Experience with Problem Based Learning in MBBS course at FijiSchool of Medicine.
Venkatesh M. Shashidhar, Joseph Flear, Neel Kamal Arora, Kamal Kishore and Sunita D. Pawar.
Introduction
What is Problem Based Learning (PBL)?
At its most fundamental level, Problem Based Learning (PBL) is an instructional design characterized by the use of real world problems as a context to learn critical thinking, and problem solving skills while actively learning the knowledge content of the course. According to Barrows, (1980), PBL can be explained as “the learning that results from the process of working toward the understanding or resolution of a problem”.
In PBL, small groups of students enact solving a real world problem. During this tutorial process, students build ontheir present knowledge and identify additional learning which is needed to solve the problem. A tutor observes and guides this process using preset guidelines, but does not participate in discussion or provides answers. FFollowing the tutorial tutor hands out study guides to helpstudents search through various resources like books, journals, laboratories, online sources, clinic visits, discussion with faculty, senior students etc, looking for what they need to solve the problem. Students get a study guide from faculty. Following this active learning phase, students discuss their learning in the next tutorial and get obtain further details of the problem, and identify further learning issues. This cycle continues till until final resolution of the problem. Final session ends with and ends with students summarizing the problem and their learning. Active learning occurs throughout the process, thus PBL develops the individual as a whole professional rather than just providing factual knowledge as in traditional classroom teaching based didactic curriculum. PBL methodology supports adult learning behaviors such as Trusttrust, respect, freedom, team work, accepting differences, responsibility, commitment, active learning and physical comfort (Knowles 1980). PBL is learner centered and :the faculty’s role is to develop a strong curriculum and then become ‘apparently’ passive observers encouraging and supporting student’s students’ active self learning. The PBL method integrates knowledge across subject traditional discipline boundaries, teaching practical problem-solving skills. There are four main objectives of PBL: structuring of knowledge in clinical contexts rather than subject disciplines, clinical reasoning, self-directed learning, and problem solvingg skills, and developing intrinsic motivation (Barrows, 1980).
History of Problem Based Learning
Medical school The Faculty of Medicine at McMasterUniversity in Canada was the first educational institute to adopt this model in 1969. Soon PBL was adopted at Newcastle University Medical School in Australia. Dr. Howard Barrows at McMaster, is the first to apply problem-based learning to medical education (Haslett, Lynn 2001). Barrow’s idea came from the concepts of adult learning (Knowles 1098). From the late 1970’s PBL methodology spread to several medical schools around the world and even other professional courses adopted this method. Presently majority of many medical schools all over the globe have adopted PBL method of teaching.Mmany have done so with several modifications to suit local needs and understanding. Hence PBL method is quite heterogenous and is continuously evolving..
History of PBL at the FijiSchool of Medicine.
During the 1970’s and 80’s the Fiji School of Medicine faced major concerns of very high attrition rates among students particularly indigenous students and students from elsewhere in the Pacific region. Up to 70% students exited the program after failing the first year and a further 40% failed eventually to qualify. (Samisoni 1994). The sSchool faced a major crisis when regional countries withdrew their students following the pPolitical coup in 1987. A medical education task force setup commissioned by WHO in 1988 reviewed the curriculum and recommended that FSM change its MBBS curriculum from a“traditional non- integrated didactic educational approach” to an integrated, problem based learning curriculum. (Samisoni). The new model was eventually developed from consultations with New CastleMedicalSchool in Australia and John Burns School of Medicine at University of Hawaii.
A A new 3 year diploma in Primary Care Practice (PCP) was established in 1992. After additional year internship, PCP’s could be registered as medical practitioners. However Health ministry could not accommodate PCP’s into already existing nurse practitioners, and the PCP program was abolished in 1997. In 1998 following further curriculum review PCP program was replaced by 6 year MBBS program with revised PBL curriculum starting 1999. First batch will graduate in 2004.
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A radical element of the new curriculum was its proposal of a two-tier exit program: After three years of education and training, a student would be awarded a Diploma in Primary Care Practice. After an additional year’s internship in their home island (which effectively became the 4th year of the 6-year MBBS program of study), Primary Care Practitioners (PCPs) could be registered as mid-level medical practitioners. They would then have the option of returning to FSM for an additional two years of intensive hospital-based training and education in the clinical disciplines, and would graduate with the MBBS degree. (Samisoni 1994).
Despite high hopes, the overall experience of the PCP program was generally disappointing. Pacific Island Ministries of Health found it difficult to accommodate PCPs into their workforce, supervision of the PCPs in their home ministries was poor or non-existent, and PCPs who eventually returned to FSM to complete the last two years of the program were deficient in areas of basic sciences and the pathophysiology of diseases. As a result of this, the PCP/MBBS Program was reoriented in the late 1990s towards a more conventional 6-year MBBS Program, without a facility for exit after three years. The PCP internship was moved from the 4th year of study, to become a final-year Training Internship, with hospital- and community-based attachments. The PBL method of teaching in the first three years of the program was retained, and the curriculum objectives more clearly defined and documented.
