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APS REFRESHER COURSE REPORT
Office of Curriculum Affairs and Department of Medical Education, Southern Illinois University School of Medicine, Carbondale, Illinois 62901-6503
Abstract
The Southern Illinois University School of Medicine (SIU-SOM) has utilized problem-based learning (PBL) in its curriculum since 1981, when Dr. Howard Barrows joined the faculty. From 1989 to 2000, SIU-SOM implemented two parallel curricula for the basic science years (years I and II), one curriculum being a problem-based learning curriculum (PBLC). An executive decision to design and implement a single curriculum, to begin in Fall 2000, fostered a review of existing pedagogy upon which to base this new curriculum: C2000. The results of this review, which considered formal outcome measures as well as internal review in consideration of the institutional mission, led to PBL becoming the predominant pedagogy for C2000, albeit with some modifications from its PBLC predecessor. C2000, then, represents the third iteration of PBL in use at SIU-SOM, and its design and rationale offer insight for the teaching of Endocrine Physiology in a PBLC.
Key words: problem-based learning; pedagogy; teaching; physiology; endocrinology
The evolutionary path from the introduction of problem-based learning (PBL) into the Southern Illinois University School of Medicine (SIU-SOM) curriculum in 1981, coinciding with Dr. Howard Barrows joining the faculty, through 10 yr of a problem-based learning curriculum (PBLC) to the current iteration of PBL as the pedagogy underpinning the current curriculum, C2000, is noteworthy for its lessons in pedagogy and the application of sound pedagogy to meet curricular and institutional goals. As the coordinator of an Endocrine/Reproductive Physiology unit (E/R) in the PBLC from 1990 to 2000, I worked with a team of faculty that 1) utilized PBL to teach Endocrine Physiology; 2) conducted ongoing reviews of the curriculum and its outcomes, and 3) instituted curriculum reforms that evolved into the iteration of PBL, which was implemented as the prevailing pedagogy for C2000.
DEFINITIONS AND CLARIFICATIONS
As the literature has grown about PBL, so have the misconceptions. Without resorting to a formal definition and classification of PBL and PBLC, as stated in Barrows (1), let us state that PBL is a pedagogy wherein the problem becomes the stimulus for the learning experience. As an adjunct to this stimulus, various learning experiences (tutor groups, lectures, laboratories, resource sessions, clinical activities, etc.) may be implemented, but the primary learning is centered on the learning issues identified as requisite to comprehend and "solve" the problem. Barrows’ (1) taxonomy serves to clarify some format issues, but for our purposes, the simplified definition provided herein is adequate. What is important to understand is that PBL is but pedagogy, a method of teaching (and learning), which is no more immune to curriculum and institutional needs and influence than any other form of pedagogy. Fundamental to PBL are two constructs relative to learning and retention. First, learning is maximized when a specific set of conditions is met: 1) a question (or series of questions) is posed to a learner (either by the learner or someone else), and 2) the learner does not "know" an "acceptable" answer to the question, and 3) the learner is motivated (either intrinsically or extrinsically) to learn an acceptable answer because of a perceived value to the question. The second construct involves the retention of (newly learned) information: that retention is a function of utility. Simply stated, the more a specific concept or piece of data is used or found to have a useful application, the greater the chance that the concept or piece of data will be retained (in an applicable mode). There are many variants of PBL in place today, mostly as a function of institutional needs or philosophies, which must be taken into consideration when implementing a PBLC, but, fundamentally, these constructs about learning and retention are integral to PBL.
