Advan. Physiol. Edu. 32: 304-311, 2008;
doi:10.1152/advan.00107.2008
1043-4046/08 $8.00
ADV PHYSIOL EDUC 32:304-311, 2008
© 2008 American Physiological Society
HOW WE TEACH
Teaching integrative physiology using the quantitative circulatory physiology model and case discussion method: evaluation of the learning experience
A. Rodríguez-Barbero and
J. M. López-Novoa
Departamento de Fisiología y Farmacología, Facultad de Medicina, Universidad de Salamanca, Salamanca, Spain
Address for reprint requests and other correspondence: J. M. López-Novoa, Departamento de Fisiología y Farmacología, Edificio Departamental, Universidad de Salamanca, Avenida Campo Charro s/n, Salamanca 37007, Spain (e-mail: jmlnovoa{at}usal.es)
 |
Abstract
|
|---|
One of the problems that we have found when teaching human physiology in a Spanish medical school is that the degree of understanding by the students of the integration between organs and systems is rather poor. We attempted to remedy this problem by using a case discussion method together with the Quantitative Circulatory Physiology (QCP) program. QCP is a Windows-based computer simulation program that offers almost real-time simulation and allows users to examine the time-dependent interactions of over 750 parameters. We evaluated students' perceptions by an anonymous questionnaire. Teachers' perceptions of this teaching approach were highly positive, as it improved students' perceptions of the complexity of biological processes, their ability to differentiate between acute and chronic responses, and promoted an integrative understanding of human body function. Teachers also identified some problems with the approach, including student difficulties in adopting self-directed learning, a lack of precision in student questions during the discussion sessions, and the lack of a tradition of using several textbooks to explain the changes observed. The results of the student questionnaire revealed that >70% of the students reported that this type of learning gave them a better understanding of the complexity of physiological processes and the role of coordinated actions of several systems in the homeostatic response and enabled them to acquire a better understanding of human body functions. Thus, we conclude that this approach promotes an integrative understanding of cardiovascular and renal functions that is difficult to achieve with other methods.
Key words: Quantitative Circulatory Physiology program; real-time simulation; cardiovascular function; computer-aided learning; European space for higher education; renal function; arteriovenous fistula; hemorrhage
|
Introduction
|
|---|
ONE OF THE MAJOR PROBLEMS we have found when teaching human physiology in a Spanish medical school is that usually every organ and system is studied separately in a sequence and, in many cases, explained by different teachers. This makes it difficult for students to understand the complex interrelationships between organ systems, including how the modification of the function of a single organ produces changes in many other organs and systems. After completing the Human Physiology course, students still have a poor understanding of the integration between different organs and systems. Problem-based learning (PBL) and the case discussion method (CDM) have been reported to stimulate a positive attitude toward learning, promote the activation of prior learning and its elaboration, and increase the motivation of university students (16, 20). PBL and CDM have gained increasing success in medical education (5, 11, 12, 18). However, in Spanish medical schools, the most common approach for teaching human physiology continues to be formal classroom theoretical lectures based on a sequential organ system presentation (13). Lectures are supplemented with a limited number of laboratory practicals, in which only a few parameters can be measured and that are very simple due to the low budget devoted to teaching physiology. This kind of teaching promotes in the student a passive attitude and, in some cases, a lack of interest in the matter. These problems have been diminished by using teaching strategies in which the student becomes responsible for their learning, such as PBL and CDM. In medical education, both techniques use a clinical situation that provokes interest in the students to be analyzed and discussed on the basis of the knowledge that the student has already acquired and identifies knowledge gaps that the student will address during the learning process (20). PBL and CDM are scarcely used in undergraduate Spanish medical schools. There are many reasons for this, including that most teachers are not trained in this type of teaching, students do not like this type of learning (as it requires more personal effort), the activities are very time consuming, and students have not been trained for this type of work in preuniversity studies (Bachillerato) or during the first university year.
