Advan. Physiol. Edu. 28: 59-63, 2004;
doi:10.1152/advan.00010.2003
1043-4046/04 $5.00
ADV PHYSIOL EDUC 28:59-63, 2004
© 2004 American Physiological Society
How We Teach
Evaluation of the teaching strategy of cardiovascular system in a problem-based curriculum: student perception
Marwan F. Abu-Hijleh1,
Salah Kassab2,
Qasim Al-Shboul3 and
Pallab K. Ganguly1
1 Department of Anatomy, Arabian Gulf University, Manama, Kingdom of Bahrain
2 Department of Physiology, Arabian Gulf University, Manama, Kingdom of Bahrain
3 Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
Address for reprint requests and other correspondence: M. F. Abu-Hijleh, Dept. of Anatomy, College of Medicine and Medical Sciences, Arabian Gulf Univ., P.O. Box: 22979, Manama, Kingdom of Bahrain (E-mail: arwanah{at}agu.edu.bh)
 |
Abstract
|
|---|
It is generally acknowledged that an integrated approach to teaching cardiovascular system (CVS) is clinically relevant. However, very little attention has been paid with respect to student perception of teaching CVS in an integrated problem-based curriculum. A questionnaire on the feedback and perception of medical students (n = 60) to their learning experience of CVS exposed early in the problem-based integrated curriculum at the Arabian Gulf University (AGU) was used. The average percentage scores of positive student responses to items related to knowledge was 62.7%, to integration was 87.3%, and to skills was 77.1%. A significant positive correlation was observed among skills and knowledge (r = 0.408, P = 0.002), skills and integration (r = 0.506, P < 0.000), and integration and knowledge (r = 0.294, P = 0.028). The lowest individual percentage score related to knowledge items was given to the role of resource sessions in understanding difficult concepts (32.7%). Interestingly, 90.7% of the students were aware of the presence of gaps in their knowledge. On the other hand, 92.7% of students expressed their satisfaction with the study experience of CVS in the integrated problem-based approach. These results indicate that students overall achieved satisfactory learning outcome during the study of CVS in the problem-based integrated curriculum at AGU. The study also points out issues where improvement and fine tuning of the educational system can take place.
Key words: problem-based learning; cardiovascular teaching; student appraisal; medical education; curriculum evaluation
|
Introduction
|
|---|
THE COLLEGE OF MEDICINE AND MEDICAL SCIENCES at Arabian Gulf University (AGU), established in 1982, adopted a problem-based, student-centered curriculum from the very beginning (1, 2, 7, 8). The medical program at AGU is divided into three phases extending over six academic years. The feature of our curriculum that has attracted the most attention is problem-based learning (PBL), which extends throughout the preclerkship phase. In this system of education, teaching and learning are carried out through an integrated organ-system process with the faculty members acting as facilitators to small groups of students (11, 14). The PBL program is backed up by resource sessions and individualized instructions/demonstrations related to each weekly problem, although the major emphasis is on student-centered learning (e.g., by interactive group sessions) and self-directed learning. The resource sessions are multidisciplinary and integrated in nature and aim to focus on difficult or cutting-edge topics. They are not discipline-based lectures as commonly practiced in traditional medical curricula. The medical school at AGU is strongly committed to follow and adhere to the basic principles of PBL. An important feature of the curriculum that also supports PBL is the integration of relevant and related professional laboratory and clinical skill training, and community-based health experiences (Fig. 1). Emphasis is given to critical thinking and reasoning as well as problem solving (5).
View larger version (18K):
[in this window]
[in a new window]
|
Fig. 1. Schema showing different learning activities that students undertake during a typical week in the preclerkship phase of a PBL curriculum (see text for details).
|
|
Monitoring and evaluation of any curriculum, as a whole or by its components, is considered integral to fine tuning and improvement of the educational system in which students and teachers are systematically and periodically involved in the program evaluation (4, 12). The cardiovascular system (CVS) was chosen in this study because it is an important system to integrate in a PBL curriculum; also, it is one of the first systems that our students encounter in their study of organ/system units of the preclerkship phase. The purpose of this paper is first to describe how the CVS is taught in a PBL curriculum and second to report the results of our recent evaluation of the course from students’ perspectives. The ultimate aim of the study is to identify where improvements can be made.
