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[Problem-based medical teaching].

A possible method of improving teaching at faculties of Health Sciences is the so-called problem-based teaching method. A student is presented with a (clinical) medical case, which is to be investigated. By means of this method, the student himself will, under guidance, formulate his individual lack of knowledge, goals, priorities, methods, and evaluation. Educational observations show that the learning process is better when the problem-solving takes place among a group of students. A tutor acts as a catalyst for the process and gives feed-back through the problem-solving. He is therefore not an intermediary of knowledge to the group, but primarily refers the student to literature or knowledge experts at the faculty. International studies have not proven any unequivocal improvement in the students' ability to pass exams or to work as doctors, but both teachers and students seem to be more satisfied with the teaching method, which has stimulated the wish to study. The use at other faculties has not caused any large increase in expenditures. This should result in an increased use of problem-based teaching in medical education.

Denmark↗

Pathology in the new pathway of medical education at Harvard Medical School.

In 1985 Harvard Medical School initiated an experimental curriculum that incorporated many of the recommendations of the report on the General Professional Education of the Physician (GPEP). Key features are problem-based small group tutorials that emphasize active learning, with increased independent study time and a decreased number of lectures. Tutors serve as guides to their students and are not necessarily experts in the discipline of the cases studied. Learning skills are taught, including information acquisition and criticism and computer literacy. Knowledge is integrated from the beginning by interdisciplinary basic science courses, by earlier introduction of the clinical sciences, and by juxtaposition of the scientific and humanistic aspects of medicine. Preventive medicine, health maintenance, and ambulatory care are given more attention. The students are organized into societies that provide vertical integration and promote cooperation among students and closer contact with faculty. Pathology has proved to be a popular and key bridge in the new curriculum. The success of the early efforts at Harvard and several pioneering medical schools should encourage others to move toward more problem-solving, student-centered, integrative medical education.

Curriculum↗

Ranking clinical problems and ocular diseases in ophthalmology: an innovative approach to curriculum design.

The MD program of the Faculty of Health Sciences, McMaster University, Hamilton, Ont., has used a problem-based, self-directed, small-group learning approach to medical education since 1969. Substantial curriculum revision was begun in 1983 as part of a process of institutional renewal. A faculty survey of all academic clinicians in the Division of Ophthalmology, Department of Surgery, was carried out in 1984 to determine which problems and diseases the teaching faculty thought had the highest priority for student learning. The results have been used by educational planners in revising the curriculum. They have also served to clarify faculty members' expectations of students within an ophthalmology rotation.

Curriculum↗

Self-assessment and learning through GOSCE (group objective structured clinical examination).

The objective structured clinical examination (OSCE) was modified to serve as a means of self-assessment and learning, rather than as an examination. The main modifications were to adapt it for use by small groups instead of individuals, and to provide a correct answer or other feedback at each station. The resulting group OSCE (GOSCE) was used as an introductory session in two residential refresher courses for general practitioners. The 300 participants rated it highly as a method of self-assessment and as an enjoyable social event. Four potential applications of the GOSCE are suggested: as an assessment instrument for formative and informal summative assessment, as a resource for learning about interpersonal and interprofessional relationships, and as a framework for problem-based short courses.

Education, Medical, Graduate↗

Modified essay questions: are they worth the effort?

The method chosen for important examinations strongly influences the nature of student learning. The Newcastle Medical School in Australia developed a 5-year problem-based curriculum and adopted the Modified Essay Question (MEQ) as the main written instrument for assessing students' problem-solving skills. Even with the best of intentions the MEQ has been abused by its over-use, as shown in this review of annual assessment for years 1, 3 and 5 of the course. Analysis of staff and students' dissatisfaction with this instrument showed some difficulties attributable to the nature of MEQ items. However, a number of problems also emerged as a result of subtle changes in the teaching staff's approach to learning and assessment. This paper concludes by acknowledging the strengths and limitations of the MEQ. It recommends ways in which the MEQ can be effective, as part of a balanced programme involving other suitable instruments.

Adolescent↗

The cost of problem-based vs traditional medical education.

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.

Costs and Cost Analysis↗

A randomized controlled trial assessing the impact of problem-based versus didactic teaching methods in CME.

A Continuing Medical Education short course was designed to examine the effect of presenting topics in three learning formats - traditional lectures, large-group, case discussions or small-group, problem-solving sessions, on knowledge and performance of family physicians. The physicians in the small group session rated the CME short course higher and performed better on one aspect of patient management than the lecture or large group physicians but there were no other differences between groups on knowledge or physician performance.

Clinical Competence↗

Residency performance of graduates from a problem-based and a conventional curriculum.

Performance of 130 graduates in residency from a community-oriented, problem-based medical curriculum, and from a parallel, conventional track, were compared on eight dimensions: knowledge, communication with patients, independent learning ability, teamwork, patient education, critical thinking ability, attention to health care costs, and self-assessment. Ratings were obtained from three evaluators: a doctor-supervisor, a nurse and the resident him/herself. The study was undertaken to identify differences between graduates from the two curricular tracks. Differences were observed in the areas of health care costs (supervisors) and communication with patients (residents), and a trend was observed in patient education (supervisors) and knowledge (nurses), The outcomes of the study are discussed in light of the literature on residency performance, and in terms of the educational experiences that characterize the two medical curricula.

Clinical Competence↗

Problem-based curriculum: outcome evaluation.

