Fu JenCatholicUniversity Fu JenCatholicUniversity The Experience of Implementing PBL Curriculum in an Asia Medical School – Can it be done? Kuo-Inn Tsou,

Fu JenCatholic University


The Experience of Implementing PBL Curriculum

in an Asia Medical School – Can it be done?

Kuo-Inn Tsou, M.DKuo-Inn Tsou, M.D

School of Medicine, College of Medicine,

Fu-Jen Catholic University, Taipei, Taiwan



Medical Schools in Taiwan

Twelve medical schools

4 national, 8 private Only 3 are located in

an University (NTU, NCKU, FJU).

The majority of medical schools offer a 7-year undergraduate program.

NTUYMTMUNDMCFJUMMC



Fu Jen Catholic University

New Taipei City

TaipeiFJUHistory of more than 80 years:•Founded in Beijing in 1925•Restored in 1961 in Taipei, Taiwan•11 colleges (including Arts and Law)•Near 27,000 students in the campus.



PBL an important innovation in education

Since the first implementation of this problem-based, self-directed learning approach at McMaster University in 1969, the spread of PBL has been rapid, both within and beyond the health professions. This trend of education reform has also swept through Asian medical schools.



No. of MS Implementing PBL

No. of medical schools(%)Country or area

PR China 5 (0.7%)

Indonesia 9 (17%)

Thailand 4 (31%)

Malaysia 5 (31%)

Korea 27 (66%)

USA 86 (70%)

Japan 63 (86%)

Taiwan 11 (100%)

Survey of 6th APC PBL- Tokyo 2006, Dr. Masahiro Tanabe, Chiba University, Japan



6

Goals of PBL

Four Main Objectives to Achieve for a Truly Problem-based Approach

Structuring knowledge for better recall and application in clinical contexts

Developing an effective clinical reasoning process

Developing an effective self-directed learning skills

Increasing motivation for learning Barrow HS. A taxonomy of problem-based learning methods. Med Educ 1986.



Assessment of the Effectiveness of PBL

Knowledge Communication with patients Independent learning ability Team-work ability Patient education Critical thinking ability Quality of oral or written presentation Self-assessment



Outcomes of PBL Students from the Literature



As Compared with Students in Traditional Curricula

PBL-students More self-regulated learning Better self-directed learning skills, such as scientific

thinking, problem solving, and conflict resolution skills, use of a broader range of resources

More active contributors to group learning process Better interpersonal skills No significant differences in test scores of medical

knowledge, in general academic competencies, such as conducting research or writing a paper.

Lycke KH, Norway, Med Teach 2006; Yalcin BM, Turkey, Croat Med J 2006; Schmidt HG, the Netherlands, Med Educ 2006



PBL Curriculum at Fu Jen Medical School



Curriculum Structure

1 2 3 4 5 6 7

Common education Common education & General sciences& General sciences

Basic sciences &Basic sciences &Some Clinical Some Clinical sciencessciences

Clinical sciences & Clinical sciences & ClerkshipClerkship

Intern-Intern-shipship

PBL at FJMS

↖

- a near-full PBL approach for the third and fourth year curriculum



Composed of integrated system-based units

Use patient cases to integrate the learning of basic medical sciences and clinical sciences

High percentage of teaching hours in small groups ( tutorial sessions)

Multiple assessment tools to evaluate different aspects of learning

12

Key FeaturesPBL at FJMS



Third year courses Introduction to Biomedical Science 3 wks Fundamental unit 3 wks Cardiovascular unit 6 wks Respiratory & circulation unit 5 wks Urological unit 6 wks Gastrointestinal unit 6 wks Endocrine & Reproductive unit 5 wks

Fourth year courses• Neuromotor unit–CNS 6 wks• Neuromotor unit–PNS 5 wks• Obstetrics/Pediatric unit

6 wks• Infection/Host defense unit 6

wks• Hematology unit 5 wks• Psychiatry/Behavior unit

6 wks

13

PBL Curriculum DesignPBL at FJMS



Lectures

Clinical skillsteaching

Resource learning

Laboratories

Self-studying, information collecting

Tutorials

PBL Related Learning Activities PBL at FJMS



15

Weekly Activities Third year

Tutorial session 3 hrs x 3(30%)