Classic paper-based discussions have been also used to teach some aspects of integrative physiology (7). This type of teaching has several limitations in Spain and, we suppose, in a great number of non-English-speaking countries. First, there are a very limited number of good physiological papers written in Spanish, and most medical students in Spain do not read English fluently. Second, in most classical papers on renal and cardiovascular physiology, there are a limited number of reported parameters, which, in turn, very much limits an integrative view of the physiological problem. Third, real-time followup of the physiological parameters is very difficult. Finally, the followup of the proposed problem cannot be changed. We have overcome these limitations by using a CDM approach together with a whole body computer simulation [the Quantitative Circulatory Physiology (QCP) program (1)]. This mathematical model provides an opportunity to simulate clinical problems found in the practice of medicine. This model is available at http://physiology.umc.edu/themodelingworkshop. The experience of QCP developers with first-year medical students at the University of Mississippi Medical Center was that this tool improved their ability to examine, integrate, and understand physiological responses (1). It should be noted that this report reflects the teachers' point of view including the students' opinion; an adequately controlled, randomized study testing the effective learning of the group subjected to this QCP program compared with another group subjected to classical teaching methods has not been performed. In addition, it should be noted that this teaching method is used as a supplement to classic lecture-based learning.
|
METHODS
|
|---|
We annually have 150 new students of human physiology at the Faculty of Medicine, University of Salamanca (taught during the second year of a 6-yr program). Their background includes biochemistry, cell biology, anatomy, and general physiology, which are the main subjects in the first year. During the course, each student receives 110 daily classroom lectures (of 50 min each) and 110 h of laboratory practicals. In the past 5 years, we have devoted 
25% of these practical hours to CDM using computer simulations. These simulations have focused mainly on presenting cardiovascular and renal physiology from an integrative point of view.
Class is held in a room with 15 PC-type computers. Two students are assigned to each computer to allow discussion of the data between them. The computer simulation model used is the QCP program (1), a mathematical model of integrative human physiology containing over 4,000 variables of biological interactions (http://physiology.umc.edu/themodelingworkshop). The model is based on documented physiological responses and allows students to calculate time-dependent solutions and interactively alter over 750 parameters that modify physiological function.
We have developed several physiological simulations, each one conducted in six steps:
Step A.
Students receive a detailed guide for the use of the hardware and software as well as a detailed guide with the necessary instructions on how to run the desired simulation.
Step B.
The teacher presents the learning objective of the activity, focusing on the major theoretical knowledge that the student must know to address the problem as well as the physiological or pathophysiological relevance of the proposed simulation. In addition, the teacher explains, in 30 min, the major characteristics and advantages of the learning method, as the students are not used to this type of learning.
Step C.
Students are provided with the practice booklet, which includes a "clinical case" and the tables to be completed (APPENDIX). In addition, the booklet also provides some questions to help students to organize and explain the data obtained. After the presentation of the clinical case by the teacher, students run the specified simulation on their own, with tutorial assistance during the first hour and without tutorial assistance for the remaining time they need to complete the simulation (90 min). If the students have not been able to complete the simulation in this time, they can run the program in the computer classroom at a different time or at home. Students have to complete the tables using the numerical data generated by the program for the parameters assigned and for several times of observation. These tables are provided with only the name of the parameter and the times of observation but without physiological units, so that the students will pay attention to the units of numerical parameters. We have previously observed that medical students have substantial problems with physiological units. Several examples of the clinical cases and tables that we provide to the student are shown in the APPENDIX.
Step D.
Students draft a report by choosing the parameters that they consider the most relevant. The report includes graphs of the data and explanations of the interactions developed with the help of textbooks. Special emphasis is given to "integrative physiology," i.e., the fact that a change in a single parameter from a system or organ involves adaptive homeostatic responses in many other systems.
Step E.
The whole group meets again for 2 h, and students discuss the results obtained, their relevance, and the difficulties, if any, that they found in explaining the results. The discussion session is led by the teacher. The students can also request further personal tutorials as many times as they need them. With all this information, each student prepares a final report including major results, the physiological explanation for these results, and their physiological or pathophysiological relevance.
Step F.
Teachers evaluate the reports to assess fulfillment of the learning objectives, and a numerical grade is given to each report.
An assessment of learning was performed by including in the examinations some questions about integrative physiology that were derived from the proposed problems and are not ordinarily found in textbooks or explained in the theoretical lectures. In addition, estimation of the students' acceptance of the learning technique and the problems that appeared during the program were evaluated after the last session using the anonymous questionnaire shown in Table 1.
|
RESULTS
|
|---|
The perceptions of the teachers about the effects of CDM using computer simulation on learning can be summarized as follows:
- This teaching method greatly improved teaching of the complexity of biological processes as well the integrative coordination of the several organs and systems (cardiovascular, renal, hormonal, nervous, etc.) in response to a single maneuver (i.e., hemorrhage, artery-venous fistula, changes in renal perfusion pressure, and saline infusion).
- Students improved their ability to differentiate between acute and chronic responses.
