PBL in the clinicPBL in the clinic

Hong Kong 2004Hong Kong 2004Associate Professor Liz FarmerAssociate Professor Liz Farmer

Co chair PBL Expert Advisory GroupCo chair PBL Expert Advisory GroupFlinders UniversityFlinders University

overviewoverview

Review PBL processReview PBL process Clinical environmentClinical environment Theoretical concepts in clinical PBLTheoretical concepts in clinical PBL Concepts of clinical expertise and PBLConcepts of clinical expertise and PBL One approachOne approach Conclude and discussConclude and discuss

Definition of PBLDefinition of PBL

PBL is the learning PBL is the learning that results from the that results from the process of process of understanding and understanding and resolving a problem-resolving a problem-

the problem comes the problem comes first in the learning first in the learning processprocess

Steps in the tutorial process

Identify key information

Generate / rank hypotheses

Identify key information

Generate / rank hypotheses

Explore and explain information

QUESTIONS

KNOWLEDGE

BASE

Identify key information

Generate / rank hypotheses

Explore and explain information

QUESTIONS

KNOWLEDGE

BASE

Identify key information

Generate / rank hypotheses

Explore and explain information

QUESTIONS

KNOWLEDGE

BASE

Learning Issues

Self-directed learning

Clinical environmentsClinical environments

Clinical environments are increasingly Clinical environments are increasingly stressed by service pressures but offer stressed by service pressures but offer unparalleled opportunities for unparalleled opportunities for independent independent self directed learners:self directed learners:

Clinical PBL: theoretical aspectsClinical PBL: theoretical aspects

Foley suggests Barrows’ 4 key elements Foley suggests Barrows’ 4 key elements must be present:must be present: Clinical context to facilitate recall and Clinical context to facilitate recall and

applicationapplication Develop clinical reasoning processesDevelop clinical reasoning processes Increases motivation for learning Increases motivation for learning Allows SDLAllows SDL

Constructivist learningConstructivist learning

PBL is a form of constructivist learningPBL is a form of constructivist learning ““Information-processing constructivism”Information-processing constructivism” Savery and Duffy Savery and Duffy ““Eight instructional principles”Eight instructional principles”

8 Principles8 Principles

Anchor learning activities to larger task or problemAnchor learning activities to larger task or problem Support ownership of problemSupport ownership of problem Authentic taskAuthentic task Design task to reflect complexity of environment the Design task to reflect complexity of environment the

learner should be able to function in at completionlearner should be able to function in at completion Ownership of process to develop solutionOwnership of process to develop solution Design environment to challenge thinkingDesign environment to challenge thinking Encourage testing of alternative views and contextsEncourage testing of alternative views and contexts Provide opportunity for and support reflection on content Provide opportunity for and support reflection on content

learned and the learning processlearned and the learning process

Evidence for Claims of PBL Evidence for Claims of PBL SchmidtSchmidt

Problem is context for learning Problem is context for learning Problem is activator of prior knowledgeProblem is activator of prior knowledge Small-group discussion as means of Small-group discussion as means of

elaboration and knowledge constructionelaboration and knowledge construction Learning is intrinsically motivatedLearning is intrinsically motivated Learning is self-directedLearning is self-directed

Why context?Why context?

Context facilitates and affects recall: Context facilitates and affects recall: “grocery store”“grocery store”

Royal navy divers Baddely 1976Royal navy divers Baddely 1976

Context dependent memoryContext dependent memory

Learned on land Learned underwater

0

5

10

15

20

25

30

35

40

45

50

Per

cen

tage

of

wor

ds

reca

lled

Recalled on land

Recalled underwater

Role of context in expertise Role of context in expertise (Hobus et al, 1995)(Hobus et al, 1995)

0

2

4

6

8

10

'Novice' Physicians

Number of correct hypotheses

cases with contextual information

General Practitioners

Role of context in expertise Role of context in expertise (Hobus et al, 1995)(Hobus et al, 1995)

