Teaching problem-solving and clinical reasoning: 20 years experience with video-supported small-group learning

In the context of a curriculum reform the Faculty of Medicine of the University of Leuven, Belgium, introduced a new teaching project: video-supported small-group learning on problem-solving and clinical reasoning. The aim of this study is to reflect 20 years experience. The video-supported sessions for sixth-year medical students during their practical year in peripheral hospitals were constructed in four stages. The first stage is the video presentation of a case with history-taking and physical examination. The students and three tutors of internal medicine make notes and can ask further questions and perform additional physical examination acts after the video presentation. The coordinator of the course, who knows the patient, then simulates the patient and the doctor to answer the questions. The second stage consists of making up individually a synoptic problem list, integrating history and physical examination; a differential diagnosis list with the most likely diagnosis fitting the problem list; and a list with investigations to be asked for confirming the diagnosis. The third stage consists of three small student groups discussing the three lists requested in stage 2. Each small group of students, passively assisted by a tutor, has to come to the consensus lists. The fourth stage is the confrontation of the consensus lists of the three groups with the aim of coming to an overall agreement. At this stage tutors are more actively involved in the discussion. Several learning processes are involved in this way of teaching. During the first stage the students learn the traditional teaching `see one, do one and teach one', a demonstration of a full history and physical examination. By asking for additional information they learn by a critical attitude and by developing a strategy of fact-finding. During the second and third stages, by making their lists and during the consensus processes, they learn the significance of individual findings, problem-framing and the synthesis of history and physical examination data in medical concepts. The third and fourth parts of the sessions bring up the process of clinical reasoning, formulation of a working hypothesis, the discussion of the pathophysiology of findings, clustering of problems and epidemiological considerations as incidence and prevalence. Finally, the exercise to select diagnostic tests gives the students the possibility of appreciating the value of sensitivity/specificity and risks, benefits and costs of diagnostic procedures. These video-supported clinical problem-solving and reasoning sessions were positively appraised by students, teachers and medical faculty over the years. Over 20 years, more than 90 cases have been recorded on video, with a widespread variation in diagnoses and clinical presentations. Small-group teaching with the aid of a video case, as described in this paper, can promote enjoyable learning for students and teachers.     

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.     

Problem-based learning in medical education: Developing a research agenda

While the use of problem-based learning (PBL) methods continues to increase in medical education, three literature reviews of PBL have appeared in the past several years which come to different opinions about their merits. This analysis summarizes the research evidence regarding PBL by examining how well it has met its originators' goals, what we know about how PBL works, and how PBL fares in a goal-free comparison with conventional curricula. A research agenda is suggested to refine our understanding of well-documented effects of PBL, to probe for other possible longer term PBL outcomes, and to examine if and how PBL affects knowledge acquisition and retention. Consistency of evidence from a variety of PBL implementations can help decide whether the effects seen can be attributed to PBL or are the results of other curricular features unique to one setting.     

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.     

One year's experience with a clinical skills resource centre

OBJECTIVES: To describe our experience of teaching clinical skills to first-year medical students in a new problem-based curriculum. DESIGN: Prospective evaluation of clinical skills acquisition using objective measures. SETTING: Students were taught in a purpose-designed clinical skills resource centre in weekly structured sessions. SUBJECTS: All 210 first year medical undergraduates in the first year of a new problem-based and clinically oriented course. RESULTS: Student performance in structured objective examinations improved over 1 year. In all but one of nine matched stations, involving history, examination and procedural skills, improvements were significant. Ninety-three per cent thought that the appropriateness of the skills training course to other course elements was 'good' or 'very good'. CONCLUSIONS: First-year medical students can learn a wide range of clinical skills. Integrated teaching of clinical skills improves satisfaction with undergraduate studies.     

The relationship between assessment measures at Newcastle Medical School (Australia) and performance ratings during internship

This study examined the utility of the domain assessment measures used in the final 2 years at Newcastle medical school in predicting performance ratings in the first year of postgraduate training (internship). Performance ratings were obtained from the clinical supervisors of two graduating classes of the University of Newcastle medical students during their five terms of internship. Three or more ratings were obtained from 57% of interns. Univariate analysis indicated that scores for three of the five domains (professional skills; identification, prevention and management of illness; self-directed learning) were significantly positively correlated with intern performance ratings. Multivariate analysis indicated that only the domain assessing iden‐tification, prevention and management of illness was predictive of higher intern performance ratings. The results support the notion that there is some value in the domain assessment model used at Newcastle in predicting the performance of junior doctors.     

