Does problem‐based learning lead to deficiencies in basic science knowledge? An empirical case on anatomy

INTRODUCTION: Problem-based learning (PBL) is supposed to enhance the integration of basic and clinical sciences. In a non-integrative curriculum, these disciplines are generally taught in separate courses. Problem-based learning students perceive deficiencies in their knowledge of basic sciences, particularly in important areas such as anatomy. Outcome studies on PBL show controversial results, sometimes indicating that medical students at PBL schools have less knowledge of basic sciences than do their colleagues at more traditional medical schools. We aimed to identify differences between PBL and non-PBL students in perceived and actual levels of knowledge of anatomy. METHODS: Samples of Year 4 students in all eight medical schools in the Netherlands completed a questionnaire on perceived knowledge and took part in a computerised anatomy test consisting of both clinically contextualised items and items without context. RESULTS: Problem-based learning students were found to have the same perceived level of anatomy knowledge as students at other medical schools. Differences in actual levels of knowledge were found between schools. No significant effects on knowledge levels were found for PBL schools versus non-PBL schools. CONCLUSION: The results of this study show that PBL does not result in a lower level of anatomy knowledge than more traditional educational approaches. It remains to be ascertained whether the levels students attain are adequate. Subjects for further study are the desired level of anatomy knowledge at the end of undergraduate medical education and the effectiveness of basic science learning within a clinical context and with repetition over the course of the curriculum.     

Impact on knowledge acquisition of the transition from a conventional to an integrated contextual medical curriculum

Context  This study set out to test the hypotheses that after the implementation of an integrated contextual medical curriculum (ICMC), ICMC students would attain higher levels of knowledge in both the basic and clinical sciences at an earlier stage than conventional medical curriculum (CMC) students, that ICMC students would perform significantly better on knowledge tests at the end of their education and, finally, that ICMC students would show a more linear acquisition of knowledge in the basic and clinical sciences.
Methods  We drew upon the Dutch Inter-University Progress Test (PT) to measure impact on knowledge acquisition and compared PT scores of 393 CMC students with scores of 1028 ICMC students (Years 2–6) in a cross-sectional design. We also compared the scores of 112 CMC students with those of 197 ICMC students in Years 3–6 in a longitudinal design.
Results  As expected, ICMC students showed a steeper learning curve in both the basic and clinical sciences: at the end of their training students had attained higher levels of knowledge in both domains. The learning curve pertaining to the clinical sciences was almost linear, whereas that for the basic sciences showed a sharper rise, indicating a continuing growth of knowledge.
Conclusions  The differential impact on knowledge acquisition of conventional and innovative curricula has seldom been studied in a longitudinal and cross-sectional design. This study confirmed our assumptions about the potential of an integrated contextual curriculum. The differences observed in ICMC students were attributed to the stronger emphasis on clinically relevant basic sciences in the early years of the ICMC and to the stronger integration of basic and clinical sciences in the ICMC.     

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.     

Influence of PBL with open-book tests on knowledge retention measured with progress tests

The influence of problem-based learning (PBL) and open-book tests on long-term knowledge retention is unclear and subject of discussion. Hypotheses were that PBL as well as open-book tests positively affect long-term knowledge retention. Four progress test results of fifth and sixth-year medical students (n = 1,648) of three medical schools were analyzed. Two schools had PBL driven curricula, and the third one had a traditional curriculum (TC). One of the PBL schools (PBLob) used a combination of open-book (assessing backup knowledge) and closed-book tests (assessing core knowledge); the other two schools (TC and PBLcb) only used closed-book tests. The items of the progress tests were divided into core and backup knowledge. T tests (with Bonferroni correction) were used to analyze differences between curricula. PBL students performed significantly better than TC students on core knowledge (average effect size (av ES) = 0.37–0.74) and PBL students tested with open-book tests scored somewhat higher than PBL students tested without such tests (av ES = 0.23–0.30). Concerning backup knowledge, no differences were found between the scores of the three curricula. Students of the two PBL curricula showed a substantially better long-term knowledge retention than TC students. PBLob students performed somewhat better on core knowledge than PBLcb students. These outcomes suggest that a problem-based instructional approach in particular can stimulate long-term knowledge retention. Distinguishing knowledge into core and backup knowledge and using open-book tests alongside closed-book tests could enhance long-term core knowledge retention.     

