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

15 years of the model study course in medicine at the Ruhr University Bochum

The Faculty of Medicine of the Ruhr University Bochum (RUB) introduced a model study course in medicine (MSM) in the winter semester 2003. For 9 consecutive years, 42 out of 280 first year students at the Ruhr University Bochum had the opportunity to begin their studies in the model study course in medicine. The places were allocated amongst the applicants internally through a raffle. The MSM was consistently problem-, practice- and patient-oriented and largely did away with lectures, broke with the distinction between a pre-clinical and clinical phase and tested basic knowledge in equivalent integrated exams focusing on clinical application. Following a comparative evaluation of the standard degree course (RSM) and the MSM, the faculty merged the two degree courses into the Integrated Reformed Medical Curriculum (IRMC), which has been on offer since 2013 and is characterized by a topic-oriented hybrid curriculum. This article examines experiences relating to the origins, conception and introduction of the MSM.

A scoping review of health professional curricula: Implications for developing integration in pharmacy

BACKGROUND

Integrated health professions curricula aim to produce graduates who are capable of meeting current and future healthcare needs. This is reflected in pharmacy education where integration is increasingly advocated by pharmacy regulators as the perceived optimal way of preparing students for registration as pharmacists. There is, however, no definition of integration. Integration can be described according to a model of horizontal, vertical or spiral integration. It can also be described by the themes used to integrate, such as a systems-based approach or by integrative teaching and learning approaches. The level of integration can also be described.

OBJECTIVE

This scoping review aimed to explore health professions education literature to inform the optimal design of integrated pharmacy curricula. This review asks: what is meant by integration in health professions curricula?

METHODS

The Arksey and O'Malley scoping review framework was utilised. Ovid MEDLINE, EMBASE, Scopus, Web of Science and ERIC were searched. Models of integration, themes for integration, integrative teaching and learning approaches, and level of integration were defined and supported data extraction.

RESULTS

There were 9696 records screened and of these 137 were included. The majority of studies (n = 88) described horizontal integration. Systems-based teaching (n = 56) was the most common theme reported. Various integrative teaching and learning approaches were described, including experiential (n = 43), case-based (n = 42) and problem-based (n = 38) learning. The majority of the curricula could be classified as levels 5-7 on Harden's ladder (n = 102). Perception outcomes were reported for 81 studies, and only 3 reported outcomes beyond perception. Reported outcomes were generally positive and included knowledge gains and increased motivation.

CONCLUSIONS

There is a need for integration to be explicitly defined by curriculum developers and researchers. Attention should be given to describing the model, theme, teaching and learning approach and level of integration. There remains a lack of evidence for integration.

Exploring an integrated curriculum in pharmacy: Educators' perspectives

BACKGROUND AND PURPOSE

Lack of consensus regarding the benefits of an integrated curriculum, and ambiguity concerning what is being integrated within a pharmacy curriculum exists, but how an integrated curriculum is viewed, epistemologically, and subsequently incorporated into teaching practice has not been investigated. This study explores how educators conceptualize, experience and enact curricula integration both pedagogically and organizationally.

EDUCATIONAL ACTIVITY AND SETTING

In-depth qualitative interviews with faculty members purposively sampled for maximum variation in disciplinary background and teaching experience were undertaken at a single site. Interviews addressed two research questions: how pharmacy educators understand an integrated curriculum and educators' experiences of it.

FINDINGS AND DISCUSSION

Analysis of the interview data suggests four essential meanings of integration: integration as a method for organizing teaching and learning; integration as enacted by self and others; integration as tension between conflicting knowledge domains; and integration as an impossible concept to apply to teaching practice. Analysis suggests that integration is an abstract rather than enacted concept and although integration is viewed as learner-centered, integration is complex and associated with a loss of in-depth learning.

SUMMARY

Differences in how faculty members conceptualize the purpose and effects of integration mean that the level and type of integration reported varied. A clearer understanding of the rationale for change, and methods for better applying theory of integration to teaching practice, may be needed to achieve curriculum standards required by bodies accrediting undergraduate pharmacy programs.

Extending the theoretical framework for curriculum integration in pre-clinical medical education

INTRODUCTION

Curriculum integration is widely discussed in medical education but remains ill defined. Although there is plenty of information on logistical aspects of curriculum integration, little attention has been paid to the contextual issues that emerge from its practice and may complicate students' knowledge integration. Therefore, we aimed to uncover how curriculum integration is manifested through context.