Didactic lecture 2 hrs x 2

Resource learning/ 2 hrs x 1Gross anatomy

Clinical skills 3 hrs x 1

Laboratory course 4 hrs x 1

Embryology 2 hr x 1

Fourth year

3 hrs x 2(23%)

2 hrs x 2

4 hrs x 2

3 hrs x 1

4 hrs x 1

Contact hours: 30 hrs/wk for third year and 26 hrs/wk for the fourth year

PBL at FJMS



Thursday

Lecture

Lab

Lab

Lab

Lab

Lecture

Tuesday

Lecture

Clinical skills

Clinical skills

Clinical skills

Lecture

Wednesday

Lecture

Elective

Elective

Monday

PBL

PBL

PBL

Embryology

Embryology

Friday

PBL

PBL

PBL

PBL

PBL

PBLResource

section

Resource section

Elective

Elective

PBL at FJMS



17

The seven steps in a tutorial session

Stage 1: brain storming1.Identify Facts & Problems2.Generate Hypotheses3.List Need to know 4.Formulating and organizing Learning objectives

Stage 2: Data searching5.Self-directed learning

Stage 3: Group learning by discussion6.Sharing knowledge with others and reanalyze

patient’s problems7.feedback

PBL at FJMS


Fu JenCatholic University Formative evaluation

• Small group assessment

oral, each tutorial session, written, mid-term and end-term

• Triple jump exercise• Personal Progress

Index (PPI)

Summative evaluation

At the end of each unit

• Tutor’s assessment (40%) Student’s performance in tutorial sessions

• Written test (60%)

18

Student AssessmentPBL at FJMS



Outstanding ( 優 ) above 90 scores

Excellent ( 甲 ) 80 - 89 scores

Good ( 乙 ) 70 - 79 scores

Fair ( 丙 ) 60 - 69 scores

Poor ( 丁 ) 50 – 59 scores

Very Poor （戊） below 50 scores

19

Grading SystemPBL at FJMS



Observation during the PBL Courses

Students have more confidence in the learning skills and time management needed in self-directed learning.

The group dynamic improves much and most of the students can engage in the discussion.

Students have made significant progress in English reading ability, oral communication skills, and the ability to chair a tutorial session.

PBL at FJMS



Observation during the PBL Courses

Students feel himself like a doctor and can have empathy of the patient’s suffer presenting in the learning cases.

Almost every student attend the class on time and very few call in sick.

Students with attitude problems or learning difficulty can be recognized very early and get appropriate attention and assistance from the tutors and the medical school.

PBL at FJMS



22

Program Evaluation at FJMS

From clinicians’ perspectives Knowledge increments in the clinical years Data collected from the medical education

studies 360 degree evaluation in the word Passing rates in the Taiwan Medical Licensure

Examination From students’ perspectives



Results - 1

From clinicians’ perspectives

FJMS students could raise up structured questions, had gaps in medical knowledge, had better skills in communication and in case presentation.

More students were honored as the best interns.

Compared with students from other medical schools.

KI Tsou, et al Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school Kaohsiung J Med Sci 2009, vol 25



Pre-test Pos-test Increment in scores

輔醫他校輔醫他校輔醫他校小兒科 45.7± 6.4

(12)51.4± 8.9(10)

64.0± 8.8(12)

62.2± 13.0(10)

18.3± 10.9(12)

10.8±9.9(10)

婦產科 45.8± 10.6(10)

47.0± 7.3(10)

77.4± 5.0(10)***

56.6± 5.2(10)

31.6± 8.7(10)***

9.6±8.6(10)

Knowledge increments in the clinical years FJMS students had significant larger increments in test scores at the end of pediatric and Obs-Gyn rotations as compared with students from the other medical school..

Results – 2



Results – 3

Data from ME studies Changes in the scores of Self-directed learning

readiness scale(SDLRS) after the PBL courses.