- Students were able to understand how the coordinated actions of several organs can return parameters to their basal values, thus emphasizing the basic concept of "whole body homeostasis."
- Students were able to understand the mechanism of disease by rerunning the simulation and maintaining some variables fixed by a simulated pharmacological treatment.
- This approach promoted an integrative understanding of human body function that is very difficult to achieve in theoretical lectures.
Some major problems observed by the teachers are that the students had:
- Severe difficulties in handling a great amount of data and in deciding the most relevant parameters.
- Some difficulties in self-directed learning, as, in most cases, this is the first time that the students have encountered this manner of learning. It should be noted that it has been reported that the students in a problem-based curriculum become more accomplished self-directed learners over the last curriculum years, and our students are in their second year of medical school.
- Some difficulties during the discussion sessions in asking in a precise way about the difficulties they found in analyzing the problem.
- Lack of tradition of using several textbooks to explain the changes observed, as most students are accustomed to buying or obtaining a single text from the library.
All the 150 students enrolled in the course completed the anonymous questionnaire, providing some important insights. Regarding the difficulties of the QCP program, most students found little or no difficulty in handling the program or understanding the language of the program (English) (Table 2). Only 30% of the students found it difficult or very difficult to handle the physiological units; 38% of the students found some or much difficulty in handling the large volume of data, whereas 53% of the students found it difficult or very difficult to choose the most relevant data to discuss or present (Table 2, summary of students' answers about the difficulty of the program). Seventy-seven percent of the students found that completing the report of the practices was very time consuming, and 85% of them reported that the preparation of the final report was difficult (Table 2, summary of students' answers about the difficulty of the program). Seventy-three percent of the students were satisfied or very satisfied with the work they had done, but only 40% of the students enjoyed this learning system (Table 2, summary of students' answers about satisfaction with this type of learning).
A major purpose of this type of teaching is the opportunity to integrate physiology, and student responses indicated that this objective was met (Table 2, summary of students' answers about the usefulness of this type of teaching for learning comparative physiology). Thus, >75% of the students indicated that this type of learning gave them a better understanding of the complexity of physiological processes and the role of coordinated actions of several systems in the homeostatic response and enabled them to acquire an understanding of human body functions. Furthermore, 70% of the students considered that this type of learning contributed to improving their knowledge of human physiology (Table 2, summary of students' answers about the usefulness of this type of teaching for learning comparative physiology).
|
DISCUSSION
|
|---|
In the present study, we report our experience in teaching integrative cardiovascular and renal physiology using a CDM approach together with a whole body computer simulation (QCP program). Our major aims were to stimulate student self-learning and improve the understanding of the integrative aspects of physiology. Both PBL and CDM make the student more responsible for their own learning than in classical lecture methods (2, 19, 20). However, both approaches differ in several major aspects. Major differences are that in PBL, the students have the responsibility of generating the knowledge and individually analyzing the problem; students then meet in small groups (5–10 students) for discussion. The teacher or instructor plays a secondary role in promoting the study and reasoning by students but without guiding the discussion or correcting misinterpretations (18). In CDM, the teacher directs the solution of the problem and analyzes the conclusions elaborated by the students, and the students then meet in groups larger than in PBL (15–30 students) to discuss the conclusions elaborated by the students. In these groups, the teacher also leads the group discussion and explains misinterpretations (18).
Mathematical models and computer programs simulating physiological processes were first developed as research tools, but they were soon applied for teaching purposes. A mathematical model (MACMAN) was developed for teaching some basic principles of hemodynamics on a computer (6). This model was adapted, later on, to teach cardiovascular physiology (10). Michael and Rovick subsequently developed a computer program called Heartsim, and it has been reported that this program helps students to be conscious of the importance of understanding the relationship between phenomena (16). Coleman and Randall (4) developed a comprehensive model (HUMAN) to teach diverse aspects of physiology. More recently, Coleman and collaborators (1) have developed the QCP model. This mathematical model of integrative human physiology, with successive improved versions, provides a teaching environment that mimics clinical problems encountered in the practice of medicine, and this is the program that we used with our students.
It should be noted that our approach is not only computer-aided learning, which is also gaining success in Spanish schools of medicine, but a CDM strategy in which the computer model is used to give the data necessary to solve the case to be analyzed. It has been reported that, although helpful, computer-aided learning does not always give results better than the classic approach (8).
In addition, the major purpose of this learning activity was to help students to understand the integrated and coordinated responses of several organs to maintain homeostasis against a change in a single parameter as well as the complexity of physiological responses in mammals.