The CVS is studied, together with the respiratory system, during the second phase of our medical curriculum; both subunits comprise Unit II of the organ/system units. The themes and intermediate objectives related to the CVS are formulated by the unit committee and included in a unit booklet. Disturbances of this system are conveniently studied through seven major health problems and extend over a period of seven weeks. These health problems cover the following general themes (objectives): function of the heart as a pump, including valves, development of the heart and great vessels, coronary circulation, cardiac electrical impulse generation and conduction, and hemodynamics (Table 1). The unit committee chooses the appropriate problems that address these objectives according to certain criteria: frequency, gravity, treatability, appropriateness for level, multisystem coverage, and potential for learning basic medical sciences, professional skills, and community health issues. Therefore, common and important cardiovascular events, diseases, and clinical presentations provide the basis for the study of the structure of the heart and blood vessels and their embryological development, regulatory and control mechanisms, important pathological processes, and pharmacological principles of treatment. The students learn not only laboratory and professional skills but also important concepts in community medicine, such as burden of illness, risk factors, screening, and health education, during the entire unit.
For example, one of the health problems that students encounter in their study of the CVS is a retired worker who had been suffering from hypertension for the past five years and developed shortness of breath and edema because of congestive heart failure (CHF). Students interact in their first tutorial (day 1; Fig. 1) so as to develop learning needs to understand the cardiac muscle and its properties, intrinsic and extrinsic control of cardiac muscle, measurement of cardiac output, control of heart rate, pathophysiology of fluid retention, investigations including chest X-ray, principles of drug treatment in heart failure, and community-oriented problems. The students within a group then distribute these learning needs among themselves and obtain the required information through textbooks, the Internet, assigned disciplinary resource staff, laboratories, anatomy museum, and audio-visual aids. At the end of that week, the second tutorial (day 5) commences with discussion of those learning needs on which self-study was undertaken (Fig. 1). On days 3 and 5, multidisciplinary resource sessions are also arranged to orient the students and to explain complex or difficult topics such as pressure-volume loop and pathophysiology of CHF as well as stressing the linkage between basic medical sciences and clinical practice. To strengthen the contention that the etiology of CHF varies, the students are given three miniproblems on day 5 (second tutorial), namely right heart failure, left heart failure, and digitalis toxicity. These miniproblems not only broaden the clinical presentation of CHF but also assist the students to gain some insight into the pathophysiology and complications of the disease process and improve self-assessment skills. For example, in the miniproblem of acute left-ventricular failure, students go through the case history of a 55-year-old man brought to the Accident and Emergency Department complaining of sudden onset of dyspnea and a history of retrosternal pain radiating to his left arm of four hours duration before the dyspnea. After being provided some additional general and chest examination findings, students are asked about the likely diagnosis, the significance of chest pain, the immediate noninvasive investigation required, and the drug therapy that is considered in this patient. On day 1 of the next new problem, an interactive review resource session on earlier issues of CHF takes place in the presence of all concerned faculty to ensure that students have acquired basic knowledge of the disease process and have been exposed to the cutting-edge research data.
Students are also exposed simultaneously to the professional skill program to appreciate the need for clinical examination. For example, during the week of CHF, the students are expected to know waves of jugular venous pressure and their significance. Also, surface markings of cardiac borders and heart valves are emphasized, and ability to interpret radiological changes of the heart is stressed. The question obviously arises as to whether or not the students find difficulty in mastering all the required knowledge and skills within one week’s time in relation to a particular problem. This is partly avoided because the triggers of the problems are constructed in such a way that many of the learning needs fall on the subsequent problems (such as electrocardiogram interpretation in the problem of myocardial infarction) so that the students get ample time to catch up. The students are also informally assessed in the tutorial by being provided multiple-choice questions at the end of the second tutorial session.