The diagnostic reasoning strategies



Self-directed Learning Attitude

Self-directed learning is an important skill for medical professionals since knowledge is continuously increasing and changing.

Self-directed learning readiness scale (SDLRS), a 5-point Likert scale questionnaire, developed by Guglielmino in 1977



Changes in SDLRS After one year of PBL, Fu-Jen medical students

showed significant increases in the total SDLRS score, and the sub-scores of learning strategy and self-assessment.

This trend of improvement persisted till the end of two years in PBL curriculum.

Items Pre-PBL One year Post-PBLTwo year Post-PBL

Total score 3.75±0.54 3.94±0.44* 3.87±0.37

Love to learn 4.08±0.64 4.16±0.51 4.02±0.49

Learning strategy 3.54±0.50 3.70±0.50* 3.78±0.37

Self assessment 3.48±0.75 3.88±0.50* 3.71±0.45

Learning belief 3.88±0.58 4.03±0.48 3.94±0.53



Diagnostic Reasoning Strategies

Gilhooly KJ; Elstein AS; Glaser R

Reasoning strategies

Explanation

Hypothetico-deductive reasoning

Prior to selecting the most likely diagnosis, the subjects analyzed one by one each alternative diagnosis presented with the clinical vignettes

Scheme-inductive reasoning

Guided by a scheme. Decisions are explicitly at the division or branch.

pattern recognition

The solution of a problem is straightforward or obvious and is directly retrieve from a well-structured network of stored knowledge with only perfunctory attention to the alternatives.



Diagnostic Reasoning Strategies

Evaluated by using the think aloud protocol Very few FJMS students use the hypothetic-deductive

reasoning strategy. For the clinical cases which were involved in the small

group sessions, they tend to grasp a few key clinical features and reach a single diagnosis without attention to the alternatives. Guessing was used when the clinical cases were not taught anywhere in the courses.

They tended to analyzed the cases with physiologic or pathophysiologic knowledge and then reasoning out a diagnosis.



Results 4: 360-Degree Evaluation of Graduates

Items Contents

Clinical reasoning ability clinical judgments based on clinical data, basic and clinical medical knowledge

Presentation ability oral presentation or paper report

Problem-solving ability data searching, discussion, find a solution

Team-work ability communication and cooperation with other health care partners

Evidence-based practice Raise question, searching and critique literature, find the most appropriate solution

Humanity concern Patient care from psychosocial and culture aspects

Doctor-patient relationship Communication with patients, and families

Professionalism Reliable, cooperative, responsible…

Supervisors, chief residents and nurses who knew the graduates well were invited .



Results of Questionnaire

As compared with graduates from other medical school, how would you evaluate our graduates? (1–much weaker, 5-much stronger)

Items Self-evaluate(N=34)

Supervisor(N=49)

Chief resident(N=34)

Nurses(N=49)

Knowledge in basic medical sciences

3.5±0.7 3.5±0.7 3.5±0.7 3.9±0.8

Knowledge in clinical sciences 3.6±0.7 3.7±0.7 3.7±0.6 3.8±0.8

General clinical skills (Hx, PE, charting) 4.0±0.6 3.7±0.7 3.7±0.7 3.9±0.8

Procedural skills 4.1±0.7 3.6±0.6 3.6±0.6 3.9±1.0

Clinical reasoning ability 3.6±0.7 3.6±0.6 3.6±0.6 3.8±0.9

Presentation ability 3.8±0.6 4.0±0.8 4.0±0.8 4.0±0.9



Results of Questionnaire As compared with graduates from other medical school, how

would you evaluate our graduates? (1–much weaker, 5-much stronger)

Items Self-evaluate(N=34)

Supervisor(N=49)

Chief resident(N=34)

Nurses(N=49)

