Testing a Causal Model for Learning in a Problem-based Curriculum

The aim of this study was to identify the relationship between elements that are important for the tutorial group process and the individual learning process in a problem-based curriculum. The variables under investigation were student-generated learning issues, individual learning process, reporting in the tutorial group, and achievement. A questionnaire containing 22 items was developed. Data were collected in the first year (N = 195) of the Medical School of the Maastricht University in the Netherlands during the academic year 1997–1998. The data were analysed using a structural modelling approach. The results indicate that the model fitted the data well. The path coefficients were moderately high, particular between the explanation-oriented approach and the depth of the reporting in the tutorial group. High path coefficients were also found between the depth of the reporting and achievement. In sum, the model gives insight into how important variables are related and it is recommended that data should be collected to test the model repeatedly. This revised version was published online in August 2006 with corrections to the Cover Date.     

Analysis of verbal interactions in tutorial groups: a process study

INTRODUCTION: Collaborative learning, including problem-based learning (PBL), is a powerful learning method. Group interaction plays a crucial role in stimulating student learning. However, few studies on learning processes in medical education have examined group interactions. Most studies on collaboration within PBL used self-reported data rather than observational data. We investigated the following types of interactions in PBL tutorial groups: learning-oriented interactions (exploratory questioning, cumulative reasoning and handling conflicts about knowledge); procedural interactions, and irrelevant/off-task interactions. AIM: The central question concerned how much time is spent on the different types of interaction during group sessions and how the types of interaction are distributed over the meeting. METHOD: Four tutorial group sessions in Year 2 of the PBL undergraduate curriculum of Maastricht Medical School were videotaped and analysed. The sessions concerned the reporting phase of the PBL process. We analysed the interactions using a coding scheme distinguishing several verbal interaction types, such as questions, arguments and evaluations. RESULTS: Learning-orientated interactions accounted for 80% of the interactions, with cumulative reasoning, exploratory questioning and handling conflicts about knowledge accounting for about 63%, 10% and 7% of the interactions, respectively. Exploratory questioning often preceded cumulative reasoning. Both types occurred throughout the meeting. Handling conflicts mainly occurred after the first 20 minutes. CONCLUSIONS: Task involvement in the tutorial groups was high. All types of learning-orientated interactions were observed. Relatively little time was spent on exploratory questions and handling conflicts about knowledge. Problem-based learning training should pay special attention to stimulating discussion about contradictory information.     

Growth of medical knowledge

BACKGROUND: Knowledge is an essential component of medical competence and a major objective of medical education. Thus, the degree of acquisition of knowledge by students is one of the measures of the effectiveness of a medical curriculum. We studied the growth in student knowledge over the course of Maastricht Medical School's 6-year problem-based curriculum. METHODS: We analysed 60 491 progress test (PT) scores of 3226 undergraduate students at Maastricht Medical School. During the 6-year curriculum a student sits 24 PTs (i.e. four PTs in each year), intended to assess knowledge at graduation level. On each test occasion all students are given the same PT, which means that in year 1 a student is expected to score considerably lower than in year 6. The PT is therefore a longitudinal, objective assessment instrument. Mean scores for overall knowledge and for clinical, basic, and behavioural/social sciences knowledge were calculated and used to estimate growth curves. FINDINGS: Overall medical knowledge and clinical sciences knowledge demonstrated a steady upward growth curve. However, the curves for behavioural/social sciences and basic sciences started to level off in years 4 and 5, respectively. The increase in knowledge was greatest for clinical sciences (43%), whereas it was 32% and 25% for basic and behavioural/social sciences, respectively. INTERPRETATION: Maastricht Medical School claims to offer a problem-based, student-centred, horizontally and vertically integrated curriculum in the first 4 years, followed by clerkships in years 5 and 6. Students learn by analysing patient problems and exploring pathophysiological explanations. Originally, it was intended that students' knowledge of behavioural/social sciences would continue to increase during their clerkships. However, the results for years 5 and 6 show diminishing growth in basic and behavioural/social sciences knowledge compared to overall and clinical sciences knowledge, which appears to suggest there are discrepancies between the actual and the planned curricula. Further research is needed to explain this.     

