Change in student attitudes to medical school after the introduction of problem-based learning in spite of low ratings

Students' attitudes to, and opinions of, their studies at medical school were investigated with the help of a questionnaire. They were asked to what extent the medical school encouraged independent, critical thinking, problem-solving skills, decision-making, studying outside the textbook and other behaviours and skills that teachers in higher education usually put forward as important. It was found that students generally had a low opinion of the extent to which their education encouraged such virtues, mean figures ranging between 3·5 and 4·6 on a 10-grade scale. The students felt that their studies to a large extent encouraged focus on details and preparation for examinations. The questionnaire was given to the students after 2½ years of traditional preclinical studies and at the end of the first clinical year. There were significant but numerically small differences for some of the items at the end of the year. However, when problem-based learning (PBL) was introduced during the first clinical year, there was a substantial change: there were now significant and numerically larger differences for seven of the nine items, even though the students were asked to give their opinion of the whole of their time at medical school on both occasions, not only of the last year. There were no other changes in the curriculum or the teaching methods other than the introduction of PBL. The change in attitudes did not depend on the student's appreciation of PBL; students' opinion of PBL was low, indicating that most of them disliked it.     

Curriculum assessment for prevention topics and the population perspective

BACKGROUND: According to the Association of American Medical College's (AAMC) Senior Questionnaire, medical students spend an inadequate amount of time learning about health promotion, disease prevention, and the population health perspective. OBJECTIVE: Determine the health promotion/disease prevention (HPDP) content of the medical school curriculum at the University of Kansas School of Medicine, using an inventory of knowledge and skills in HPDP and using physician education objectives from Healthy People 2000. METHODS: A 121-item survey to evaluate curriculum content was developed. All course directors evaluated their course by using this instrument. An average of three medical students used this instrument to assess each curriculum lecture and every clinical clerkship day in the required medical school curriculum. A teaching session was defined as spending a minimum of 3-5 minutes teaching an HPDP topic. RESULTS: Of 21 required courses in the medical school curriculum, 11 accounted for the 393 teaching sessions in HPDP. Seventy-five percent (293 sessions) of these dealt with clinical prevention. Quantitative methods received 40 sessions, whereas the health services organization and delivery and the community dimensions of medical practice received 37 and 23 sessions, respectively. Course directors and students disagreed significantly in which HPDP topics were taught in the curriculum. CONCLUSIONS: Clinical prevention was fairly well covered in the medical school curriculum. Quantitative methods, health services organization and delivery, and community dimensions of medical practice were poorly covered. This assessment was used to substantially improve the curriculum. To track and improve curriculum content in all courses, course directors need to know more precise details about the content of their courses, so this detail can be used to better evaluate the overall curriculum.     

A preliminary study of empathy, emotional intelligence and examination performance in MBChB students

CONTEXT: There is considerable interest in the attributes other than cognitive ability that medical students need in order to be professionally successful, with a particular focus on empathy and emotional intelligence (EI). Selection considerations have also motivated interest in such attributes as predictors of academic success. There are reports of declines in empathy in US medical students, but no comparative information is available for UK students. OBJECTIVES: This study aimed to compare empathy levels in medical students in Years 2, 3 (pre-clinical) and 5 (clinical), to examine gender differences in empathy and EI, and to investigate whether EI and empathy are related to academic success. METHODS: Questionnaires assessing EI and empathy were completed by students. Previous empathy scores for the Year 2 cohort were also available. Empathy trends were examined using anova; trends for the Year 2 group for whom Year 1 scores were available were examined using repeated-measures anova. Associations of EI and empathy with academic success were examined using Pearson correlation. RESULTS: A significant gender x cohort effect was found, with male empathy scores increasing between Years 1 and 2, whilst female scores declined. Peer ratings in Year 2 problem-based learning (PBL) groups were positively correlated with EI. CONCLUSIONS: Trends in levels of empathy differed by gender. The reasons for this require further investigation, particularly in relation to course content. Associations between academic performance and EI were sparse, and there were none between academic performance and empathy, but the effects of EI (and other characteristics) on PBL group functioning represent a promising area for future study.     

Early effects of a new problem-based clinically oriented curriculum on students' perceptions of teaching

OBJECTIVES: To compare the course experiences of medical students in a new problem-based (PBL) undergraduate medical course with those of their peers in a conventional curriculum. DESIGN: Whole class questionnaire survey using a pre-validated research instrument. SETTING: University of Liverpool, UK. SUBJECTS: First and second year medical students RESULTS: New curriculum students were more satisfied with their course when compared to their conventional course peers. Problem solving, team working and motivation scores were significantly higher amongst new course (PBL) students. New course students were more anxious about clarity of objectives and standard of work required. CONCLUSIONS: Early evidence suggests that curriculum reform from conventional teaching to a small group problem analysis programme results in improvement in student satisfaction with teaching and the development of appropriate learning skills.     

