Problam based learning...

[mellsworth21]

Does any Caribbean schools offer this? I know IAU offers clinical based...

[stephew]

here's the problem: PBL is a "catchall"phrase like "family values". What the heck does that mean? Using problem sets and cases to augment teaching? Plenty of places do. I dont know if many schools dont use that. Many confuse this with organ system learning which I think is a horrible way of teaching. I teach at harvard and the harvard students struggle with the nebulous system. carib students would really flounder. Perhaps if you define exactly what you mean.

[BrendaB_MD]

There have been a number of studies that have compared the effectiveness of PBL vs standard lecture-based teaching. Last time I looked there were about a dozen or so such studies. The majority of these studies showed that PBL is as effective or better than lectures.

You can easily go to Medline and do a search on PBL+USMLE to get an updated list of studies. I would be interested to learn what you find.

[stephew]

Originally Posted by BrendaB_MD

There have been a number of studies that have compared the effectiveness of PBL vs standard lecture-based teaching. Last time I looked there were about a dozen or so such studies. The majority of these studies showed that PBL is as effective or better than lectures.

You can easily go to Medline and do a search on PBL+USMLE to get an updated list of studies. I would be interested to learn what you find.

trust me i know about these studies. I also know the limitations of the studies. Plus I do the "new pathway" at harvard. I stand by what I said. Bottom line, you need a good school, not a particular style curriculum if you need to go offshore.

[BrendaB_MD]

Originally Posted by stephew

trust me i know about these studies. I also know the limitations of the studies. Plus I do the "new pathway" at harvard. I stand by what I said. Bottom line, you need a good school, not a particular style curriculum if you need to go offshore.

While the studies have quality flaws (generally nonrandomized, non-blinded, etc) they are typical of social science and educational research and, unfortunately, are the best available evidence. Thus, it is misleading to say that PBL is a disaster relative to lecture based delivery. I think it is more accurate to say that there are some indications that PBL may be as good or better but that the jury is still out.

Students seem to learn under either PBL or traditional lecture so I agree that the choice of curriculum is a minor issue.

[stephew]

Originally Posted by BrendaB_MD

While the studies have quality flaws (generally nonrandomized, non-blinded, etc) they are typical of social science and educational research and, unfortunately, are the best available evidence. Thus, it is misleading to say that PBL is a disaster relative to lecture based delivery. I think it is more accurate to say that there are some indications that PBL may be as good or better but that the jury is still out.

Students seem to learn under either PBL or traditional lecture so I agree that the choice of curriculum is a minor issue.

my saying so is no more misleading that the studies, which also show early weakness among those students, who later catch up. Why? Well because most were from a highly selective school. So the students tend to (eventually) do well no matter what. Ie harvard students. They struggle with the curriculm, have a weak rep as clinicians early on but ultimately do very well. It could just as easily be interpreted that these brilliant kids are weakened by the curriculum but then catch up because they are billiant. and I stand by the point that PBL has to be defined. THere are few if any schools that dont incorporate problems in their teaching. The systems based is ofen what people incorrectly use synonymously with PBL and that that is the disaster.

[mellsworth21]

What do the studies say in how PBL is in relation to the USMLE?

[BrendaB_MD]

Originally Posted by mellsworth21

What do the studies say in how PBL is in relation to the USMLE?

As I recall, there were a number of papers that showed that PBL students did better. As stephew points out, many of these studies are 'before and after' studies which are considered low quality evidence; however, you are rarely going to get random allocation in a study of this type and blinding is not possible so you have to take what you can get.

University of New Mexico did a study in which they randomly allocated students to PBL vs lecture during the first year of their program (early 1990s). They found that PBL students performed slightly worse on Step I but better on Step II.

There was another more recent study in which students were randomly allocated to PBL vs lecture for pathology. They found that PBL training outperformed lecture based training.

PBL is designed to influence a range of competencies and outcomes and the USMLE is a relatively narrow measure that would not be expected to capture the benefits of PBL. However, given the practical importance of the USMLE (misplaced or not) it is important to assess the impact of PBL on USMLE performance. Unfortunately, there are no good systematic reviews on this subject; however, here are two recent papers that address this question:


Unique Identifier10667879
StatusMEDLINE
AuthorsBlake RL. Hosokawa MC. Riley SL.
Authors Full NameBlake, R L. Hosokawa, M C. Riley, S L.
InstitutionUniversity of Missouri-Columbia School of Medicine, 65212, USA.
TitleStudent performances on Step 1 and Step 2 of the United States Medical Licensing Examination following implementation of a problem-based learning curriculum.
SourceAcademic Medicine. 75(1):66-70, 2000 Jan.
AbstractPURPOSE: To examine students' performances on Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE) following the implementation of a problem-based learning curriculum. METHOD: Performances on Step 1 of the USMLE for four classes at the University of Missouri-Columbia School of Medicine that completed a new problem-based learning curriculum (1997, 1998, 1999, and 2000) were compared with those of the last two classes to learn in the traditional curriculum (1995 and 1996). Performances on Step 2 of the USMLE for the classes of 1997, 1998, and 1999 were also compared with those of the classes of 1995 and 1996. The authors analyzed matriculation data (GPAs and MCAT scores) for all six classes. They compared all data with those of U.S. and Canadian first-time USMLE takers. RESULTS: The mean scores were higher on USMLE Step 1 for classes in the problem-based learning curriculum than for classes in the traditional curriculum. The mean scores for Step 2 were above the national mean for classes in the revised curriculum and below the national mean for classes in the traditional curriculum. The admission profiles of these classes were essentially the same before and after the change in curriculum. CONCLUSIONS: Major PBL revisions of the curriculum did not compromise the performances of medical students on the licensing examinations; in fact, they may have contributed to higher scores.
Publication TypeComparative Study. Journal Article.