Faculty opinions about a revised pre-clinical curriculum

INTRODUCTION: Medical schools having innovative curricula have been encouraged to ascertain the levels of satisfaction of faculty members with the curriculum. Faculty at schools that employ problem-based learning (PBL) have been shown to have positive perceptions, but not all schools are in a position to adopt PBL on a large scale. This study sought to determine faculty members' opinions about a new curriculum that is less ambitious than one utilizing true PBL. CONTEXT AND SETTING: Since 1997, the University of Otago Medical School (Dunedin, New Zealand) has had an integrated, modular pre-clinical curriculum that emphasizes clinical relevance. It has proved popular with students. This study focused on faculty members' impressions. METHODS: We surveyed faculty members' opinions with a questionnaire identical to one used in studies at PBL schools. Faculty compared the students and their own levels of satisfaction in the old and new curricula on 7 to 10 items. The overall response rate was 85.4% (152 of 178). RESULTS: Perceptions of the new curriculum were positive among teachers who taught during the pre-clinical years and those who taught the students only after they reached the clinical years. Results for individual questions were in the same direction and generally similar in magnitude to those reported on identical items for PBL. CONCLUSION: We conclude that a hybrid curriculum that is more acceptable to many traditional teachers and students than is PBL has almost as great a positive effect on faculty members' perceptions of students' abilities and of the curriculum as does PBL.     

Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study

Since its first implementation in a medical programme at McMaster University, Canada, problem-based learning (PBL) has become a well-established means of teaching and learning medicine. Extensive research has been conducted and a number of strengths of the method are well supported. Several items, however, remain unclear although there is evidence that no relevant difference exists in factual knowledge among students from PBL and traditional curricula, a controlled, randomized study has not been conducted to address this issue. The Medical Faculty of the University of Cologne is in the process of integrating elements of PBL into its curriculum. In the spring term of 1997, after seven semesters of experience with PBL supplementing the traditional course of basic pharmacology, we did for the first time use PBL instead of the lecture-based course (LBL) and conducted a controlled prospective study to determine the effects of this intervention. One-hundred and twenty-three students were randomly assigned to either PBL (n = 63), with tutorial groups of up to nine students, or to the traditional, lecture-based course (n = 60). Analysis of the results of both groups in the examination of basic pharmacology, consisting of multiple-choice and short-essay questions, revealed similar scores with a tendency favouring PBL students in the category of short-essay questions. Hence, it seems clear that PBL does not imply a disadvantage in terms of factual knowledge. Students considered PBL to be an effective learning method and favoured it over the lecture format. Furthermore, students reported positive effects of PBL in terms of use of additional learning resources, interdisciplinarity, team work and learning fun.     

A Qualitative Analysis of the Transition from Theory to Practice in Undergraduate Training in a PBL-Medical School

In spite of numerous curricular innovations, the problems medical students encounter in making the transition from theoretical training to clinical training remain unresolved and the problem has received scant attention in the literature. We performed a qualitative study to explore students' perceptions and attitudes regarding this transition in undergraduate medical training. Twenty fifth-year students of the Maastricht Medical School participated in focus group discussions about the transition from the preclinical phase to the clinical phase of the curriculum. All focus group discussions were videotaped, literally transcribed and qualitatively analysed using content analysis. The results suggest that students have difficulty in bridging the gap between the theoretical and clinical phase of the curriculum. The problems they experience arise largely from professional socialisation processes. However, students also find it difficult to apply theoretical knowledge in clinical practice. Students find contacts with real patients highly motivating. In the clinical phase their learning changes from passive acquisition of knowledge to more active learning. Since the problem-based learning approach is supposed to enhance application of basic science concepts to clinical problems, it is surprising that students experience difficulties in applying their knowledge in practice. To facilitate the transition from theory to practice in the Maastricht Medical School some curricular changes could be introduced, such as early patient contacts to motivate students and help them learn usable knowledge. Furthermore, the advantages of a problem-based preclinical curriculum to student learning should be fully exploited. Finally, the assessment system must be congruent with the educational programme, because examinations have a powerful effect on student learning. This revised version was published online in June 2006 with corrections to the Cover Date.     