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.     

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.     

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.     

Differences in knowledge development exposed by multi-curricular progress test data

Progress testing provides data on the growth of students’ knowledge over the course of the curriculum obtained from the results of all students in the curriculum on periodical similar tests pitched at end-of-curriculum level. Since 2001, three medical schools have jointly constructed and administered four progress tests annually. All students in the 6-year undergraduate curricula of these schools take the same tests resulting in 24 distinct measurements per academic year (four tests for six student year groups), which may be used to compare performance between and within schools. Because single point measurements had proven unreliable, we devised a method to use cumulative information to compare schools’ test performance. This cumulative deviation method involves calculation of the deviations of schools’ scores from the cross-institutional average score for 24 measurement moments in 1 year. The current study shows that it appears to be feasible to use a combination of the cumulative deviation method and trend analysis for subdomains of medical knowledge to detect strengths and weaknesses in knowledge development in medical curricula. We illustrate the method by applying it to data from 16 consecutive progress tests administered to all students (4,300) of three medical schools in the academic years 2001/2002 through 2004/2005.     

An international comparison of knowledge levels of medical students: the Maastricht Progress Test

The increasing international mobility of medical students has inspired the search for an international assessment format. As one step along this line, kinetics of knowledge acquisition and final cognitive levels of students were compared among one Dutch, one German and four Italian medical faculties. For this comparison, the Maastricht Progress Test (MPT) was used. For four out of the six participating faculties, it was possible to compare the level of knowledge of sixth-year students. These data showed no significant differences on the test as a whole. On the other hand, as judged from cross-sectional data on students from all study years, the kinetics of knowledge acquisition showed different trends. In one school applying problem-based learning, acquisition of knowledge by students occurred almost linearly. In another school, over the first 2 years, acquisition of knowledge occurred only in the basic sciences but not in clinical or public health/behavioural sciences. In two other schools over that same period, students seemed to gain no knowledge at all. In some faculties, a marked boost in knowledge was noted with third- or fourth-year students. These findings may be explained by peculiarities of the respective curricula, selection of students during their studies, and national or local assessment procedures. It is preliminarily concluded that the different educational approaches and assessment systems in medical education in Europe seem to have only limited influence on the final level of knowledge of the graduates. On the other hand, these differences may influence the kinetics of knowledge acquisition, especially in distinct domains like basic or clinical sciences. Therefore, the MPT may not be suitabe to solve the problem of assessment of individual international exchange students, but it may be helpful in identifying corresponding cognitive levels on, for example, basic sciences for students in different curricula.     

Growth of knowledge in psychiatry and behavioural sciences in a problem-based learning curriculum

PURPOSE: To evaluate the effectiveness of undergraduate medical education in the domains of psychiatry and behavioural sciences, we examined the growth of knowledge in those disciplines in a 6-year, problem-based learning (PBL) curriculum. Psychiatry and behavioural sciences are taught in the 4 preclinical years and in the psychiatric clerkship. The integrative nature of this PBL curriculum led us to hypothesise that the knowledge growth curves for these disciplines are similar and show a steady upward trend throughout the curriculum. METHODS: All items pertaining to psychiatry and behavioural sciences in the progress tests administered in the period from September 1993 through May 2001 were identified. For those items, the percentage of correct scores in the 6 year groups were considered a multivariate observation reflecting knowledge growth across the 6-year programme. RESULTS: Knowledge growth for psychiatry and behavioural sciences increased significantly, from 12% to 59% and from 28% to 60%, respectively, between Year 1 and the end of Year 6. Apparently, students know more about behavioural sciences than about psychiatry when they enter medical school, but this difference vanishes in the last 2 years of training. Moreover, the growth curves for psychiatry and behavioural sciences started to level off after Years 3 and 4, respectively, with no additional significant growth in any of the later years. CONCLUSIONS: Psychiatry and behavioural sciences showed different patterns of knowledge growth and the 2 growth curves levelled off in Years 5 through 6. Because a student-centred, horizontally and vertically integrated PBL curriculum is aimed at effecting steady growth in knowledge in all disciplines, the slowdown in growth in the later years was among the reasons for initiating a major curricular innovation in 2001.     