Problem-solving ability 4.0±0.8 3.9±0.7 3.9±0.7 3.9±0.8

Team-work ability 4.2±0.7 4.0±0.8 4.0±0.8 3.9±0.7

Evidence-based practice 3.7±0.8 3.8±0.7 3.8±0.7 3.8±0.9

Humanity concern 3.8±0.7 3.7±0.8 3.7±0.8 3.7±0.7

Doctor-patient relationship 4.0±0.7 3.8±0.8 3.8±0.8 3.9±0.8

Professionalism 3.8±0.6 4.0±0.8 4.0±0.8 4.0±0.9

Overall abilities among all R 7.1±1.3 7.5±1.3 7.5±1.3 6.9±1.4



Result 5 Passing rates in the national licensure examination

Students from the first three cohorts had the highest passing rate for the part 1 test (basic sciences in medicine) and had 100% passing rate for the part 2 test (clinical medicines)

Class Med2000-2002 Med2003 Med2004 Med2005 Med2006 Med2007

Category Part I Part I Part I Part I Part I Part I

FJMS passing rate 89.16% 75% 85.71% 68.00% 68.75% 79.25%

National average 70.65% 50.27% 69.99% 63.50% 66.02% 63.50%

Category Part II Part II Part II Part II Part II

FJMS passing rateMed2000

100%Med2001

100%Med2002

100%Med2003

95.83%Med2004

100%

National average 98.80% 97.83% 97.79% 97.99% 92.89%



Effectiveness of PBL Curriculum -

Students’ Perspective



Students’ views

Study design• Semi-structured interviews (5th and 6th year

students) in 2006• Questionnaire with 5-point Likert scale questions

and open questions (5th to 7th year students and residents) in 2009 and 2010

Effectiveness of PBL • Knowledge learned during the 3rd and 4th year• Clinical reasoning, communication skills, self-

directed learning skills, and motivation for learning


Fu JenCatholic University Semi-structured qualitative interview was conducted

on 12 fifth or sixth year medical students

Students identified themselves having active learning attitude, better learning skills, stronger clinical reasoning abilities and good understanding of the mechanisms, and connections between concepts, and could apply the knowledge in explaining the symptoms or signs of a patient.

On the other hand, there was gap in the knowledge of clinical medicine.

36

The impact of PBL on the Learning of Clinical Medicine



Results of Questionnaire Were you well-prepared for the learning in the

hospital? (0–100% adequacy, 5-point Likert scale)

Items 5th year(N=74)

6th year(N=89)

7th year(N=82)

Resident(N=34)

Self-directed learning ability 4.0±0.7 3.9±0.8 4.0±0.7 4.0±0.8

Active learning attitude 3.8±0.7 3.8±0.9 3.9±0.7

Communication skills 3.5±0.8 3.5±0.8 3.8±0.6 4.1±0.7

Build up doctor-patient relationship

3.4±0.8 3.4±0.8 3.8±0.7 4.0±0.7

Clinical reasoning ability 3.4±0.8 3.5±0.8 3.5±0.7 3.6±0.7

Logical thinking ability 3.5±0.7 3.6±0.7 3.7±0.7 3.9±0.7

In red color: p<0.05 as compared with 5th and 6th year students, in blue color: p<0.05 as compared with 7th year students.



Results of Questionnaire Were you well prepared for the learning in the



6th year(N=89)

7th year(N=82)

Resident(N=34)

Knowledge in basic medical sciences

3.4±0.9 3.3±0.7 3.5±0.6 3.5±0.7

Knowledge in clinical sciences 3.1±0.9 3.0±0.9 3.6±0.6 3.6±0.7

The coverage of common illness 3.1±0.9 3.0±0.9

The depth of common illness 3.2±0.9 3.1±0.9

History taking 3.7±0.7 3.4±0.83.8±0.6 4.0±0.6

Physical examination 3.3±0.8 3.3±0.8

In red color: p<0.05 as compared with 5th and 6th year students



Results of Questionnaire Were you well prepared for the learning in the


Items 7th year (N=82)

Resident(N=34)

Presentation ability 3.8±0.6 4.0±0.8

Problem-solving ability 3.8±0.7 4.0±0.8

Team-work ability 3.9±0.6 4.2±0.7

Evidence-based practice 3.6±0.7 3.7±0.8

Humanity concern 3.6±0.8 3.8±0.7

Professionalism 3.7±0.7 3.8±0.6



In Summary - 1

PBL curriculum at the 3rd and 4th year could prepare students well for their learning in clinical years in terms of presentation ability, self-directed learning abilities, active learning attitude, communication skills and logical thinking abilities.