Influence of curriculum type on student performance in the United States Medical Licensing Examination Step 1 and Step 2 exams: problem-based learning vs. lecture-based curriculum

INTRODUCTION: The results of the United States Medical Licensing Examination Step 1 and 2 examinations are reported for students enrolled in a problem-based and traditional lecture-based curricula over a seven-year period at a single institution. There were no statistically significant differences in mean scores on either examination over the seven year period as a whole. There were statistically significant main effects noted by cohort year and curricular track for both the Step 1 and 2 examinations. These results support the general, long-term effectiveness of problem-based learning with respect to basic and clinical science knowledge acquisition. CONTEXT: This paper reports the United States Medical Licensing Examination Step 1 and Step 2 results for students enrolled in a problem-based and traditional lecture-based learning curricula over the seven-year period (1992-98) in order to evaluate the adequacy of each curriculum in supporting students learning of the basic and clinical sciences. METHODS: Six hundred and eighty-nine students who took the United States Medical Licensing Examination Step 1 and 540 students who took Step 2 for the first time over the seven-year period were included in the analyses. T-test analyses were utilized to compare students' Step 1 and Step 2 performance by curriculum groups. RESULTS: United States Medical Licensing Examination Step 1 scores over the seven-year period were 214 for Traditional Curriculum students and 208 for Parallel Curriculum students (t-value = 1.32, P=0.21). Mean Step 2 scores over the seven-year period were 208 for Traditional Curriculum students and 206 for Parallel Curriculum students (t-value=1.08, P=0.30). Statistically significant main effects were noted by cohort year and curricular track for both the Step 1 and Step 2 examinations. CONCLUSION: The totality of experience in both groups, although differing by curricular type, may be similar enough that the comparable scores are what should be expected. These results should be reassuring to curricular planners and faculty that problem-based learning can provide students with the knowledge needed for the subsequent phases of their medical education.     

Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.     

Structured packs for independent learning: a comparison of learning outcome and acceptability with conventional teaching

OBJECTIVES: The GMC recommends that students become independent learners, while tutor time is an increasingly precious resource. A set of structured learning materials requiring students to undertake and reflect on practical tasks in five learning areas was developed. DESIGN: The study used a randomized control trial to evaluate the effectiveness of using these structured learning materials in place of conventional teaching for 228 third-year undergraduate students and 55 teachers, on both hospital and community based medical and general practice firms. Evaluation involved assessing student performance on an examination question and a writing task, together with a student and tutor satisfaction questionnaire. SETTING: King's College School of Medicine and Dentistry, London. SUBJECTS: Third-year medical (first-year clinical) undergraduates. RESULTS: No significant difference in learning outcome was found for students on community- and hospital-based medical and general practice firms between students who had used the structured materials and those who had had conventional teaching on the same topic. The packs were acceptable to tutors and students. CONCLUSIONS: Such resources represent a mid-point between formal didactic teaching and self-directed learning. They may be particularly suitable for promoting independent learning for students on traditional medical courses. They offer an appropriate way to cover certain topics in the clinical curriculum and help to protect tutor time for topics which cannot be effectively taught in other ways.     

Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills

OBJECTIVES: A recent review of problem-based learning's effect on knowledge and clinical skills updated findings reported in 1993. The author argues that effect sizes (ES) seen with PBL have not lived up to expectations (0.8-1.0) and the theoretical basis for PBL, contextual learning theory, is weak. The purposes of this study were to analyse what constitutes reasonable ES in terms of the impacts on individuals and published reports, and to elaborate upon various theories pertaining to PBL. DESIGN: Normal theory is used to demonstrate what various ESs would mean for individual change and a large meta-analysis of over 10 000 studies is referred to in identifying typical ESs. Additional theories bearing upon PBL are presented. RESULTS: Effect sizes of 0.8-1.0 would require some students to move from the bottom quartile to the top half of the class or more. The average ES reported in the literature was 0.50 and many commonly used and accepted medical procedures and therapies are based upon studies with ESs below 0.50. CONCLUSIONS: Effect sizes of 0.8-1.0 are an unreasonable expectation from PBL because, firstly, the degree of changes that would be required of individuals would be excessive, secondly, leading up to medical school, students are groomed and selected for success in a traditional curriculum, expecting them to do better in a PBL curriculum than a traditional curriculum is an unreasonable expectation, and, thirdly, the average study reported in the literature and many commonly used and accepted medical procedures and therapies are based upon studies having lesser ESs. Information-processing theory, Cooperative learning, Self-determination theory and Control theory are suggested as providing better theoretical support for PBL than Contextual learning theory. Even if knowledge acquisition and clinical skills are not improved by PBL, the enhanced work environment for students and faculty that has been consistently found with PBL is a worthwhile goal.     