METHODS

We collected data from the official curriculum and interviewed ten participants (including curriculum designers, facilitators, and students) in the bachelor's medical program at Aalborg University. We observed various learning activities focused on pre-clinical education. Inspired by grounded theory, we analyzed the information we gathered.

RESULTS

The following theoretical constructs emerged after the inductive analysis: 1) curriculum integration complexity is embedded in the institutional learning perspectives; 2) curriculum integration is used to harmonize conflicting learning perspectives in curriculum practice; 3) curriculum integration creates tensions that self-organize its structure; and 4) curriculum integration becomes visible in collaborative learning spaces.

DISCUSSION

These constructs provide a framework for analyzing curriculum integration in the context in which it is meant to appear, which may assist educationalists to gain a more specific understanding of the term. This may enable effective curriculum integration since contextual issues are addressed in addition to the goals specified in the official curriculum.

Vertical integration of biochemistry and clinical medicine using a near-peer learning model

Vertical integration has been extensively implemented across medical school curricula but has not been widely attempted in the field of biochemistry. We describe a novel curricular innovation in which a near-peer learning model was used to implement vertical integration in our medical school biochemistry course. Senior medical students developed and facilitated a case-based small group session for first year biochemistry students. Students were surveyed before and after the session on their attitudes about biochemistry, as well as the effectiveness of the session. Prior to the session, the students believed biochemistry was more important to understanding the basic science of medicine than it was to understanding clinical medicine or becoming a good physician. The session improved students' attitudes about the importance of biochemistry in clinical medicine, and after the session they now believe that understanding biochemistry is equally important to the basic sciences as clinical medicine. Students would like more sessions and believe the senior student facilitators were knowledgeable and effective teachers. The facilitators believe they improved their teaching skills. This novel combination of near-peer learning and vertical integration in biochemistry provided great benefit to both first year and senior medical students, and can serve as a model for other institutions. © 2016 by The International Union of Biochemistry and Molecular Biology, 44(6):507-516, 2016.

Cognitive Load Theory: implications for medical education: AMEE Guide No. 86

Cognitive Load Theory (CLT) builds upon established models of human memory that include the subsystems of sensory, working and long-term memory. Working memory (WM) can only process a limited number of information elements at any given time. This constraint creates a "bottleneck" for learning. CLT identifies three types of cognitive load that impact WM: intrinsic load (associated with performing essential aspects of the task), extraneous load (associated with non-essential aspects of the task) and germane load (associated with the deliberate use of cognitive strategies that facilitate learning). When the cognitive load associated with a task exceeds the learner's WM capacity, performance and learning is impaired. To facilitate learning, CLT researchers have developed instructional techniques that decrease extraneous load (e.g. worked examples), titrate intrinsic load to the developmental stage of the learner (e.g. simplify task without decontextualizing) and ensure that unused WM capacity is dedicated to germane load, i.e. cognitive learning strategies. A number of instructional techniques have been empirically tested. As learners' progress, curricula must also attend to the expertise-reversal effect. Instructional techniques that facilitate learning among early learners may not help and may even interfere with learning among more advanced learners. CLT has particular relevance to medical education because many of the professional activities to be learned require the simultaneous integration of multiple and varied sets of knowledge, skills and behaviors at a specific time and place. These activities possess high "element interactivity" and therefore impose a cognitive load that may surpass the WM capacity of the learner. Applications to various medical education settings (classroom, workplace and self-directed learning) are explored.

A comparison of unguided vs guided case-based instruction on the surgery clerkship

BACKGROUND

Guided case-based instruction is an effective and efficient means of learning for third year medical students on the surgery clerkship. Compared with an unguided format for teaching biliary disease, we observed greater student satisfaction as well as a more efficient utilization of student as well as faculty time with the guided instruction.

OBJECTIVE

While case-based instruction (CBI) has become an extremely popular teaching modality during the first 2 years of medical school, there has been little published regarding its utilization during the clinical years of medical school. The purpose of our study was to compare guided CBI (G-CBI) to unguided CBI (UG-CBI) during the surgery clerkship.

DESIGN

From July 2007 to July 2008, we utilized a UG-CBI format to teach biliary disease, formerly taught by a standard lecture. The unguided style is used by our institution for the first 2 years of medical school education, where the role of the facilitator is minimal. From July 2008 to December 2010, we changed to a G-CBI format where 5 different clinical scenarios were presented that all dealt with some form of biliary disease. A Likert-like scale was used to analyze student opinion comparing guided to the traditional unguided format. Questions regarding biliary disease contained in the National Board of Medical Examiners (NBME) shelf examination, given to all students at the end of the rotation, were also compared between the 2 groups. Cohen's d statistic was used to assess effect size.