At AGU, students are assessed in a comprehensive manner. Multiple strategies are used, as it is known that no single examination can test effectively the three domains of learning, namely knowledge, skills, and attitudes (9, 10). In each organ/system unit of the preclerkship phase, continuous evaluation in the tutorial and end-of-unit examination (multiple-choice questions, questions on patient management problems, and objective, structured, practical examination) provides the basis for assessing students’ knowledge and skills. Students must also score "satisfactory" in three other components: professional skills, communication skills, and community health to progress from one year to the next. The next section of this article reports the results of our recent evaluation study of the CVS course from student perspective.
|
METHODS
|
|---|
A quantitative study, using a structured questionnaire and focus group discussions, was carried out in an attempt to get feedback from the second-year medical students. Opinions and perceptions about the teaching/learning experience of the CVS in the PBL curriculum were obtained from the students (n = 60) after they had completed Unit II, which comprises the CVS. The ultimate aim was to identify areas of strength and/or weakness of the course and degree of success in meeting the goal of promoting integrative, self-directed, problem-based learning. A prototype questionnaire was developed from interviews and discussions with medical students and with staff members from the basic medical science departments. The reliability of the questionnaire was calculated using Cronbach’s 
-coefficient. The questionnaire preserved anonymity, and its structure form comprised two parts: part 1 included 11 closed-ended question items (Table 2), with related items being grouped under three main sections/categories according to their relevance to each of the principle domains of learning, namely knowledge, skills, and integration. Each of the 11 items contained a specific question with two boxes of "yes" or "no" answers for ticking. Part 2 included three open-ended types of questions about the course, namely points of strength, suggestions for improvement, and other personal comments. Data were analyzed using the SPSS 11.0 statistical package. Relevant descriptive statistics were compiled. 
2 Tests of contingency tables were used to test the associations among items in part 1 of the questionnaire. With regard to part 2 of the questionnaire, members of the research group individually analyzed the frequency of different statements made by students who made any comments. Subsequently, the research group agreed on a common, collective consensus on the analysis of these comments.
|
RESULTS
|
|---|
Student responses.
Of 60 questionnaires distributed, 90% were completed sufficiently for data analysis. Respondents consisted of 42 females and 18 males, and their mean age was of 20 years. Data from the closed-ended questions were analyzed by assigning 1 to the "yes" response and 0 to the "no" response about the items in the questionnaire. The Cronbach’s -coefficient of the questionnaire was 0.72. The relative frequency distribution of each item was obtained. Qualitative content analysis of the open-ended questions in part 2 of the questionnaire was also done.
Responses to part 1 of the questionnaire.
The average percentage scores of student positive responses to items related to the three main domains of learning (knowledge, integration, and skills) were 62.7, 87.3, and 77.1%, respectively. Percentage scoring of student positive responses to individual items in the questionnaire (Table 3) indicate that the lowest score was given to the role of resource sessions in understanding difficult concepts (32.7%), and the highest score was given to student overall satisfaction with the study of the unit in the integrated problem-based approach (92.7%). Interestingly, 90.7% of the students were aware of the presence of gaps in their knowledge at the end of the unit.
A series of 2 tests was used to test the associations among the items of the questionnaire. Those tests show significant associations among the items. Figure 2 shows the Spearman rank correlation coefficients and their corresponding P values among the three main sections/categories of the questionnaire (knowledge, skills, and integration). Achievement of unit objectives was significantly associated with 1) integration between different disciplines (2 = 7.74, P = 0.005), 2) linkage between different problems (2 = 14.25, P < 0.000), 3) role of the anatomy museum in promoting self-study (2 = 13.44, P < 0.000), and finally 4) overall satisfaction with the study of the unit (2 = 10.67, P = 0.001). Integration among different disciplines of the unit was significantly associated with 1) linkage between different problems (2 = 8.58, P = 0.003), 2) role of basic science laboratory skills (2 = 5.58, P = 0.018), 3) awareness of gaps in knowledge, and 4) achievement of unit objectives. In addition to the association with achievement of unit objectives and integration among the different disciplines of the unit, linkage between different problems in the unit was also significantly associated with items such as application of basic science knowledge in clinical diagnosis (2 = 13.94, P < 0.000), role of the anatomy museum in promoting self-study (2 = 33.70, P < 0.000), and overall satisfaction of the study of the unit (2 = 14.26, P < 0.000). Also, there was a significant association between problem-solving skills and role of the anatomy museum in promoting self-study (2 = 4.52, P = 0.034). Finally, the role of the anatomy museum in promoting self-study was significantly associated with overall satisfaction with the study of the unit (2 = 5.95, P = 0.015) besides its association with other items mentioned.
