Malmo, Sweden January 2008

1. Malmo, SwedenJanuary 2008 The University of Adelaide The University of Adelaide Beyond PBL: opportunities and challenges Professor Grant Townsend The University of Adelaide, South Australia, and The University of Liverpool, UK

2. Outline of presentation • Background on dental education in Australia, particularly in Adelaide - trends, pressures • PBL – a change in focus from teachers and teaching to learners and learning • Beyond PBL – where to from now? – building not discarding • Some relevant literature -reports from Dublin meeting - IFDEA website -editorial by Geoff Norman -redesigned course by Mastricht group -concept of ‘blended learning’ -Variation Theory Suggestions for discussion curriculum, students, staff (faculty), community (public), environment

3. AUSTRALIAN DENTAL SCHOOLS - 2006

4. Until 10-15 years ago, the conventional model of dental education in Australia was: • a 5-year university degree course (BDS or BDSc) • basic/applied sciences first, followed by clinic in later years • most applicants came directly from school • admission (selection) was based on academic results only

5. In Adelaide in the early 1990s, we were becoming increasingly concerned about several aspects of the conventional BDS model. Problems included: • our program was unbalanced and over-crowded, with too many formal contact hours • students did not seem to be able to apply their knowledge • there was not enough time for the students to “think for themselves” There was also: • an explosion of knowledge in dentistry with new philosophies, technologies and controversies • major changes in the pattern of dental diseases • advances in teaching methodologies • negative feedback from the students

6. Major objectives of the Adelaide BDS curriculum review in the early 1990s were: • to develop a more flexible curriculum structure • to reduce formal contact hours for students • to provide more opportunities for self-directed learning • to facilitate more opportunities for contextual learning • to introduce more problem-based learning so that students would be able to better integrate material and apply their knowledge • to make more use of information and computer technology (ICT) • to develop a course that students would find stimulating and enjoyable and one that would create a desire to continue learning after graduation

7. The review process included: • endorsement by Faculty of the major objectives • a series of curriculum workshops with broad representation • formation of working groups • several alternative models were considered including • a postgraduate model, ie basic degree followed by dental degree • a “general” first year followed by a 4-year dental degree • a fully-integrated 5-year BDS • we chose the third option, but no detailed cost-benefit analysis was undertaken

8. The main features of the “new” Adelaide BDS program were: • introduction of small number of integrated streams rather than a large number of separate subjects • early exposure to clinical practice • development of a more coordinated assessment process • emphasis on an overall educational philosophy based on PBL and SDL • We aimed to make the learning environment enjoyable for students and staff!! • The departmental structure was changed – we became a single department school

9. Adelaide BDS curriculum

10. Problem based learning - PBL • It’s been around since the 1960s – eg McMaster, Canada • Newcastle Medical School in Australia introduced PBL in the early 1980s • Introduced in the 1990s in dental schools: Malmo, Sweden Adelaide, Australia University of Southern California, USA • Many dental schools have now introduced ‘PBL’ in varying ways and to varying extents – the term means different things to different people!

11. Educational objectives of PBL • to assimilate new knowledge that is integrated from different disciplines and structured to facilitate recall and application • to develop systematic approaches to the analysis of clinical situations • to develop the ability to evaluate one’s own performance and that of others • to develop good team and interpersonal skills • to develop self-directed learning skills and the skills and behaviours to continually learn

12. New BDS program in Adelaide has been running for 15 years and new admissions process for 11 years What evidence is there of improvements?

13. Evaluation of the ‘new’ Adelaide BDS curriculum Multi-level approach • Students • Staff • New graduates • Employers • International benchmarking

14. Outcomes of evaluations We have achieved some of our aims: Students enjoy the program more They say they can see the relevance of the basic sciences to clinical practice They feel they are well-prepared for practice Employers rate them highly Graduates compare favourably with other schools Together with our own reflections, this feedback has been used for a continual process of curriculum review

15. Linking the admissions process to program philosophy and requirements • Apart from a new curriculum, we introduced a new admissions process in 1997. Prior to this, selection was based only on academic record and many applicants had missed out on medicine. • The new admissions process is based on three components:  • Academic results • UMAT – psychometric test – problem-solving, critical thinking • Structured interview – motivation, knowledge of the course, communication skills

16. Outcomes of new admissions process Feedback Community Applicants Staff Performance and attributes of students Need to consider time, effort, transparency -move away from interviews (Queensland)

17. In the last 5-10 years or so, there have been severe pressures on Australian dental schools Decreased funding in real terms to unis – dental schools particularly vulnerable Shortage of dentists – more students (doubling in Adelaide) Shortages of dental academics Limited facilities/resources

