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