Medical Students' attitudes toward basic sciences: influence of a primary care curriculum

The emerging popularity of family medicine and primary care among medical students with an attendant pressure for clinical relevance in pre-clinical coursework and early clinical exposure has raised questions in the minds of many academicians about the Students' perceived value of basic sciences in such an educational environment.
A comparison was made of attitudes toward the basic sciences between students in two, concurrent, pre-clinical medical school curricula at the University of New Mexico School of Medicine. The conventional curriculum offers a teacher-centered, 2-year curriculum of basic sciences taught predominantly by basic scientists in a lecture format. The experimental curriculum entitled the Primary Care Curriculum (PCC), offers a student-centered, 2-year curriculum in which pertinent basic and clinical science learning is derived primarily from common, primary care, patient problems, discussed in small group tutorials. There are no formal lectures. Half the tutors are primary care clinicians, half basic scientists.
Attitude scales were administered in two successive classes of students in both curricula at the beginning of the first and second terms of the first year. Increased cynicism toward the curriculum and its relevance to future practice was observed among conventional, but not among PCC students. This finding lends support to the hypothesis that modification in educational methods in general and relevant, primary care experience in particular can favourably influence Students' attitudes toward basic sciences.     

Problem-based learning: measurable outcomes

Problem-based learning (PBL) could potentially contribute to four key objectives in the education of doctors. (1) Motivating learning. Three studies show that students studying PBL problems choose fewer topics to study than those identified by the faculty, but one study of a critical care rotation showed that students were motivated to learn over a wider range of basic science topics than had been included in the basic science curriculum. (2) Developing clinical reasoning. One study compared methods of solving problems in PBL and conventional track curricula and suggested that PBL students work backwards from clinical information to theory, while conventional curriculum students tend to reason forward from theory. One study showed that computer searches provide knowledge for helping solve some PBL problems, and another study showed that specific knowledge in emergency medicine correlated with test scores. (3) Structuring knowledge in clinical contexts. A few studies show that PBL students perform less well on basic science examinations but better on clinical examinations. Educational outcomes, however, have been assessed quantitatively mainly by the U.S. National Boards of Medical Examiners Examinations or by clinical examinations with small samples. Only one study includes a power computation to assess type II error. There are no studies that examine how much variance occurs between PBL programmes in their curricular methods and outcomes. (4) Developing self-learning skills. PBL students use a much wider range and number of resources than conventional track students. There is only one study comparing the knowledge of doctors trained by PBL and conventional curricula after the doctors have been in practice for a substantial number of years, and no studies of patient outcomes. Patient outcomes need to be assessed with randomized controlled trials, and sample sizes should be determined by power computations to avoid Type II error. Four possible methods of improving PBL would be to derive national and internationally accepted PBL curricula; to organize internationally accepted and psychometrically validated methods of evaluation; to develop attitudes among students and tutors to facilitate co-operative PBL teamwork; and to teach group process diagnostic skills.     

