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RESEARCH-ARTICLE
Discipline of Physiology, School of Medical Sciences, Faculty of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
Address for reprint requests and other correspondence: M. A. Tufts, Discipline of Physiology, School of Medical Sciences, Univ. of KwaZulu-Natal, Private Bag X54001, Durban 4000, Kwazulu-Natal, Republic of South Africa (e-mail: tufts{at}ukzn.ac.za).
Abstract
Physiology is an integral component of any medical curriculum. Traditionally, the learning of physiology has relied heavily on systems-based didactic lectures. In 2001, the Nelson R. Mandela School of Medicine (NRMSM; Durban, South Africa) embarked on a problem-based curriculum in which the learning of physiology was integrated with relevant clinical scenarios. Students are expected to gain an understanding of physiology through self-directed research with only certain aspects being covered in large-group resource sessions (LGRSs). It has gradually become evident that this approach has resulted in significant gaps in students' understanding of basic physiological concepts. A survey of student perceptions of needs for physiology was undertaken to gain a better understanding of their perceived problems and also to inform them of proposed curricular changes. Students were asked to what extent they thought physiology was essential for their understanding of pathology, interpretation of patients' clinical signs and presentation of symptoms, and analysis of laboratory results. Students were also invited to detail the difficulties they experienced in understanding in LGRSs on clinical and physiological topics. The results of the survey indicate that greater interaction of students with experts is needed. In particular, students felt that they lacked the basic conceptual foundations essential for the learning and understanding of physiology, since the difficulties that the students identified are mainly terminological and conceptual in nature.
Key words: medical education; physiology teaching; student feedback; South Africa; curricular change; problem-based learning
PHYSIOLOGY is seen as an important core component of any medical curriculum (27). Traditionally, the learning of physiology at medical schools has relied heavily on systems-based didactic lectures (4). More recently, with changes to the medical curricula globally, it is increasingly being taught in a number of different ways, ranging from problem based in various forms (1, 26), case based (13), and a combination of many processes (14). A current trend in the literature on physiology education is to highlight ways in which the teaching of physiology can be successfully incorporated into medical curricula and be converted from a staff-centered, more passive learning environment to one that encourages more active student-centered learning (27). There have been a number of studies evaluating the teaching and learning of various aspects of physiology integrated into both traditional (11, 10, 9) and problem-based learning (PBL)-orientated (2, 3, 5) medical curricula. As early as 1994, Reagan and Menninger (25) reported on 10 yr of experience with a 2-yr foundation course based on organ systems, in which physiology was integrated with other basic biomedical disciplines such as anatomy, biochemistry, pharmacology, etc. using a PBL format.
In 2001, the medical curriculum at the Nelson R. Mandela School of Medicine (NRMSM; Durban, South Africa) changed from a 6-yr, discipline-based, didactic curriculum to a 5-yr, student-centered, problem-based curriculum (16). As a result of this curriculum change, there was a forced transformation in the way that physiology was taught to medical students at our institution (Tables 1 and 2).
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120 didactic physiology lectures in their second year of study (Table 1). This series of lectures was predominantly systems based but were preceded by basic cellular concepts and concluded by applied integrated topics such as exercise and shock. There were also a number of practicals that ran concurrently with the lectures. These practicals were used to assist students in applying physiology to clinical scenarios. For example, in the lung function practical, students were asked to act as subjects and to analyze and compare their spirometry and vitalography tracings with those from patients with either obstructive or restrictive lung disease. In addition, asthmatic students on bronchodilator therapy were asked to volunteer to demonstrate the effects of their therapy on measurements of peak expiratory flow rate and forced expiratory volume in 1 s. Another example is the oral glucose tolerance test practical, where, once again, students were asked to act as subjects, plot their blood glucose concentrations over time, and analyze and compare their results with those of patients with either diabetes mellitus or an insulinoma. During the practical sessions, staff members interacted with the students to ensure that they understood the underlying physiological concepts and their applicability to pathophysiology and clinical conditions. Furthermore, self-assessment questions were included in the practical notes provided to the students. The assessment of physiology was comprehensive in that five tests were conducted throughout the year and two examination papers were written at the end of the academic year. One of these examination papers was a 3-h theory paper (multiple-choice format); the other examination paper was a 90-min applied short-answer paper.
