The 'expert' in problem-based and case-based learning: necessary or not?

Does your group matter? How group function impacts educational outcomes in problem-based learning: a scoping review

BACKGROUND

Problem-based learning (PBL) is a common instructional method in undergraduate health professions training. Group interactions with and within PBL curricula may influence learning outcomes, yet few studies have synthesized the existing evidence. This scoping review summarized the literature examining the influence of group function on individual student PBL outcomes. Following Kirkpatrick's framework, experiential, academic, and behavioral outcomes were considered. The impacts of three aspects of group function were explored: (1) Group Composition (identities and diversity), (2) Group Processes (conduct and climate, motivation and confidence, and facilitation), and (3) PBL Processes (tutorial activities).

METHODS

A literature search was conducted using Medline, CINAHL, and APA PsychInfo from 1980-2021, with the help of a librarian. English-language empirical studies and reviews that related group function to learning outcome, as defined, in undergraduate health professions PBL curricula were included. Relevant references from included articles were also added if eligibility criteria were met. The methods, results, discussions, and limitations of the sample were summarized narratively.

RESULTS

The final sample (n = 48) varied greatly in context, design, and results. Most studies examined junior medical students (n = 32), used questionnaires for data collection (n = 29), and reported immediate cross-sectional outcomes (n = 34). Group Processes was the most frequently examined aspect of group function (n = 29), followed by Group Composition (n = 26) and PBL Processes (n = 12). The relationships between group function and outcomes were not consistent across studies. PBL experiences were generally highly rated, but favorable student experiences were not reliable indicators of better academic or behavioral outcomes. Conversely, problematic group behaviors were not predictors of poorer grades. Common confounders of outcome measurements included exam pressure and self-study.

CONCLUSIONS

The main findings of the review suggested that (1) group function is more predictive of experiential than academic or behavioral PBL outcomes, and (2) different Kirkpatrick levels of outcomes are not highly correlated to each other. More research is needed to understand the complexity of group function in PBL tutorials under variable study contexts and better inform curricular training and design. Standardized tools for measuring PBL group function may be required for more conclusive findings.

Case-based blended eLearning scenarios-adequate for competence development or more?

BACKGROUND

Learning, competence development and scientific thinking in medicine need several strategies to facilitate new diagnostic and therapeutic ways. The optimal collaboration between creative thinking and biomedical informatics provides innovation for the individual patient and for a medical school or society. Utilizing the flexibilities of an e‑learning platform, a case based blended learning (CBBL) framework consisting of A) case based textbook material, B) online e‑CBL with question driven learning scenarios and C) simulated patient (SP) contact seminars was developed and implemented in multiple medical fields. Real-life clinical cases were anonymized and transferred into an interactive and an interdisciplinary eLearning platform.

METHODS

As an example of the offered clinical teaching-case collection, an example of a psychiatric case for the disease "posttraumatic stress disorder (PTSD)" is presented: a 30-year-old man with a history of insomnia with difficulties in falling asleep and sleeping through, nightmares, nervousness and psychomotor restlessness. The students are challenged to identify possible differential diagnoses and further get to know the patient's personal history (loss of relatives due to war, torture and flight from home country). Further, the students are guided through the principles of fear conditioning including translational aspects like neurotransmitter signaling of PTSD pathomechanism (translational and research aspects like dopamine transporter gene polymorphism, long term potentiation and synaptic signaling).

RESULTS/CONCLUSION

The case presentation comprises different learning aspects: First, declarative knowledge has to be acquired and collected in basic medical sciences, knowledge that is in fact available and can be accessed on the conscious and preconscious level in long-term memory. Second, associative learning leads to the formation of neuronal connections and is an important way of learning and discovering, founded in neural associations. Third, polythematic-crosslinking thinking is needed as ability to link information in a meaningful way. These steps are a typical intellectual ability of gifted learners and researchers that combine previously seemingly unrelated areas to each other and drive innovation.

Case-Based Learning in Dermatology

IMPORTANCE

The instruction of dermatology can be challenging due to its large scope, heavy clinical nature, and limited curriculum space. Case-based learning (CBL) is an emerging education paradigm and has no current literature on its use in dermatology.

OBJECTIVES

Assess CBL in undergraduate dermatology medical education.

