiatives they describe for enhancing pharmacology medical education are relevant to other medical schools that are also seeking ways to better integrate pharmacology into PBL-based curricula.

Effect of worksheet scaffolds on student learning in problem-based learning

The purpose of this study was to investigate the effect of worksheets as a scaffolding tool on students' learning achievement in a problem-based learning (PBL) environment. Seventeen PBL classes (N = 241) were randomly assigned to two experimental groups-one with a worksheet provided and the other without. Students' learning of the topic at hand was evaluated by comparing results from pre- and post-lesson concept recall tests. We also obtained information about students' perceptions of factors impacting their learning using a Learning Impact Questionnaire. The data was analyzed by means of analyses of variance. Results of the study indicated that there was no statistically significant difference between the levels of understanding for both groups of students. In addition, survey results revealed that the strongest factor perceived by students to impact their learning in a PBL context is the tutor followed by team and class dynamics, while the influence of the worksheet was rated lowest. These findings suggest that scaffolds such as worksheets may not play a significant role in enhancing students' learning within the social constructivist framework of problem-based learning. On the other hand, the importance of the role of tutor and collaborative small group learning which are key features of PBL is reinforced.

Six ways problem-based learning cases can sabotage patient-centered medical education

PURPOSE

Problem-based learning (PBL) cases tell a story of a medical encounter; however, the version of the story is typically very biomedical in focus. The patient and her or his experience of the situation are rarely the focus of the case despite a prevalent discourse of patient-centeredness in contemporary medical education. This report describes a qualitative study that explored the question, "How does PBL teach medical students about what matters in medicine?"

METHOD

The qualitative study, culminating in 2008, involved three data collection strategies: (1) a discourse analysis of a set of PBL cases from 2005 to 2006, (2) observation of a PBL tutorial group, and (3) semistructured, in-depth, open-ended interviews with medical educators and medical students.

RESULTS

In this report, using data gathered from 67 PBL cases, 26 hours of observation, and 14 interviews, the author describes six specific ways in which PBL cases-if not thoughtfully conceptualized and authored-can serve to overlook social considerations, thereby undermining a patient-centered approach. These comprise the detective case, the shape-shifting patient, the voiceless PBL person, the joke name, the disembodied PBL person, and the stereotypical PBL person.

CONCLUSIONS

PBL cases constitute an important component of undergraduate medical education. Thoughtful authoring of PBL cases has the potential to reinforce, rather than undermine, principles of patient-centeredness.

Thai nursing students' adaption to problem-based learning: a qualitative study

Student-centred forms of learning have gained favour internationally over the last few decades including problem based learning, an approach now incorporated in medicine, nursing and other disciplines' education in many countries. However, it is still new in Thailand and being piloted to try to offset traditional forms of didactic, teacher-centred forms of teaching. In this qualitative study, 25 undergraduate nursing students in northern Thailand were interviewed about their experiences with problem-based learning in a health promotion subject. Content analysis was used to interrogate interview data, which revealed four categories: adapting, seeking assistance, self-development, and thinking process development. Initially participants had mixed emotions of confusion, negativity or boredom in the adaption process, but expressed satisfaction with creativity in learning, group work, and leadership development. They described increased abilities to problem solve and think critically, but struggled to develop questioning behaviours in learning. Socio-culturally in Thai education, students have great respect for teachers, but rarely question or challenge them or their learning. We conclude that problem-based learning has great potential in Thai nursing education, but educators and systems need to systematically prepare appropriate learning environments, their staff and students, to incorporate this within curricula.

Teacher perceptions of desired qualities, competencies and strategies for clinical skills teachers

INTRODUCTION

Clinical skills centres (or Skillslabs) prepare students for patient-encounters. Evidence on teaching skills in these centres is lacking. What teaching skills do teachers view as effective in supporting the acquisition of physical examination skills in undergraduate medical training?

METHOD

Structured interviews of 10 teachers (1/3 of staff of Maastricht University, Skillslab) were conducted. Selection was based on even representation of age, years teaching experience, gender and previous experience at Maastricht University. A topic grid was used to ensure comparability. Interviews (average 70 min, range 33-95 min) were recorded and transcripts were analyzed independently by two researchers.

