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.     

Building confidence for work as house officers: student experience in the final year of a new problem-based curriculum

INTRODUCTION: Newly qualified doctors require an appropriate level of confidence for their new roles. Development of this confidence was a key objective in the final year of a new integrated course with an emphasis on student self-direction. CONTEXT: There are 5 placements in the final year course. Students use a Learning Planner to help them choose suitable placements and objectives to serve their learning needs. Educational supervision focuses on helping students determine their objectives and assessing them against these. METHODS: Course evaluation was by means of a questionnaire during final assessments. Cohorts of 310 and 316 students in successive years completed the evaluation. The interrelationship between variables was explored using logistic regression. RESULTS: 220/310 students in the 2000 cohort and 214/316 in the 2001 cohort agreed they felt confident with their prospective role as a pre-registration house officer (PRHO). Confidence was significantly associated with confidence in their clinical skills, belief in their ability to cope with uncertainty and feeling able to work as a team member. The experience of the 2 hospital placements and (in 2000 only) the elective was associated with increased confidence. In all placements helpful educational supervision and the achievement of the self-directed learning plan was associated with increased confidence as a potential doctor. CONCLUSION: Students perceive a relationship between learning experiences in the final year of a self-directed course and development of confidence for their future role. Whilst further elucidation of the nature of this relationship is required, this provides encouragement to curriculum planners to promote self-direction.     

Recruiting problem-based learning (PBL) tutors for a PBL-based curriculum: the Flinders University experience

OBJECTIVES: To examine the contribution made to problem-based learning (PBL) by individual teachers and by departments in years 1 and 2 of a new graduate-entry medical programme (GEMP) with a PBL-based curriculum. METHODS: We compiled a database on all PBL tutoring undertaken in years 1 and 2 during the first 3 years in which the GEMP was delivered. This allowed us to quantify and analyse the contribution made by individuals and by departments. RESULTS: At 3 years following introduction of the GEMP, 136 (25.9%) of the school's 525 staff had trained as PBL tutors and 98 (18.7%) had tutored. Both individuals and departments differed greatly in the amount of time devoted to PBL tutoring. Staff who tutored once tended to tutor again in subsequent years. Compared with staff in clinical departments, those in non-clinical departments (who constituted 12% of the total) made a greater relative contribution though a smaller absolute contribution to tutoring. CONCLUSIONS: These findings prompted us to develop a formula that distributes the PBL tutoring load more evenly across departments. This was successfully introduced in 1999. It recognizes the fact that only a minority of staff will volunteer to become PBL tutors. Strategies that might encourage more staff to tutor are briefly discussed.     

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.     

Effectiveness of problem-based learning curricula: theory, practice and paper darts

In a recent review article, Colliver concluded that there was no convincing evidence that problem-based learning was more effective than conventional methods. He then went on to lay part of the blame on cognitive psychology, claiming that 'the theory is weak, its theoretical concepts are imprecise. the basic research is contrived and ad hoc'. This paper challenges these claims and presents evidence that (a) cognitive research is not contrived and irrelevant, (b) curriculum level interventions are doomed to fail and (c) education needs more theory-based research.     

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.     

Techniques used by "expert" and "non-expert" tutors to facilitate problem-based learning tutorials in an undergraduate medical curriculum

BACKGROUND: There is inconclusive debate within the literature as to whether the best problem-based learning (PBL) tutors are subject experts or not. The debate hinges on whether knowledgeable tutors are tempted to intervene too often in PBL discussions compared to non-expert tutors, and whether the latter may not be able to sufficiently challenge the students' level of understanding. PURPOSE: To describe approaches used by tutors in PBL tutorials and to identify differences between tutors from medical and non-medical backgrounds. METHODS: The research reported in this paper was undertaken during the academic session 1999-2000 at the University of Liverpool Faculty of Medicine. A qualitative exploratory case study method was used and two PBL groups were observed. One of these groups had a medically qualified tutor and the other had a tutor from a humanities background. The focus of the observation was the discourse between tutor and students, which was analysed using a framework drawn from linguistics. Results were fed back to both the tutors and the students to check their perceptions of the interactions. RESULTS: Analysis of the tutorial group interaction revealed that tutors from both backgrounds used similar techniques to raise students' awareness, facilitate the group process and direct students' learning. Differences were noted between the two tutors: the medical tutor set out to raise students' awareness by using questioning techniques herself, whereas the non-medical tutor expected students to question each other. The non-medical tutor was observed to facilitate the group process more often than the medical tutor. CONCLUSIONS: Qualitative analysis of spoken discourse in PBL tutorials provides valuable insights into the processes involved in PBL, thereby generating material which is useful for both training of and giving feedback to PBL tutors.     