The statement "I am very satisfied with the work done" refers to the satisfaction that the student feels after the completion of the final report and the belief that this kind of learning has been useful. The statement "I have enjoyed this learning system" refers to the pleasure obtained by the student with this type of learning. For instance, our students "enjoy" watching videos on physiology, but most of them don't "enjoy" to solving mathematical problems on physiological parameters, such as to calculate heart work from arterial pressure and cardiac output, although they could understand the usefulness of these problems.
The results obtained from the students' opinions do not always coincide with those observed by the teachers. Most of the problems observed by us during the introduction of this kind of teaching were not reflected in answers to the anonymous questionnaire obtained after the last session. For instance, although the students complained in the tutorial sessions about the difficulty of handling the large amount of data, in the written evaluation at the end of all the sessions only 2% of them considered this as a major difficulty, whereas 24% of them reported moderate difficulty, 67% of them reported little difficulty, and 7% of them considered that there was no difficulty with this aspect (Table 2). Our opinion is that the initial student dissatisfaction was more due to the novelty of the method and the increase of homework it represented than to actual problems of the learning method. It would be helpful to emphasize these points in future classes to reduce student anxiety and dissatisfaction.
Further positive responses in relation to the purpose of these teaching instruments were obtained with respect to the perception of the integration and complexity of physiological homeostatic responses. Almost 80% of the students recognized that these instruments helped them to understand the complexity, integration, and involvement of different systems in response to modification of a single physiological parameter and, thus, a deeper knowledge of human physiology (Table 2).
Other institutions have reported successful initiatives to help students understand the mechanisms of health and disease. Most of these methods are designed to show the importance of basic medical sciences and to capture student interest (7a). A large amount of the evidence revealed that case-based learning (CBL) was enjoyed by both students and tutors (21). Curran et al. (4a) reported that CBL facilitated interprofessional learning and emphasized the importance of small-group collaborative learning to enhance student satisfaction. On the other hand, Grauer et al. (6a), who compared traditional and CBL/PBL in a large group, observed that evaluation of examination suggests that the two teaching methods were of similar efficacy.
The integration of Spain in the European Space for Higher Education requires new approaches to reduce lecture-based teaching time and allows learners more time for self-directed learning. We think that CBL could aid in this purpose and also help medical undergraduates to acquire an integrative knowledge of biological functions. We are going to work to extend this method to the Spanish medical teaching community.
An important issue that needs to be addressed is the ability to predict that students have not only enjoyed their new learning experience but whether this modifies the way in which they learn and practice. In this way, it would be interesting to measure whether CBL had any impact on skill improvement when our students became professionals. To this respect, we intend to evaluate the impact of CBL on last-year students.
In conclusion, our perception of the learning effectiveness of a simulation computer-based, case-based approach, in contrast to classical lectures and laboratory practical sessions, is very positive, with good acceptance and recognition by students and with a high level of satisfaction on the part of teachers.
|
APPENDIX: EXAMPLES OF THE PROBLEMS PROPOSED
|
|---|
Problem 1: Effect of a Hemorrhage on the Regulation of Cardiovascular Function
Major teaching purposes.
The major teaching purposes of this problem were as follows:
- To understand the intrinsic mechanisms of the cardiovascular, renal, and autonomic nervous systems as well as renin-angiotensin-aldosterone system responses to a hemorrhage
- To analyze in an integrative way the changes in the different systems as well as the mechanisms of recovery
- To compare the differences between a moderate and severe acute hemorrhage and the different involvement of the hormonal and nervous systems in these responses
Clinical case.
A 54-yr-old man (normotensive, habitual smoker, drinker of 50–60 ml alcohol/day, and with a previous history of gastric ulcer) enters the emergency room with severe gastric pain, general malaise, loss of consciousness, and perspiration. Physical exploration revealed the following: tachycardia, low peripheral perfusion with cold and underperfused skin, and reduction of central venous pressure. Analysis showed elevated levels of renin, aldosterone, and antidiuretic hormone. Severe gastrointestinal hemorrhage was diagnosed, and controlled intravenous administration of liquids (saline isotonic) was begun. After 24 h, hemodynamic parameters had recovered partially, but analysis showed a decrease in the hematocrit value. After 48 h, cardiovascular evaluation showed normalized values, but the hematocrit value was still very low.
Tables given to the students.
The following tables were given to the students to complete: changes in basic hemodynamic parameters, organ blood flow, changes in the sympathetic nervous system, changes in the renin-angiotensin system, and changes in blood volumes.