After entering internship, students felt that they were especially competent in problem solving, presentation, team work, doctor-patient relationship, logical thinking and professionalism.



In Summary - 2

As a resident, the attending physicians, chief residents and nurses viewed the FJ graduates stronger than graduates from other medical school in presentation, problem-solving , team-work, build up doctor-patient relationship and professionalism. Besides, they thought FJ graduates had comparable or a little better knowledge in basic medical sciences and clinical sciences.

• FJ graduates also viewed themselves that way.



Results of Questionnaire

How much were you satisfied with the following? (0–100% agreement, 5-point Likert scale)


6th year(N=89)

PBL curriculum design 3.0±1.1 2.9±1.1

The impact of PBL learning strategy and process on the learning in clinical years

3.2±1.0 3.1±1.0

The effectiveness of learning during the 3rd and 4th year

3.1±1.0 2.9±1.1

Laboratory sessions (four hours a week) 2.9±1.0 3.0±1.0



In Summary - 3

• The satisfaction of PBL was low Too much pressure Poorly organized knowledge Not adequate coverage and depth of clinical

medicine Not efficient in learning

Qualitative analysis of open questions in the questionnaire.



Possible Reasons

• Poorly organized knowledge The knowledge gained through self-directed

learning and through discussion in the tutorial sessions was not organized, deep, digested and not systematic. Due to:

1. Not enough study time

2. Not being able to identify the key area of study

3. Do no have enough ground knowledge in basic or clinical sciences for self-directed learning

Qualitative analysis of open questions in the questionnaire.


Fu JenCatholic University A near-full PBL curriculum in an Asian undergraduate

medical school Students gain competency in self-directed learning,

communication skills and logical thinking ability. Students are more active learners. In postgraduate training, PBL students were valued

high in team-work, problem-solving ability and professionalism. In general, they were evaluated as above average.

However, students could not enjoy the learning and were not satisfied with the knowledge acquisition.

45

Experiences Learned from the Past Night Years of PBL Curriculum



The Nature of PBL?

Anxious about the adequacy of knowledge when entering clinical clerkships, is a ubiquitous finding in medical students, no matter what curriculum they attend.

A near-full PBL is likely to stress factual knowledge less than traditional programs with un-integrated, i.e. discipline oriented lecture series and exams.

A lower level of factual basic science knowledge may be (partly) compensated by a strong attitude toward learning in the clinical setting.



Ways Used to Strengthen the Learning in PBL Curriculum

Using concept map or concept-based design (the clinical problems are given in sequence based on the concepts underlying the problems) Rendas 2006, Neville 2007

Revised model for case study (not focus on problem-solving skills but meaningful discussion on ideas) Shanley 2007

Structured tutorial (preceded the first tutorial session with a “home review” patient case) Espey 2007

Use of e-learning tool Terry 2007



Question Remained

“Could teaching of schemes and scheme inductive reasoning as used with the Clinical Presentation curriculum further facilitate developing expertise among PBL students?”

Clinical presentation curriculum is characterized by using clinical presentations as the context to impart relevant basic and clinical sciences information; second, teaching expert-derived problem-solving strategies (schemes) to enable students to apply forward reasoning, or scheme-inductive reasoning, for problem-solving.



49

Goals of PBL

Four Main Objectives to Achieve for a Truly Problem-based Approach

Structuring knowledge for better recall and application in clinical contexts

Developing an effective clinical reasoning process

Developing an effective self-directed learning skills

Increasing motivation for learning Barrow HS. A taxonomy of problem-based learning methods. Med Educ 1986;20: 481-6.



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Documents

Fu JenCatholicUniversity Fu JenCatholicUniversity The Experience of Implementing PBL Curriculum in an Asia Medical School – Can it be done? Kuo-Inn Tsou,