18. New models of dental education have been introduced in Australia Sydney - basic degree followed by 4-year graduate entry – PBL with medicine Griffith - 3-year oral health degree followed by 2-year postgraduate degree – conventional Queensland – 1-3-1 model – some PBL New programs for hygienists/therapists – several universities 3-year Bachelor of Oral Health degree (BOH) – some PBL

19. Environment is becoming more and more competitive universities and schools looking for advantage cost of dental education is a limiting factor expected to do more with less difficulties in maintaining quality But we want to encourage collaboration between schools

20. How can we maintain quality? -Internal school and university processes -Australian Dental Council (ADC) -Australian Universities Quality Agency (AUQA) No national exams in dentistry in Australia Can register and practise on graduation Worldwide trend – setting up ‘dental schools’ on the cheap, with a handful of staff, linked with medicos for basic sciences, sub-contracting clinical training, teaching-only staff How long before loss of quality is noticed???

21. Another curriculum review at Adelaide - 2007 • Educational consultant employed • Outcomes-based approach ‘what does the student need to know and be able to do at the end of the program’ • More co-ordinated approach to assessment • Outreach clinics, private practice opportunities • Focus on learning and use of technology

22. Approach is consistent with key curriculum recommendations from recent meeting in Dublin Development and planning -read widely prior to commencement of process -establish the need and support for change -realise that implementation is the most challenging task Curriculum features -competency and outcome based -learning in context and in action -horizontal and vertical integration -patient-centred clinical learning and teaching -explicit formative and summative assessment with regular constructive feedback -use of electives or research projects to facilitate a spirit of enquiry Oliver et al. Curriculum structure: principles and strategy

23. Other very relevant reports from Dublin meeting • Evidence-based approach (Tracey Winning et al ) • IT in dental education (Nikos Mattheos et al ) • Molecular biosciences and technologies (Pauline Ford et al ) • Students’ perspective (K. Divaris et al) • Leadership, governance and management (Grant Townsend et al)

24. Beyond PBL – opportunities and challenges I’ll consider from different perspectives: The curriculum The students The faculty The community The environment – within and without

25. Some key references that have informed, and are consistent with, my thoughts for the future Norman G (2004) Editorial – beyond PBL. Advances in Health Sciences Education 9: 257-260. Arts JOS, Gijselaers WH, Segers MSR (2002) Cognitive effects of an authentic computer-supported, problem-based learning environment. Instructional Science 30: 465-495. Oliver M, Trigwell K (2005) Can ‘blended learning’ be redeemed? E-learning 2:17-26. Marton F, Trigwell K (2000) Variatio est mater studiorum. Higher Education Research and Development 19: 381-395. (there is also work by Runesson from Goteborg on Variation Theory)

26. Drawing on the concepts in these publications, I believe that we could move ‘beyond PBL’ by: • Developing more authentic scenarios - virtual patients - that are coordinated more closely with clinical activities – a ‘practice-based’ rather than a ‘systems-based’ approach • Providing more flexibility in our programs, with more student control, based around small learning groups resembling future practice teams • Applying concepts from Variation Theory to enhance learning experiences by emphasising the extent of variation in dental situations and providing more opportunities for discernment • Developing a sophisticated but user-friendly, e-learning environment to facilitate information sharing and access, with very good support for students and staff to optimise outcomes

27. Geoff Norman – beyond PBL • ‘we are not dealing with absence of evidence, but with evidence of absence’ • efficacy (best of all possible worlds) vs effectiveness (real world) • Underlying assumptions of PBL are not supported eg, notion of general problem solving skills, self-assessment can be learned, learning a concept in a clinical problem will automatically facilitate using that concept to solve other problems • If curriculum is based around organ systems, can lead to lack of ‘cognitive scaffolding’ • There is now evidence that learning with multiple examples is a prerequisite for transfer

28. Arts et al - beyond PBL Three main aspects of a regular PBL course in Business were redesigned: • Authenticity of the case studies was optimised – ill-structured, real-life information from real companies • Control aspects between students and tutors were tailored – students given increased control over their tasks and encouraged to work more independently in small self-steering teams • Students’ ways of social collaboration were adapted to resemble teamwork in business practice. Student collaboration on problem solving and information delivery was supported through electronic communication tools

29. Oliver and Trigwell – beyond PBL • The term ‘blended learning’ has been used increasingly to describe particular forms of teaching with technology • Oliver and Trigwell argue against the common use of the term – ineffective as a discriminating concept, refers to teaching methods rather then learning • The term may be redeemable by arguing that learning gains attributed to ‘blended learning’ have their explanation in Variation Theory

30. Marton and Trigwell – beyond PBL • ‘Variatio est mater studiorum’ - ‘Variation is the mother of learning’ (rather than repetition) • ‘There is no learning without discernment. And there is no discernment without variation. If good teaching is about making learning possible, how do good teachers help students experience variation? We argue that they constitute a space of learning which contains those aspects of the object of learning that are subject to variation simultaneously. For learning to occur, whether it be in the formal learning contexts established by these teachers, or in the less formal contexts of participation in social practices, there must necessarily be a certain pattern of variation present to experience, and this pattern must be experienced.’

