The Experience of Implementing PBL Curriculum in an Asia Medical School – Can it be done?

1. The Experience of Implementing PBL Curriculum in an Asia Medical School – Can it be done? Kuo-Inn Tsou, M.D School of Medicine, College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan

2. Medical Schools in Taiwan • Twelve medical schools 4 national, 8 private • Only 3 are located in an University (NTU, NCKU, FJU). • The majority of medical schools offer a 7-year undergraduate program. NTU YM TMU NDMC FJU MMC

3. Taipei FJU History of more than 80 years: • Founded in Beijing in 1925 • Restored in 1961 in Taipei, Taiwan • 11 colleges (including Arts and Law) • Near 27,000 students in the campus. Fu Jen Catholic University New Taipei City

4. PBLan important innovation in education • Since the first implementation of this problem-based, self-directed learning approach at McMaster University in 1969, the spread of PBL has been rapid, both within and beyond the health professions. This trend of education reform has also swept through Asian medical schools.

5. No. of MS Implementing PBL Survey of 6th APC PBL- Tokyo 2006, Dr. Masahiro Tanabe, Chiba University, Japan Country or area No. of medical schools(%) PR China 5 (0.7%) Indonesia 9 (17%) Thailand 4 (31%) Malaysia 5 (31%) Korea 27 (66%) USA 86 (70%) Japan 63 (86%) Taiwan 11 (100%)

6. Goals of PBL Four Main Objectives to Achieve for a Truly Problem-based Approach • Structuring knowledge for better recall and application in clinical contexts • Developing an effective clinical reasoning process • Developing an effective self-directed learning skills • Increasing motivation for learning Barrow HS. A taxonomy of problem-based learning methods. Med Educ 1986.

7. Assessment of the Effectiveness of PBL • Knowledge • Communication with patients • Independent learning ability • Team-work ability • Patient education • Critical thinking ability • Quality of oral or written presentation • Self-assessment

8. Outcomes of PBL Students from the Literature

9. As Compared with Students in Traditional Curricula PBL-students • More self-regulated learning • Better self-directed learning skills, such as scientific thinking, problem solving, and conflict resolution skills, use of a broader range of resources • More active contributors to group learning process • Better interpersonal skills • No significant differences in test scores of medical knowledge, in general academic competencies, such as conducting research or writing a paper. Lycke KH, Norway, Med Teach 2006; Yalcin BM, Turkey, Croat Med J 2006; Schmidt HG, the Netherlands, Med Educ 2006

10. PBL Curriculum at Fu Jen Medical School

11. 1 2 3 4 5 6 7 Common education & General sciences Basic sciences & Some Clinical sciences Clinical sciences & Clerkship Intern-ship PBL at FJMS Curriculum Structure ↖ - a near-full PBL approach for the third and fourth year curriculum

12. PBL at FJMS Key Features • Composed of integrated system-based units • Use patient cases to integrate the learning of basic medical sciences and clinical sciences • High percentage of teaching hours in small groups ( tutorial sessions) • Multiple assessment tools to evaluate different aspects of learning

13. PBL at FJMS PBL Curriculum Design Third year courses • Introduction to Biomedical Science 3 wks • Fundamental unit 3 wks • Cardiovascular unit 6 wks • Respiratory & circulation unit 5 wks • Urological unit 6 wks • Gastrointestinal unit 6 wks • Endocrine & Reproductive unit 5 wks Fourth year courses • Neuromotor unit–CNS 6 wks • Neuromotor unit–PNS 5 wks • Obstetrics/Pediatric unit 6 wks • Infection/Host defense unit 6 wks • Hematology unit 5 wks • Psychiatry/Behavior unit 6 wks

14. PBL at FJMS PBL Related Learning Activities Lectures Resource learning Tutorials Clinical skills teaching Laboratories Self-studying, information collecting

15. Third year Tutorial session 3 hrs x 3(30%) Didactic lecture 2 hrs x 2 Resource learning/ 2 hrs x 1 Gross anatomy Clinical skills 3 hrs x 1 Laboratory course 4 hrs x 1 Embryology 2 hr x 1 Fourth year 3 hrs x 2(23%) 2 hrs x 2 4 hrs x 2 3 hrs x 1 4 hrs x 1 PBL at FJMS Weekly Activities Contact hours: 30 hrs/wk for third year and 26 hrs/wk for the fourth year

16. PBL at FJMS Monday Tuesday Wednesday Thursday Friday Lecture Lecture PBL PBL Lecture Lecture Lecture PBL PBL PBL PBL Resource section PBL PBL PBL Resource section Embryology Clinical skills Lab Elective Embryology Clinical skills Lab Elective Clinical skills Elective Lab Elective Lab