Self-Directed Learning and Student Pragmatism

OBJECTIVE: To explore the experience and practice of students entering a problem-based (PBL) medical undergraduate course and to identify contributory social, curricular and contextual factors. DESIGN: A multiple case study exploiting the natural experimental features of the setting. Qualitative data collection methods, including participant observation, interviews and focus groups were supplemented by a survey. SETTING: The medical school at the University of Liverpool between 1996 and 1998, which launched an integrated PBL curriculum in line with recommendations of the General Medical Council of the UK. PARTICIPANTS: Two successive cohorts of first year medical students entering the PBL course. RESULTS: The first case study findings demonstrated student insecurity and dependence on the faculty resources rather than conforming to PBL principles. Uncertainty gradually diminished but resource dependence persisted, endorsed by peer interaction. Survey results confirmed the qualitative findings. The hypotheses raised for the second case study predicted replications of resource dependent learning, social influences and initial insecurity. Only the first two were upheld. Second year students' advice on textbooks undercut initial uncertainty but insecurity and social comparison reappeared following the changeover of PBL groups and tutors in the second semester. Survey results were replicated. CONCLUSION: Student learning was socially agreed amongst the peer group and directed by faculty given resources. It was not self-directed. Claims made for PBL type curricula may not be justified and GMC recommendations may remain unfulfilled without rigorous attention to educational principles.     

Integration of pharmacology into a problem–based learning curriculum for medical students

The purpose of this study is threefold: (1) to describe a method of integration of pharmacology subject matter with other disciplines, in a problem-based learning (PBL) curriculum employed at the Northwest Center for Medical Education (NWCME), Indiana University School of Medicine; (2) to present various evaluation methods employed to assess students' learning of pharmacology knowledge; and (3) to compare the academic performance of students who underwent a traditional curriculum versus the PBL curriculum in terms of class evaluations and the standard national board medical licensure examinations. The PBL curriculum is designed for the first 2 years of medical education and consists of six sequential steps: steps 1 and 2 deal with biochemistry and anatomy respectively; steps 3, 4 and 5 deal with physiology, neuroscience and general pathology/microbiology respectively; and step 6 is a multidisciplinary step, which integrates basic science subjects with clinical medicine, emphasizing the mechanism of disease in an organ-system approach. In the PBL curriculum students start learning pharmacology within 6 months of admission. The content and process of pharmacology are spread across the first and in the second year. The pharmacology content is divided into three segments, each of which is integrated with other basic science subjects that have maximum mutual relevance. The three segments are as follows: the general and systemic pharmacology (50%) was included in step 3; the neuropharmacology and toxicology (35%) part was included in step 4; the third segment consisted of antimicrobial agents, anticancer and antiinflammatory agents (15%) and was included in step 5. The class evaluation of student performance in the PBL curriculum consisted of two elements, the content examinations and the process evaluations, which include the tutorial and the triple-jump evaluations of problem-solving skills. In order to assess the overall academic performance of the PBL curriculum and traditional curriculum groups, three classes of students who took the PBLC were compared with three classes of students who underwent a TC for performance in terms of class grades and scores of National Board examinations (NBME I and/or USMLE I). The PBL curriculum students performed as well as or better than the TC students as measured by the NMBE I and/or USMLE I. The gain in pharmacology knowledge of PBL students is accompanied by the presence of a positive experience that learning pharmacology is enjoyable. Our experience suggests that the segmental integration approach of instruction coupled with a system of content (internal and external examinations) and process (tutorial and triple-jump) evaluations, as outlined in this paper is a contextualized learning method that offers an effective way of imparting pharmacology knowledge to medical students.     

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。     

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.     

Medical students' attitudes towards and perception of the basic sciences: a comparison between students in the old and the new curriculum at the University Medical Center Utrecht,The Netherlands

OBJECTIVES: The attitudes towards the basic sciences of medical students enrolled in either of 2 different curricula at the University of Utrecht Medical School in The Netherlands were investigated. The purpose of this study was threefold: first, to compare students (beginning clerks) in a conventional and an innovative curriculum; second, to compare beginning clerks with advanced clerks; and third to compare the present results with those of 2 previous American and Canadian studies in which the same questionnaire was used. SETTING: Beginning clerks in the old and in the innovative curriculum, and advanced clerks in the old curriculum, rated 9 statements on a 5-point (disagree - agree) Likert scale. The statements assessed students' attitudes toward the basic sciences. RESULTS: The results showed that beginning clerks in our innovative curriculum, unlike those in a conventional curriculum, consider the basic sciences as somewhat less important for medical practice and do not think that as many biomedical facts as possible should be learned before entering clinical practice. On the other hand, students in the innovative curriculum are more excited by the faculty's teaching of the basic sciences. This latter result confirms the findings in a previous Canadian study. No significant differences were found between beginning and advanced clerks in the conventional curriculum. CONCLUSION: Students experience teaching of the basic sciences as more exciting when they are integrated in organ system blocks with clinical bearings, though they are somewhat less positive about the actual importance of these sciences.     