A lesson from the introduction of a problem-based, graduate entry course: the effects of different views of self-direction

OBJECTIVES: Difficulties in the early years of a new curriculum are to be expected as staff and students come to terms with new structures, and with different approaches to teaching and learning. During the first year of implementation of the Graduate Medical Course at the Graduate School of Medicine, The University of Queensland, we experienced our share of 'teething troubles'. One source of difficulty was different interpretations of the concept of 'self-directed learning' as it was to be applied in the new course. This paper presents an analysis of the effects of these differences on the development of the curriculum. DESIGN: An orientation programme was designed to introduce students to staff, facilities and the PBL process. SETTING: The University of Queensland. SUBJECTS: Problem-based learning (PBL) tutors, medical students. RESULTS: The overall effect was to place in jeopardy the achievement of student self-direction and commitment to lifelong learning as a goal of the course. To counter the undesirable effects of different interpretations, we have developed a conceptual framework to promote an agreed understanding of the meaning of self-direction, and to guide review and further development of the curriculum. A further paper describes the framework. CONCLUSIONS: Consistency in interpretation of key concepts is an important factor in the success of problem-based curricula.     

Composite undergraduate clinical examinations: how should the components be combined to maximize reliability?

BACKGROUND: Clinical examinations increasingly consist of composite tests to assess all aspects of the curriculum recommended by the General Medical Council. SETTING: A final undergraduate medical school examination for 214 students. AIM: To estimate the overall reliability of a composite examination, the correlations between the tests, and the effect of differences in test length, number of items and weighting of the results on the reliability. METHOD: The examination consisted of four written and two clinical tests: multiple-choice questions (MCQ) test, extended matching questions (EMQ), short-answer questions (SAQ), essays, an objective structured clinical examination (OSCE) and history-taking long cases. Multivariate generalizability theory was used to estimate the composite reliability of the examination and the effects of item weighting and test length. RESULTS: The composite reliability of the examination was 0.77, if all tests contributed equally. Correlations between examination components varied, suggesting that different theoretically interpretable parameters of competence were being tested. Weighting tests according to items per test or total test time gave improved reliabilities of 0.93 and 0.81, respectively. Double weighting of the clinical component marginally affected the reliability (0.76). CONCLUSION: This composite final examination achieved an overall reliability sufficient for high-stakes decisions on student clinical competence. However, examination structure must be carefully planned and results combined with caution. Weighting according to number of items or test length significantly affected reliability. The components testing different aspects of knowledge and clinical skills must be carefully balanced to ensure both content validity and parity between items and test length.     

Validation of learning style measures: implications for medical education practice

BACKGROUND: It is unclear which learners would most benefit from the more individualised, student-structured, interactive approaches characteristic of problem-based and computer-assisted learning. The validity of learning style measures is uncertain, and there is no unifying learning style construct identified to predict such learners. OBJECTIVE: This study was conducted to validate learning style constructs and to identify the learners most likely to benefit from problem-based and computer-assisted curricula. METHODS: Using a cross-sectional design, 3 established learning style inventories were administered to 97 post-Year 2 medical students. Cognitive personality was measured by the Group Embedded Figures Test, information processing by the Learning Styles Inventory, and instructional preference by the Learning Preference Inventory. The 11 subscales from the 3 inventories were factor-analysed to identify common learning constructs and to verify construct validity. Concurrent validity was determined by intercorrelations of the 11 subscales. RESULTS: A total of 94 pre-clinical medical students completed all 3 inventories. Five meaningful learning style constructs were derived from the 11 subscales: student- versus teacher-structured learning; concrete versus abstract learning; passive versus active learning; individual versus group learning, and field-dependence versus field-independence. The concurrent validity of 10 of 11 subscales was supported by correlation analysis. Medical students most likely to thrive in a problem-based or computer-assisted learning environment would be expected to score highly on abstract, active and individual learning constructs and would be more field-independent. CONCLUSIONS: Learning style measures were validated in a medical student population and learning constructs were established for identifying learners who would most likely benefit from a problem-based or computer-assisted curriculum.     

