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Problem based learning - Friend or Foe?

What is Problem Based Learning? During my time at medical school, I enjoyed (at times) a curriculum delivered through the traditional model. As the name suggests, this is an approach experienced by the majority of doctors to date. The traditional model was first implemented by the American Medical College Association and American Academy of Medicine in 1894 (Barr, 2010) and has been used by the majority of medical schools. It traditionally consists of didactic lectures in the initial years covering the basic sciences followed by clinical years, where students learn clinical medicine while attending hospital placements. Is It Better? A few years after my graduation I found myself teaching at a university which had fully adopted the use of problem based learning (PBL) in the delivery of their curriculum. PBL is a philosophy of teaching that has increasingly been used in medical education over the past 40 years. It has rapidly been replaced or supplemented in medical education as opposed to the traditional model. PBL seeks to promote a more integrated and active approach to learning right from the first year with less reliance on didactic lectures. Having been involved in these two different approaches to medical education, I was interested to explore what the evidence was for and against each. For the purposes of this blog, I have looked at four specific areas. These include student attitudes, academic achievement, the academic process of learning and clinical functioning and skills. Student Attitudes Student attitudes to PBL have been highly featured in studies and many show that there is a clear favourability towards this philosophy of teaching. Blumberg and Eckenfel (1988) found that students in a problem based preclinical curriculum rated this three times higher than those in the a traditional group in terms of what they expect to experience, what they would like, and what they actually experienced. Heale et al (1988) found physicians in the problem-solving sessions rated a Continuing Medical Education short course higher compared to others who attended traditional lectures and large-group sessions. Vernon and Black (1993) performed a Meta analysis on 12 studies that looked at attitudes and towards PBL and found PBL was favored in some way by all studies. PBL appears to be preferred by the majority of students at a range of academic levels. However, Trappler (2006) found that converting a conventional curriculum to a problem based learning model for part of a psychopathology course did not show complete favourability. Students preferred the conventional lectures given by experts, rather than PBL groups run by mentors and not experts. They did however show preference towards PBL small group sessions run by experts Academic Achievement Academic achievement is an important factor to assess. Vernon and Blake (1993) compared a number of studies and found that those, which could be compared, showed a significant trend favouring traditional teaching methods. However, it was felt this might not be reliable. When looking at the heterogeneity of the studies there was significant variation that could not be accounted for by chance alone. Interestingly, they found that there was significant geographical variation across the United States such that New Mexico showed consistently negative effects and Michigan State showed consistently positive. Other studies have shown that the traditional method may show a slightly better outcome when assessing academic achievement. Schmidt et al (1987) looked at the same progress test taken among students in six different Universities in the Netherlands and found that those taught by a traditional approach showed slightly better outcomes. Baca et al (1990) compared performances of medical students in two separate tracks, one PBL the other a traditional model. Baca et al found that PBL students scored slightly lower in the National Board of Medical Examiners (NBME) examinations. Dochy et al (2003) conducted a meta analysis comparing 43 studies and found that when considering the effect of PBL on the knowledge of students the combined effect size is slightly negative. The academic process of learning It is important in medical education to enable people to continue life long learning, to overcome problems and fill in knowledge gaps. Coles (1990) and Entwistle (1983) found that PBL students would place more emphasis on understanding and meaning compared to just rote learning, seen more in those taught by a traditional approach. Students on a PBL course also place more focus on using resources such as the library and online sources rather than those taught in a traditional approach (Rankin, 1992). Students taught by a traditional model place more emphasis on the resources supplied by the faculty itself. It has also been shown that students who learn through a process of problem solving, are more likely to use this spontaneously to solve new problems in the future compared with those taught in a traditional way (Bransford et al, 1989). Clinical functioning and skills Clinical competence is an important aspect in medical education and has been measured in studies comparing PBL and traditional methods. The traditional model focuses acquisition of clinical competence in the final years of a program with hospital placements. In a PBL course it may be more integrated early on. There are however, only a few studies that look at clinical competence gained in undergraduate PBL courses. Vernon and Blake (1993) compared some of these studies and found that students obtained better clinical functioning in a PBL setting compared to a traditional approach. This was statistically significant, however there was still significant heterogeneity amongst studies and for conclusive results to be made 110 studies would have to be compared, rather that the 16 samples they were able to use. They also found that in contrast to the NBME I giving better results in the traditional model, PBL students score slightly higher in NBME II and federation licensing examination which related more on clinical functioning than basic sciences. On reflection, this evidence has indicated to me that PBL is a very valuable approach and it has a number of benefits. The traditional model in which I was taught has provided a good level of academic education. However, it may not have supported me as well as a PBL course in other areas of medical education such as academic process, clinical functioning and satisfaction. On reflection and current recommendations are for a hybridisation of the PBL and traditional approach to be used (Albanese, 2010) and I would support this view in light of the evidence. References Baca, E., Mennin, S. P., Kaufman, A., and Moore-West, M. A Comparison between a Problem-Based, Community Orientated track and Traditional track Within One Medical school. In Innovation in Medical Education; An Evaluation of Its Present Status. New York: Springer publishing Barr D. (2010) Revolution or evolution? Putting the Flexner Report in context. Medical Education; 45: 17–22 Blumberg P, Eckenfels E. (1988) A comparison of student satisfaction with their preclinical environment in a traditional and a problem based curriculum. Research in Medical Education: Proceedings of the Twenty-Seventh Annual Conference, pp. 60- 65 Bransford, J. D., Franks, J. J., Vye, N. J., & Sherwood, R. D. (1989). New Approaches to Instruction: Because Wisdom Can't Be Told. In S. Vosiadou & A. Ortony (Eds.), Similarity and Analogical Reasoning (pp. 470 297). New York: Cambridge University Press. Coles CR. (1990) Evaluating the effects curricula have on student learning: toward a more competent theory for medical education. In: Innovation in medical education: an evaluation of its present status. New York: Springer publishing; 1990;76-93. Dochy F., Segersb M., Van den Bosscheb P., Gijbelsb D., (2003) Effects of problem-based learning: a meta-analysis. Learning and Instruction. 13:5, 533-568 Entwistle NJ, Ramsden P. Understanding student learning. London: Croom Helm; 1983 Heale J, Davis D, Norman G, Woodward C, Neufeld V, Dodd P. (1988) A randomized controlled trial assessing the impact of problem-based versus didactic teaching methods in CME. Research in Medical Education.;27:72-7. Trappler B., (2006) Integrated problem-based learning in the neuroscience curriculum - the SUNY Downstate experience. BMC Medical Education 6: 47. Rankin JA. Problem-based medical education: effect on library use. Bull Med Libr Assoc 1992;80:36-43. Schmidt, H G; Dauphinee, W D; Patel, V L (1987) Comparing the effects of problem-based and conventional curricula in an international sample Journal of Medical Education. 62(4): 305-15 Vernon D. T., Blake R. L., (1993) Does Problem-based learning work? A meta-analysis of evaluated research. Academic Medicine.  
Dr Alastair Buick
over 6 years ago
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Medical students face new NHS entry exam