Although it may be implemented in various ways, i.e., undergraduate, graduate, hybrid (24, 26), PBL has a number of core characteristics: namely, small-group learning facilitated by a tutor, use of problems to stimulate active learning, minimal expert inputs by means of lectures, and an integrated, multidisciplinary approach devoid of discipline-specific courses (15). The PBL curriculum introduced at the NRMSM has been previously described by McLean (16), Van Wyk and Madiba (29), and Singaram et al. (28). Briefly, the first 4 yr were initially (2001–2005) divided into six themes, each lasting 6 wk (16, 29). Students were given 1 or 2 cases/wk to work through in a small group during two facilitated tutorial sessions spaced 5 days apart. Each tutorial was scheduled for 2 h. During the first tutorial, students familiarized themselves with the case(s) and formulated learning goals that were arrived at after brainstorming possible explanations for the main issues that they had identified for the case(s). Students were expected to realize these learning goals by means of self-study using a variety of resources available to them, including library books and journals, the internet, CD ROMs, and other scheduled activities. During the second tutorial, students reported back on their findings, shared and pooled their knowledge, and evaluated their own learning (29).
Various practical sessions (2 h), skills sessions (2 h), healthcare visits (2 h), and 6-8 h of large-group resource sessions (LGRSs) were scheduled during the week as additional learning resources (16). During the first 2 yr (Table 2), healthcare visits were designed to expose students to real-life scenarios. Healthcare visits in the first year, for example, ranged from visits to various community sites concerned with the care of physically and mentally handicapped children in the Growth and Development theme to visits to the family planning and antenatal clinics, labor wards, and a neonatal nursery at a local teaching hospital during the Reproductive Health theme. In the Trauma and Emergency Health theme, students were required to spend a 12-h shift with an ambulance crew. These skill sessions introduced the students to communication skills and examination techniques using simulations including computers and mannequins. In addition, teaching of clinical medicine was only introduced from the fourth year onward (Table 2). It is worth noting that, as from 2006, changes have been made to the curriculum, with the fourth year becoming mainly clinical. The fifth year of study has remained entirely clinical since the inception of the PBL curriculum at the NRMSM.
Interested and suitably qualified individuals drawn from both within and outside the faculty, who had undergone training (3-day workshop), served as facilitators. During their training, the facilitators were introduced to the educational principles of PBL and aspects of group dynamics. They were also shown how to encourage active student learning and critical thinking and how to promote both self- and cooperative (group based) student learning. While the majority of facilitators were drawn from the academic ranks, only a few were expert physiologists (15). We are aware that PBL can assume a number of formats, as described by Savin-Baden (26), and that it is a complex process. Savin-Baden (26) highlighted a number of factors that can have an impact of this type of learning approach, including the role and training of facilitators, the way the curriculum is implemented and resourced, the extent to which assessment is driving learning, and whether or not the learning of basic sciences can be accomplished by the PBL process.