31. Variation theory is a recent development of phenomenography • There are different ways of seeing the same phenomenon • Every phenomenon is the sum of all the possible ways of experiencing it • Learning involves a change in the way we see or experience something • We can help students learn by offering opportunities for them to see things from different perspectives • We can structure the learning environment to maximise opportunities for discernment by considering the different ways of seeing a phenomenon, eg a patient, a concept like caries, a technical procedure FITS NICELY WITH A FOCUS ON EXPERIENTIAL LEARNING AND AN HOLISTIC APPROACH Marton and Booth (1997) Learning and awareness. NJ: Lawrence Earlbaum

32. Suggestions for ‘beyond PBL’ - curriculum • ‘Pay much more attention to how concepts are learned’ • ‘Sequence the curriculum to permit scaffolding and growth in understanding’ • ‘practice with multiple examples’ Norman(2004) • Don’t use the term PBL - we don’t only deal with problems – more appropriate for medical model than dentistry - ‘if learning is best in context, how do we prepare for future contexts that are unknowable….not all ‘problems’ have ‘solutions’ – Boud

33. Suggestions for ‘beyond PBL’ - curriculum • Don’t use a systems-based approach – base curriculum around the concept of a practice with patients, real and virtual 1st year – medically & dentally healthy young adults 2nd year – healthy children and adults 3rd year – medically healthy, all ages 4th year – medically compromised, all ages 5th year – GDP Use scenarios to highlight the extent of variation we see (‘normal’ and ‘abnormal’), to increase the pool of patients to which students are exposed, and to emphasise the need for follow-up over time. • None of these are done well in our clinics at present

34. Students in the 21st century • 1/3, 1/3, 1/3 rule! Work, Socialise, Study • IT savvy • More demanding • Heterogeneous – international students

35. Suggestions for beyond PBL - students Task, control and social dimensions of PBL Task -students stimulated to perform a more thorough problem analysis in a setting that leads to more than one problem explanation -use of authentic scenarios -more emphasis on reflection, generalizing and making abstractions -greater use of ICT to provide access to multiple sources of information and to facilitate exchange of information

36. Suggestions for beyond PBL - students Control -gradually offer students higher levels of control over the process of learning according to maturity -offer settings for independent learning with freedom in time and place -emphasis on guidance and scaffolding (through ICT tools) to optimise the tutor’s role as a facilitator of the learning process Social -generating ideas or explanations to be carried out by individuals working on their own initially, then discussed in small teams of about 4 persons -after individual brainstorming, ICT programs can provide help for exchanging ideas and problem analysis

37. Assessment and self-assessment • How do we approach these issues? To discuss in session to follow

38. Intra- and inter- professional learning opportunities • Dentists, hygienists, therapists, technicians • Medicos, physios etc • To discuss in session later perhaps

39. Suggestions for beyond PBL – staff (faculty) • Basic science staff must understand how knowledge is, and will be, translated to the clinic • Clinicians must have a solid foundation in basic sciences that they can apply • More interchange is required – but we’ll need to deal with issues of power/control and vulnerability

40. Suggestions for beyond PBL – staff (faculty) • Need support for ‘young’ staff, staff development, mentoring, accountability and rewards for teams not just individuals • Need to deal with staff ‘burn-out’ • Need to develop a culture of scholarship in the broad sense throughout the school • Need to improve the quality of dental education research – and increase funding

41. Suggestions for beyond PBL – the community (public) • Outreach clinics for undergraduate students – needs to be an educational experience not just service provision • CDE for graduates – could follow the educational approaches advocated for undergraduates, not just glitzy lectures Must consider: ‘What makes a good dentist? – now and in 20 years time?’ There will be increasing need for application of biodental sciences and technology We must ensure that quality of care is not eroded

42. Beyond PBL – the environment Within schools - Departmental structure, trends in UK, RAE - Research-teaching nexus - Pressures on academics Outside schools - Competition vs collaboration – uni rankings (international collaborations and benchmarking may prove more rewarding than national ones – overcomes some of the jealousies) • IFDEA initiatives

43. Summary – beyond PBL • PBL – has led to a change in focus from teachers and teaching to learners and learning • But it’s time to move on – to build not discard • There are ideas, theoretical frameworks and evidence to help us -reports from Dublin meeting - IFDEA website -editorial by Geoff Norman -redesigned course by Mastricht group -concept of ‘blended learning’ -Variation Theory I’ve offered some suggestions: curriculum, students, staff (faculty), community (public), environment NOW’S THE TIME TO DISCUSS AND SHARE THANK YOU