THE EARLY YEARS: 1981–1989
Coinciding with a series of initial workshops to educate faculty about PBL, problem-based learning modules (PBLMs) (6) were developed to replace the existing series of "clinical correlates," which were used to illustrate clinical aspects of the basic sciences. The concept of a PBLM arose from the P-4 Deck developed and utilized by Barrows and others at MacMaster University. A PBLM is an "ill-structured patient problem" written and presented in such a manner that learners make relatively free inquiry against a medical problem with a task of arriving at an explanation of the basic science mechanisms underlying the problem and/or the patient’s presentation of the problem (6). Basic scientists were encouraged to author PBLMs for material within their areas of teaching responsibility with the assistance of clinical faculty who validated the clinical presentation of the patient problem. By 1983, PBLMs authored for use within the Endocrine/Reproduction unit included hypothyroidism, female infertility, and a diabetic pregnancy, with several others under construction. The PBLM format addressed an institutional goal to integrate clinical and basic sciences without serious sacrifice to either science, namely that elements of clinical reasoning, physical examination skills, and diagnosis, etc., could be related to the signs and symptoms of a specific patient with established physical findings related to specific basic science mechanisms. However, the use of PBLMs was still restricted in that they were an adjunct to an existing "traditional" curriculum. As such, PBL was also an adjunct pedagogy, not the primary pedagogy of the curriculum. We were learning about PBL "on the job" as we progressed through a period of increased utilization of PBLMs and PBL in the curriculum. In 1986, with the establishment of an accepted set of commencement objectives, a performance-based set of objectives to which students would be held accountable to obtain the M.D. degree and a performance-based examination to determine students’ performance against same (2), a new review of the existing pedagogy at SIU-SOM was undertaken. In 1989, an executive approval was given to plan for the implementation of a PBLC as a parallel basic science curriculum, which would result in a split class for the first 2 yr of medical school: a portion of the students in the traditional curriculum and the others in the PBLC.
THE PBLC YEARS: 1990–2000
Beginning with the class that matriculated in the Fall of 1990, all students accepted to SIU-SOM were invited to self-select for the PBLC, with a supplemental selection by PBLC faculty based on nonacademic factors. Effectively, this provided a split cohort of students undertaking two content-similar, but very pedagogically different, curricula. Comparisons between the two curricula, and student performance, became inevitable but also formed the basis for ongoing review of pedagogy and learning, both against established extrinsic outcomes and intrinsic criteria related to the institutional mission.
Because both curricula were viewed as parallel tracks, providing preparation for United States Medical Licensing Examination (USMLE) Step 1 and entrance into the clinical years, a base assumption was made that basic science content should be essentially the same for both curricula. Although content knowledge was just one of five overall objectives within the PBLC, content mapping in the curriculum design phase provided a means to assign specific learning objectives to particular patient problems and provided an overall viable curriculum. Table 1 provides an overview of the Endocrine Physiology modules from the traditional curriculum for 1999–2000, and Table 2 provides a similar overview for the Endocrine Physiology learning issues (identified by the students) for the E/R unit in the PBLC, also for 1999–2000. The overlap, which is evidenced by comparison of these two tables, is consistent with our experience in congruency with design objectives and with achieving similar results across tutor groups (4). Similar congruency was achieved with respect to student achievement. As reported by Colliver (3), a comparison of the 47 PBL students and the 154 standard curriculum students in the classes of 1994, 1995, and 1996 showed small to moderate advantages for PBL on USMLE Step 1 [difference (weighted means) (d) = +.18; P = .2,707] and USMLE Step 2 (d = +.39; P = .0197). Similar small differences were reported for clerkship ratings (d = +.50; P = .0028) and performance on the postclerkship standardized patient examination (d = +.30; P = .0703) (3). SIU-SOM has long instituted a policy of following its graduates through residency, with information gleaned from residency directors (5). Although this information has not been formally tabulated and reported, it, too, suggests differences favoring the PBLC students.
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Although the differences in student performance were small, they were significant in that they were achieved while the PBLC was providing new indices of student performance in areas outside basic science content. Clearly, the PBLC was not producing students who were deficient in content knowledge, and it was producing students who were performing slightly better as physicians. We, as faculty, were becoming better at "making PBL work." We learned the necessity of providing tutors who were well schooled in the pedagogy and we learned the necessity of educating resource faculty not to give mini-lectures but to provide guidance, helping students learn what they needed to solve the patient problems. To account for varying differences in "content expertise" in tutors, we developed a system of tutor guides, outlining potential learning issues and probes, categorizing such objectives by priority. We also learned that a PBLC does not confine itself neatly in spaces on a calendar, an attribute that has become a construct for C2000 under the rubric of "horizontal and vertical integration." Such integration became a hallmark of the PBLC as we became less territorial and effected integration of content across disciplines and organ systems (horizontal) and between basic and clinical science presentation (vertical). Last but not least, we learned to make PBL work at SIU-SOM by designing a PBLC that met our needs and was adapted to mesh with our institutional needs and mission, a prerequisite for any curriculum to be effective. Two examples of such adaptation within the E/R unit are illustrative of how we came to make PBLC work.