Guide questions.
The following guide questions were provided:
- Why was the patient's heart rate high?
- What was the cause of the low peripheral pressure?
- What organs were involved and why?
- What were the autonomic nervous system adaptations? What were the consequences?
- How did the liquid volumes in the organism change?
- Why did the blood and plasma volumes change in a different way?
Problem 2: Effect of an Arteriovenous Fistula on Several Hemodynamic Parameters
Major teaching purposes.
The major teaching purposes of this problem were as follows:
- To understand the concept of cardiac preload and the mechanisms involved in heart function regulation by increased preload
- To understand the concepts of vascular resistance and conductance
- To understand how a reduced amount of blood available is distributed among several organs
- To understand the intrinsic mechanisms of the cardiovascular, renal, and autonomous nervous systems as well as renin-angiotensin-aldosterone system responses to reduced organ perfusion
- To understand the mechanisms regulating heart rate
Clinical case.
A 67-yr-old woman (obese, hypercolesterolemic, and diagnosed with peripheral arteriosclerosis) underwent an acute infarct of the myocardium 6 mo ago. At the present time, it presents as an unstable angina that begins with moderate effort. The functional cardiac tests diagnose the partial obstruction of a coronary artery. She arrives at the hospital so that a catheterism can be done with the purpose of clearing the obstacles of the affected coronary artery. During the introduction of the catheter through the femoral artery, with cardiovascular monitorization, difficulty in the advance of the catheter through the aorta is observed, which advises a removal of the catheter. Immediately after removal, the patient complains of strong tachycardia, and, in the monitorization, an abrupt increase of central venous pressure and cardiac output is observed, with a diminution of arterial pressure. Formation of a central arteriovenous fistula is diagnosed as the catheter has crossed the wall of the aorta and penetrated into the abdominal vein cava.
Tables given to the students.
The following tables were given to the students to complete: changes in basic hemodynamic parameters, organ blood flow, changes in the sympathetic nervous system, changes in the renin-angiotensin system, and changes in blood volumes.
Guide questions.
The following guide questions were provided:
- Which was the cause of the increase in central venous pressure?
- Which was the cause of the increase in cardiac output?
- What organs received this increase of flow and why?
- Which was the mechanism of increase in the stroke volume after the fistula?
- What was the reason for the change in heart rate?
- Why did the arterial pressure diminish?
- What adaptations did the autonomic nervous system undergo? What were their consequences?
- What happened in regard to the renin-angiotensin-aldosterone system? What were the consequences?
- How did the liquid volumes of the organism change? What were the reasons for this change?
Problem 3: Effect of an Intravenous Infusion on the Integrated Regulation of Cardiovascular and Renal function
Major teaching purposes.
The major teaching purposes of this problem were as follows:
- To understand how the increases in plasma volume and/or in total water volume are detected and the mechanisms by which these changes modify cardiovascular and renal function
- To understand the effects of increasing plasma volume and total water volume on cardiovascular and renal function
- To understand the mechanisms regulating the distribution of cardiac output between organs in the case of increased cardiac output
- To understand the different effects of saline or dextrose infusion on body water compartments
Clinical case.
A 22-yr-old man without importance antecedents suffers an accident while he driving a motorcycle in Salamanca, getting hit in the helmet by an elbow and suffering nasal and head skin hemorrhage. He enters in the emergency room with loss of consciousness and cold perspiration. In the face of hemorrhage, a controlled administration of liquids by intravenous route is begun.
Two intravenous infusion are studied and compared: 1) 1 liter of saline solution (0.9% sodium chloride) and 2) 1 liter of 5% dextrose solution.
Tables given to the students.
The following tables were given to the students to complete: changes in basic hemodynamic parameters, organ blood flow, changes in the sympathetic nervous system, changes in the renin-angiotensin system, changes in body liquid volumes, changes in antidiuretic hormone secretion, and changes in urinary composition.
Guide questions.
The following guide questions were provided:
- Which are, in your opinion, the most important adaptations that happened in the cardiovascular system immediately after the infusion(s)?
- How did the volumes of the organism change? Why the blood volume and plasma volume change in such a different ways?
- What was the relation between the changes in central venous pressure and cardiac output? Why was the perfusion of the organs so different?
- What adaptations did the autonomous nervous system undergo? What were the consequences?
- What happened in regard to the renin-angiotensin-aldosterone system? What were the consequences?