SETTING

The study took place at the University of Arizona College of Medicine.

PARTICIPANTS

There were 88 students in the UG-CBI group and 146 in the G-CBI group.

RESULTS

Ninety-six percent of the students preferred G-CBI over the unguided format utilized during the basic science years. Eighty-two percent felt that the guided format sessions were a more efficient method of instruction and 91% of students agreed or strongly agreed that time was more efficiently utilized in preparing for the case discussion during the guided format. Shelf examination scores analyzing biliary disease questions (2-4 per examination) showed a moderate size effect favoring the G-CBI, although the numbers were too small to draw definite conclusions in this regard.

CONCLUSIONS

G-CBI is more suited for the surgery clerkship than the UG-CBI utilized during the first 2 years of medical school. Lack of a clinical knowledge base among the students rotating on the surgery clerkship as well as time limitations for both the student and clinical faculty favor this more efficient means of learning.

Differential student attrition and differential exposure mask effects of problem-based learning in curriculum comparison studies

PURPOSE

Studies that compare the effects of problem-based and conventional medical curricula on student performance generally show no significant differences. However, curriculum comparison studies are at best quasi-experimental, so they are prone to forms of selection bias. The purpose of this study was to reanalyze data from such comparisons by controlling for two potential biases: differential student attrition and differential exposure.

METHOD

The authors reanalyzed 104 previously published comparisons involving a single, problem-based medical school in the Netherlands (Maastricht University's medical school), using student attrition and study duration data from this school and the schools with which it was compared. The authors removed bias by reequalizing the comparison groups in terms of attrition and study duration.

RESULTS

The uncorrected data showed no differences between problem-based and conventional curricula: Mean effect sizes as expressed by Cohen d were 0.02 for medical knowledge and 0.07 for diagnostic reasoning. However, the reanalysis demonstrated medium-level effect sizes favoring the problem-based curriculum. After corrections for attrition and study duration, the mean effect size for knowledge acquisition was 0.31 and for diagnostic reasoning was 0.51.

CONCLUSIONS

Effects of the Maastricht problem-based curriculum were masked by differential attrition and differential exposure in the original studies. Because this school has been involved in many studies included in influential literature reviews published in the past 20 years, the authors' findings have implications for the assessment of the value of problem-based learning put forward by these reviews.

Process of discovery: a fourth-year translational science course

BACKGROUND

The Liaison Committee on Medical Education notes the importance of educating medical students on clinical and translational research principles.

PURPOSE

To describe a fourth-year course, "Process of discovery," which addresses teaching these principles, and to discuss students' perceptions of the course.

METHODS

Core components and pedagogical methods of this course are presented. Course assessment was performed with specific pre- and post-course assessments.

RESULTS

During academic years 2004 to 2009, 562 students were enrolled, with assessment response rate of 94% pre-course and 85% post-course. The students' self-assessment of their current understanding of clinical and translation research significantly increased, as well as their understanding of how clinical advances will take place over the next decade.

CONCLUSIONS

A fourth-year course teaching clinical and translational research is successful, is seen as a positive experience and can meet the requirements for including clinical and translational research in the medical school curriculum.

Can learning style predict student satisfaction with different instruction methods and academic achievement in medical education?

The curriculum of our medical school has a hybrid structure including both traditional training (lectures) and problem-based learning (PBL) applications. The purpose of this study was to determine the learning styles of our medical students and investigate the relation of learning styles with each of satisfaction with different instruction methods and academic achievement in them. This study was carried out with the participation of 170 first-year medical students (the participation rate was 91.4%). The researchers prepared sociodemographic and satisfaction questionnaires to determine the characteristics of the participants and their satisfaction levels with traditional training and PBL. The Kolb learning styles inventory was used to explore the learning styles of the study group. The participants completed all forms at the end of the first year of medical education. Indicators of academic achievement were scores of five theoretical block exams and five PBL exams performed throughout the academic year of 2008-2009. The majority of the participants took part in the "diverging" (n = 84, 47.7%) and "assimilating" (n = 73, 41.5%) groups. Numbers of students in the "converging" and "accommodating" groups were 11 (6.3%) and 8 (4.5%), respectively. In all learning style groups, PBL satisfaction scores were significantly higher than those of traditional training. Exam scores for "PBL and traditional training" did not differ among the four learning styles. In logistic regression analysis, learning style (assimilating) predicted student satisfaction with traditional training and success in theoretical block exams. Nothing predicted PBL satisfaction and success. This is the first study conducted among medical students evaluating the relation of learning style with student satisfaction and academic achievement. More research with larger groups is needed to generalize our results. Some learning styles may relate to satisfaction with and achievement in some instruction methods.