View larger version (12K):
[in this window]
[in a new window]
|
Fig. 2. Spearman rank correlation coefficients and their corresponding P values among the 3 main theme sections/categories of the student questionnaire.
|
|
Responses to part 2 of the questionnaire.
Table 4 shows the percentages of the main comments made by 32 students only. In general, comments described the points of strength in the unit, in descending order, as 1) interesting and enjoyable learning experience, 2) good deal of horizontal integration within the unit, 3) laboratory skills (both basic sciences and clinical) were useful, and 4) well-organized unit. Suggested points for improvement in the unit included 1) more time to be assigned for the unit, 2) more facilities to made available in laboratories and anatomy museum, and 3) request for review sessions made available before end-of-unit exams.
|
DISCUSSION
|
|---|
The evidence and experience to date support the assertion that students in general achieved satisfactory learning outcomes from the study of the CVS as part of the PBL curriculum at AGU. The distinctive features of the course include good structuring and organization, acquisition of sufficient basic knowledge, a good deal of horizontal integration, the central role of self-directed learning, the usefulness of learned skills in clinical reasoning and diagnosis, and special emphasis on appropriate personal needs and limitations.
As expected, learning CVS with the problem-based approach is considered an interesting method to study medicine as a majority of the students were satisfied and enjoyed studying the unit. The system of PBL practiced at AGU, while allowing some degree of early exposure to clinical situations in the form of professional skills, enables students to deal with hypothetical cases. Students perceive such exercise to be more interesting and enjoyable than lectures on the basic medical sciences, as is commonly practiced in conventional curricula. Furthermore, the feeling of satisfaction derived from the act of discovery certainly adds to the enjoyment of learning (6). However, despite this perceived advantage of PBL, more than 90% of our students felt that there might be gaps in their knowledge after completing study of the CVS, as the health problems do not necessarily address all the knowledge and skills they are required to master at this early stage of the curriculum and in a relatively short period of time. Gaps in knowledge are probably the same in both traditional and PBL curricula for the same obvious reason: time factor limitations vs. how much "core" knowledge needs to be covered. However, what perhaps is unique in PBL is the conscious realization and awareness by students of the presence of such gaps. This feature of self-appraisal or -awareness by itself can be considered a skill, which highlights two important aspects applicable to PBL. First the ability of students to make real assessments of their knowledge needs and second the awareness of the presence itself of knowledge gaps will motivate students for further self-directed learning. Furthermore, our current medical curriculum allows valuable means of filling some of these gaps later in the clerkship phase in the form of integrated multidisciplinary seminars and specially tailored courses in applied basic medical sciences given during clinical hospital rotations. As the learning process advances and more health problems are studied in units to come and beyond in the curriculum, knowledge and problem-solving skills will certainly increase in both depth and breadth in a spiral fashion, amplifying vertical integration (1).
One of the greatest advantages claimed for PBL is that it encourages integration of learning. Although this is logically so, it was interesting to determine whether students in fact undertake an integrated learning approach when they review material in preparation for the CVS examination. In fact, the new face of the anatomy museum at AGU, which comprises 42 modules or learning carrels that focus on specific organ systems incorporating labeled gross, microscopic, and radiological anatomy specimens (3), has helped the students in promoting self-study by focusing on unit themes and has encouraged them to study across cardiovascular health problems as well. PBL is an important educational strategy for integrating components of the curriculum, which has been shown to bring real benefit to student learning (13). In the present study, the student evaluation percentage score for integration between basic and clinical sciences was 87% and between different problems within the CVS was 94%.
