Student and Faculty Attitudes Towards a Neurosciences PBL Pilot in a Traditional Curriculum

INTRODUCTION

Problem-based learning (PBL) is a student-centered approach to teaching and learning that emphasizes in-depth understanding, critical reasoning, teamwork, and contextual learning. During a typical two-part PBL session, a small group of students systematically uncover a clinical case through the help of an instructor who takes on the role of facilitator rather than an expert lecturer. In the first session students identify concepts they do not know and assign these among themselves to research. During the subsequent session, students return to discuss what they learned and integrate these ideas around the problems of the patient.

The evidence base surrounding PBL is abundant and varied. While there is much disagreement and debate regarding basic sciences academic achievement, problem solving, and clinical performance, it is generally agreed that student satisfaction is superior in the PBL model.^1,2,3 The disparity is further evidenced by the ways in which some authors interpret the equivocal body of literature ranging from “the results generally support the superiority of the PBL approach over more traditional methods” ² to “PBL curricula provides no convincing evidence that PBL improves knowledge base and clinical performance”. ¹ A recent study comparing USMLE Step1 and Step 2 exam outcomes following a PBL implementation found that PBL ?[does] not compromise the performances of medical students. . . in fact, they may have contributed to higher scores”. ⁴ Others suggest that PBL methods may be more effective at helping students minimize the rote learning required to navigate traditional medical school curricula. ⁵ While many advocates claim that PBL can improve generic problem solving abilities, some have found problem solving not to be a generalizable skill. ^6,7 Most studies do assert that current outcome measures are not sufficient to understand the true effect of PBL.

Despite national discussions regarding measurement and outcomes, many educators have found PBL to be an attractive and enjoyable alternative to conventional educational modalities. Studies of faculty satisfaction with the PBL technique reveal no major frustrations once they have had an opportunity to experience the process as a facilitator. ³ Many instructors have experimented with PBL variants by altering the case structure and logistics. Others have used technology to develop, deliver, and evaluate PBL activities. ⁸

The resource-intense nature of PBL is commonly cited as a drawback. A five-year study at The University of Sherbrooke found that teaching loads can increase as much as thirty percent. ⁹ An analysis of the use of PBL in a pathology course estimated that PBL activities require an average of 17.4 faculty hours per year per student compared to 4.8 for traditional lectures. ¹⁰ Class size also appears to be an important factor. PBL may be resource prohibitive for class sizes greater than 100.³

At The University of Oklahoma College of Medicine, many faculty had followed the PBL trend with interest but struggled with a way to feasibly adopt it into the moderately large classes of 150-160 students. Nonetheless, several instructors in the Neurosciences course were interested in piloting this technique. With little experience in problem-based learning and few volunteers for facilitators they developed a pilot project to determine student and faculty reception to problem-based learning and compare faculty effort with traditional techniques.

METHODS

All 153 first-year medical students were required to participate in the pilot as part of the Spring 2000 Neurosciences course. To accommodate the pilot PBL activities, the course director decided to cut five hours (out of eleven total) of lecture from his personal section of the course on motor systems. Students were informed early in the semester that the course was going to implement a PBL pilot and that attendance was mandatory.
Two cases were developed for the pilot. One case was selected to integrate content previously covered in the classroom. This case concerned a lesion in the lateral portion of the caudal pons. The students had previously covered the anatomy and physiology of the brainstem, and were taught all of the classic lesions involving the brainstem. The second case was chosen to present a novel situation that could be addressed using previous material. This case presented a thalamic lesion. Although the students had been taught the basic anatomy and physiology of the thalamus, they were not taught any thalamic lesions. For this case, the students had to use information previously taught to localize a type of lesion they had not seen before.

Learning objectives were pre-identified and outlined on instructor’s version of case. To reduce the group size each instructor was asked to repeat the experience by facilitating two separate groups of students. Each group covered the two cases over three 1-hour sessions (roughly 1.5 hours spent on each case). There were two to three days between sessions during which students were asked to research their learning issues.