The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors

CONTEXT Medical education in the UK has recently undergone radical reform. Tomorrow's Doctors has prescribed undergraduate curriculum change and the Foundation Programme has overhauled postgraduate education. OBJECTIVES This study explored the experiences of junior doctors during their first year of clinical practice. In particular, the study sought to gain an understanding of how junior doctors experienced the transition from the role of student to that of practising doctor and how well their medical school education had prepared them for this. METHODS The study used qualitative methods comprising of semi-structured interviews and audio diary recordings with newly qualified doctors based at the Peninsula Foundation School in the UK. Purposive sampling was used and 31 of 186 newly qualified doctors self-selected from five hospital sites. All 31 participants were interviewed once and 17 were interviewed twice during the year. Ten of the participants also kept audio diaries. Interview and audio diary data were transcribed verbatim and thematically analysed with the aid of a qualitative data analysis software package. RESULTS The findings show that, despite recent curriculum reforms, most participants still found the transition stressful. Dealing with their newly gained responsibility, managing uncertainty, working in multi-professional teams, experiencing the sudden death of patients and feeling unsupported were important themes. However, the stress of transition was reduced by the level of clinical experience gained in the undergraduate years. CONCLUSIONS Medical schools need to ensure that students are provided with early exposure to clinical environments which allow for continuing 'meaningful' contact with patients and increasing opportunities to 'act up' to the role of junior doctor, even as students. Patient safety guidelines present a major challenge to achieving this, although with adequate supervision the two aims are not mutually exclusive. Further support and supervision should be made available to junior doctors in situations where they are dealing with the death of a patient and on surgical placements.

Determinants of successful deanship

With the significant changes taking place in health and education as well as the rising demands and expectations, deans of medical faculties must exhibit strong and effective leadership skills. Deans need to focus on the broad scope and to translate their dreams into applied institutional operations and functions. It is thus necessary that the deans must identify the institution's core ideology, lead strategic planning, create a common vision and offer direction to the collective membership of the institution. Some personal qualities that appear to be critical for effective deanship include being visionary, fair, trustworthy and exemplary. Prospective deans should receive training in leadership. New deans must be properly informed on the strategic plan of the faculty before they are appointed.

Students' hopes and fears about early patient contact: lessons to be learned about preparing and supporting students during the first year

BACKGROUND

Medical students increasingly have contact with real patients ('early patient contact', EPC) from the beginning of their first year. Little is known about their expectations of meeting patients at this time. Understanding their hopes and fears might usefully influence the design and delivery of EPC.

AIM

To explore students' views of EPC before arrival at medical school and the impact of EPC on them after 1 year.

METHODS

A two-part study comprising a pre-registration questionnaire, with open-ended questions, sent to the complete year group, and four focus groups conducted after 1 year with randomly selected students.

RESULTS

Students anticipated benefits from EPC, especially in promoting personal and professional development. After 1 year most of their hopes were realized. They feared feeling inadequate and doing harm to patients or themselves. Fears were reinforced when students felt underprepared, were not made welcome on hospital wards and treated disrespectfully by some staff.

CONCLUSION

Understanding how students anticipate meeting patients for the first time is crucial to maximize the educational potential of EPC. Students' preparation for EPC and the organization of these real patient encounters are of paramount importance in determining to what extent their hopes and fears are realized and their consequent learning.

Medical education reform: the Asian experience

Medical education reform is taking place all over the world including Asia, which has 60% of the world's population. Confronted with diverse social and cultural needs as well as resource constraints, various regions in Asia have carried out medical education reform at different levels and directions. In this article, the authors describe the application of Western-inspired reforms and localization and adaptation of Western models to fit the cultural and community needs in the five different subregions of Asia: (1) Eastern Asia, (2) Southern Asia, (3) Southeastern Asia, (4) Central Asia, and (5) Western Asia. The article reviews whether the medical education reforms brought improvement to the medical curricula and effectively fulfilled the cultural and social needs of Asian countries. The authors also explore the establishment of medical education departments in many Asian medical schools and the incorporation of research findings into medical practice. Departments of medical education will facilitate localization and promote further development of medical education reform in Asia despite the challenges ahead.