RESULTS

Teaching skills identified include the ability to adapt content of the training, level of depth and teaching method according to the needs of any particular group. Thorough comprehension of students' context (level of knowledge,prior experience and insight in the curriculum) is considered helpful. Explicitly inviting students to ask questions and providing relevant literature is seen to stimulate learning. Providing constructive feedback is essential, as is linking physical examination skills training to clinical situations. The ideal attitude includes appropriate dress and behaviour, as well as the use of humour. Affinity for teaching is regarded as the most important reason to work as a teacher.

CONCLUSION

Desired characteristics for undergraduate skills teachers resemble findings in other teaching roles. Affinity for teaching and flexibility in teaching methods are novel findings.

Conducting the symphony: a qualitative study of facilitation in problem-based learning tutorials

CONTEXT

Tutors in problem-based learning (PBL) tutorials have a complex role to play in facilitating students' learning. This includes providing support for students' acquisition of content knowledge and skills in critical thinking, coaching of group processes and modelling of reflective practice. Few studies which investigate the key role of tutors in the PBL tutorial process are qualitative in design.

METHODS

This study explores the nature and technique of facilitation provided by PBL tutors from the students' viewpoint. Data were obtained from written responses to an open-ended question asking students about the effectiveness of their PBL tutor(s) and from in-depth interviews carried out with two randomly selected students.

RESULTS

Three main themes arose from the inductive analysis of qualitative data: (i) role confusion by tutors; (ii) tutor management of sensitive issues, and (iii) facilitation 'style'. The theme of tutors' facilitation style was dominant and three sub-categories were apparent. These were: (i) managing the learning in PBL tutorials; (ii) facilitating group processes, and (iii) guiding group discussion.

CONCLUSIONS

Findings highlight the need for tutors to regularly review the PBL tutorial processes and group dynamics within the tutorial setting. These findings have implications for tutor training and programmes of ongoing professional development for PBL facilitators.

Student views on the effective teaching of physical examination skills: a qualitative study

OBJECTIVES

The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers.

METHODS

We organised focus group discussions with students from Years 1-3 of a 6-year undergraduate medical curriculum. A total of 30 randomly selected students, divided into three groups, took part in two sessions. They discussed what teaching skills helped them to acquire physical examination skills.

RESULTS

Students' opinions related to didactic skills, interpersonal and communication skills and preconditions. Students appreciated didactic skills that stimulate deep and active learning. Another significant set of findings referred to teachers' attitudes towards students. Students wanted teachers to be considerate and to take them seriously. This was reflected in student descriptions of positive behaviours, such as: 'responding to students' questions'; 'not exposing students' weaknesses in front of the group', and '[not] putting students in an embarrassing position in skill demonstrations'. They also appreciated enthusiasm in teachers. Important preconditions included: the integration of skills training with basic science teaching; linking of skills training to clinical practice; the presence of clear goals and well-structured sessions; good time management; consistency of teaching, and the appropriate personal appearance of teachers and students.

CONCLUSIONS

The teaching skills and behaviours that most facilitate student acquisition of physical examination skills are interpersonal and communication skills, followed by a number of didactic interventions, embedded in several preconditions. Findings related to interpersonal and communication skills are comparable with findings pertaining to the teaching roles of tutors and clinical teachers; however, the didactic skills merit separate attention as teaching skills for use in skills laboratories. The results of this study should be complemented by a study performed in a larger population and a study exploring teachers' views.

Problem-based learning at the receiving end: a 'mixed methods' study of junior medical students' perspectives

Qualitative insights about students' personal experience of inconsistencies in implementation of problem-based learning (PBL) might help refocus expert discourse about good practice.

AIM

This study explored how junior medical students conceptualize: PBL; good tutoring; and less effective sessions.

METHODS

Participants comprised junior medical students in Liverpool 5-year problem-based, community-orientated curriculum. Data collection and analysis were mostly cross-sectional, using inductive analysis of qualitative data from four brief questionnaires and a 'mixed' qualitative/quantitative approach to data handling. The 1999 cohort (end-Year 1) explored PBL, generated 'good tutor' themes, and identified PBL (dis)advantages (end-Year 1 then mid-Year 3). The 2001 cohort (start-Year 1) described critical incidents, and subsequently (end-Year 1) factors in less effective sessions. These factors were coded using coding-frames generated from the answers about critical incidents and 'good tutoring'.

