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.     

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.     

Measuring knowledge and clinical reasoning skills in a problem-based curriculum

The purpose of this study was to investigate the validity of the Progress Test that was specially designed for measuring the growth of knowledge and clinical reasoning skills in a problem-based medical curriculum. Scores and subscores of students from the different categories of the Progress Test were compared with their scores on a Clinical Reasoning Tests. Both the Progress Test and the Clinical Reasoning Test revealed the same pattern of increasing scores over the years, and had a high intercorrelation. Further analyses revealed that the clinical sciences subscore in the progress test explained the variations in the clinical reasoning test scores. The knowledge of the behavioural sciences subscore made a small but independent contribution. The knowledge of the biomedical sciences subscore did not have this independent effect. These outcomes are discussed in this paper from the perspective of development of medical expertise research and theory. Some educational consequences are also discussed.     

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.     

Effectiveness of problems used in problem-based learning

Where problem-based learning (PBL) is the main method used in medical curricula, the literature suggests that it is crucial that the problems used are effective in facilitating students to identify relevant learning issues. These learning issues guide the students' studying. The present investigation explores the extent to which students identify relevant issues following exposure to prepared paper problems. In the preparatory year, in an Introduction to Medicine module, four groups of students were exposed to six themes (Health Care System, Environment and Health, Alternative and Islamic Medicine, Chronic Illness, Infectious Diseases, and Prevention and Health Promotion). Each group had two facilitators per theme. Having discussed the prepared problems, the students identified learning issues which were collected for the purpose of the study. Two content experts, using a Likert scale, analysed learning issues for their concordance to staff objectives per theme. Kappa coefficients were computed for the six PBL themes in order to assess inter-rater agreement. Learning issues identified as having no relationship to theme objectives were further analysed for their relevance to theme objectives. No objective was totally omitted by any student group. There was a 100% concordance of objectives to learning issues demonstrated over four themes. The relationship of learning issues to theme objectives ranged from 55–85% in the theme on health care system, and 73–94% in the theme on environment and health. Irrelevant learning issues were identified in the first two PBL themes addressed. Kappa coefficients over the six PBL themes varied from 0·49 to 0·82.     

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

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

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.     

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.     

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.     

A conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula

CONTEXT: The information explosion and continual changes in the means of accessing information have reinforced the importance of preparing graduates to direct their own learning throughout their careers. Increasingly, medical schools are turning to problem-based curricula to develop in graduates the capacity to 'self-direct' further learning. PROBLEM: Experience shows that, to achieve this goal, there needs to be consistency in interpretation of the goal and faculty-wide agreement about the way the problem-based curriculum fosters self-direction. SUGGESTED SOLUTION: This paper describes the conceptual framework developed by the Graduate School of Medicine, The University of Queensland, to guide the achievement of self-directed, lifelong learning in a graduate entry, problem-based curriculum. IMPLICATIONS: It may be useful for others who are experiencing difficulties with implementing problem-based curricula, and for those who are contemplating changing to problem-based models.     

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.     

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

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

A process evaluation of medical ethics education in the first year of a new medical curriculum

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.     

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

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

Evaluating problem-based learning in a multilingual student population

OBJECTIVES: The University of Natal Medical School in South Africa provides training for a student body composed of two groups: one with English as a first language and the other with an African language as a first language and English as the second. A new methodology was developed to evaluate an innovative course using modified problem-based learning techniques in this heterogeneous environment. DESIGN: The learning model proposed required achieving a balance of three components: content, enquiry/learning process and social interaction/group process. A multidimensional system, felt to be consistent with this educational philosophy, was developed using seven different quantitative and qualitative techniques. SETTING: The University of Natal Medical School. SUBJECTS: First-year multilingual medical students. RESULTS: The results revealed that social interaction was highly successful in reducing barriers between the student groups and between students and facilitators. However, the emphasis on group participation may have overshadowed the enquiry process, leading to superficial discussions of problems and feelings of repetitiveness. During the course students and facilitators expressed concern that the innovative assessments used did not assess the course content adequately. While the group presentations and projects were useful exercises for consolidation and group interaction, they did not enable facilitators to identify struggling students. CONCLUSIONS: The outcome of the evaluation stressed the need of achieving an appropriate balance both in the curriculum and assessments of the three components of the learning model, particularly in a setting where student backgrounds and language ability differ. Multidimensional methodology is needed for effective evaluation that promotes critical reflection.     

Evaluation of an integrated curriculum using problem-based learning in a clinical environment: the Manchester experience

DESCRIPTION OF COURSE: In 1994, a new problem-based leaning (PBL) curriculum for year 1 medical students was introduced at the University of Manchester. The use of PBL has continued into the clinical clerkships. Year 3 of the curriculum is based entirely in a clinical environment with PBL groups meeting in three teaching hospitals. During this year, all students undertake two integrated 14-week modules with overarching themes. Each week, groups of eight students discuss a trigger problem connected to the relevant theme. The steps the groups use in the PBL process have been amended to encourage students to link their discussion with clinical experience. EVALUATION: At the end of each module, all 309 students were requested to complete an evaluation questionnaire. The response rates were 80% (n=247) and 89% (n=275) for the two core modules. RESULTS: The students have remained 'happy with the way the course is going' (83% at the end of module 2). They were also asked to rate a number of statements on a 5-point Likert scale (5=strongly agree). Concerning PBL, the students remained confident about working in a group (median 4), producing a set of learning objectives (median 4) and linking clinical experience with other knowledge (median 4). However, there were changes over the year. Fewer students agreed at the end of module 2 that 'the working problems were stimulating' (P=0.002) or 'motivated them to learn' (P < 0.001), but the clinical firms were seen as providing more appropriate experience (P=0.01) and being aware of the new curriculum and responding to it (P=0.018). We also surveyed the PBL tutors and had 65 returns from 78 people involved in the 38 PBL groups in year 3. The great majority of these are doctors employed by the National Health service. Virtually all the responders were happy to continue being a tutor (97%) and would recommend it to a colleague (93%). CONCLUSIONS: The evaluation has been positive with PBL having been successfully implemented in a clinical environment. We have identified significant changes over the year, which we need to address as we consolidate the curriculum.     

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.     

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.