- What were the most important changes in renal function? What were the mechanisms involved in these changes?
|
Acknowledgments
|
|---|
The authors thank to Diane I. Garvey Zaccaro (Central Scientific Translation Service, Universidad de Salamanca, Salamanca, Spain) for the revision of English writing and style.
Received for publication November 27, 2007.
Accepted for publication September 24, 2008.
|
REFERENCES
|
|---|
- Abram SR, Hodnett BL, Summers RL, Coleman TG, Hester RL. Quantitative Circulatory Physiology: an integrative mathematical model of human physiology for medical education. Adv Physiol Educ 31: 202–210, 2007.[Abstract/Free Full Text]
- Antepohl W, Herzig S. Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study. Med Educ 33: 106–113, 1999.[CrossRef][Web of Science][Medline]
- Coleman TG, Randall JE. A role for mathematical and computer simulations in teaching physiology? Physiologist 26: 231–235, 1983.
- Coleman TG, Randall JE. HUMAN-a comprehensive physiological model. Physiologist 26: 15–21, 1983.[Medline]
- Curran VR, Sharpe D, Forristall J, Flynn K. Student satisfaction and perceptions of small group process in case-based interprofessional learning. Med Teach 30: 431–433, 2008.[Medline]
- Devitt P, Palmer E. Computer-aided learning: an overvalued educational resource? Med Educ 33: 136–139, 1999.[CrossRef][Medline]
- Dickinson CJ, Goldsmith CH, Sackett DL. MACMAN: a digital computer model for teaching some basic principles of hemodynamics. J Clin Comput 2: 42–50, 1973.
- Grauer GF, Forrester SD, Shuman C, Sanderson MW. Comparison of student performance after lecture-based and case-based/problem-based teaching in a large group. J Vet Educ 35: 310–317, 2008.
- Gwirtz PA. Teaching the interrelationship between stress, emotions, and cardiovascular risk using a classic paper by Walter Cannon. Adv Physiol Educ 32: 18–22, 2008.[Abstract/Free Full Text]
- Hudson JN, Buckley P. An evaluation of case-based teaching: evidence for continuing benefit and realization of aims. Adv Physiol Educ 28: 15–22, 2004.[Abstract/Free Full Text]
- Jayawickramarajah PT. Problems for a problem-based learning: a comparative study of documents. Med Educ 30: 272–282, 1996.[Medline]
- Madin H, Jones A, Woloschuk W, Harasym P. Helping students learn to think like experts when solving clinical problems. Acad Med 72: 173–179, 1997.[Web of Science][Medline]
- Michael J. In pursuit of meaningful learning. Adv Physiol Educ 25: 145–158, 2001.[Abstract/Free Full Text]
- Mpofu DJ, Das M, Murdoch JC, Lanphear JH. Effectiveness of problems used in problem-based learning. Med Educ 31: 330–334, 1997.[CrossRef][Medline]
- Pales J, Gual A. Active and problem-based learning: two years, experience in physiology at the Medical School of the University of Barcelona. Med Educ 26: 466–472, 1992.[Medline]
- Reagan CR, Menninger RP. Ten years of basic medical physiology in the Mercer problem-based curriculum. Adv Physiol Educ 11: 24–32, 1994.
- Rothe CF. A computer model of the cardiovascular system for effective learning. Physiologist 23: 49–53, 1980.[Medline]
- Rothe CF, Gersting JM. Cardiovascular interactions: an interactive tutorial and mathematical model. Adv Physiol Educ 26: 98–109, 2002.[Abstract/Free Full Text]
- Rovick AA, Brenner L. Heartsim: a cardiovascular simulation with didactic feedback. Physiologist 26: 236–239, 1983.
- Sheader E, Gouldsborough I, Grady R. Staff and student perceptions of computer-assisted assessment for physiology practical classes. Adv Physiol Educ 30: 174–180, 2006.[Abstract/Free Full Text]
- Schmidt HG. Foundations of problem-based learning: some explanatory notes. Med Educ 27: 422–432, 1993.[Web of Science][Medline]
- Schmidt HG. Assumptions underlying self-directed learning may be false. Med Educ 34: 243–245, 2000.[CrossRef][Web of Science][Medline]
- Tärnvik A. Revival of the case method: a way to retain student-centered learning in a post-PBL era. Med Teach 29: 32–36, 2007.
- Williams W. Case based learning a review of the literature: is there scope for this educational paradigm in pre-hospital education? Emerg Med J 22: 577–581, 2005.[Medline]
Copyright © 2008 by the American Physiological Society.
TOP
Abstract
Introduction