Student perceptions of a virtual learning environment for a problem-based learning undergraduate medical curriculum

OBJECTIVE: To investigate the effects of a virtual learning environment (VLE) on group interaction and consultation of information resources during the preliminary phase, self-study phase and reporting phase of the problem-based learning process in an undergraduate medical curriculum. METHODS: A questionnaire was administered to 355 medical students in Years 1 and 2 to ask them about the perceived usefulness of a virtual learning environment that was created with Blackboard for group interaction and the use of learning resources. RESULTS: The students indicated that the VLE supported face-to-face interaction in the preliminary discussion and in the reporting phase but did not stimulate computer-mediated distance interaction during the self-study phase. They perceived that the use of multimedia in case presentations led to a better quality of group discussion than if case presentations were exclusively text-based. They also indicated that the information resources that were hyperlinked in the VLE stimulated the consultation of these resources during self-study, but not during the reporting phase. CONCLUSIONS: Students indicated that the use of a VLE in the tutorial room and the inclusion of multimedia in case presentations supported processes of active learning in the tutorial groups. However, if we want to exploit the full potential of asynchronous computer-mediated communication to initiate in-depth discussion during the self-study phase, its application will have to be selective and deliberate. Students indicated that the links in the VLE to selected information in library repositories supported their learning.     

Child health and obstetrics-gynaecology in a problem-based learning curriculum: accepting the limits of integration and the need for differentiation

BACKGROUND AND OBJECTIVES: The University of Manchester's undergraduate curriculum was reorganised in 1994. Problem-based learning (PBL) was chosen as the central educational method throughout the 5 years. A thematic interdisciplinary style provided a framework around which to select and integrate content. The theme for family, reproductive and child health for the 14-week Families and Children Module (FCM) in year 4 integrated content from obstetrics-gynaecology, paediatrics (including child psychiatry), genetics and public health. This paper focuses on the FCM which has put to test some of the principles of integration. METHODS: The educational process and outcome of the FCM was evaluated with information from (1) Open Forum feedback sessions (2) student questionnaires and (3) students' performance in an objective structured clinical examination (OSCE). RESULTS: Significant problems were encountered during the first year of the FCM (1997--98). An Open Forum for all students and staff was convened after each module in order to address the level of concern. Students' responses to questionnaires reflected the overall impression obtained from the Open Forum. Difficulties appeared to be more than the anxieties and challenges inherent in organisational change and were not simple practical timetabling problems. Tutors perceived a loss of coherence and student contact; students reported difficulties maintaining sufficient continuity of focus in clinical and academic learning experiences. The intended level of integration of paediatrics and obstetrics-gynaecology was unmanageable. Consequently, the FCM (1998-99) was divided into separate attachments for clinical learning and experience in paediatrics and obstetrics-gynaecology, each of 7 weeks' duration. Further open feedback sessions revealed that the modifications implemented in 1998-99 were associated with positive experiences for students and tutors. Comparison of responses to the evaluation questionnaires showed that students' overall rating of the module was higher (P=0.002) for 1998-99 (mean 3.4, SD 0.9) than for 1997-98 (mean 3.0, SD 1.1). CONCLUSIONS: We emphasise that horizontal integration can result in an experience of disintegration for students and tutors. Certain disciplines, such as paediatrics and obstetrics-gynaecology, may not have enough in common for full curriculum integration.     

The limits of tutors' comfort zones with four integrated knowledge themes in a problem-based undergraduate medical curriculum (Interview study)