Eight faculty, a combination of experts and non-experts, were recruited to act as facilitators for the cases (roughly one facilitator per ten students, with each facilitator supervising two groups). A role-playing training session was conducted to familiarize the instructors to the traditional PBL approach. During this session one of the authors acted as the facilitator to the rest of the instructors who played the role of students. After role-playing the exercise each instructor was given the actual cases for study.

As with the traditional PBL method of teaching and learning, students identified learning objectives during the first session and reported on these during the second session. Students were given the freedom to allocate learning issue responsibilities as they saw fit.

Student attendance and participation were assessed during each of the three sessions using a simple checklist system. As long as a student made some effort to contribute they were given full participation credit (a total of 11 points for the three sessions, out of 360 possible for the entire course). Students who were not able to attend one of the sessions were able to make up credit through a PBL exercise held later in the semester.

Student attitudes were assessed using a postexercise Likert scale survey. In addition, students had space to write written comments. Faculty attitudes were assessed with individual interviews that asked their perception of the interaction and how it affected their teaching workload.

RESULTS

Ninety-seven percent (149/153) of students responded to the survey. Table 1 reveals that an overwhelming majority of students found the experience useful and desired more PBL sessions in the curriculum. Slightly fewer felt like they were evaluating a real patient by working through the problem. Written comments were equally favorable. Of the fifteen written comments (see Table 2) most described the experience with positive language. The students of one facilitator were noted to have received less enthusiastic ratings and comments from students.

Most facilitators experienced a teaching time increase of 7 hours (6 contact hours plus one preparation hour). However, for the instructor that cut lecture hours the increase of time was 5 hours (-5 lecture, +7 hours as described for other faculty, +3 hours developing the case). When instructors were interviewed individually they noted that they enjoyed the personal interaction with students; even though total teaching time increased, it was not prohibitive because the preparation time was minimal compared to traditional lectures.

The PBL experience had no obvious effect on student grades relative to the written exams. However, students still believed that the cases helped them prepare for the exams because case presentations are a significant proportion of the exams; up to 50% of the exam questions (fewer on the first exam, more on the final exam) involved clinical situations.

An unexpected impression occurred to many faculty. As noted previously, several students did not participate in the discussions to the extent that other students did. We expected this to occur, but we thought that it would be more related to personality or being uncomfortable in a group setting. After the case discussions were completed, and the names of some of these students were mentioned to the course director, it became evident that many of these students were performing poorly in the course.

Table 2. Student Attitudes Regarding the Neurosciences PBL pilot (Comments)

Written Comments

• I thought these were helpful in evaluating our knowledge of the systems we have talked about. PBLs integrate our knowledge and make us think.
• It is very helpful to learn with this problem solving/case study concept.
  
• This should definitely be a BIGGER part of the curriculum!
  
• This is an excellent integrative tool. Let’s do more of them.
  
• Please include radiograms, etc., next year.
  
• Rarely attend lecture –just confuses me; Love this! I like the active learning!
  
• A combination of clinical correlations & case-based learning would be helpful! (50/50)
  
• Please include more of these interactive & integrative learning seminars in the curriculum. I found this experience to be a dynamic and unique approach to understanding Neurosciences.
  
• I already feel fairly taxed in terms of sheer class load & this tends to add more time required for school that I could use for studying.
  
• More, more, more!! We should have PBL for ALL classes!!
  
• How about switching [meeting] times for groups? This group ALWAYS had to get here early. All in all, very good exercise!
  
• This was very enjoyable, and more helpful than some clinical correlations.
  
• I think it might be helpful to have more case studies for the amount of time we spend on this project. Three hours is a lot of time and I would like to get through more cases.
  
• This was great. I would actually prefer more of these small group sessions even if it means more time outside of regular lecture.
  
• One PBL exercise each week or every other week would be an appropriate time spent.