17. PBL at FJMS The seven steps in a tutorial session Stage 1: brain storming 1.Identify Facts & Problems 2.Generate Hypotheses 3.List Need to know 4.Formulating and organizing Learning objectives Stage 2: Data searching 5.Self-directed learning Stage 3: Group learning by discussion 6.Sharing knowledge with othersand reanalyze patient’s problems 7.feedback

18. PBL at FJMS Student Assessment Formative evaluation • Small group assessment oral, each tutorial session, written, mid-term and end-term • Triple jump exercise • Personal Progress Index (PPI) Summative evaluation At the end of each unit • Tutor’s assessment (40%) Student’s performance in tutorial sessions • Written test (60%)

19. PBL at FJMS Grading System Outstanding (優) above 90 scores Excellent (甲) 80 - 89 scores Good (乙) 70 - 79 scores Fair (丙) 60 - 69 scores Poor (丁) 50 – 59 scores Very Poor （戊） below 50 scores

20. PBL at FJMS Observation during the PBL Courses • Students have more confidence in the learning skills and time management needed in self-directed learning. • The group dynamic improves much and most of the students can engage in the discussion. • Students have made significant progress in English reading ability, oral communication skills, and the ability to chair a tutorial session.

21. PBL at FJMS Observation during the PBL Courses • Students feel himself like a doctor and can have empathy of the patient’s suffer presenting in the learning cases. • Almost every student attend the class on time and very few call in sick. • Students with attitude problems or learning difficulty can be recognized very early and get appropriate attention and assistance from the tutors and the medical school.

22. Program Evaluation at FJMS • From clinicians’ perspectives • Knowledge increments in the clinical years • Data collected from the medical education studies • 360 degree evaluation in the word • Passing rates in the Taiwan Medical Licensure Examination • From students’ perspectives

23. Results - 1 • From clinicians’ perspectives FJMS students could raise up structured questions, had gaps in medical knowledge, had better skills in communication and in case presentation. • More students were honored as the best interns. Compared with students from other medical schools. KI Tsou, et al Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school Kaohsiung J Med Sci 2009, vol 25

24. Results – 2 Knowledge increments in the clinical years FJMS students had significant larger increments in test scores at the end of pediatric and Obs-Gyn rotations as compared with students from the other medical school..

25. Results – 3 • Data from ME studies • Changes in the scores of Self-directed learning readiness scale(SDLRS) after the PBL courses. • The diagnostic reasoning strategies

26. Self-directed Learning Attitude • Self-directed learning is an important skill for medical professionals since knowledge is continuously increasing and changing. • Self-directed learning readiness scale (SDLRS), a 5-point Likert scale questionnaire, developed by Guglielmino in 1977

27. Changes in SDLRS • After one year of PBL, Fu-Jen medical students showed significant increases in the total SDLRS score, and the sub-scores of learning strategy and self-assessment. • This trend of improvement persisted till the end of two years in PBL curriculum.

28. Diagnostic Reasoning Strategies Gilhooly KJ; Elstein AS; Glaser R

29. Diagnostic Reasoning Strategies • Evaluated by using the think aloud protocol • Very few FJMS students use the hypothetic-deductive reasoning strategy. • For the clinical cases which were involved in the small group sessions, they tend to grasp a few key clinical features and reach a single diagnosis without attention to the alternatives. Guessing was used when the clinical cases were not taught anywhere in the courses. • They tended to analyzed the cases with physiologic or pathophysiologic knowledge and then reasoning out a diagnosis.

30. Results 4:360-Degree Evaluation of Graduates Supervisors, chief residents and nurses who knew the graduates well were invited .

31. Results of Questionnaire • As compared with graduates from other medical school, how would you evaluate our graduates? (1–much weaker, 5-much stronger)

32. Results of Questionnaire • As compared with graduates from other medical school, how would you evaluate our graduates? (1–much weaker, 5-much stronger)

33. Result 5 • Passing rates in the national licensure examination Students from the first three cohorts had the highest passing rate for the part 1 test (basic sciences in medicine) and had 100% passing rate for the part 2 test (clinical medicines)

34. Effectiveness of PBL Curriculum - Students’ Perspective

35. Students’ views • Study design • Semi-structured interviews (5th and 6th year students) in 2006 • Questionnaire with 5-point Likert scale questions and open questions (5th to 7th year students and residents) in 2009 and 2010 • Effectiveness of PBL • Knowledge learned during the 3rd and 4th year • Clinical reasoning, communication skills, self-directed learning skills, and motivation for learning

36. The impact of PBL on the Learning of Clinical Medicine • Semi-structured qualitative interview was conducted on 12 fifth or sixth year medical students • Students identified themselves having active learning attitude, better learning skills, stronger clinical reasoning abilities and good understanding of the mechanisms, and connections between concepts, and could apply the knowledge in explaining the symptoms or signs of a patient. • On the other hand, there was gap in the knowledge of clinical medicine.