Comparing the long-term retention of a physiology course for medical students with the traditional and problem-based learning

The rapid improvements in medical sciences and the ever-increasing related data, however, require novel methods of instruction. One such method, which has been given less than due attention in Iran, is problem-based learning (PBL). In this study, we aimed to evaluate the impact of study skills and the PBL methods on short and long-term retention of information provided for medical students in the course of respiratory physiology and compare it with traditional learning method. In this study, 39 medical students from Medical School of Kerman University of Medical Sciences, Kerman, Iran (2006–2010) were enrolled in the study and allocated randomly in three equal groups (13 in each group). All groups underwent a pre-test to be assessed for their basic information regarding respiratory physiology. Two groups were instructed using the traditional method, and one group used PBL. Among the two groups of the traditional method, one was instructed about study skills and the other was not. Once the PBL group took the study skill workshop, they were aided by tutors for their education. In the final term test, those students who had learned study skills and were instructed with the traditional method scored higher compared to other groups (p < 0.05). However, in the 1 year (p < 0.05) and 4 year (p < 0.01) interval examinations, the PBL group achieved significantly higher scores. Despite the fact that PBL had no positive effect on the final term exam of our students, it yielded a more profound and retained understanding of the subject course. Moreover, considering the positive effect of study skills on long-term student scores, we recommend students to receive instructions regarding the appropriate study skills when initiated into universities.     

Instructions in learning skills: an integrated approach

Summary. The transition from school to university education and a medical school environment can be difficult even for the very best students. However, little appears to be done to assist students in making this transition and in developing study skills during the early stages of their training. This article outlines a scheme which has been called supplemental instruction. Although developed for medical students in the United States, it is particularly well suited to developing essential study skills in first-year medical students in the United Kingdom. The scheme has been successfully introduced into some degree and diploma subjects in this country, with improvement in course grades and lower attrition rates, but has yet to be introduced into medical education. Evaluation data for non-medical courses show that student participation in supplemental instruction significantly improves overall course marks and could be of significant value in the medical curriculum.     

Providing early clinical experience in primary care

Undergraduate courses in British medical schools are changing following recommendations from the General Medical Council. Increasing emphasis has been placed on teaching in the community. Nottingham Medical School has pioneered the teaching of basic clinical skills in primary care during the pre-clinical course to help produce an integrated curriculum. This qualitative study evaluated the first two years of the new early clinical experience course at Nottingham by using interviews with 19 students and their GP tutors. Students claimed to have gained confidence in talking to patients, their understanding of the role of the doctor and the importance of the doctor-patient relationship. Students were less confident about examining patients and some reported having had little opportunity to practice examination skills. Half the students thought that the early clinical visits had helped them to understand and be more motivated to learn their basic medical sciences course. The newly recruited GP teachers were highly motivated, very positive about the early clinical teaching and all wanted to continue to teach the pre-clinical students. Difficulties in providing the course included communication with students and staff, organization of student travel and variation in the quality of teaching. However, the Nottingham early clinical experience course has shown that basic clinical skills can be successfully taught to pre-clinical students in primary care.     

Assessing the development of communication skills in undergraduate medical students

CONTEXT: The teaching of clinical communication skills' teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training. AIMS: To determine the change in communication skills between early and mid-stages of the students' 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to observed performance. PARTICIPANTS: Students entering as the first cohort to the new medical curriculum at Liverpool Medical School (n=207). Nine students withdrew leaving 198 students who completed two summative assessments in June 1997 (level 1) and November 1998 (level 2). STATISTICAL ANALYSIS: Repeated measures multivariate ANOVAS were applied to the main study data to detect any change in performance between levels 1 and 2. RESULTS AND CONCLUSIONS: An improvement in communication skills was found in medical students over 17 months of their undergraduate teaching: that is from the level 1 to the level 2 assessment. Knowledge and understanding of communication skills at initial assessment did not show the predicted association with performance at level 2.     

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.     