The College of Medicine and Medical Sciences of the Arabian Gulf University (CMMS-AGU) in Bahrain is, in its innovativeness, unique in the region in that a problem-based strategy is used in the planning and implementation of the curriculum. The first batch of graduates have completed their internship programme in the different countries of the region. This paper presents an evaluative study of the outcome of the programme in relation to the institutional goals. Assessment of the intern's performance in clinical competence, interpersonal relations, self-directed learning, and their relative standing vis-à-vis graduates from other schools was done by supervisors. The findings of the study confirm the relative merits of the problem-based curricular strategy in medical education.

Bahrain↗

Teaching medicine as a human experience: a patient-doctor relationship course for faculty and first-year medical students.

We developed a required, longitudinal course for first-year medical students that addressed the patient-doctor relationship. Our course linked understanding patients' experiences and perspectives on illness with listening to, talking with, and establishing a rapport with patients while obtaining their medical histories. Learning was enhanced by use of an interdisciplinary faculty and by small-group continuity and faculty mentoring. Our curriculum adapted problem-based, self-directed educational methods to convey medical humanism. We focused on bedside interviewing as the means for exploring patients' social, emotional, and ethical concerns.

Attitude of Health Personnel↗

Problem-based curriculum and its value to Indian medical schools: description of the curriculum.

The decade of the 80's has seen the implementation of the problem-based curriculum (PC) (also called "parallel" or "student-centred" curriculum) in several medical schools in the United States. This new educational technique emphasizes active student participation and a hands-on learning process supplemented by judicious intervention by the faculty teachers. The students (often volunteers) are usually selected for their motivation rather than for highest intelligence or class ranking. For a period of two years, they meet twice or thrice-weekly in group sessions to explore problem cases developed by faculty for that special purpose. We describe the parallel curriculum here in some detail and suggest that medical educators in India give serious consideration to implementation of such a curriculum or its modification in their institutions. Medical graduates will benefit from the hands-on emphasis of this curriculum as well as the development of a disciplined approach in the handling of clinical problems. PC diminishes the stress levels associated with the traditional curriculum and lets the students play an active role in their education. PC will make them better prepared to face challenges during their clinical years and subsequent careers and should offset some of the weaknesses in the current educational system.

Curriculum↗

Development of faculty consultants in a problem-based third year community medicine clerkship.

This paper describes the development of consultancy groups in behavioral science, epidemiology and biostatistics, and information science in a required community medicine rotation with a twenty year history. The addition of consultants to individual student tutors and field preceptors has led to a structure which promotes student-project flexibility, development of critical assessment skills and independent learning while maximizing faculty expertise and effectiveness.

Behavioral Sciences↗

Self-assessment in problem-based groups.

Medical students in a tutorial program rated themselves in Year 1 and again in Year 2 on Knowledge, Reasoning, Communication and Interpersonal Skills. Student and tutor ratings were similar in Year 1 but different in Year 2. Both self- and tutor ratings increased from Year 1 to Year 2 but self-ratings were independent of achievement while tutor ratings were related to achievement. Possible reasons for these results were discussed with reference to the learning goals of the tutorials.

Achievement↗

[Evaluation of medical education at the McMaster University, Canada, based on the case method concept].

Students of three different levels and the chairman of the MD-Program evaluated the educational system of McMaster University, Canada, using the six criteria of the case method as defined by Renschler. This analysis provided a very differentiated evaluation of the McMaster curriculum, demonstrating a systematic progress of learning methods from the second to the last phase. The instrument showed differences in the ratings of the demonstrative lectures between the chairman and the students. Free access to patients and responsibility, gradually growing during the 3-year program, are important features of the educational system. The problem-based system provides a unique integration of acquiring theoretical knowledge in the basic sciences through clinical problem solving which was highly rated in all analysed phases. Ratings given by the interviewed students for evaluation of documented work were lower than expected by the chairman and the authors. The results are discussed in relationship to the McMaster Philosophy and to the conditions of studying medicine in America and in Germany.

Attitude of Health Personnel↗

Continuing medical education and career choice among graduates of problem-based and traditional curricula.

A survey was conducted among graduates of two Canadian medical schools who have been in practice for more than 9 years. The purpose of the study was to test the hypothesis that graduates of a problem-based curriculum differ from graduates of a traditional curriculum in their attitude to and participation in continuing medical education (CME) activities. Differences were noted in the rate of participation in certain CME activities (attendance at national and international conferences and meetings) between specialists and family doctors in both groups of alumni. However, the data indicate that the differences in learning-teaching methods employed in the course of the undergraduate medical curriculum do not exert a decisive influence upon the learning habits of the graduates.

Attitude of Health Personnel↗

A first-year problem-based curriculum in health promotion and disease prevention.

This paper describes Harvard Medical School's integration of a curriculum on health promotion and disease prevention into the first year of its New Pathway to General Medical Education. The goals of the curriculum were to develop in each student (1) the knowledge and skills necessary to evaluate critically the major issues in prevention and (2) an attitude that acknowledges the pertinence of prevention in virtually every clinical encounter. The case method was used for all teaching in the curriculum, as it is throughout the New Pathway. Students worked together in small groups, addressing the issues raised by each case under the direction of faculty preceptors. The component was taught by clinicians as part of a two-year course in which students learned clinical skills and addressed topics from the social sciences and medical humanities. In addition, issues in health promotion and disease prevention were integrated into the cases used to teach the other components of the New Pathway curriculum.

Boston↗