A model of clinical problem-based learning for clinical attachments in medicine

CONTEXT

Problem-based learning (PBL) has been widely adopted in medical curricula for early-years training, but its use during clinical attachments has not been extensively explored. Objectives This study aimed to develop and evaluate a new model, 'clinical problem-based learning' (CPBL), to promote learning skills, attitudes and knowledge during clinical attachments.

METHODS

The CPBL model takes the principles of PBL and applies them to learning during clinical attachments. Real patient encounters are guided by a list of broadly defined case types to ensure curriculum coverage. By discussing history taking and examination in the context of differential diagnosis and problem listing, students generate learning objectives relating to clinical skills, disease mechanisms and clinical management. These are explored through self-directed learning before the second tutorial, in which the tutor takes the role of 'expert', demonstrating how learned material translates into clinical practice. We evaluated which components contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus (Delphi process) method.

RESULTS

Students found CPBL a positive learning experience. Identification of suitable cases for discussion was readily achieved, although follow-up was sometimes difficult. The tutor's level of expertise and a non-threatening learning environment, conducive to student questioning, were highly rated contributors to successful CPBL. Comments reinforced the view that CPBL is a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching.

CONCLUSIONS

Clinical problem-based learning was well received in clinical placements. Key elements were the learning interval, the involvement of expert tutors and a non-threatening learning environment.

Back to the basic sciences: an innovative approach to teaching senior medical students how best to integrate basic science and clinical medicine

Abraham Flexner persuaded the medical establishment of his time that teaching the sciences, from basic to clinical, should be a critical component of the medical student curriculum, thus giving rise to the "preclinical curriculum." However, students' retention of basic science material after the preclinical years is generally poor. The authors believe that revisiting the basic sciences in the fourth year can enhance understanding of clinical medicine and further students' understanding of how the two fields integrate. With this in mind, a return to the basic sciences during the fourth year of medical school may be highly beneficial. The purpose of this article is to (1) discuss efforts to integrate basic science into the clinical years of medical student education throughout the United States and Canada, and (2) describe the highly developed fourth-year basic science integration program at the University of Pittsburgh School of Medicine. In their critical review of medical school curricula of 126 U.S. and 17 Canadian medical schools, the authors found that only 19% of U.S. medical schools and 24% of Canadian medical schools require basic science courses or experiences during the clinical years, a minor increase compared with 1985. Curricular methods ranged from simple lectures to integrated case studies with hands-on laboratory experience. The authors hope to advance the national discussion about the need to more fully integrate basic science teaching throughout all four years of the medical student curriculum by placing a curricular innovation in the context of similar efforts by other U.S. and Canadian medical schools.

How interdisciplinary teams can create multi-disciplinary education: the interplay between team processes and educational quality

CONTEXT

Many undergraduate medical education programmes offer integrated multi-disciplinary courses, which are generally developed by a team of teachers from different disciplines. Research has shown that multi-disciplinary teams may encounter problems, which can be detrimental to productive co-operation, which in turn may diminish educational quality. Because we expected that charting these problems might yield suggestions for addressing them, we examined the relationships between team diversity, team processes and course quality.

METHODS

We administered a questionnaire to participants from 21 interdisciplinary teams from 1 Dutch and 1 German medical school, both of which were reforming their curriculum. An adapted questionnaire on team learning behaviours, which had been validated in business contexts, was used to collect data on team processes, team learning behaviours and diversity within teams. We examined the relationship between the team factors and educational quality measures of the courses designed by the teams.

RESULTS

A total of 84 teachers (60%) completed the questionnaire. Bivariate correlation analysis showed that several aspects of diversity, conflict, working climate and learning behaviour were correlated with course quality.

CONCLUSIONS

The negative effects of the diversity measures, notably, value diversity, on other team processes and course quality and the positive association between psychological safety and team learning suggest that educational quality might be improved by enhancing the functioning of multi-disciplinary teams responsible for course development. The relationship between team processes and educational quality should be studied among larger study populations. Student ratings should also be considered in measuring educational quality.