DISCUSSION

The Neurosciences PBL experience was a successful pilot for several reasons. Students found that this method gave them a clear application of basic sciences to clinical situations and in most cases considered this similar to evaluating a real patient. The increased faculty-student interaction and small group setting likely contributed to positive ratings as well. Faculty also reported a positive experience. This effect on faculty and students attitudes is consistent with the literature. However, the faculty effect may have been due to the novel nature of the pilot and may not be sustained if many more PBLs were included in the curriculum without reducing other teaching responsibilities (e.g., lectures).

We feel the grading system could have been improved. Because the students were essentially awarded 11 points for just attending and minimally participating in the discussions, they were given 3.1% of their final course grade for relatively little effort. This problem became evident at the end of the course when several students passed the course without having passed any of the individual written exams. When we planned the PBL exercises, we felt that the exercises should be graded for two main reasons. First, since this was the first time that PBL-like cases would be used in this course, we wanted to encourage student attendance. Second, we felt that students should receive some reward for working on the problems during class time as well as between sessions. The grading system could have been more rigorous. We intend to continue to examine this issue for the next occurrence of the course.

The overall impact of non-expert facilitators was minimal. One of the non-experts was rated slightly below the other facilitators, which did slightly detract from overall positive review. However, other non-experts were reviewed as favorably as the expert facilitators. It was noted that this particular facilitator was not quite as enthusiastic about the process.

The course director would like to explore alternatives to assessing student contribution and performance during PBL sessions. While other medical schools have had success with reflective narrative assessment, it is difficult to accomplish this de novo in a class size of 153 students. Standardization of assessment will be an important issue. Of particular interest is an assessment approach for early identification of students who will have difficulty in the course.

Because of the success of the Neurosciences PBL pilot, more cases will be infused into the curriculum during the upcoming academic year. The course director is interested in developing more interdisciplinary cases to integrate and reinforce concepts from multiple courses. Convincing additional faculty that this method can replace lecture hours will continue to be a challenge.

CONCLUSIONS

Our specific plan for the coming year is to present the results of this experiment to other course directors in the first year of our curriculum, with the hope that they will incorporate some cases into their courses. At the same time, we will use faculty who facilitated the cases this year to help recruit additional faculty, partly by emphasizing how much fun it was to interact this directly with students. For the Neuroscience course specifically, we plan to expand to three cases. We do not plan to grade the student participation in each case. Rather, they will be required to attend the case studies, and questions based on the cases will appear on the exams. We hope that this system will reward the students adequately for participation in the case studies.

REFERENCES

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3. Albanese, M.A., and Mitchell, S. Problem-Based Learning: A Review of Literature on Its Outcomes and Implementation Issues. Academic Medicine. 68:52-81, 1993.
4. Blake R.L., Hosokawa M.C. and Riley, S.L. Student Performances on Step 1 and Step 2 of the United States Medical Licensing Examination Following Implementation of a Problem-based Learning Curriculum. Academic Medicine. 75:66-70, 2000
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6. Elstein, A.S., Shulman, L.S. and Sprafka, S.A. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, Massachusetts: Harvard University Press, 1978
7. Schmidt, H.G., Norman, G.R. and Boshuizen, H.P.A. A Cognitive Perspective on Medical Expertise: Theory and Implications. Academic Medicine. 65:611-621, 1990.
8. Carlile, S. Medical Problem-Based Learning Supported by Intranet Technology: A Natural Student Centered Approach. International Journal of Medical Informatics. 50: 225-233, 1998.
9. Des Marchais, J.E. A student-Centered, Problem-Based Curriculum: 5 Years’ Experience. Canadian Medical Association Journal. 148:1567-1572, 1993.
10. Donner, R.S. and Bickley, H. Problem-Based Learning: An Assessment of Its Feasibility and Cost. Human Pathology. 21:881-885, 1990.

Correspondence should be addressed to Dr. Candler, Assistant Dean for Curriculum Development, Office of Educational Development and Research, 941 Stanton L. Young Blvd., BSEB 115A, Oklahoma City, OK 73190. Special thanks to Mrs. Michelle James for compiling and editing the PBL materials.