Integrating cultural competency into the undergraduate medical curriculum

CONTEXT: A significant movement is underway to develop standardised curricula that provide medical students with a fundamental knowledge of cultural sensitivity. METHODS: This paper reviews the recent initiative to integrate cultural competency training into the curricula of American undergraduate medical institutions. RESULTS: Despite these initiatives, few medical institutions have achieved a comprehensive curriculum providing for continued cultural experiences and assessment of related skill sets. The article proposes a framework for the introduction of continued instruction in and assessment of cultural competency within the undergraduate medical education. CONCLUSIONS: The described components of cultural competency education in the undergraduate medical curricula provide a framework to facilitate early and continued exposure to experiences designed to promote cultural sensitivity.     

Influence of national culture on the adoption of integrated and problem-based curricula in Europe

Context  There is an evident misbalance in the frequency of medical schools with problem-based learning (PBL) curricula in northern versus southern Europe. This study explores the hypothesis that national culture influences the flexibility of (medical) schools in terms of their propensity to adopt integrated and PBL curricula.
Methods  National culture was defined by a country's scores on indexes for 4 dimensions of culture as described by Hofstede, defined as: power distance ; individualism/collectivism ; masculinity/femininity , and uncertainty avoidance . Non-integrated medical curricula were defined as those that included courses in 2 of the 3 basic sciences (anatomy, biochemistry and physiology) in the first 2 years; otherwise, by exclusion, curricula were assumed to be integrated. The medical curricula of 134 of the 263 schools in the 17 European countries included in Hofstede's study were examined.
Results  Correlations were calculated between the percentage of integrated medical curricula in a country and that country's scores on indexes for each of the 4 dimensions of culture. Significant negative correlations were found between the percentage of integrated curricula and scores on the power distance index (correlation coefficient [CC]: − 0.692; P  =   0.002) and the uncertainty avoidance index (CC: − 0.704; P  =   0.002). No significant correlations were found between the percentage of integrated curricula and scores on the indexes for individualism/collectivism and masculinity/femininity .
Conclusions  A (medical) school which is considering adopting an integrated or PBL curriculum and which is based in a country with a high score on Hofstede's power distance index and/or uncertainty avoidance index must a priori design strategies to reduce or overcome the obstructive effects of these dimensions of culture on the school's organisation.     

The impact of curricular change on medical students' knowledge of anatomy

BACKGROUND: In recent years, following the publication of Tomorrow's Doctors, the undergraduate medical curriculum in most UK medical schools has undergone major revision. This has resulted in a significant reduction in the time allocated to the teaching of the basic medical sciences, including anatomy. However, it is not clear what impact these changes have had on medical students' knowledge of surface anatomy. AIM: This study aimed to assess the impact of these curricular changes on medical students' knowledge of surface anatomy. SETTING: Medical student intakes for 1995-98 at the Queen's University of Belfast, UK. METHODS: The students were invited to complete a simple examination paper testing their knowledge of surface anatomy. Results from the student intake of 1995, which undertook a traditional, 'old' curriculum, were compared with those from the student intakes of 1996-98, which undertook a new, 'systems-based' curriculum. To enhance linear response and enable the use of linear models for analysis, all data were adjusted using probit transformations of the proportion (percentage) of correct answers for each item and each year group. RESULTS: The student intake of 1995 (old curriculum) were more likely to score higher than the students who undertook the new, systems-based curriculum. CONCLUSION: The introduction of the new, systems-based course has had a negative impact on medical students' knowledge of surface anatomy.