Current PBL process at the FijiSchool of Medicine:
The cCurrent MBBS program consists now of first 3 years of integrated PBL learning involving all clinical and basic science and public health disciplines. This is followed by 2 years of clinical and community medicine attachments and a final 1 year of training internship.
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As PBL is highly interactive process, and requires greater language and communication skills, students in the beginning of first year undergo screening and remedial process at Center for Enhancement of Learning and Teaching (CELT) department at University of South Pacific (USP).
Yearly intake into MBBS program currently is 70 students (60% from Fiji, rest from regional countries). Each class is divided into 7 tutorial groups of 10 students. Each group is balanced for gender, ethnicity & country of origin, and is assigned an experienced PBL tutor from among the MBBS Program’s pool of PBL tutors..
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Initial orientation period of 3 weeks is designed to introduce PBL process to students where students solve learn through simple every day problem situations situations such as solving puzzles, a situation in a restaurant, shopping mall etc. New problem scenarios have been created to introduce the course to students such as How do one become a doctor? What do the letters ‘MBBS’ mean? Problems in campus? During this orientation period students are given introductory sessions by various faculty about their subject also given sessions in behavior, medical ethics and professionalism.Orientation also includes language and study skills assessment and remedial process at Center for Enhancement of Learning and Teaching (CELT) department at University of South Pacific (USP). We even developed new problems such as what is a pediatrician? How do one become a doctor? What do the letters ‘MBBS’ mean? During this orientation period students are given introduction to various faculty and their subject areas, campus behavior, medical ethics and professionalism.
Tutorial groups meet regularly twice a week on Tuesday and Friday for two hours each. In the first tutorial students are given a patient case scenario related to a medical specialty and students discuss the problem with information they already possess. , Dduring the process, students identify additional learning needed. This process is supervised by thea tutor. At the end of each tutorial, the students get a one page study guides for each of important ‘core’ learning issues,.which outlines the topic and guides the students in their study search for additional information from various resources such as books, library, online, laboratories, clinical attachments etc.
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Classroom lectures are not typical in FSM the PBL MBBS curriculum, however when complex topics are identified, an interactive resource session between expert faculty and students are is arranged to facilitate assisted learning. These resource sessions are different from traditional classroom lectures in that the faculty member does not lecture, instead but rather, interactively provides explanation to student queries at personal level.
At FSM we have developed a novel alternative to practical laboratory sessions we call them Fixed Resource Session (FRS). Fixed Resource Sessions (FRS) have been developed to complement practical laboratory sessions. In FRS sessions, problem related specimens, models, charts, radiographs etc. are displayed in laboratories with guiding statements. And Students are allowed encouraged to browse through them on their own with the help of self assessment questions and answers, and are encouraged to approach a faculty if they need additional help. This has greatly improved students motivation and learning. Also hands on training ishand on training is offered in pathology laboratory, such as . For example students learn to measuring e hemoglobin level in the blood when they are discussing a patient of anemia case, or and learn to examine urine sample while discussing a patient case of kidney disease.
Classroom lectures are not typical in FSM, however when complex topics are identified, an interactive resource session between expert faculty and students are arranged to facilitate assisted learning. These resource sessions are different from traditional classroom lectures in that faculty member does not lecture instead, interactively provides explanation to student queries at personal level.
In between tutor assisted tutorials,students the tutorial group meetsinformally known as in a ‘self directed tutorials’ without their tutor and discusseswhat they have learnt to share information among the group. This has become more popular among been made an essential part of the students’ weekly timetable, students and has greatly improved their the students’ level of learning and motivation.
Following this these active learning activitieys, students return to next tutorial session and discuss their newly acquired knowledge.gaining confidence and self esteem.The Tutor then provides further details of the case and students start discussing to identify further learning issues and the cycle continues till until satisfactory resolution of the case.
During the final tutorial session, students summarize the case and their learning experience. They draw together what they’ve learned from each of the disciplines, as they explain how the information in the history, the physical examination, and the investigations demonstrates the mechanisms at work in causing the patient’s problem. At the end of each problem cycle, . Students also get set of self assessment questions and are encouraged to solve them. Model answers are given to tutors who are expected to guide students to find answers but not give direct answer. This forms important formative assessment exercise.
There is regular review of PBL process. At the end of every problem cycle, tutors and coordinators meet as debriefing meetings to discuss the overall performance, problems faced, group dynamics, student performance, student feed back etc. This feed back is used to modify the curriculum for future. Since its introduction in 1999, PBL at FSM has undergone several enhancements.