METHODS

Case-based learning was implemented in the preclerkship dermatology curriculum at the University of Toronto to 3 student cohorts (totaling 710 students and 93 tutors) between May 2016 and April 2017. We analyzed assignment performance, pre- and post-CBL knowledge test scores, and experience surveys on students and tutors. Surveys were evaluated using aggregate descriptive statistics for quantitative data and thematic data analysis for qualitative data. All assessments were anonymous and voluntary.

RESULTS

We received strong positive feedback on the CBL experience, with no score less than 3.8 on a 5-point scale (where 5 indicated strongly agree with a positively phrased question). Thematic data analysis revealed several key themes, including positive comments for a specialist tutor, the use of visual media, and the "mini-cases" style of CBL, while challenges included a lack of motivation. Group assignments scored high, ranging from 88.9% to 99.3%. Tracked pre- and post-CBL knowledge test scores showed a 32% (from 42% to 74%) increase in scores after the CBL experience. Conclusion and Relevance: CBL in dermatology medical education was well received by students and tutors, with high scores in content evaluation and knowledge assessment. Future studies should examine optimal delivery methods and its long-term effects on knowledge retention.

Comparison of physical examination performance of medical students trained by musculoskeletal versus non-musculoskeletal specialists

AIM

To compare the musculoskeletal (MSK) physical examination skills, knowledge acquisition and performance of first-year medical students trained by MSK specialist tutors to students trained by non-MSK specialist tutors, after a 6-week MSK physical examination tutorial program.

METHODS

Twenty-first year medical students took part in the study. They were recruited into two groups, according to their exposure to either an MSK specialist or a non-MSK specialist tutor during their 6-week MSK training block. Knowledge acquisition was measured via a pre- and post-training objective structured clinical examination (OSCE). We assessed students' self-belief and confidence levels regarding their newly acquired skills via a questionnaire. Independent t tests were used to examine mean group differences of OSCE scores and perceived level of confidence.

RESULTS

Both groups demonstrated a significant improvement (3.9 and 3.8 points, respectively, on an eight-point scale for shoulder assessment, P < 0.01, 3.3 and 3.5, respectively, on a five-point scale for spine assessment, P < 0.01) in OSCE scores compared to baseline after completing the 6-week MSK physical examination tutorial program. There was no between-group difference in the OSCE scores from pre- to post-training (P = 0.92 for shoulder, P = 0.66 for spine) or for perceived level of confidence in performing a basic MSK examination after training (P = 0.91).

CONCLUSION

Students exposed to MSK specialist tutors did not demonstrate increased skill levels or knowledge in the area of MSK physical examination compared to those receiving the same training under the supervision of non-MSK specialist tutors. Both student groups demonstrated improvement.

Perception of content and non-content expert facilitators of PBL according to students' performance levels

OBJECTIVE

Problem-based learning (PBL) is a student-centred learning system that involves multidisciplinary fields focused on problem solving. Facilitators of PBL are not necessarily content experts but little is known on how this concept has affected the outcomes of PBL sessions in learning Medical Biochemistry. We aimed to evaluate the impact of having the content expert as a facilitator in conducting PBL.

METHODS

A total of 150 first and second year medical students from the University Kebangsaan Malaysia were interviewed with a validated set of questions to acquire their views on the roles of facilitators in PBL in learning Medical Biochemistry. Their achievement were evaluated through their essay marks derived from various PBL packages.

RESULTS

All respondents agreed that PBL sessions associated with Medical Biochemistry are best appreciated when conducted by a content-expert facilitator. Their exam marks reflected well on their perception.

CONCLUSION

PBL sessions related to Medical Biochemistry is best facilitated by Biochemistry lecturers as the content experts.

Effective use of real-life events as tools for teaching-learning clinical pharmacology in a problem-based learning curriculum

Aim:

This paper describes how in a problem-based learning (PBL) medical curriculum, having identified the learning outcomes, problems can be developed from real-life events for teaching-learning clinical pharmacology topics for which PBL cases might be inadequate. Such problems can be very interesting and educational.

Methodology:

Using the story of the development and withdrawal of rofecoxib (Vioxx^®), we developed a problem for undergraduate medical students to address important issues related to clinical pharmacology and therapeutics such as new drug development, preclinical testing, clinical trials, adverse drug reactions, professionalism, and critical appraisal of literature. These topics would otherwise be difficult to address in patient-based problems.

Results:

The evaluation of the problem based on pooled feedback from 57 tutorial groups, each comprising 8–10 students, collected over 5 years, supported the effectiveness of the problem.