1) The patient problem we used for female reproductive physiology and the endocrine control of menses and ovulation was a patient problem of primary infertility with underlying mechanisms of polycystic ovarian syndrome (PCOS) and endometriosis. This was a "proven" case with a plentitude of good learning issues and a time-tested presentation. Two problems with this patient problem became evident: a) the clinicians tended to refer to PCOS as a "garbage can diagnosis" wherein a multitude of etiologies might be present with little means of differentiation and new information about PCOS was coming on line; and b) we had symptoms of a larger problem with both curricula: students’ learning tended to be textbook dependent, as confirmed by an in-house study (A. R. Sutphin, unpublished data). Multiple attempts at "artificial means" to promote the use of primary resources (e.g., "journal clubs," "readings and presentations," etc.) were considered, but all came with a cost of already impacted curricular time. Although the PBLC made an impact on increasing the students’ use of primary resources, most students were still textbook dependent (A. R. Sutphin, unpublished data). A clinician affiliated with the school, who also happened to be the director of Women’s Health on campus, attended the American College of Obstetrics and Gynecology Annual Meeting in New Orleans in May 1998. The clinician saw Dr. Leon Speroff present an all-day seminar on the management of PCOS. Included was in-depth coverage of such topics as the link between PCOS and Syndrome X, the physiological mechanisms of insulin resistance (e.g., end organ sequalae at the ovarian level and on coronary vasculature, molecular biology of insulin receptors, etc.), and current therapies for PCOS, including the Syndrome X therapies of diet, exercise, and metformin. At that time, the clinician from our campus was treating a patient for PCOS who happened also to be Syndrome X, so this seminar was of particular interest to her. Interestingly, she was also a party to concerns about PBL in the E/R unit and realized the applicability of this case as a potential patient problem for the unit. After she worked with a team of basic scientists, a new patient problem was authored and inserted within the E/R unit, replacing the previous patient problem and revising the content map of the unit. The information students needed to solve the new patient problem could only be accessed through the newer primary resources, because the information was "too new" to be included in textbooks. Tutors were provided access to the new information with revised probes in the tutor guide. Students, by default, had to adapt their behavior to access the current information. The use of primary resources, an institutional goal, increased accordingly.
2) One of the more complicated E/R patient problems involves a case of primary hyperparathyroidism, involving concurrent inadequate hormone replacement therapy for Hashimoto’s thyroiditis and a familial presentation of postmenopausal osteoporosis. In reviewing the learning objectives for this patient problem, the obvious relationships to learning objectives for the Cardiovascular, Renal, and Gastrointestinal units came into consideration, a prime example of horizontal integration. The tutor guides for these units were rewritten to include patient problem listings, vertically integrating basic science mechanisms with clinical management of patient problems involving endocrine learning objectives. Students are presented with the concept and management issues of secondary hyperparathyroidism during the Cardiovascular/Respiratory/Renal unit some 6 mo before encountering this patient problem in the E/R unit. By recognizing and accounting for the natural extension of learning objectives across disciplinary units, rejecting the notion that learning of specific disciplines must accompany "allocations of designated blocks of time," students are exposed to the diverse nature of endocrine mechanisms and their pathophysiological effects on other organ systems. A recurring review of material from other units during the E/R unit is an additional bonus.
WHY C2000?
In 1998, a recommendation was approved to begin planning for a single curriculum for years I and II. The driving force for this curricular change was mostly related to resource utilization; it was considered to be an ineffective use of resources to offer two "competing" curricular tracks for the basic science years. Design teams for all 4 yr of medical school were organized with an immediate task for years I and II, to establish a pedagogical basis for the basic science curriculum.
C2000
C2000 is a PBLC, but it is not the PBLC of 1990–2000. There are those who would claim it to be a "hybrid curriculum," but it borrows so little from traditional curricula that the hybrid label hardly applies. Its primary pedagogy is PBL, with about the only concession to traditional curricula being "whole class resource sessions" that are not required and which must be responsive to students’ questions (arising from the patient problems) E-mailed to the resource faculty by the previous day. Obviously, little prepared lecturing can endure in this format. Many resource sessions are less than whole class, in response to concerns arising within individual tutor groups. Whole class resource sessions are generally organized to economize on scarce resources (e.g., volunteer clinician time). The learning focus of C2000 remains the patient problems, designed and organized in the time-tested methods perfected through the years of PBLC. Indeed, a comparison of the patient problems used during E/R in the PBLC (Table 3) with those used for E/R in C2000 (Table 4) reveals that the patient problems utilized in the Endocrine unit in C2000 are the identical problems used in the E/R unit of the PBLC, with some additional patient problems added to cover material prioritized during the content mapping.