RESULTS

Overall, 61.2% (137), 77.9% (159), 71.0% (201), and 71.0% (198) responded to the four surveys, respectively. Responders perceived PBL as essentially process-orientated, focused on small-groupwork/dynamics and testing understanding through discussion. They described 'good tutors' as knowing when and how to intervene without dominating (51.1%). In longitudinal data (end-Year 1 to mid-Year 3), the main perceived disadvantage remained lack of 'syllabus' (and related uncertainty). For less effective sessions (end-Year 1), tutor transgressions reflected unfulfilled expectations of good tutors, mostly intervening poorly (42.6% of responders). Student transgressions reflected the critical incident themes, mostly students' own lack of work/preparation (54.8%) and other students participating poorly (33.7%) or dominating/being self-centred (31.6%).

CONCLUSION

Compelling individual accounts of uncomfortable PBL experiences should inform improvements in implementation.

Problem based learning in the clinical setting--a systematic review

Problem based learning (PBL) is widely utilised as a curricula modality within the health professions and extensive literature exists to support its application. Recently nurse educators have embarked on the PBL journey as a method of contextualizing theory into practice in the classroom and clinical setting. The University of Queensland, in partnership with key health care providers, introduced an innovative undergraduate nursing curriculum in 2004. The curriculum incorporates problem based learning, clinical skills sessions, lectures and clinical practice as part of an intense weekly program from first year onwards. The program facilitates integration of evidence based theoretical and clinical knowledge driven by the PBL philosophy. However, in reality is PBL utilised by clinicians as a method of clinical teaching in undergraduate health professional programs? A systematic review of the literature was undertaken to answer this question revealing a paucity of evidence supporting or confirming the application of PBL in the clinical setting. The findings of this review highlight the current gaps in the PBL literature, supporting further research into the role of PBL as a teaching strategy for undergraduate nurses in the clinical practice setting.

Revitalizing problem based learning: student and tutor attitudes towards a structured tutorial

BACKGROUND

The pre-clinical curriculum at the University of New Mexico School of Medicine is a hybrid model that includes small group, problem-based learning (PBL) tutorials and didactic lectures. A structured tutorial format was piloted for the human sexuality/reproduction organ system block for the PBL component. The objective of this study was to compare the acceptability of the structured format and its effectiveness with that of a traditional PBL tutorial.

METHODS

Students were surveyed after the renal/endocrinology block of 2004 (traditional tutorial format) and after the human sexuality/reproduction block of 2004 (structured tutorial format) (n = 70). Survey questions covered the quality of learning and of tutorial. Students (n = 132) and tutors (n = 24) who participated in human sexuality/reproduction in 2004 and 2005 were surveyed for attitudes about the structured tutorial overall and specific components. Means of responses were compared using t-tests.

RESULTS

Students indicated that the structured tutorial format supported a greater improvement in their basic science and clinical knowledge and their ability to evaluate information (p < 0.05). The majority of students and tutors recommended the structured format for tutorials in other blocks.

CONCLUSIONS

We demonstrated the acceptability of a structured tutorial format to students and faculty. Faculty members perceived greater depth of learning and participation by the students.

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.

Forensic aspects of maxillofacial radiology

Radiology has been used extensively in conventional dental identification, anatomically based identification and identification using maxillofacial skeletal landmarks such as the frontal sinus. Examples of these are well documented in the literature. The purpose of this paper was to revisit the methods where radiographic methods may be used to determine identity using the teeth, the root structures and the frontal sinuses. Additionally suggestions are offered for management of radiography in mass disasters and cases where age determination is required. Computer assisted tomography can be used in the assessment of the degree of fit of a weapon to a wound in cases of blunt force skull injury and plane films can assist in depicting the pattern of post mortem skull fractures. Micro-computed tomography has been used in matching weapons to wounds in sharp-force injury cases. The radiologist's role in cases of civil litigation and fraud is discussed and case examples are given. There are gaps in the science where radiological methods are used. The author offers several suggestions for possible research projects to close some of these gaps.