PURPOSE: To explore how a cohort of problem-based learning (PBL) tutors (with diverse medical and other content expertise) conceptualised their students' integrated learning agenda, particularly for content less familiar to the vast majority, such as public health elements. SETTING: Problem-based undergraduate medical curriculum, The University of Liverpool, in its first-ever year. PARTICIPANTS: Foundation PBL tutors for Year 1 students, Semester 1. METHOD: A cross-sectional, semistructured telephone interview study was undertaken during spring 1997, with open-ended questions about Semester 1 experience of the four main themes. Qualitative data were analysed inductively and iteratively for emerging patterns and instances. RESULTS: All 34 tutors responded. Of these, 26/34 (76%) were male and 23 (68%) were medically qualified. Towards the end of each approximately (median) 20-minute interview, reflecting on the curriculum themes, tutors mostly identified with the basic/clinical science theme (Structure and Function). Almost half articulated a clear division (implicitly or explicitly 'fact' versus 'non-fact') between it and the 'other three' themes of behavioural science, population science, and ethicolegal aspects of professional practice, respectively. Only 14/34 (41%) of tutors (including both public health doctors) outlined the public health-based theme adequately without disclosing confusion, antagonism/indifference or difficulties/uncertainty. CONCLUSION: This study provides baseline qualitative insights about new PBL tutors' insecurities when facilitating student discussion across integrated content. Given the difficulties of recruiting suitable educators into this role and potential resource limitations, staff retention and development strategies still must confront the reality of PBL tutors' bemusement when they are placed outwith their usual comfort zones.     

Strategic planning in medical education: enhancing the learning environment for students in clinical settings

BACKGROUND: The 1999 Cambridge Conference was held in Northern Queensland, Australia, on the theme of clinical teaching and learning. It provided an opportunity for groups of academic medical educators to consider some of the challenges posed by recent changes to health care delivery and medical education across a number of countries. PURPOSE: This paper describes the issues raised by the practical challenges posed by the current environment and how they might be addressed in ways that could promote more effective learning in clinical settings. METHOD: A SWOT analysis is a tool that can help in forward planning by identifying the strengths, weaknesses, opportunities and threats presented by any situation. Our SWOT analysis was used to generate a list of items, from which we chose those most feasible and most likely to promote positive change. RESULTS: Twenty different issues were identified, with four of them chosen by consensus for further elaboration. The discussion gave rise to four main recommended strategies: ensuring that clinical teachers thoroughly understand the purpose and process of learning in clinical settings; equipping learners with 'survival skills'; making the best use of learning resources within different clinical environments and making judicious use of information technology to enhance learning efficiency. CONCLUSIONS: The four strategies were selected not only because of their inherent importance, but also because of their feasibility. Modest changes can motivate students to feel part of a clinical team and a 'community of practice' and enhance their capacity for self-regulated practice.     

Consistency of teaching in parallel surgical firms: an audit of student experience at one medical school

BACKGROUND: Traditional clinical clerkships have been based on the apprenticeship model of learning, with opportunistic teaching by doctors on presenting patients. Students at King's College School of Medicine, London had expressed concern that they were receiving inequitable experiences in different clerkships. This had become more apparent since the introduction of a school-wide end-of-year skills assessment. We decided to assess the consistency of delivery of the surgical syllabus. METHOD: A multistage questionnaire survey was undertaken with third-year (first clinical year) undergraduate medical students on surgical clerkships. The questionnaire required students to record topics about which they had been taught, and practical skills on which they had been supervised, from the surgical syllabus pertaining at the time. RESULTS: 194 (46.4%) questionnaires were returned. A low level of consistency was reported in the teaching of theoretical topics and practical skills across surgical clerkships in eight different locations. There were substantial differences, both in overall coverage of the syllabus and in the priority given to different topics. There were no overall differences between teaching hospital- and district general hospital-based clerkships. DISCUSSION: Students in so called 'parallel' clerkships did not receive comparable teaching. The traditional opportunistic nature of clinical teaching led, in effect, to individual curricula within each clerkship. The General Medical Council has called for a core curriculum to be delivered across different clinical sites within each medical school. To achieve this, medical schools may need to introduce guidelines to direct teaching in the same way that clinical protocols have been developed to achieve greater standardization in clinical practice.     

Using real patients in problem-based learning: students' comments on the value of using real, as opposed to paper cases, in a problem-based learning module in general practice

OBJECTIVES: To explore the feasibility and value of using real patients as trigger material in problem-based learning (PBL). DESIGN: A questionnaire was given to all students participating in a PBL module including a question about 'the added value of using real, as opposed to paper cases', in problem-based learning. Resources used by students and assessment of feasibility were recorded by the course tutors. SETTING: A 7-week student-selected problem-based module in general practice in the fourth-year undergraduate medical curriculum, University of Newcastle upon Tyne. SUBJECTS: 69 students participating in the module over 2 years. RESULTS: All students valued the use of real patients. A total of 10 categories were identified, all congruent with accepted educational principles for effective adult learning. Real patients stimulated the use of a very wide range of resources and imaginative presentation of what had been learned. CONCLUSION: Real patients are potent trigger stimuli in problem-based learning. The use of real patients in this general practice-based module presented no organizational or ethical difficulties. Their use should be considered more widely.     