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

PURPOSE: This paper reports a prospective, randomised study comparing a problem-oriented practical (POP) course based on paper cases to a personal bedside teaching (PBT) practical course and a standard practical course. METHODS: During 2 consecutive terms, students were randomly allocated to either 2 POP groups/term (n = 10/group), 2 PBT groups/term (n = 10/group) or the standard practical course, which consisted of a rotating system of lectures and bedside teaching with randomly appointed tutors. Each course was evaluated with the same 12-item questionnaire and multiple-choice test administered at the beginning and end of the course. RESULTS: The numbers of students evaluated were 36 for the POP groups, 37 for the PBT groups, and 155 for the standard course. The PBT and POP courses were rated significantly better (P < 0.001) than the standard course for all items. Aggregate marks (mean +/- SD) were: 1.59 +/- 0.8 for the POP course; 1.69 +/- 0.68 for the PBT course, and 2.71 +/- 0.98 for the standard course. There were no significant differences between the POP and PBT courses. Significantly better learning rates as indicated by an increase in the number of correctly answered questions were observed in students attending the POP and PBT courses. CONCLUSION: This prospective study demonstrated that there was no difference in the rating of a POP course and a bedside teaching course by students randomly assigned to 1 of 3 different pedagogical approaches. Furthermore, both alternative options achieved better ratings than the standard course, which is current teaching practice in our medical school. The PBT and POP approaches provided superior learning success and POP helped solve the problems of standardisation and patient recruitment.     

Standardized patients in the early acquisition of clinical skills

OBJECTIVES: Facing dramatic reductions of inpatient beds and fewer faculty tutors, the Queen's University medical school has had to consider alternatives to the traditional inpatient encounter for the early acquisition of clinical skills. The purpose of this study was to investigate the feasibility and impact on students of a model for a first-year clinical skills course, using exclusively standardized patients in place of inpatients, and using a smaller ratio of faculty to students. DESIGN: Twenty volunteers were selected from the first-year class of 75 students to participate as the experimental group. The remaining 55 students formed the control group. SETTING: Queen's University medical school, Ontario, Canada. SUBJECTS: First-year medical students. RESULTS: In measures of student satisfaction with the amount of performance feedback received during the course, there was a non-significant trend towards greater satisfaction among the experimental group compared to the control group. This occurred despite a tutor to student ratio of 1.5:10 in the experimental group compared to 3:10 in the control group. In the student evaluation of their tutors, mean scores for the two groups were 4.28 for the experimental group and 4. 06 for the control group (P = 0.10). The mean OSCE scores for the two groups were 76.4 for the experimental group and 76.5 for the control group (P = 0.93). There is no practical or statistical difference in either of these two scores. CONCLUSIONS: We conclude that this new model is feasible, was well received by the students and that the reduced tutor to student ratio and lack of inpatient encounters did not appear to adversely affect their learning.     

Early introduction of clinical skills teaching in a medical curriculum--factors affecting students' learning

OBJECTIVE: To evaluate the effects of the early introduction of clinical skills teaching on students' learning following an overhaul of the curriculum of a traditional Asian medical school. METHODS: Randomly selected medical students in Year I and II were invited to participate in 30 focus group interviews while all students were asked to assist with the questionnaire survey. Most students were contacted personally to help them understand the objectives of the study. Confidentiality was emphasised and a non-faculty interviewer was recruited for the interviews. RESULTS: Two hundred and eight of Year I/Year II students attended the lunchtime focus group interviews (response rate=86.7%) while 252 (73.5%) students returned the questionnaire. The majority of them (87%) agreed or strongly agreed that it was good to introduce clinical skills in the early years of the curriculum. They reflected that the course enhanced their learning interest and made them feel like doctors. They also made many constructive suggestions on how the course could be improved during the interactive focus group interviews so that the negative effects could be minimised. CONCLUSION: It is useful to introduce clinical skills in the early years of a medical curriculum. A comprehensive course evaluation, using both quantitative and qualitative methods, helps to collect useful information on how the course can be improved.     

First step: report on a pilot course for personal and professional development

OBJECTIVE: To describe a pilot course in personal and professional development, entitled 'Becoming a doctor: the first step' and our suggestions for what might be incorporated into future courses. SETTING AND CONTEXT: Leeds Medical School begins a new curriculum in September 1999 with a proportion of the first 3 years being devoted to a new module on personal and professional development. This module will include courses involving communication skills, ethics, working in groups and early patient contact through community visits. Some of these topics were piloted in a short course for first-year medical students in 1998. LEARNING METHODS: The course ran for 9 weeks and was largely experiential. The group facilitators came from diverse health and social care backgrounds. A variety of learning methods were used, concentrating on self-reflection, discussion, community visits and information gathering. EVIDENCE FOR EFFECTIVENESS: The views of both facilitators and students were analysed. Students particularly appreciated the community visits and group work. The facilitators were positive about the course overall while suggesting improvements, including their own involvement in future development of the course. CONCLUSIONS: The pilot course has helped us to focus on objectives for the new curriculum and to plan the new course. In particular there is a need for more attention to be given to the involvement of facilitators in course development.     