0

2

4

6

8

10

'Novice' Physicians

Number of correct hypotheses

cases with contextual information

cases without contextual

information

General Practitioners

Activating prior knowledgeActivating prior knowledge

Activating prior knowledge facilitates Activating prior knowledge facilitates processing of new informationprocessing of new information

Activation and elaboration at time of Activation and elaboration at time of learning enhances recall and transfer of learning enhances recall and transfer of that knowledge (Schmidt 1993)that knowledge (Schmidt 1993)

Activating means problem first plus Activating means problem first plus discussiondiscussion

recall is context dependent recall is context dependent

Students presented with problem first plus Students presented with problem first plus attempts to solve and explain do better in attempts to solve and explain do better in long term recall than those where problem long term recall than those where problem presented and explained all at oncepresented and explained all at once

A theory of clinical knowledgeA theory of clinical knowledge George BordageGeorge Bordage1.1. Reduced:Reduced: absent or inaccessible absent or inaccessible2.2. High / dispersedHigh / dispersed lacks organization lacks organization 3.3. High / elaboratedHigh / elaborated organized, modelled or organized, modelled or

structured to more global and accessible structured to more global and accessible representations of the problemrepresentations of the problem

4.4. High / compiledHigh / compiled elaborated networks elaborated networks condensed by experience, does not engage in condensed by experience, does not engage in detailed reasoning, uses other factors such as detailed reasoning, uses other factors such as pattern recognition pattern recognition

Dispersed:Dispersed:Flight Connections SIB AirlinesFlight Connections SIB Airlines

Maastricht - Amsterdam vvMaastricht - Brussels vvAmsterdam - Hamburg vvAmsterdam - Edinburgh vvAmsterdam - Brussels vvAmsterdam - London (Gatwick) vvBrussels - Paris vvBrussels - London (Heathrow) vvManchester - London (Heathrow) vv

Elaborated Elaborated Flight Connections SIB AirlinesFlight Connections SIB Airlines

expertiseexpertise

Extensive application allows knowledge to Extensive application allows knowledge to be be compiledcompiled and subsumed and subsumed

When faced with non-routine problems When faced with non-routine problems experts’ causal models are more coherent, experts’ causal models are more coherent, account for more data and are more account for more data and are more accurate (Norman 1994)accurate (Norman 1994)

Why focus on explanatory Why focus on explanatory structures?structures?

Aim is to bring students to highAim is to bring students to high elaborated elaborated knowledge levels in each knowledge levels in each contextcontext

A theory of clinical knowledgeA theory of clinical knowledge George BordageGeorge Bordage1.1. Reduced:Reduced: absent or inaccessible absent or inaccessible2.2. High / dispersedHigh / dispersed lacks organization lacks organization 3.3. High / elaboratedHigh / elaborated organized, modelled or organized, modelled or

structured to more global and accessible structured to more global and accessible representations of the problemrepresentations of the problem

4.4. High / compiledHigh / compiled elaborated networks elaborated networks condensed by experience, does not engage in condensed by experience, does not engage in detailed reasoning, uses other factors such as detailed reasoning, uses other factors such as pattern recognition pattern recognition

One approach:One approach:“Live clinical PBL”“Live clinical PBL”

Lead student sees patient chosen with tutorLead student sees patient chosen with tutor Lead student presents case as PBL Tut 1Lead student presents case as PBL Tut 1 Group discuss hypotheses and further Group discuss hypotheses and further

information required (? Tutor required)information required (? Tutor required) Group SDL while lead student follows up patientGroup SDL while lead student follows up patient Tutorial 2 group presents work in context, Tutorial 2 group presents work in context,

student offers follow up data, progress and student offers follow up data, progress and actual managementactual management

Tutor present; gives clinical feedback only at the Tutor present; gives clinical feedback only at the endend of the session of the session

conclusionsconclusions

Clinical expertise is complexClinical expertise is complex Theory Theory and evidenceand evidence can underpin our can underpin our

approach to the learning environment:approach to the learning environment: PBL processPBL process Nature of expertiseNature of expertise

Clinical PBL helps to integrate these Clinical PBL helps to integrate these domainsdomains

Exciting opportunities for GP educatorsExciting opportunities for GP educators