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.     

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.     

Clinical teachers and problem-based learning: a phenomenological study

AIM: To explore how clinicians perceive their roles in problem-based medical education, and how closely those perceptions link to the curriculum they teach. METHOD: All 14 general physicians in a teaching hospital took part in 6 semistructured discussions, which were analysed phenomenologically. RESULTS: Third year clinical teaching was described in terms that bore little relation to problem-based learning (PBL). Teachers placed great importance on the social dimension of professional learning. They expressed strongly positive affects towards learners and their learning that they found hard to express as PBL tutors. Their narratives of education were remarkably divorced from modern day clinical practice. CONCLUSIONS: Problem-based method lacked some important conditions for professional teaching and learning. Traditional apprenticeship is unsustainable under present day conditions of practice. There is a need for new educational methods that help the learner to build a professional identity through social interaction with practitioners.     

Learning in a problem-based medical curriculum: students' conceptions

The purpose of this study was to examine students' conception of their learning in a problem-based learning medical curriculum. A multiple case study design was used with two units of analyses: two PBL lab groups; and 15 individual students within each lab group. Data collected included weekly journals by students, video-tapes of PBL sessions, focus group interviews with students, two open-ended questionnaires completed by students, and interviews with the PBL tutors. Three thematic categories of students' conceptions of their learning emerged: (1) awareness of PBL goals and expectations; (2) efficiency and expertise; and (3) the role of the tutor.     

Profiles of effective tutors in problem-based learning: scaffolding student learning

OBJECTIVES: Research on tutoring in problem-based learning has not focused so far on the variation in tutoring and how this variation can be interpreted by conceptions about effective tutoring. DESIGN: This study focuses on the profiles of tutors generated by means of an instrument, the so-called Tutor Intervention Profile (TIP), and tries to determine which profiles are more or less effective. The TIP contains four dimensions of tutor behaviour: (1) elaboration; (2) directing the learning process; (3) integration of knowledge; and (4) stimulating interaction and individual accountability. SETTING: The medical school of the University of Maastricht, The Netherlands. SUBJECTS: Sixty-seven tutors who run 67 tutorial groups across three units (courses) in the academic year 1996-97. RESULTS: It appeared that high, average and low performing tutors differ in their performance on each of the four dimensions of the TIP. Several different profiles of tutor performance could be distinguished, which were more or less effective. One group of tutors demonstrated a tutor intervention profile that was characterized as relying more on the use of expert knowledge, whereas another group of tutors was characterized as relying more on their abilities to stimulate the learning process in the tutorial group. The tutor intervention profile that was perceived by students as most effective showed high scores on each of the four dimensions, as expected. Notably, a tutor stressing the learning process in the tutorial group was perceived as more effective than a tutor stressing content (expert tutor). This is especially true for a relatively poor scoring tutor. CONCLUSIONS: The results of this study are consistent with research on human tutoring and research on tutoring in problem-based learning.     

First year medical student stress and coping in a problem-based learning medical curriculum

OBJECTIVE: To examine the prevalence of psychological morbidity, sources of stress and coping mechanisms in first year students in a problem-based learning undergraduate medical curriculum. DESIGN: Longitudinal cohort questionnaire survey. SETTING: Glasgow University Medical School. PARTICIPANTS: All first year students (n = 275) in the 1997-98 intake. MAIN OUTCOME MEASURES: Scores on the 12-item General Health Questionnaire (GHQ-12), sources of stress and coping strategies. RESULTS: The prevalence of psychological morbidity and mean GHQ-12 scores increased significantly between term 1 and term 3, with no significant gender differences. Principal stressors were related to medical training rather than to personal problems, in particular uncertainty about individual study behaviour, progress and aptitude, with specific concerns about assessment and the availability of learning materials. The group learning environment, including tutor performance, and interactions with peers and patients caused little stress. Students generally used active coping strategies. Both stressor group scoring and coping strategies showed some variation with gender and GHQ caseness. CONCLUSIONS: Increased student feedback and guidance about progress throughout the year and the provision of adequate learning resources may reduce student stress. Educational or pastoral intervention regarding effective coping strategies may also be beneficial. Continued follow-up of this cohort could provide information to inform further curriculum development and, if appropriate, aid the design of programmes for the prevention of stress-related problems.