Problem-based examining: a different approach to assessment

An attempt to achieve problem-based examining by the structured assessment of presentations is described. Students can choose to participate in the scheme in teams and then elect to use their awarded mark instead of part of the formal examination assessment. The element of choice of the study or examination method is seen as being a valuable element of the scheme. The scheme can be introduced without radical revision of existing curricula or substantial investment of staff time, and meets some of the expressed desires of the UK General Medical Council in terms of the introduction of novel methods of assessment.     

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.     

Task-based learning: the answer to integration and problem-based learning in the clinical years

INTRODUCTION: Integrated teaching and problem-based learning (PBL) are powerful educational strategies. Difficulties arise, however, in their application in the later years of the undergraduate medical curriculum, particularly in clinical attachments. Two solutions have been proposed - the use of integrated clinical teaching teams and time allocated during the week for PBL separate from the clinical work. Both approaches have significant disadvantages. Task-based learning (TBL) is a preferred strategy. In TBL, a range of tasks undertaken by a doctor are identified, e.g. management of a patient with abdominal pain, and these are used as the focus for learning. Students have responsibility for integrating their learning round the tasks as they move through a range of clinical attachments in different disciplines. They are assisted in this process by study guides. METHOD: The implementation of TBL is described in one medical school. One hundred and thirteen tasks, arranged in 16 groups, serve to integrate the student learning as they rotate through 10 clinical attachments. RESULTS: This trans-disciplinary approach to integration, which incorporates the principles of PBL offers advantages to both teachers and students. It recognizes that clinical attachments in individual disciplines can offer rich learning opportunities and that such attachments can play a role in an integrated, as well as in a traditional, curriculum. In TBL, the contributions of the clinical attachments to the curriculum learning outcomes must be clearly defined and tasks selected which will serve as a focus for the integration of the students' learning over the range of attachments.     

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.     

The role of basic sciences in a problem-based learning clinical curriculum

BACKGROUND: Very little is known about the use of problem-based learning (PBL) during the later years of the undergraduate medical course and how it influences further acquisition of basic science knowledge. Similarly to many other Faculties, the PBL approach is used at Manchester in years 1 and 2, but more unusually, the curriculum continues to be centred on PBL in the clinical modules. OBJECTIVES: To explore whether and how basic science learning was continued in year 3 of the PBL clinical curriculum. METHODS: 10 of the weekly problems from the two core modules in year 3 were analysed to determine: (a) whether the design teams were using basic science objectives in devising the problems, and (b) whether PBL student groups were setting basic science learning objectives. The basic science knowledge of year 3 and 4 students was also measured. RESULTS: Similar numbers of objectives were being set by the management groups for each weekly problem (Heart, lung and blood (HLB) module, median 15, range 11-20; Nutrition, metabolism and excretion (NME) module, median 13, range 9-21). In the basic sciences, there was a median of 3 objectives per problem (range 0-6) in the NME module, but only 1 objective (0-2) per problem in the HLB module. The objectives set by six PBL groups in each module were analysed. Overall, agreement was reached on 130 occasions (62%) between the design team basic science objectives and those set for themselves by the student groups. In addition, there was a median of 2 (range 1-8) new basic science objectives brought out by the PBL groups that were not listed by the HLB module design team. In the NME module, there was again a median of 2 new objectives (range 0-6). The performance of year 3 and year 4 students in the multiple-choice questions progress test was analysed. For the 65 basic science questions, the year 3 mark was 40.8 +/- 12.3% compared with 57.1 +/- 12.3% for year 4 (P < 0.0001). CONCLUSIONS: (a) The design teams are setting basic science objectives; (b) the working problems are triggering students to set learning objectives in the basic sciences; (c) most of the objectives being set by the design teams are being triggered in the majority of group sessions; (d) the students knowledge of basic sciences increases in years 3-4.     

Crafting cases for problem-based learning: experience in a neuroscience course

Clinical cases for problem-based learning should capture the relevance of patient encounters, and not serve merely as a 'take-off' point for scientific study. As a vehicle of learning, the case should drive the science and the science should drive the case. Decision points elicit intellectual commitment, and help to raise the level of inquiry. Our cases are focused, avoiding clinical complexity and reliance on pattern recognition. We emphasize formulation of evidence-based mechanistic hypotheses. The case does not stand alone, but must suit its position in the course and curriculum.     