---------------------------------------------
Unique Identifier15734816
StatusMEDLINE
AuthorsDistlehorst LH. Dawson E. Robbs RS. Barrows HS.
Authors Full NameDistlehorst, Linda H. Dawson, Elizabeth. Robbs, Randall S. Barrows, Howard S.
InstitutionDepartment of Medical Education, Southern Illinois University School of Medicine, PO Box 19681, Springfield, IL 62794-9681, USA. ldistlehorst@siumed.edu
TitleProblem-based learning outcomes: the glass half-full.[see comment].
CommentsComment in: Acad Med. 2007 May;82(5):479-85; PMID: 17457072
SourceAcademic Medicine. 80(3):294-9, 2005 Mar.
AbstractPURPOSE: To compare the characteristics and outcome data of students from a single institution with a two-track, problem based learning (PBL) and standard (STND) curriculum. METHOD: PBL and STND students from nine graduating classes at Southern Illinois University School of Medicine were compared using common medical school performance outcomes (USMLE Step 1, USMLE Step 2, clerkship mean ratings, number of clerkship honors and remediation designations, and the senior clinical competency exam), as well as common admission and demographic variables. RESULTS: PBL students were older, and the cohort had a higher proportion of women. The two tracks had similar USMLE Step 1 and 2 mean scores and pass rates. Performance differences were significant for PBL students in two clerkships as well as in the clerkship subcategories of clinical performance, knowledge and clinical reasoning, and noncognitive behaviors. In addition, the proportion of PBL students earning honors was greater. CONCLUSIONS: The traditional undergraduate educational outcomes for the PBL and STND students are very positive. In several of the clerkship performance measures, the PBL students performed significantly better, and in no circumstance did they perform worse than the STND students.
Publication TypeComparative Study. Evaluation Studies. Journal Article.

[BrendaB_MD]

Here is a recent systematic review of the literature on PBL vs traditional lecture. The good thing about this review is that they did an exhaustive search, assessed papers with respect to methodological quality and included only high quality papers.