At the time of the study, the physiology content in the PBL curriculum was delivered across the first 3 yr with some input into the fourth year (Table 2). The lecture contact time has been reduced significantly (from 146 to 50 h), but this has also been accompanied by a change in format. The emphasis of the LGRS is geared toward 1) giving an overview of the physiology pertaining to the week's case, 2) conducting a question and answer (Q&A) session, or 3) providing a framework upon which the students can build. For example, in the Cardiorespiratory Disorders theme (Table 2), one of the physiology LGRSs was devoted to explaining the physiological basis of the signs and symptoms of valvular and congenital heart disease that were highlighted in the cases for the week. The Q&A session was entirely student driven and designed to address student questions that were provided either before or during the session. Similarly, for the LRGS dealing with the concept of pulmonary ventilation, students were expected to have a knowledge of the basic concepts of the gas laws, flow, and pressure. Furthermore, they were expected, through the use of other resources, to familiarize themselves and gain an understanding of those cellular mechanisms related to their case(s). These included mechanisms responsible for bronchoconstriction, consequences of bronchoconstriction, and mechanisms of action of bronchodilators, etc. The physiology LGRS, due to time constraints, could thus only provide a global perspective of the topic and direct the students to further reading. The number of physiology practicals that each student was exposed to was, however, the same as the old traditional curriculum. However, the duration of each practical session was reduced (Tables 1 and 2). In terms of assessment, physiology was no longer assessed as a separate subject but was incorporated into end of theme tests and twice yearly progress examinations, which were in place up to 2005.
Over the years, it has become increasingly evident to both authors acting as nonexpert facilitators in tutorials and physiology experts giving LGRSs and practicals that there were significant shortcomings in the students' grasp of basic physiological concepts. On a number of occasions, we have realized that the students did not understand such concepts as autonomic control, receptors, receptor agonists and antagonists, and intracellular second messenger systems, all of which are vital for the comprehension of most systemic physiological processes. One specific example concerns a case on asthma, which was covered in the first-year theme on infection and inflammation (Table 2). While students were able to accurately list the types of drugs used in the treatment of asthma, they did not appreciate the significance of their names, such as β2-agonists and anticholinergics, nor did they understand their function. Similar such experiences were noted when dealing with gastrointestinal function, such as the mechanism and control of gastric acid secretion. It is worth noting that our views were later corroborated not only by other members of the faculty but also by the review panel of the Health Professions Council of South Africa in 2005 (29). Students were also expressing concern as the vast majority of them had entered their medical studies directly upon completion of secondary schooling (16, 28) and consequently had little prior exposure to physiology.
There is a growing awareness within the physiology community worldwide that students are having difficulty with learning and understanding physiology and that they need assistance (19). Michael (19) has reviewed active learning in various disciplines, including physiology, and cited a number of studies that exemplify the types of issues currently being explored that relate to student misconceptions and teaching and learning in physiology. In 2007, Michael published the findings of a survey that investigated the reasons why teachers feel that physiology is a difficult subject for students to learn (20). The survey included the opinions of 63 physiology teachers (mainly from the United States with 7 other countries but none from Africa). In his concluding remarks, Michael suggests that we can be more effective, as teachers, if we explore directly from the students themselves the sources of the difficulties that they are experiencing with the learning of physiology (20). In 2007, Fyrenius and coworkers (7, 8) reported their results relating to the understanding of physiological phenomena in a PBL setting. Using in-depth interviews on a cohort of students, they not only investigated how students viewed physiology and conceived the underlying principles to gain an understanding of physiological phenomena (7) but also explored how the process of developing understanding is related to the theory of learning approaches and how understanding is achieved by these students (8).
Despite the above-mentioned studies, there is still a paucity of data on the evaluation of the teaching and learning of all aspects of physiology in a theme-based PBL structured curriculum, such as that found at NRMSM, in which the learning of physiology is integrated both horizontally and vertically into clinical cases throughout the 5 yr of the medical program. The present study was undertaken to quantify and confirm students' perceived problems and their needs in the learning of physiology and to inform proposed curricular changes. In doing so, it highlights the various challenges faced by staff and students alike in the teaching and learning of physiology at the NRMSM. Although the findings of this study deal with a specific curriculum and its associated problems, they nevertheless, as Michael in 2007 (20) exhorted, contribute to our overall understanding, as teachers of physiology, of the difficulties that our students face in trying to learn, understand, and conceptualize physiological phenomena.