A written test as an alternative to performance testing

Performance tests are logistically complex and time consuming. To reach adequate reliability long tests are imperative. Additionally, they are very difficult to adapt to the individual learning paths of students, which is necessary in problem-based learning. This study investigates a written alternative to performance-based tests. A Knowledge Test of Skills (KTS) was developed and administered to 380 subjects of various educational levels, including both first-year students and recently graduated doctors. By comparing KTS scores with scores on performance tests strong convergent validity was demonstrated. The KTS failed discriminant validity when compared with a general medical knowledge test. Also the identification of sub-tests discriminating between behavioural and cognitive aspects was not successful. This was due to the interdependence of the constructs measured. The KTS was able to demonstrate differences in ability level and showed subtle changes in response patterns over items, indicating construct validity. It was concluded that the KTS is a valid instrument for predicting performance scores and could very well be applied as supplementary information to performance testing. The relative ease of construction and efficiency makes the KTS a suitable substitute instrument for research purposes. The study also showed that in higher ability levels the concepts which were meant to be measured were highly related, giving evidence to the general factor theory of competence. However, it appeared that this general factor was originally non-existent in first-year students and that these competencies integrate as the educational process develops.     

Can medical students from two cultures learn effectively from a shared web‐based learning environment?

OBJECTIVE: This study aimed to establish whether medical students from 2 different cultures can learn effectively from a shared web-based learning environment. METHODS: Students from the College of Medicine, Edinburgh, UK and the Medical School, Gifu, Japan shared 2 weeks of teaching and learning in clinical genetics, using problem-based learning in a web-based application (WBA). Questions about language, time zone, agreement about the curriculum (learning outcomes, tutor activity and assessment) and specific pedagogical issues about the educational effectiveness of students' learning were considered. RESULTS AND CONCLUSIONS: The evidence indicates that a shared WBA is practical where the learning outcomes and problem scenarios are common and students are fluent in the same language. Problem-based learning transfers itself best to online discussion boards when the numbers in the group are 16 or more. Students do not use the WBA as a primary source of resource material, and they augment the discussion boards with face-to-face meetings with peers and tutors.     

The essential role of the student in curriculum planning

Medical school curricula are planned, written and organized by academic and clinical staff within medical schools. While these medical educators may well be experts in their given field, they lack first-hand experience of what it is to be a medical student in 1995. For a medical curriculum to be an effective means of learning for today's students, it must be written with a knowledge of their priorities, needs and abilities. The way in which this can be best achieved is by the inclusion of current students in all stages of designing a new curriculum.
In my second year of medicine at Flinders University, I became involved in planning for the new Graduate Entry curriculum. In the role of student advocate, I have found I am able to offer teaching staff a unique perspective, the student perspective , on various issues.
Students, through experience from their own education, are able to give advice on student resources and facilities and are in a favourable position to judge other aspects of curricula, such as the balance and relevance of course content and assessment. Students need to realize the valuable insight they have to offer their faculties and the way in which this can benefit future students. It is by actively seeking student involvement and using their input, that faculties will be able to create a consumer-friendly curriculum.     