37. Results of Questionnaire • Were you well-prepared for the learning in the hospital? (0–100% adequacy, 5-point Likert scale) In red color: p<0.05 as compared with 5th and 6th year students, in blue color: p<0.05 as compared with 7th year students.

38. Results of Questionnaire • Were you well prepared for the learning in the hospital? (0–100% adequacy, 5-point Likert scale) In red color: p<0.05 as compared with 5th and 6th year students

39. Results of Questionnaire • Were you well prepared for the learning in the hospital? (0–100% adequacy, 5-point Likert scale)

40. In Summary - 1 • PBL curriculum at the 3rd and 4th year could prepare students well for their learning in clinical years in terms of presentation ability, self-directed learning abilities, active learning attitude, communication skills and logical thinking abilities. • After entering internship, students felt that they were especially competent in problem solving, presentation, team work, doctor-patient relationship, logical thinking and professionalism.

41. In Summary - 2 • As a resident, the attending physicians, chief residents and nurses viewed the FJ graduates stronger than graduates from other medical school in presentation, problem-solving , team-work, build up doctor-patient relationship and professionalism. Besides, they thought FJ graduates had comparable or a little better knowledge in basic medical sciences and clinical sciences. • FJ graduates also viewed themselves that way.

42. Results of Questionnaire • How much were you satisfied with the following?(0–100% agreement, 5-point Likert scale)

43. In Summary - 3 Qualitative analysis of open questions in the questionnaire. • The satisfaction of PBL was low • Too much pressure • Poorly organized knowledge • Not adequate coverage and depth of clinical medicine • Not efficient in learning

44. Possible Reasons Qualitative analysis of open questions in the questionnaire. • Poorly organized knowledge • The knowledge gained through self-directed learning and through discussion in the tutorial sessions was not organized, deep, digested and not systematic. Due to: • Not enough study time • Not being able to identify the key area of study • Do no have enough ground knowledge in basic or clinical sciences for self-directed learning

45. Experiences Learned from the Past Night Years of PBL Curriculum A near-full PBL curriculum in an Asian undergraduate medical school • Students gain competency in self-directed learning, communication skills and logical thinking ability. • Students are more active learners. • In postgraduate training, PBL students were valued high in team-work, problem-solving ability and professionalism. In general, they were evaluated as above average. • However, students could not enjoy the learning and were not satisfied with the knowledge acquisition.

46. The Nature of PBL? • Anxious about the adequacy of knowledge when entering clinical clerkships, is a ubiquitous finding in medical students, no matter what curriculum they attend. • A near-full PBL is likely to stress factual knowledge less than traditional programs with un-integrated, i.e. discipline oriented lecture series and exams. • A lower level of factual basic science knowledge may be (partly) compensated by a strong attitude toward learning in the clinical setting.

47. Ways Used to Strengthen the Learning in PBL Curriculum • Using concept map or concept-based design (the clinical problems are given in sequence based on the concepts underlying the problems)Rendas 2006, Neville 2007 • Revised model for case study (not focus on problem-solving skills but meaningful discussion on ideas) Shanley 2007 • Structured tutorial (preceded the first tutorial session with a “home review” patient case) Espey 2007 • Use of e-learning tool Terry 2007

48. Question Remained • “Could teaching of schemes and scheme inductive reasoning as used with the Clinical Presentation curriculum further facilitate developing expertise among PBL students?” • Clinical presentation curriculum is characterized by using clinical presentations as the context to impart relevant basic and clinical sciences information; second, teaching expert-derived problem-solving strategies (schemes) to enable students to apply forward reasoning, or scheme-inductive reasoning, for problem-solving.

49. Goals of PBL Four Main Objectives to Achieve for a Truly Problem-based Approach • Structuring knowledge for better recall and application in clinical contexts • Developing an effective clinical reasoning process • Developing an effective self-directed learning skills • Increasing motivation for learning Barrow HS. A taxonomy of problem-based learning methods. Med Educ 1986;20: 481-6.