Conclusion:

A systematic approach described in this paper can be used for the development and validation of educational material for introducing focal topics of pharmacology/clinical pharmacology integrated with other disciplines in innovative medical (and other health profession) curricula.

A prospective randomized trial of content expertise versus process expertise in small group teaching

BACKGROUND

Effective teaching requires an understanding of both what (content knowledge) and how (process knowledge) to teach. While previous studies involving medical students have compared preceptors with greater or lesser content knowledge, it is unclear whether process expertise can compensate for deficient content expertise. Therefore, the objective of our study was to compare the effect of preceptors with process expertise to those with content expertise on medical students' learning outcomes in a structured small group environment.

METHODS

One hundred and fifty-one first year medical students were randomized to 11 groups for the small group component of the Cardiovascular-Respiratory course at the University of Calgary. Each group was then block randomized to one of three streams for the entire course: tutoring exclusively by physicians with content expertise (n = 5), tutoring exclusively by physicians with process expertise (n = 3), and tutoring by content experts for 11 sessions and process experts for 10 sessions (n = 3). After each of the 21 small group sessions, students evaluated their preceptors' teaching with a standardized instrument. Students' knowledge acquisition was assessed by an end-of-course multiple choice (EOC-MCQ) examination.

RESULTS

Students rated the process experts significantly higher on each of the instrument's 15 items, including the overall rating. Students' mean score (±SD) on the EOC-MCQ exam was 76.1% (8.1) for groups taught by content experts, 78.2% (7.8) for the combination group and 79.5% (9.2) for process expert groups (p = 0.11). By linear regression student performance was higher if they had been taught by process experts (regression coefficient 2.7 [0.1, 5.4], p < .05), but not content experts (p = .09).

CONCLUSIONS

When preceptors are physicians, content expertise is not a prerequisite to teach first year medical students within a structured small group environment; preceptors with process expertise result in at least equivalent, if not superior, student outcomes in this setting.

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.

Educação a distância sobre cardioversão e desfibrilação para enfermeiros

Este estudo teve como objetivo desenvolver e avaliar um curso a distância, sobre Cardioversão e Desfibrilação para enfermeiros, utilizando o ambiente virtual de aprendizagem Teleduc. A metodologia de ensino escolhida para este curso foi a Aprendizagem Baseada em Casos, explorando a característica de aprendizagem colaborativa. Foram convidados 23 enfermeiros, sendo que 21 iniciaram o curso e 11 o concluíram. O curso foi avaliado por profissionais com experiência em Educação a Distância e Unidade de Terapia Intensiva, que consideraram o curso adequado, mas que, no geral, precisava de pequenas reformulações. Quanto à avaliação do curso pelos alunos, a grande maioria apresentou opinião favorável, com boa aceitação da metodologia utilizada e bom desempenho durante o curso.

Problem-based Learning in Undergraduate Dental Education: Faculty Development at the University of Southern California School of Dentistry

The University of Southern California School of Dentistry (USCSD) seeks to educate oral health professionals with a balanced curriculum covering health promotion, risk assessment and disease prevention, diagnostics, treatments, and therapeutics. Based on critical analyses of a 5-year educational demonstration project, the USCSD proposed to use problem-based learning (PBL) to achieve its goals. Among the many changes required to convert a traditional dental educational curriculum to PBL, none is more important than that of faculty development. To achieve this, the USCSD Curriculum Subcommittee on Faculty Development, Mentoring, and Evaluation has designed and implemented a series of workshops to train its faculty as facilitators. There are four Core Skills Workshops: PBL Process Workshop, Facilitation of Learning Workshop, Student Assessment and Feedback Workshop, and PBL in the Clinical Environment.

An analysis of peer, self, and tutor assessment in problem-based learning tutorials

OBJECTIVE

The purpose of this study was to explore self-, peer-, and tutor assessment of performance in tutorials among first year medical students in a problem-based learning curriculum.

METHODS

One hundred and twenty-five students enrolled in the first year of the Bachelor of Medicine and Bachelor of Surgery Program at the University of Queensland were recruited to participate in a study of metacognition and peer- and self-assessment. Both quantitative and qualitative data were collected from the assessment of PBL performance within the tutorial setting, which included elements such as responsibility and respect, communication, and critical analysis through presentation of a case summary. Self-, peer-, and tutor assessment took place concurrently.