Problem-based learning makes a difference. But why?
Geoffrey Norman, PhD

Geoffrey Norman is with the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ont.
Correspondence to: Dr. Geoffrey Norman, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, MDCL 3519, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 572-7099; norman@mcmaster.ca
A serious look at how educational innovations are disseminated may give the thoughtful observer cause to question the pervasiveness of the "scientific method." Sometimes it seems that education moves from one fad to the next. In my now longish career, I have seen many educational methods come and go: patient-management problems, modified essay questions, behavioural objectives, learning styles and more. This decade's "flavours of the month" — reflective practice, e-learning and high-fidelity simulations — appear to be no more evidence-based than all those that have come (and gone) before. Sadly, although good evidence in support of a particular educational innovation may exist, it is rarely instrumental in decisions to adopt that innovation.
Nowhere is this pattern more evident than with the locally grown phenomenon, problem-based learning. In this radically different approach to medical education, learning is driven by challenging, open-ended problems; students work in small groups; learning is facilitated by a tutor; courses do not exist; and lectures are minimal. Problem-based learning originated at McMaster University in Hamilton, Ontario, in the late 1960s. The method's "founding fathers" were an iconoclastic group of physicians and basic scientists from the Toronto–Hamilton area who were recruited by the school of medicine's first dean, John Evans. They all shared a negative view of their undergraduate experiences and thought they could do better. Their goals were straightforward: in the words of Bill Walsh, the first associate dean of education, "All we want is for them to get an MD and have some fun doing it." Within a very few years, we had evidence that this was true.
In the meantime, to everyone's surprise, the method caught on like wildfire. Within a few years there were problem-based learning curricula in the Netherlands, Australia, Israel and the United States. And the method has continued to spread: now, several hundred schools profess to offer some form of problem-based learning.
All this happened without any really convincing evidence that problem-based learning made much difference in terms of learning outcomes. As Koh and colleagues1 point out in this issue of CMAJ, 2 highly cited systematic reviews were done in the early 1990s, but these reviews found more similarities than differences in outcomes, particularly in licensing exam scores, among graduates from problem-based learning and traditional curricula. There were some indications that graduates of problem-based learning curricula were more caring and compassionate than graduates of traditional curricula;2 however, there was always a concern that these findings may have been related to selection bias during the admissions process, a consequence of a deliberate attempt to select students with specific personal characteristics.
The study by Koh and colleagues provides a significant contribution because the authors systematically reviewed all of the studies in medicine linking problem-based learning to outcomes. One critical inclusion criterion of theirs was that the study had to have used a control group comprising graduates of a traditional curriculum. Although Koh and colleagues have not ruled out selection bias entirely, we can be confident that the differences in psychosocial outcomes were not a consequence of other differences, such as different selection criteria at admissions or other institutional differences, that confounded the findings of earlier studies. A second critical methodological point of their review was to analyze self-and observer assessments of outcomes separately. As the authors correctly point out, the literature on self-assessment so consistently points out the nonrelation between self-assessed abilities and observed abilities, that it really makes little sense to rely on such judgments. More's the pity that proponents of continuing professional development and maintenance of certification continue to place great stock in physicians' abilities to identify their own weaknesses.
Koh and colleagues did find differences in outcomes in just the place where we might have hoped. Compared with graduates of traditional curricula, graduates of problem-based learning curricula had better diagnostic and communication skills; had a greater appreciation for the cultural aspects of care as well as legal and ethical issues; demonstrated greater responsibility; and were better able to cope with uncertainty. Given current attention to cultural and ethical issues, as reflected in the CanMEDS Physician Competency Framework,3 the Medical Council of Canada's C2LEO (Cultural–Communication, Legal, Ethical and Organizational Aspects of Medicine) objectives and the usual concern about poor communication skills demonstrated in complaints to medical regulatory authorities, it bodes well for graduates of problem-based learning curricula that they are doing well in these high-priority areas.
One concern with the study by Koh and colleagues is that their designation of strength of evidence was based on replication and study quality. For example, a small and possibly educationally nonsignificant effect of problem-based learning that was replicated over 2 good studies might have been considered strong evidence, whereas a single study showing a very large effect of problem-based learning would be viewed as weaker evidence. Before we advocate for problem-based learning curricula to be implemented around the world, there should be quantitative evidence of how much difference such a change is likely to make. A second concern is that one wonders about what measures were used to observe these effects. A review of the original articles can yield such information, but we must nevertheless accept that when the reviewer refers to "cultural sensitivity," we must take on faith that this was what was actually measured.
Finally, the real conundrum is why these effects of problem-based learning were observed at all. We have ruled out selection of more compassionate students in the admission process of problem-based learning curricula, but where does this leave us? What is the active ingredient in the problem-based learning method — a mixed bag of nostrums if ever there was one — that is causing better outcomes for graduates of this type of curriculum? Does the process of working in small groups help problem-based learning graduates acquire better communication and interpersonal skills? Is it that problem-based learning curricula typically have more input from professionals, such as social workers and psychologists, who may be more concerned about physicians having a better appreciation of the cultural, legal and ethical aspects of care? Is the curriculum itself more likely to contain objectives that better prepare graduates to cope with uncertainty? Such questions need to be answered so that the potential benefits identified in the study by Koh and colleagues can be incorporated into the curricula of other medical schools.
For years we have endured debate about the relative merits and weaknesses of problem-based learning. Now there is good evidence that the method delivers on some very important issues. The next step is to determine why the method works.
@ See related article page 34
Key points of the article
• Although good evidence in support of a particular education innovation may exist, it is rarely instrumental in decisions to adopt that innovation.
• Given the importance placed on cultural and ethical issues, it bodes well for graduates of problem-based learning curricula that they are doing well in these high-priority areas.
• Now that there is evidence in support of problem-based learning, the next step is to determine why the method works so that the potential benefits can be incorporated into the curricula of other medical schools.


Footnotes
Competing interests: None declared.


REFERENCES Top
REFERENCES

1. <LI value=1>Koh GCH, Khoo HE, Wong ML, et al. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178:34-41.[Abstract/Free Full Text] <LI value=2>Woodward CA, Cohen M, Ferrier BM, et al. Correlates of certification in family medicine in the billing patterns of Ontario general practitioners. CMAJ 1989;141:897-904.[Abstract]
2. The Royal College of Physicians and Surgeons of Canada. The CanMEDS physician competency framework. Available: http://rcpsc.medical.org/canmeds (accessed 2007 Nov. 19).

Related Articles
The effects of problem-based learning during medical school on physician competency: a systematic review Gerald Choon-Huat Koh, MD MMed, Hoon Eng Khoo, PhD, Mee Lian Wong, MD MPH, and David Koh, MD PhD
Can. Med. Assoc. J. 2008 178: 34-41. [Abstract] [Full Text]

[BrendaB_MD]

Unique Identifier8594393
StatusMEDLINE
AuthorsSivam SP. Iatridis PG. Vaughn S.
Authors Full NameSivam, S P. Iatridis, P G. Vaughn, S.
InstitutionNorthwest Center for Medical Education, Indiana University School of Medicine, Gary 46408, USA.
TitleIntegration of pharmacology into a problem-based learning curriculum for medical students.
SourceMedical Education. 29(4):289-96, 1995 Jul.
AbstractThe 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 (NBMEI and/or USMLE I). The PBL curriculum students performed as well as or better than the TC students as measured by the NMBEI 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.
Publication TypeComparative Study. Journal Article.