Test-enhanced learning in medical education

CONTEXT: In education, tests are primarily used for assessment, thus permitting teachers to assess the efficacy of their curriculum and to assign grades. However, research in cognitive psychology has shown that tests can also directly affect learning by promoting better retention of information, a phenomenon known as the testing effect. COGNITIVE PSYCHOLOGY RESEARCH: Cognitive psychology laboratory studies show that repeated testing of information produces superior retention relative to repeated study, especially when testing is spaced out over time. Tests that require effortful retrieval of information, such as short-answer tests, promote better retention than tests that require recognition, such as multiple-choice tests. The mnemonic benefits of testing are further enhanced by feedback, which helps students to correct errors and confirm correct answers. APPLICATION TO MEDICAL EDUCATION: Medical educational research has focused extensively on assessment issues. Such assessment research permits the conclusion that clinical expertise is founded on a broad fund of knowledge and effective memory networks that allow easy access to that knowledge. Test-enhanced learning can potentially strengthen clinical knowledge that will lead to improved expertise. CONCLUSIONS: Tests should be given often and spaced out in time to promote better retention of information. Questions that require effortful recall produce the greatest gains in memory. Feedback is crucial to learning from tests. Test-enhanced learning may be an effective tool for medical educators to use in promoting retention of clinical knowledge.     

Use of learning contracts in an office-based primary care clerkship

OBJECTIVES: This paper describes implementation of the learner-centred learning goal within the primary care clerkship at a Midwestern, United States medical school. DESIGN: The learner-centred learning goal exercise was developed to tailor students' educational activities to their personal level of development and to enhance their commitment to life-long learning in medicine. In the learner-centred learning goal exercise, each student records three specific learning goals early in the primary care clerkship. Students record the methods by which they will pursue and document achievement of each goal. Attainment of the learner-centred learning goal is evaluated based on an oral presentation at the end of the clerkship. We compiled presented learning goals along with the corresponding grade. Students' ratings of the learner-centred learning goal exercise were also compiled. Evaluations and ratings were made on a 1-5 Likert scale, where 1 is the best rating and 5 is worst. SETTING: Department of Medicine, Northwestern University Medical School, Chicago, USA. SUBJECTS: One hundred and seventy-seven third- and fourth-year medical students who presented learner-centred learning goals between 1 July 1995 and 30 June 1996. RESULTS: Students rated pursuing their individual learning goals more worthwhile than most clerkship lectures but less worthwhile than the office experience. Several learning goals were chosen by a disproportionate number of students, potentially indicative of some perceived deficiencies elsewhere in the curriculum. Third-year students ranked the learner-centred learning goal exercise more favourably than fourth-year students (2.14 vs. 2. 51, P = 0.03). CONCLUSIONS: The learner-centred learning goal exercise is a feasible and well-received method within our primary care clerkship. Further study is required to determine whether the exercise promotes independent learning after formal medical school education is completed.     

Predicting communication skills with a paper-and-pencil test

AIM: This study was conducted to investigate the value of a written knowledge test of communication skills for predicting scores on a performance test of communication skills. METHOD: A paper-and-pencil test of knowledge about communication skills and a performance test of communication skills, consisting of four stations with standardised patients, were administered to students of two classes of the medical schools of Maastricht and Leiden, the Netherlands. The results on these tests were compared. RESULTS: From the results of both instruments, the classes of the participating students could be recognised equally well: 60% correct qualifications of the classes by the knowledge test and 64% by the multiple station examination. Between the two tests an overall, disattenuated correlation of 0.60 was found (N=133, P < 0.01), suggesting moderate predictive value of the knowledge test for the performance test of communication skills. The correlation is stronger for students from Maastricht medical school than for their colleagues in Leiden. Correlation between the knowledge of communication skills test and other available test results of the participating Maastricht students is close to zero, suggesting that the test measures a distinct quality of students' competence. DISCUSSION: The paper-and-pencil test of knowledge of communication skills has predictive value for the performance of these skills, but this value seems to be less pronounced than similar findings for clinical procedural skills. The stronger relationship between 'knowing how' and 'showing' in the Maastricht student group might be indicative of an effect of the training format.     

Approaches to learning in a problem-based medical programme: a developmental study

In this study we investigate how the introductory phase of the problem-based medical programme in Maastricht affects the study methods of students. On the first day of the academic year, 142 men and women medical students completed the Short Inventory of Study Approaches and again at the end of the introductory period. The study indicates that these study methods are fostered by training in problem-based learning given during the introductory period.