RESULTS

Scores obtained from tutor assessment correlated poorly with self-assessment ratings (r = 0.31-0.41), with students consistently under-marking their own performance to a substantial degree. Students with greater self-efficacy, scored their PBL performance more highly. Peer-assessment was a slightly more accurate measure, with peer-averaged scores correlating moderately with tutor ratings initially (r = 0.40) and improving over time (r = 0.60). Students consistently over-marked their peers, particularly those with sceptical attitudes to the peer-assessment process. Peer over-marking led to less divergence from the tutor scoring than under-marking of one's own work.

CONCLUSION

According to the results of this study, first-year medical students in a problem-based learning curriculum were better able to accurately judge the performance of their peers compared to their own performance. This study has shown that self-assessment of process is not an accurate measure, in line with the majority of research in this domain. Nevertheless, it has an important role to play in supporting the development of skills in reflection and self-awareness.

Peer assessment in problem-based learning: a qualitative study

Peer assessment provides a powerful avenue for students to receive feedback on their learning. Although student perceptions of peer assessment have been studied extensively in higher education, little qualitative research has been undertaken with medical students in problem-based learning (PBL) curricula. A qualitative study of students' attitudes to, and perceptions of, peer assessment was undertaken within the framework of a larger study of metacognition with first-year medical students at the University of Queensland. A highly structured format for provision of feedback was utilised in the study design. Many recommendations from the higher education literature on optimal implementation of peer-assessment procedures were put into practice. Results indicated the existence of six main themes: (1) increased responsibility for others, (2) improved learning, (3) lack of relevancy, (4) challenges, (5) discomfort, and (6) effects on the PBL process. Five of these themes have previously been described in the literature. However, the final theme represents a unique, although not unexpected, finding. Students expressed serious concerns about the negative impact of peer assessment on the cooperative, non-judgmental atmosphere of PBL tutorial groups. The practical implications of these findings are considered.

Twelve tips for recruiting and retaining facilitators in a problem-based learning programme

Successful curriculum reform requires considerable staff development. It is imperative for management to ensure that its academic staff members are committed to the change. This requires planning and negotiation. As facilitators form the 'teaching' backbone of a problem-based learning programme, faculty management must ensure mechanisms are in place to recruit facilitators, and that once recruited, the experience is sufficiently rewarding personally for their enthusiasm to be sustained. This article offers several solutions to difficulties which many medical schools encounter during the early years of an undergraduate PBL programme which replaces a traditional curriculum. The advice offered ranges from recruiting facilitators from the private sector to encouraging staff to become involved in other areas of curriculum development. Most importantly, however, is the reward and incentive system, which must be well advertised in advance of any programme implementation. The suggestions presented in this article will be useful to faculties planning to implement problem-based learning as well as those who already have a programme in place.

Case based learning--a review of the literature: is there scope for this educational paradigm in prehospital education?

This paper discusses the findings of a literature review of case based learning (CBL) from a multidisciplinary health science education perspective and attempts to draw comparisons with the available literature relating to prehospital education and CBL.CBL is an exciting educational prospect in which to develop research capacity, strategies, and opportunities. This paper provides an examination of the literature exploring the major consistencies and inconsistencies, and reveals areas of potential future research for prehospital education institutions.

To the point: reviews in medical education teaching techniques

Medical educators are faced with the difficult dilemma of decreased time available for teaching as a result of increased demands for clinical time. Yet few physicians have formal training in teaching methods. Educational research is reviewed to assist educators to select the best teaching technique to meet the learning objectives.

Learning from the problems of problem-based learning

BACKGROUND

The last decade has witnessed a rapid expansion of biomedical knowledge. Despite this, fashions in medical education over the same period have shifted away from factual (didactic) teaching and towards contextual, or problem-based, learning (PBL). This paradigm shift has been justified by studies showing that PBL improves reasoning and communication while being associated with few if any detectable knowledge deficits.

DISCUSSION

Analysis of the literature indicates that the recent rapid rise of PBL has closely paralleled the timing of the information explosion. The growing dominance of PBL could thus worsen the problems of information management in medical education via several mechanisms: first, by creating the impression that a defined spectrum of core factual knowledge suffices for clinical competence despite ongoing knowledge expansion (quality cost); second, by dissuading teachers from refining the educational utility of didactic modalities (improvement cost); and third, by reducing faculty time for developing reusable resources to impart factual knowledge more efficiently (opportunity cost).