医学研究生PBL教学效果评价及影响因素分析

目的:评价医学研究生PBL课程的教学效果及其主要影响因素,为推进研究生教学改革提供依据。方法:设计信度、效度较好的PBL教学质量评价问卷,选取某医科大学参与PBL课程的研究生开展问卷调查。结果:PBL在医学研究生中应用有较好的教学效果。多因素分析结果表明,学生课前资料准备情况、学生所修课程与专业的相关程度、课程类型、学生同一学期选课门数、教师是否担任研究生导师、学生课堂讨论参与度、学生对PBL模式的认知程度以及学生有既往是否有工作经历是影响PBL课程教学质量的主要因素。结论:PBL模式在医学研究生中的教学效果可通过完善教学管理、合理组建教学团队、加强研究生自主学习意识培养等环节进一步改善。     

Assessment of student performance in problem-based learning tutorial sessions

OBJECTIVES: To assess student performance during tutorial sessions in problem-based learning (PBL). DESIGN: A 24-item rating scale was developed to assess student performance during tutorial sessions in problem-based learning (PBL) as conducted during the pre-clinical years of Medical School at the National Autonomous University of Mexico. Items were divided into three categories: Independent study, Group interaction and Reasoning skills. Fourteen tutors assessed 152 first and second-year students in 16 tutorial groups. An exploratory factor analysis with an Oblimin rotation was carried out to identify the underlying dimensions of the questionnaire. SETTING: Medical School at the National Autonomous University of Mexico. SUBJECTS: Medical students. RESULTS: Factor analysis yielded four factors (Independent study, Group interaction, Reasoning skills, and Active participation) which together accounted for 76.6% of the variance. Their Cronbach reliability coefficients were 0.95, 0.83, 0.94 and 0. 93, respectively, and 0.96 for the scale as a whole. CONCLUSIONS: It was concluded that the questionnaire provides a reliable identification of the fundamental components of the PBL method as observable in tutorial groups and could be a useful assessment instrument for tutors wishing to monitor students' progress in each of these components.     

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.     

Retention of interviewing skills learned by first-year medical students: a longitudinal study

A pilot interviewing course was offered as an elective to first-year medical students in the spring of 1985. A quasi-experimental pre-test/post-test control group demonstrated that students who took the course exhibited a significant increase in interviewing skills. Subjects, 15 in the experimental group and 11 in the control group, were assessed in each of the following 3 years. Data consisted of five 10-minute videotaped interviews with real or stimulated patients for each subject and subject's responses on a degree of confidence, familiarity and anxiety scale. Interviews were rated on 43 behaviours by two independent coders with a 90% simple agreement. The experimental group did not maintain their scores on interviewing skills and both groups showed a significant decline in nine skills comprising empathy. The only significant difference between the groups in fourth year was on the degree of confidence experienced. While interviewing skills can be learned they decline in the clinical years as students learn medical problem-solving. If medical students are to graduate with their original empathy intact, a follow-up course in fourth year is indicated.     

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools

BACKGROUND AND OBJECTIVES: The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions. METHODS: A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire. RESULTS: Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students. CONCLUSION: Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.     

Non-cognitive characteristics of medical students: entry to problem-based and lecture-based curricula

The effectiveness of problem-based learning (PBL) versus lecture-based learning (LBL) continues to be debated all over the world. These arguments have often been based on students' cognitive measures of performance. Little emphasis has been placed on non-cognitive factors that may directly or indirectly affect the medical school performance of students in either curriculum. The purpose of this study was to (1) document possible differences in student cognitive and non-cognitive characteristics at entry between the two curricula and (2) to explore the relationships that exist between cognitive and noncognitive factors. Data were obtained from three medical school classes (   n = 281  ). The results indicate that students who entered the PBL curriculum at this medical school had higher total Medical College Admission Test and undergraduate grade point average than students who entered the LBL curriculum. Students who entered the PBL curriculum were also more self-sufficient and were more likely to do well in individualistic and less structured settings. There were no strong correlations between cognitive and non-cognitive variables. Before conclusions can be drawn about the effectiveness of either PBL or LBL curricula, we need to document patterns in entry characteristics to control for a priori differences that affect student performance.