The Health Service Journal have announced this week that medical students could be given a license to practice medicine in the NHS as soon as they graduate. What do we know? The proposal comes from Health Education England. Students would qualify by taking an additional exam when applying for the Foundation Programme. The aim is to improve the standard of medics joining the NHS. Another driving force is to reduce the rising number of med students applying for the two-year Foundation Programme (currently the only way for junior doctors to achieve a full license to practice). Last year there were 297 more applicants than places. If approved the plan would require changes to the Medical Act. Statement from the BMA Dr Andrew Collier, Co-Chair of the BMA’s Junior Doctor Committee said: “We do not feel the case has yet been made for a wholesale change in foundation programme selection process, especially as the system was significantly overhauled and implemented only one year ago. There is little evidence that another new national exam over and above current medical school assessment methods will add any benefit either for graduating students or the NHS as a whole. It is also unlikely to solve the ongoing oversubscription to the foundation programme which will only be addressed by well thought out workforce planning.” Will it work? This proposal has certainly come as a surprise to me so soon after recent changes to the Foundation Programme selection process. I would love to know what you think about it. Do you agree with Dr Collier’s statement? If the plan goes ahead do you think it will be effective in achieving the desired outcomes? Please post your comments and thoughts. Nicole Read more: http://www.hsj.co.uk/news/exclusive-medical-students-face-new-nhs-entry-exam/5066640.article#.UrbyS2RdVaE  
Nicole Chalmers
over 5 years ago
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Clinics - Making the most of it

Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it? The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed. Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history. Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors. So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take. Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck. This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.  
James Wong
over 5 years ago
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A licence to cure

Almost 800 years ago the Ordinances of the Guild of Pepperers of Soper Lane (1316) prohibited mixing products of different quality and price, adulteration, and wetting to falsify.1 UK medicines regulation has seen the establishment of the Committee on Safety of Drugs,2 the Medicines and Healthcare Products Regulatory Agency (MHRA), and the Commission on Human Medicines.  
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