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PBL curriculum content at the Fiji School of Medicine:
The PBL curriculum at FSM has been developed to cover broadly various medical specialties and personal and professional development. Each problem builds on students knowledge and is a prerequisite to the next problem. PBL problems presented later in the series prompt students to recall, revise, and use knowledge which they learned earlier in the year, or in a previous year. Various spheres of knowledge such as basic and and clinical science, clinical skills, professional and personal development and public health, are built in a spiral manner through three years. PBL problems in the first two years introduce students to the various systems in turn (Musculoskeletal, Blood, Cardiovascular, Respiratory, etc); PBL problems in the third year revise these systems, and emphasise aetiology and patient management.
[Consider deleting the Figure, as I’m not sure it clarifies what is in the text:]Major domains of competencies and the structuring of problem based learning at FSM is outlined in figure 1.
Figure 1 represents the different dDomains of competency fostered at FSM.
Outline of curriculum spiral in the first of 3 years of PBL curriculum at FSM is shown in table 1.
MBBS I Year / MBBS II Year / MBBS III YearOrientation – 3 weeks
Homeostasis – 2 weeks
Musculoskeletal - 6 weeks
Blood/Immune - 8 weeks
Cardiovascular - 7 weeks
Ear, Nose, Throat - 2 weeks
Respiratory - 7 weeks
Total 35 weeks / Gastrointestinal - 9 weeks
Urinary System - 5 weeks
Endocrine System - 6 weeks
Reproductive - 4 weeks
Nervous System - 10 weeks
Eye - 2 weeks
Total 36 weeks / Genetics - 3 weeks
Cancer - 3 weeks
Immunology - 3 weeks
Respiratory - 4 weeks
Infections - 5 weeks
Gastrointestinal / Nutrition - 2 weeks
Endocrine - 3 weeks
Renal - 1 week
Musculoskeletal - 3 weeks
Cardiovascular - 4 weeks
Psychiatry - 4 weeks
Gynaecology - 1 week
Total 36 weeks
CClinical exposure:
From the first year, students spend one-half day each week at various medical centers including Maternal and Child Health Clinics, Family Planning Clinics, Outpatients Clinics, Antenatal Clinics, Specialty Clinics such as Diabetes, Eye, Skin, TB, Physiotherapy and Rehabilitation Clinics. These visits are organized and supervised by clinical skills team. Major objectives for clinical visits is to experience genuine clinical situations, to interact with patients and staff, to set their own learning goals based on their experience, and . to integrate their clinical experience to enrich their PBL learning.
A Assessment & Evaluation in FSM:
ssessment & Evaluation in FSM:
We believe that aAssessment drives learning, but an important objective of assessment in PBL is its ability to bring positive change in the learner, rather than a tool to judge. a students learning. In FSM there are multiple assessments both formative and summative during the year. Apart from four times a year traditional paper based examinations there are several non formal assessments such as student presentations, learning journal, Objective Structured Practical and clinical examinations, tutor evaluation etc. Over the years, emphasis of year end examinations have been reduced to present level of 50% and remaining 50% grade comes from various summative assessments throughout the year.
Also assessments have to be frequent and spread throughout the course aiming at bringing positive change in student learning well before final evaluation. PBL does not put much emphasis on end of course summative assessment as it has no learning advantage.
Written Paper based, written examinations are conducted several times during the year and an year end examination. Eexaminations known as PBL paper are integrated across subject areas and also include ethical, professional and clinical skill components. Examinations attempt to recreate to some extent the tutorial process and questions start with a clinical problem as a trigger followed by questions and further patient details and more questions from different subjects but related to the patient scenario. Thus examinations test integrated approach to clinical problem solving, apart from subject content.
Practical examinations are Integrated Objective Structured Practical Examinations (OSPE). Each station has an anatomy model, x-ray, pathology specimen, or a microscope slide, culture plate, or mock patient record, etc. with related questions it. Students spend 5 minutes answering questions at each station. Some stations may have a standardized patient and students are required to demonstrate clinical skills while a facultyn observer records students performance (Objective Structured Clinical Examination (OSCE).
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Typical Assessments During a Year.First Semester:
- Student presentation
- First Formative Examination (Paper based)
- First Summative Examination (Paper based)
- Student presentation
- First formative OSPE/OSCE examination.
- First Tutor Evaluation (end of semester)
- Student presentation
- Second Formative Examination (Paper based)
- Second Summative Examination (Paper based)
- Student presentation
- End of Year OSPE/OSCE Examination.
- Student Learning Journal.
- Tutor Evaluation (end of year)
In setting examinations, examination questions are vetted by group of faculty representing all major specialtyies. Following the examination, results are analyzed for whole class with each question being checked for its relevance, discriminating power and student performance. Based on these, a detailed feedback is given to the class with class statistics and model answers. ‘PBL learning depends on team work’ and competition or academic politics is detrimental to PBL learning, hence individual results are not posted publicly. Tutors discuss results individually with students.