The observation that the percentage scoring of the role of the scheduled resource sessions in understanding difficult learning issues of the CVS was only 32.7% emphasizes a characteristic feature of the PBL process. It certainly strengthens the contention that students prefer the self-learning approach to didactic lectures/seminars. Whether or not the degree and level of integration in these resource sessions has any impact on student learning, however, needs to be carefully examined and addressed in the future. Nevertheless, our study clearly indicates that, by developing the skill of self-directed learning, PBL aids students to develop the ability to identify what they need to learn, the ability of recognizing limitations and/or deficiencies, and the ability of criticism. All these qualities are important in promoting the habit of critical self-appraisal and commitment for lifelong education.
In conclusion, although the present report emphasizes student perception of learning of CVS in a PBL curriculum, it remains to be seen whether this perception changes as students progress to study other system units. Nevertheless, results of the present study of the CVS have identified some characteristic features, as indicated by student responses. These include good structuring and organization, acquisition of sufficient knowledge, a good deal of integration, the usefulness of learned skills in clinical reasoning and diagnosis, the important role of self-directed learning, and recognition of appropriate personal needs and limitations, all blended in an enjoyable atmosphere of learning experience. These results support the assertion that students overall achieved satisfactory learning outcomes from the study of the CVS as part of the PBL curriculum at AGU.
|
Acknowledgments
|
|---|
We are grateful to Profs. Raja Bandaranayake and Hossam Hamdy for their encouragement and continued support.
Received for publication April 30, 2003.
Accepted for publication December 22, 2003.
|
REFERENCES
|
|---|
- Albanese MA and Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 68: 52–81, 1993.[ISI][Medline]
- Bligh J. Problem-based learning in medicine: an introduction. Brit Med J 311: 323–326, 1995.
- Ganguly KP, Chakravarty M, Abdul-Latif N, Osman M, and Abu-Hijleh M. Teaching anatomy in a problem-based curriculum at the Arabian Gulf University: the new face of the museum. Clin Anat 16: 256–261, 2003.[CrossRef][ISI][Medline]
- General Medical Council. Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education. London: Education Cmte. of General Medical Council, 1993.
- Hamdy H, Greally M, Grant IN, El-Shazali H, Nayar U, Rajab K, Al-Roomi K, Mohammad AM, Hamza AA, Al-Awadhi MA, and Al-Refai AM. Professional skills programme in a problem-based learning curriculum: experience at the College of Medicine & Medical Sciences, Arabian Gulf University. Med Teacher 23: 223–225, 2001.
- Harris PF, Abu-Hijleh M, and Moqattash S. Teaching anatomy in the Middle East: opportunities and challenges at a new medical school. Clin Anat 7: 152–155, 1994.[CrossRef]
- Maudsley G. Roles and responsibilities of the problem based learning tutor in the undergraduate medical curriculum. Br Med J 318: 657–661, 1999.[Free Full Text]
- Maudsley G. Do we all mean the same thing by "problem-based learning"? A review of the concepts and a formulation of the ground-rules. Acad Med 74: 78–85, 1999.
- Moqattash S, Harris PF, Gumaa KA, and Abu-Hijleh MF. Assessment of basic medical sciences in an integrated system-based curriculum. Clin Anat 8: 139–147, 1995.[CrossRef][Medline]
- Nendaz MR and Tekian A. Assessment in problem-based learning medical schools: a literature review. Teach Learn Med 11: 232–243, 1999.[CrossRef]
- Pallie W and Carr DH. The McMaster Medical Education philosophy in theory, practice and historical perspective. Med Teacher 9: 59–71, 1987.
- __________. Report from the World Federation on Medical Education. WFME task force on defining international standards in basic medical education. Med Educ 34: 665–675, 2000.[CrossRef][ISI][Medline]
- Schmidt HG. Foundations of problem-based learning: some explanatory notes. Med Educ 27: 422–432, 1993.[ISI][Medline]
- Walton HJ and Matthews MB. Essentials of problem-based learning. Med Educ 23: 542–558, 1989.[ISI][Medline]
Copyright © 2004 by the American Physiological Society.
TOP
Abstract
Introduction