SUMMARY

These costs of PBL imply a need for strengthening the knowledge base of 21st-century medical graduates. New initiatives towards this end could include the development of more integrated cognitive techniques for facilitating the comprehension of complex data; the design of differentiated medical curricula for producing graduates with defined high-priority skill sets; and the encouragement of more cost-effective faculty teaching activities focused on the prototyping and testing of innovative commercializable educational tools.

What can we learn from facilitator and student perceptions of facilitation skills and roles in the first year of a problem-based learning curriculum?

BACKGROUND

The small group tutorial is a cornerstone of problem-based learning. By implication, the role of the facilitator is of pivotal importance. The present investigation canvassed perceptions of facilitators with differing levels of experience regarding their roles and duties in the tutorial.

METHODS

In January 2002, one year after problem-based learning implementation at the Nelson R. Mandela School of Medicine, facilitators with the following experience were canvassed: trained and about to facilitate, facilitated once only and facilitated more than one six-week theme. Student comments regarding facilitator skills were obtained from a 2001 course survey.

RESULTS

While facilitators generally agreed that the three-day training workshop provided sufficient insight into the facilitation process, they become more comfortable with increasing experience. Many facilitators experienced difficulty not providing content expertise. Again, this improved with increasing experience. Most facilitators saw students as colleagues. They agreed that they should be role models, but were less enthusiastic about being mentors. Students were critical of facilitators who were not up to date with curriculum implementation or who appeared disinterested. While facilitator responses suggest that there was considerable intrinsic motivation, this might in fact not be the case.

CONCLUSIONS

Even if they had facilitated on all six themes, facilitators could still be considered as novices. Faculty support is therefore critical for the first few years of problem-based learning, particularly for those who had facilitated once only. Since student and facilitator expectations in the small group tutorial may differ, roles and duties of facilitators must be explicit for both parties from the outset.

Collaborative e-learning using streaming video and asynchronous discussion boards to teach the cognitive foundation of medical interviewing: a case study

BACKGROUND

Advances in electronic technology have created opportunities for new instructional designs of medical curricula.

OBJECTIVE

We created and evaluated a 4-week online elective course for medical students to teach the cognitive basis for interviewing skills.

METHODS

Ten students, from 2 medical schools, studied online modules on interviewing concepts and viewed videos illustrating the concepts. They then participated in asynchronous discussion groups designed to reinforce course concepts, stimulate reflective learning, and promote peer learning.

RESULTS

In qualitative evaluations, learners reported improvements in self-awareness; increased understanding of interviewing concepts; and benefits of online learning vs face to face learning. Participants reported high levels of satisfaction with online learning and with achievement of course objectives. Self-reported knowledge scores increased significantly from pre-course completion to post-course completion.

CONCLUSIONS

Online education has significant potential to augment curriculum on the medical interview, particularly among students trained in community settings geographically distant from their academic medical center.

Radiologists as clinical tutors in a problem-based medical school curriculum

RATIONALE AND OBJECTIVES

The authors sought to evaluate the experience of radiologists teaching in a problem-based pre-clinical medical school curriculum.

MATERIALS AND METHODS

The undergraduate medical school curriculum at Wake Forest University includes 2 problem-based preclinical years that integrate basic and clinical sciences. Sixteen radiology fellows served as general clinical tutors for 5-9 weeks, each guiding the work of six 2nd-year students, often in tandem with a basic science tutor. On completion of the tutoring. the radiologists and the students were surveyed by means of a questionnaire. A follow-up group interview was conducted with the radiologists.

RESULTS

The response rate to the questionnaire was 81% for the radiologists and 47% for the students. On average, radiologists spent 6.1 hours weekly on preparation and tutoring and 3.5 hours in total on administration and grading. All radiologists thought tutoring was rewarding, but seven of the 13 respondents (54%) disliked assigning grades. Radiologists spent less time teaching radiology residents and performing research, but few thought their clinical work was adversely affected. Nearly half of the radiologist-tutors thought that the preliminary orientation and training provided to them by the medical school was not adequate, and nearly all of them thought that they could have been better prepared. All of the medical students improved their perceptions of radiologists after having had a radiologist as a tutor, and most thought that the radiologist-tutors performed as well as or better than tutors from other disciplines.

CONCLUSION

Radiologists can be successful as general tutors in a problem-based medical school curriculum. benefiting both radiologists and students. Better orientation and training by the medical school would improve the program.