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1
What’s new in –PROBLEM-BASED LEARNING
CLINICAL SKILLSCURRICULUM INNOVATION
Dr Allan CummingAssociate Dean
University of Edinburgh Medical School
2
histology
anatomy
biochemistry
physiology
social & behavioural
science
pathology
genetics
immunology
microbiology
pharmacology and therapeutics
psychological
medicine
environment,
lifestyle, occupational health,
public health
and
epidemiology
normality, abnormality and variation of condition in:
• child
• adolescent
• young adult
• mature adult
• aged
• gender
signs and symptoms
Case
health economics
investigation &
diagnosis
description
communication,
clinical and
practical skills
history of medicine
roles of other professions
ethical and legal implications
nutrition
multi-professional
issues
management &
rehabilitation
PBL/independent study pathway vs lecture/discussion pathway
3
% Problem-based learning
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10
School No
% c
urri
culu
m ti
me
Survey of Universitas 21 medical schools, September 2001
Does it matter?Definition of curriculum –
PBL schools – list of problems or presentations
Non-PBL schools – list of teaching content and learning objectives
Different attitude to knowledge base
4
? PBL or notKnowledge - ↑ or ↓ (but may retain more1)Clinical reasoning/diagnosis – small ↑ c PBLStudent satisfaction - ↑ c PBL
But - effects are at best small in relation to resource requirement; curriculum intervention studies are inherently flawed2.
1. Norman GR, Schmidt HG. The physiological basis of problem-based learning – a review of the evidence. Acad. Med, 1992:67:557.2. Colliver J. Effectiveness of problem based learning curricula. Acad. Med. 2000;75:259.
Education theories used to support PBL1
Contextual learning theoryInformation-processing theoryCo-operative learning theorySelf-determination theoryControl theory – basic needs are to survive and reproduce; belong and love; gain power; be free; have fun
1. Albanese M. Problem-based learning; why curricula are likely to show little effect on knowledge and skills. Medical Education, 2000; 34:729.
5
Lectures
Computer-aided learningPracticals
Project work -
group or individual
Clinical skills teaching
Tutorials
Experience on attachmentsResuscitation training
Problem/case-based learning
Independent learning
Lectures
Computer-aided learning
Practicals
Clinical skills teaching
Tutorials
Experience on attachments
Resuscitation training
Problem orcase
-based learning
Independent study
Project work
Independent learning
Learning in context
Learning facts
6
Introduction to Clinical Practice
Infection,Inflammation andImmunopathology
NeurosciencesEndocrinology
Thrombosis NeoplasiaClinical genetics
Year Two - Biology of Disease
Term 1
Term 2 Term 3
Cystic fibrosisIHD stroke menopauseinfection
Option 2 Option 3
Health and illness behaviour
CSPPD -Evidence-based medicine
Life cycle, health development
Talking with Families
Population health and provision of health services
Health needs of elderly people
Molecular biology
Cell physiology Respiratory system Renal function
Digestion and nutrition Cardiovascular system
Year One - Molecules to SocietyTerm 1 Term 2 Term 3
BIOMEDICAL SCIENCE
HEALTH & SOCIETY
Option 1-Clinical Options Project
Bones & joints
Down’ssyndrome
Health Promotion & Ethics
Cardiac health& disease
Nutrition& health
OPTIONS
CSPPD Clinical skills - nutritional assessment,respiratory function testing
Clinical skills - pulse and blood pressure, urinalysis
Environmental/occupational health
Review weekCARDIOVASCULAR RESPIRATORY GASTROINTESTINAL LOCOMOTOR
YEAR 3 - Process of Care (i)OSCE
PSYCHIATRY
NEUROLOGY
GENERAL PRACTICE
OBSTETRICS /GYNAECOLOGY
RENAL MEDICINE/UROLOGY
HAEMATOLOGY
GU MEDICINE
YEAR 4 - Process of Care (ii)
OPTION 4SPECIAL STUDY
MODULE DERMATOLOGY
OPHTHALMOLOGYENT
GENERAL MEDICINE (P)
GENERAL PRACTICE
CHILD LIFEAND
HEALTH
PREPFOR
PRAC-TICE
OPTION 5
(ELECTIVE)
FINALS
YEAR 5 - Preparation for practice
GENERAL SURGERY, A/E,
ANAESTHETICS,INTENSIVE CARE
GENERALMEDICINE (C)
GERIATRICS2 weeks
CSPPD
CSPPD
CSPPD
Review week
Option 2 Option 3
OSCE
CBL
CBL
Vertical themesVertical themes
Case description
report
patient leaflet
Year 1 - Integrative Clinical Topics
Problem-based learning
7
Our problems
Recruitment of tutorsPassive facilitation - frustrating and wasteful of staff expertise Value of teaching as a professional activityNon-engagement of some studentsRooms
Clinical PBL
Students (group of 6) given paper case on day 12 unfacilitated group meetingsCase may be “expanded” between meetingsThen - meet with expert tutor for case conferenceTutor ensures achievement of learning objectives, enthuses and rewards students
8
Clinical skills
Clinical skillsCommunication skillsConsultation skills (history, examination, explanation and advice)Clinical reasoning and judgementDiagnostic and management skillsPractical skills and proceduresResuscitation and First Aid
9
A formal practical clinical skills curriculum?
