PBL in the clinic

1. PBL in the clinic Hong Kong 2004 Associate Professor Liz Farmer Co chair PBL Expert Advisory Group Flinders University

2. overview • Review PBL process • Clinical environment • Theoretical concepts in clinical PBL • Concepts of clinical expertise and PBL • One approach • Conclude and discuss

3. Definition of PBL • PBL is the learning that results from the process of understanding and resolving a problem- • the problem comes first in the learning process

4. Steps in the tutorial process Identify key information Generate / rank hypotheses

5. QUES T I ONS KNOWLEDGE BASE Identify key information Generate / rank hypotheses Explore and explain information

6. KNOWLEDGE BASE QUES T I ONS Identify key information Generate / rank hypotheses Explore and explain information

7. QUES T I ONS KNOWLEDGE BASE Identify key information Self-directed learning Generate / rank hypotheses Learning Issues Explore and explain information

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

10. Clinical PBL: theoretical aspects • Foley suggests Barrows’ 4 key elements must be present: • Clinical context to facilitate recall and application • Develop clinical reasoning processes • Increases motivation for learning • Allows SDL

11. Constructivist learning • PBL is a form of constructivist learning • “Information-processing constructivism” • Savery and Duffy • “Eight instructional principles”

12. 8 Principles • Anchor learning activities to larger task or problem • Support ownership of problem • Authentic task • Design task to reflect complexity of environment the learner should be able to function in at completion • Ownership of process to develop solution • Design environment to challenge thinking • Encourage testing of alternative views and contexts • Provide opportunity for and support reflection on content learned and the learning process

13. Evidence for Claims of PBL Schmidt • Problem is context for learning • Problem is activator of prior knowledge • Small-group discussion as means of elaboration and knowledge construction • Learning is intrinsically motivated • Learning is self-directed

14. Why context? • Context facilitates and affects recall: “grocery store” • Royal navy divers Baddely 1976

15. Context dependent memory 50 45 40  35  Recalled on land  30 Recalled underwater  25 Percentage of words recalled   20 15 10 5 0 Learned on land Learned underwater

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

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

18. Activating prior knowledge • Activating prior knowledge facilitates processing of new information • Activation and elaboration at time of learning enhances recall and transfer of that knowledge (Schmidt 1993)

19. Activating means problem first plus discussion • recall is context dependent • Students presented with problem first plus attempts to solve and explain do better in long term recall than those where problem presented and explained all at once

20. A theory of clinical knowledge • George Bordage • Reduced: absent or inaccessible • High / dispersed lacks organization • High / elaborated organized, modelled or structured to more global and accessible representations of the problem • High / compiled elaborated networks condensed by experience, does not engage in detailed reasoning, uses other factors such as pattern recognition

21. Dispersed:Flight Connections SIB Airlines Maastricht - Amsterdam vv Maastricht - Brussels vv Amsterdam - Hamburg vv Amsterdam - Edinburgh vv Amsterdam - Brussels vv Amsterdam - London (Gatwick) vv Brussels - Paris vv Brussels - London (Heathrow) vv Manchester - London (Heathrow) vv

22. Elaborated Flight Connections SIB Airlines

23. expertise • Extensive application allows knowledge to be compiled and subsumed • When faced with non-routine problems experts’ causal models are more coherent, account for more data and are more accurate (Norman 1994)

24. Why focus on explanatory structures? • Aim is to bring students to high elaborated knowledge levels in each context

25. A theory of clinical knowledge • George Bordage • Reduced: absent or inaccessible • High / dispersed lacks organization • High / elaborated organized, modelled or structured to more global and accessible representations of the problem • High / compiled elaborated networks condensed by experience, does not engage in detailed reasoning, uses other factors such as pattern recognition

26. One approach:“Live clinical PBL” • Lead student sees patient chosen with tutor • Lead student presents case as PBL Tut 1 • Group discuss hypotheses and further information required (? Tutor required) • Group SDL while lead student follows up patient • Tutorial 2 group presents work in context, student offers follow up data, progress and actual management • Tutor present; gives clinical feedback only at the end of the session

27. conclusions • Clinical expertise is complex • Theory and evidence can underpin our approach to the learning environment: • PBL process • Nature of expertise • Clinical PBL helps to integrate these domains • Exciting opportunities for GP educators