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1) PBL was producing a better end product (new physicians) as determined by external measures (USMLE scores) and other "measures" (clerkship performance, honors, performance on the postclerkship standardized patient examination, and residency director ratings).
2) We were observing direct evidence that our PBL students were designing effective self-directed learning strategies, coinciding with an institutional objective of promoting the notion of effective clinicians being life-long learners. PBL also provided a means to promote textbook-free learning where direct applicability of the new knowledge was "part of the package."
3) Integration of material, both horizontal and vertical, promoted internal review and applicability of physiological concepts across curricular units in an applicable mode in which students could easily understand their utility.
4) Our internal studies indicated that content coverage would not be an issue. Whatever curriculum time devoted to learning objectives other than basic science content would not appreciably compromise learning outcomes (i.e., USMLE scores remain viable, actually showing improvement, and the clinicians were pleased with the PBL-trained product in the clerkships, as reflected in the clerkship ratings of PBLC students).
5) Institutional needs were attended to under PBL much more so than under traditional formats: integration of material; infusion of new concepts, technology, and therapies, etc.; promotion of the use of primary resources without artificial means; a less impacted schedule; more active, as opposed to passive, learning; and readily demonstrated applicability of basic science concepts in the clinical setting, etc.
ENDOCRINE PHYSIOLOGY IN C2000
Because virtually the same patient problems are used in the Endocrine unit in C2000 as were used in the E/R unit in PBLC, and since PBL remains the pedagogy underpinning the curriculum, one might reasonably assume that C2000 looks very similar to the PBLC. This is true in many respects: tutors and faculty are well trained in the PBL pedagogy; tutor support is present in the form of printed tutor guides; weekly meetings with the unit coordinator and the case manager for each patient problem; E-mail linkages with support personnel, other tutors, web sites, and resource faculty; and vertical files established in the Medical Resource Center for quick content review, etc. PBL may become maintenance intensive, but the support mechanisms keep the content current and the tutors apprised of changes in curricular content. The effective life of a given patient problem is variable, depending on the current nature of the information contained therein as well as the nature of the information needed to solve it. We review our patient problems on an annual basis as standard procedure and more frequently if changes in the database warrant it. Horizontal and vertical integration was an evolutionary process in the PBLC; it is a design prerequisite in C2000. Integration linkages are actively sought and being developed. With the Endocrine unit being the last unit in year I, most unit coordinators are very cooperative because they view endocrine linkages as another chance to foster student review of other organ system material. These linkages further the notion of the Endocrine unit material not being confined to neat spaces in a designated time allocation on a calendar and promote application of learned material in a clinical context.
Evaluations are being continued in formats pioneered in the PBLC: performance-based, utilizing patient problem formats (standardized patients, diagnostic reasoning module, clinical comprehensive examinations, objective structured clinical examinations, etc.) combined with specific content examinations over learning issues identified in the patient problem encounters. Tutor group assessments are still part of the total evaluation package. A revived concept is computerized self-assessment items. Although content coverage is a function of the tutor group experience, it was decided to use self-assessments of content to help students ascertain adequate depth-of-coverage of content. Remediation experiences are designed to use the same pedagogy as the curriculum.
SUMMARY
At SIU-SOM, PBL is the pedagogy on which the new curriculum, C2000, is based. Our experience with PBL, dating back to 1981, has yielded information that shows PBL to be a flexible pedagogy, well suited to adaptation to meet the curriculum needs and mission of SIU-SOM. Ten years of experience with the PBLC yielded valuable experience and lessons that have enhanced the transition to C2000 as the single curriculum for the basic science years.
Acknowledgments
Address for reprint requests and other correspondence: D. W. Brewer, Office of Curriculum Affairs and Dept. of Medical Education, Southern Illinois Univ. School of Medicine, Carbondale, IL 62901-6503 (E-mail: dbrewer{at}siumed.edu).
REFERENCES
This article has been cited by other articles:
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  M. A. Tufts and S. B. Higgins-Opitz What makes the learning of physiology in a PBL medical curriculum challenging? Student perceptions Advan Physiol Educ, September 1, 2009; 33(3): 187 - 195. [Abstract] [Full Text] [PDF]
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 J. Kong, X. Li, Y. Wang, W. Sun, and J. Zhang Effect of Digital Problem-Based Learning Cases on Student Learning Outcomes in Ophthalmology Courses Arch Ophthalmol, September 1, 2009; 127(9): 1211 - 1214. [Abstract] [Full Text] [PDF]
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