0123456789
10
Yes Yes with reservations No
Num
ber
of s
choo
ls
Survey of Universitas 21 medical schools, September 2001
Clinical skills teaching facitlities?
0123456789
10
Yes Yes with reservations No
Num
ber o
f sch
ools
Survey of Universitas 21 medical schools, September 2001
10
OUT
OpportunismOsmosisSee one/do one/teach one
Clinical skills labsSimulators and CALsSimulated patientsMulti-disciplinary learningCS in the communityAssessment and validation (OSCEs, OSLERs, CEX, SCEE)Shadowing before graduation
IN
Edinburgh practical skills & resuscitation curriculumYear 1
Measuring pulse rate and blood pressureNutritional assessmentTesting respiratory functionUrinalysisTwelve-lead ECGFirst aid and basic life support
Year 2VenepunctureTaking blood cultureBlood glucose testingAdministration and dosage of insulinMoving and handling techniquesAirway management
Year 3Rectal examination and FOBEstablishing intravenous access
ECG interpretationRhythm recognitionDefibrillationBasic suturingPlastering
Year 4/5Fundoscopy/auroscopyMaking up drugs for parenteral useUse of IV infusion pump IV, IM injectionArterial puncturePain controlLumbar punctureUrethral catheterisationAggression management and disengagementAdvanced Life Support algorithmAdvanced Trauma Life Support algorithm
11
12
13
Curriculum innovation
A Problem-based approach
PROBLEM
Student portfolios –everyone has them but what are they for?
Require students to reflect on and write about curriculum vertical themes
ANSWER
14
FACULTY OF MEDICINE, UNIVERSITY OF EDINBURGH
PORTFOLIO ENTRIES for theMBChB Course
YEAR OFCOURSE
NUMBER OFITEMS
NAME OF STUDENT:
No Portfolio entries Mark
Year 1 2 1 Option 1 (Clinical Problem Based Learning Project) *
2 Talking with Families *
Year 2 4 3 Option 2 *
4 Option 3 *
5 Biology of Disease - from Clinical Case Conference *
6 Biology of Disease - from Clinical Case Conference *
Year 3 4 7 Process of Care – Cardiovascular Module
8 Process of Care – Respiratory Module
9 Process of Care – Locomotor Module
10 Process of Care – Gastrointestinal Module
Year 4 6 11 Option 4 (Special Study Module)
12 Process of Care – General Practice
13 Process of Care – Psychiatry
14 Process of Care – Obstetrics & Gynaecology
15 Process of Care – Renal/Haematology/GUM
16 Overview Essay on a selected Portfolio Vertical Theme (PVT) Carriedforward
to Finals
Year 5 5 17 Option 5 (Elective)(for students undertaking remedial attachments, an alternative arrangement willbe made)
18 Paediatrics
19 Geriatric Medicine
20 Acute Specialities
21 Second Overview essay, on a different PVT Carriedforward
to Finals
FINALS Total 21 Viva examination to assess the student’s understanding of thePVTs
PORTFOLIO VERTICAL THEMES (PVTs)
Disability*PainNutritionLife cycle**Personal developmentCommunicationEvidence-based practiceEthicsLegal responsibilitiesPsychological aspects of clinical practicePharmacology and therapeutics Public health***
PROBLEM
Student portfolios – 30,000 items of submitted work
Submission, marking, and feedback over the web
ANSWER
15
Portfolio screen shot
PROBLEM
GMC states “appropriate attitudes should be inculcated”
Personal development as a vertical themeAttendancePeer assessmentMentoringFitness to Practise committee
ANSWER
16
The doctor as a professional
Outcomes for Personal DevelopmentPersonal development within the context of undergraduate medical education is a complex issue. The underlying personality of the individual graduate and his/her life experiences outwith the university have a major influence on personal development, as do experiences relating specifically to their training. Personal development is, of course, an ongoing, life-long process but it is possible to identify a number of important outcomes for the undergraduate period.