A comparison of learning outcomes and attitudes in student- versus faculty-led problem-based learning: an experimental study

OBJECTIVES: To compare learning outcomes and perceptions of facilitator behaviours and small-group process in problem-based learning (PBL) groups led by students and those led by faculty. DESIGN: A prospective, Latin-square cross-over design was employed. Second-year medical students participated in 11 PBL cases over the course of the academic year. For each case, half the student groups were led by faculty and the other half by a student group member selected randomly to serve in the facilitator role. Learning outcomes were assessed by performance on objective examinations covering factual materials pertinent to the case. Perceptions of facilitator behaviours and of group functioning were assessed with a questionnaire completed at the end of each individual case. Focus-group discussions were held to gain more in-depth information about student perceptions and experience. Student-led sessions were observed at random by the investigators. SETTING: A state-supported, US medical school with a hybrid lecture-based and problem-based curriculum. SUBJECTS: One hundred and twenty-seven second-year medical students and 30 basic science and clinical faculty. RESULTS: No differences were detected in student performance on the objective evaluation based on whether the facilitator was a faculty member or peer group member, nor were there any differences in the perceptions of group process. Students gave peer facilitators slightly higher ratings in the second semester of the experiment. In the focus-group discussions, students voiced a general preference for student-led groups because they felt they were more efficient. Observation and focus-group reports suggest that groups led by students sometimes took short cuts in the PBL process. CONCLUSION: In a hybrid lecture- and PBL-based curriculum, student performance on objective examinations covering PBL materials is unaffected by the status of the facilitator (student vs. faculty). However, in peer-facilitated groups, students sometimes took short cuts in the PBL process that may undermine some of the intended goals of PBL.     

Computer-based management of content in planning a problem-based medical curriculum

The Faculty of Medicine at the University of Sydney has undertaken a major educational change from a traditional didactic 6-year, undergraduate entry programme to a 4-year problem-based programme to which only graduates are admitted. We have used two computer-based tools which proved invaluable in developing and managing the content of the new curriculum. The first, developed using a commercial database and made available on the Faculty's Intranet, provided a means for eliciting appropriate problems, organizing content fields and searching the information. The second, based on a spreadsheet, provided a means of displaying agreed content on implementation grids, both for self-directed learning and conventional teaching sessions. Both provided ready access for scrutiny, interaction, review and planning by staff and they greatly enhanced the process of understanding the nature of the new curriculum, and thus in reassuring staff about the change. By merging the two tools, a definitive curriculum database is emerging.     

Predicting doctor performance outcomes of curriculum interventions: problem-based learning and continuing competence

Context  Problem-based learning (PBL) is an educational strategy designed to enhance self-assessment, self-directed learning and lifelong learning. The present study examines a peer review programme to determine whether the impact of PBL on continuing competence can be detected in practice.
Objectives  This study aimed to establish whether McMaster graduates who graduated between 1972 and 1991 were any less likely to be identified as having issues of competence by a systematic peer review programme than graduates of other Ontario medical schools.
Methods  We identified a total of 1166 doctors who had graduated after 1972 and had completed a mandated peer review programme. Of these, 108 had graduated from McMaster and 857 from other Canadian schools. School of graduation was cross-tabulated against peer rating. A secondary analysis examined predictors of ratings using multiple regression.
Results  We found that 4% of McMaster graduates and 5% of other graduates were deemed to demonstrate cause for concern or serious concern, and that 24% of McMaster doctors and 28% of other doctors were rated as excellent. These differences were not significant. Multiple regression indicated that certification by family medicine or a specialty, female gender and younger age were all predictors of practice outcomes, but school of graduation was not.
Conclusions  There is no evidence from this study that PBL graduates are better able to maintain competence than graduates of conventional schools. The study highlights potential problems in attempting to link undergraduate educational interventions to doctor performance outcomes.     

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.     

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning

OBJECTIVE: To develop a model linking the processes and outcomes of workplace learning. METHODS: We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students. RESULTS: To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning. CONCLUSIONS: The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.     

Problems for problem-based learning: a comparative study of documents

In medical education the problem-based approach to learning can be considered as the most significant educational innovation in the past two decades. This paper examines the ways and extent to which health problems have been designed for implementation of problem-based curriculum. Content analysis of curriculum documents of three problem-based schools was carried out in a systematic way from identification of unit of analysis, categorization, sampling, data analysis and interpretation. The comparative study revealed common areas in curriculum organization, arrangement of problems in stages, problem selection criteria, and basic concepts in the early stages of the curriculum. About one-third of the health problems were found to be similar in the schools compared. However, there was no uniformity in the sequence of organ-systems or the health problems. This study provides a framework for the development of problem-based curriculum in three stages with essential concepts identified for the first stage. Criteria for a balanced selection of problems and problem design features which affect the quality of health problems have been identified. These findings could be of value for those who are in the process of developing or revising a problem-based curriculum.     

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.     

Basic sciences in problem-based learning and conventional curricula: students' attitudes

The purpose of this study was to compare the attitudes toward basic sciences of students in a preclinical problem-based curriculum and a conventional lecture-based curriculum at the end of their second year of medical school. The results showed that the PBL class had more positive attitudes toward basic sciences than students in the conventional class. These results may reflect a learning environment where students meet many scientist role models as teachers and where basic science is learnt in the context of clinical problems.