Students' perceptions of early patient encounters in a PBL curriculum: a first evaluation of the Maastricht experience

INTRODUCTION

Real patient encounters before the clinical phase of undergraduate medical education are recommended to stimulate integration of theory and practice. Such encounters are not easy to integrate into the three phases of the problem-based learning cycle, i.e. preparation, self-study and reporting. The authors studied students' perceptions of problem-based learning with real patient encounters as the starting point for learning.

METHOD

Students' perceptions of the programme with real patients were evaluated by means of a questionnaire. Mean item scores on a five-point Likert scale and 95% confidence intervals were calculated.

RESULTS

Students showed satisfaction with the patient encounters and said they learned a lot from them. Reporting was also highly rated, particularly the integration of theory and practice. Preparation and self-study received lower scores.

DISCUSSION

The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students' and teachers' views and behaviours in respect of this type of learning.

Using clinical experience in discussion within problem-based learning groups

A key principle in problem-based learning (PBL) is the student linking learning from different sources to enrich understanding. We have explored how medical students based in a clinical environment use clinical experience within PBL groups. We recorded the discussion of 12 third-year groups, which were meeting for the second time on a PBL case, where students report back on the learning objectives. Discussions covering five separate PBL paper cases were recorded. Analysis of the transcripts was based on constant comparative method using a coding framework. The range of discussion segments of clinical experience was 2-15, with 9 of 12 groups having at least five separate segments. Our initial coding framework covered 10 categories, of which the most common were: a specific patient encounter (19%); an experience in the community (15%); and a personal health experience (15%). Students often used emotive phrases with 37 examples in the clinical experience segments compared with 9 from the longer non-clinical discussion. Most clinical descriptions triggered further discussion with almost half leading to some related medical topic. The discussion segments were subsequently coded into; 'confirming' (40); 'extending' (40); and 'disconfirming' (16) the understanding of the group for that topic. Discussion of clinical experience encouraged students to connect to the affective aspects of learning. It helped students to bridge between the tutorial and real clinical contexts. A clinical experience was often a powerful pivotal point, which confirmed, extended or refuted what was being discussed.

Views, behaviours and perceived staff development needs of doctors and surgeons regarding learners in outpatient clinics

INTRODUCTION

The need to use outpatient clinics as a major learning environment in hospitals for students and doctors-in-training is clear. However, consultant supervisors perceive major barriers to this and continue to rely heavily on traditional inpatient learning. This quantitative study examines what approaches consultant supervisors employ in outpatient learning, together with what they perceive themselves to use and what they would value in further training.

METHODS

We observed learning episodes for students and doctors-in-training in medical and surgical clinics. A questionnaire on outpatient teaching was also sent to consultant doctors and surgeons. This was based on these observations and focus groups with students and doctors-in-training.

RESULTS

There was an overall survey response rate of 62% (194/311). The dominant forms of learning we observed were 'arms-length' supervision for doctors-in-training and 'modelling' for students. Only 7% of learning episodes involved a doctor-in-training doing something under direct supervision. In contrast to the observation results, consultants considered that students and doctors-in-training received a lot of direct supervision and interaction. For example, 45% considered that doctors-in-training 'may see patients with me in a joint consultation'. Only 30% of respondents would be interested in staff development in learning in outpatient clinics.

CONCLUSIONS

Although consultants reported that they frequently used an active approach to learning in outpatient clinics, modelling was used predominantly for students and arms-length supervision was used for doctors-in-training.

Student-selected components in the undergraduate medical curriculum: a multi-institutional consensus on assessable key tasks

This paper describes further progress by the Northern Universities SSC Consortium in achieving consensus on the contribution of the Student Selected Components (SSCs) to undergraduate medical courses. Following the identification of common purposes and outcomes, the group has matched these to assessable key tasks which students may undertake in order to demonstrate competence on a range of attributes not normally fully assessed in the core curriculum. In some schools, SSCs may be the predominant route through which students gain exposure to research methods and reflective practice. In addition to opportunities to acquire knowledge and skills outside the core curriculum, SSCs can contribute towards enhancement of core skills. SSCs may also contribute to the overall longitudinal assessment of personal and professional development. The potential role of portfolios in maximizing student learning from SSCs is discussed, and future areas for development identified.

Problem-based learning: future challenges for educational practice and research

CONTEXT

Problem-based learning (PBL) is widely used in higher education. There is evidence available that students and faculty are highly satisfied with PBL. Nevertheless, in educational practice problems are often encountered, such as tutors who are too directive, problems that are too well-structured, and dysfunctional tutorial groups.