This could include:
Self-awareness The ability to conduct oneself as a reflective and accountable practitioner including seeking out sources of informed criticism and valuing, reflecting and responding to them appropriately.Enquiring into own competence and evaluating own capabilities and personal effectiveness
Self-learner The ability to manage own learning as demonstrated by:searching out and selecting appropriate learning resources of all typesmaking use of all available technical aidsemploying appropriate and effective study skillsrecognising limitations of current personal understanding and capabilities and identifying areas needing refreshed or extendedsetting realistic and appropriate personal learning goalsselecting learning strategies that take account of personal learning preferences and that are likely to succeedsetting challenging personal learning goals as a basis for personal growth
Self-care Recognition of the pressures of a demanding professional life on health, well-being and relationships with others and the need to maintain a balance between personal, professional and social goals and activities.Evidence of attention to lifestyle, diet, exercise and relaxation.Making use of available help and advice in stressful circumstances.Recognition of the hazards of self-medication or substance abuse in dealing with stress.
Career choice Identify short and long-term career and personal plans and aspirations and work towards these by establishing realistic development plans involving relevant activities.Participate fully in the life of the professional community and make use of professional and other networks of all types.
Motivation Recognising key personal motivating factors and their importance in sustaining a high level of motivation.
Commitment Demonstrating dedication to one’s chosen career pathway through adherence to the codes of conduct and behaviour expected of undergraduate medical students and doctors and an acceptance of any limitations that might be associated with them.
PROBLEM
GMC says –“students must be familiar with complementary medicine - at least as familiar as the patients they encounter”
??? – research project under way to define best practice
ANSWER
17
PROBLEM
Anatomy not viable as an academic department
2 “core anatomists”Developmental biologists, pathologist, radiologists, surgeonsPaid demonstratorsAnatomy Learning Resource CentreCAL development
ANSWER
PROBLEM
Public health not well taught, poorly rated by students
Public health, epidemiology, statistics, appraisal, evidence-based medicine – linked as vertical themeCAL developmentNew attachments
ANSWER
18
PROBLEM
We are unsure how prepared our graduates are for the PRHO year –now allocated and organised on a Scottish national basis
The Outcomes project –“The Scottish Doctor – a competent and reflective practitioner”
ANSWER
http://biology.st-and.ac.uk/scottishdoctor
19
What the doctor is able to do
Outcomes for Health Promotion and Disease PreventionEvery contact between a doctor and a patient can be seen as an opportunity for health promotion and disease prevention. It is therefore essential that the new graduate knows how to make the most of these opportunities through demonstrable knowledge of the principles involved both for individual patients and populations.
This could include:
Recognition of the causes of disease and the threats to the health of individuals and populations at risk
Assessment of distribution of risk factors in the population.
To be able to implement, where appropriate, risk reduction strategies for individual patients
Knowing how to change risk factors. The use of evidence-based medicine and effective interventions.
Appreciate that health promotion and disease prevention depend on collaboration with many other professionals and agencies
Identify who the other professionals and agencies are and what their role is.
Plan health promotion taking into account barriers to preventing disease and promoting health both in the individual and the population
Consideration of; political, economic, behavioural andorganisational barriers.
Screening Criteria for determining appropriate implementation of screening programmes.
20
PROBLEMHow do we pull it all together? The Edinburgh
Electronic Medical Curriculum (EEMeC)
ANSWER
http://www.eemec.med.ed.ac.uk
•course content, study guides, handouts
•self-assessment questions
•links to web based resource materials
•Web-based discussion areas
•interactive personalised timetables
•personalised EEMeC noticeboard
•location maps
Eemec screen shot