PURPOSE

The aim of this paper is to demonstrate that PBL has the potential to prepare students more effectively for future learning because it is based on four modern insights into learning: constructive, self-directed, collaborative and contextual. These four learning principles are described and it is explained how they apply to PBL. In addition, available research is reviewed and the current debate in research on PBL is described.

DISCUSSION

It is argued that problems encountered in educational practice usually stem from poor implementation of PBL. In many cases the way in which PBL is implemented is not consistent with the current insights on learning. Furthermore, it is argued that research on PBL should contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances. Examples of studies are given to illustrate this issue.

A model of how students link problem-based learning with clinical experience through "elaboration"

PURPOSE

In 1994, the medical school at the University of Manchester introduced a new integrated course that uses problem-based learning (PBL) throughout the clinical clerkships as the major approach for delivery of the core curriculum. This study explored how students linked PBL and clinical experiences.

METHOD

All third- and fourth-year students were asked to respond to an open-ended question on the end-of-module course evaluation. Their responses were analyzed and grouped into themes. The authors also conducted three focus groups of third-year students and a further three focus groups of fourth-year students to explore how students viewed the links between PBL and clinical experiences. The discussions were taped and subsequently analyzed by the researchers independently.

RESULTS

The authors found that the students used clinical experience as a means of elaborating their knowledge either at the time of encountering an appropriate patient (outside the group) or by bringing their experiences back to the PBL group for discussion (inside the group). Major facilitators of elaboration were the match between the clinical clerkship and the content of the PBL case, the role of the tutor, and the self-directedness of the student. A theoretical model of how students linked PBL with their clinical experience was derived based on a cognitive psychological approach to learning.

CONCLUSIONS

The model will be of benefit as the authors try to improve the course for those students who were unable to use their clinical experiences to achieve the goals of their PBL discussions.

Child health nurses' perceptions of enquiry-based learning

Since the publication of Fitness for Practice (UKCC, 1999), most preregistration nursing curriculae embrace the principles of enquiry-based learning (EBL) as a method of educating students. EBL uses genuine real-life client scenarios which provide the students with an opportunity to explore a range of issues directly pertaining to client care in a variety of contemporary nursing settings (Long et al, 1999). This evaluative study of one group (n=12) of child branch students conducted during the last EBL session of the course reflects the students' experiences of this method of teaching over a 3-year period. Nominal group technique (Delbecq and Van de Ven, 1971) was utilized to give a quantitative dimension to the reporting and recording of individual student reflections of EBL. The results demonstrate overall satisfaction with this method of student learning. A number of concerns raised by students reflect some of the pitfalls associated with EBL and these have important ramifications for nurse educators and clinical placement mentors. However, the small size limitations of this study do not allow for generalizability.

Improved student learning in ophthalmology with computer-aided instruction

PURPOSE

Recent changes in the medical school curriculum and in teaching styles have stimulated the development of novel learning resources. We investigated the impact of computer-aided learning in the field of ophthalmology at a large Australian undergraduate medical school.

METHODS

Clinical case studies describing common ophthalmic conditions were incorporated into a computing program which uses a problem-solving format. The program was made available to 85 medical students for a 2 week period. A control group of 20 medical students did not have access to this material. Acquisition of new knowledge was assessed as the improvement in score on a knowledge-based multiple-choice examination which students took both before and following the learning interval.

RESULTS

Students in the control group showed no improvement over the test period, whilst the students who had access to the computer significantly increased their knowledge base, both for material provided on the program (p = 0.0001) and in related areas (p = 0.0015).

CONCLUSIONS

Suitably constructed material on the computer is a useful aid in teaching ophthalmology to medical undergraduates. The material and the medium may also act as a stimulus for further learning.

Changing face of medical curricula

The changing role of medicine in society and the growing expectations patients have of their doctors means that the content and delivery of medical curricula also have to change. The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. Medical training is becoming more student centred, with an emphasis on active learning rather than on the passive acquisition of knowledge, and on the assessment of clinical competence rather than on the ability to retain and recall unrelated facts. Rigid educational programmes are giving way to more adaptable and flexible ones, in which student feedback and patient participation have increasingly important roles. The implementation of sustained innovation in medical education continues to present challenges, especially in terms of providing institutional and individual incentives. However, a continuously evolving, high quality medical education system is needed to assure the continued delivery of high quality medicine.