MATERIALS AND METHODS
In late 2004, semistructured questionnaires (supplemental material)1were handed out to medical students in their second (n = 204), third (n = 196), and fourth (n = 169) years of study. The questionnaire given to students consisted of five major sections and was composed of simple yes/no options and an assesment section where students were asked to give their opinions on a prompted statement (rated using a Likert scale from 1 to 5, where 1 = strongly agree and 5 = strongly disagree) as well as open-ended questions. Questionnaires were administered independently to students during a clinical skill training session by staff not involved in physiology teaching.
In the first section, students were asked whether or not they had prior exposure to either physiology or biology as part of a health science or related course that they had previously attended at a university or related tertiary institution. In the second section, students were asked to rate to what extent they thought that physiology was essential for their understanding of pathology, patients' clinical signs and presentation of symptoms, and for the interpretation of laboratory results. A survey of which textbooks student used comprised the third section. In the fourth section, students were asked whether or not they had difficulties studying physiology on their own and whether or not physiology staff referred to basic concepts in LGRSs that they were not familiar with. Students were also asked whether or not academic staff in the clinical disciplines referred to basic physiological concepts that they were not familiar with. In addition to the above, students were requested to provide specific examples of the physiological concepts that they did not know or had difficulties in understanding.
In the final section of the questionnaire, students were also asked to indicate their willingness to participate in focus group discussions and to take a test to ascertain the level of their knowledge and understanding of physiology. Finally, students were invited to provide any additional comments they wanted to make.
Student responses were categorized as 1) agree ("yes" responses as well as strongly agree and agree responses, respectively), 2) disagree ("no" responses as well as disagree and strongly disagree responses, respectively), and 3) no opinion. They were the entered into a spreadsheet (Microsoft Office Excel 2003) and analyzed quantitatively. Results are expressed as percentages of the numbers of respondents to each question.
Qualitative data (specific examples of physiological concepts and additional comments) were grouped into themes and analyzed accordingly.
Ethical approval (HSS/0717/08) was obtained for the study from the Human Sciences Ethics Committee of the University of KwaZulu-Natal. The necessary steps were taken to ensure the security and confidentiality of student inputs.
RESULTS
The student responses obtained are shown in Tables 3
–6 and are presented according to the various themes as outlined in METHODS. For the purposes of reporting and discussing the results, percent student responses have been rounded off to the nearest whole number. Information from those respondents who indicated that they had no opinion is not shown. It is worth noting, however, that this involved only a few respondents.
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It is evident that very few of the students had prior exposure to biology or physiology at a tertiary level. Only 13%, 18%, and 10% of the second-, third-, and fourth-year respondents, respectively, reported having completed a physiology course at the tertiary level, whereas 29%, 27%, and 9% of these respondents reported having done a tertiary level biology course.
Importance of physiology. It is evident from the results that the vast majority of the students questioned (97% of the second-year class, 90% of the third-year class, and 95% of the fourth-year class) thought that an understanding of physiology was necessary to master pathology. Similarly, 96%, 92%, and 92% of the students, respectively, thought that physiology was essential for their understanding and interpretation of patient presentation signs and symptoms and for interpreting laboratory results (92%, 88%, and 91% of students, respectively).
Resources used. As shown in Table 3, the vast majority of the students used a dedicated textbook. The details of the textbooks used are shown in Table 4. Not surprisingly, the textbook used most commonly by students was the prescribed textbook.
Difficulties encountered. A high percentage of respondents (70%, 83%, and 81% for second-, third-, and fourth-year students, respectively) reported that the attendance of LGRSs assisted their self-directed research on physiology and requested additional enrichment sessions (83%, 70%, and 79% of students, respectively). Despite this, only about half of the respondents reported experiencing difficulties understanding basic physiological and medical science concepts, either while reading or during LGRSs.
Students were also asked about the difficulties they had in understanding LGRSs given by faculty staff. Table 3 shows that 57% of second-year students had difficulties understanding what was being taught in physiology sessions compared with 53% of third-year students and 44% of fourth-year students. Similarly, students reported difficulties understanding the terminology used in clinical sessions (52% of the second-year class vs. 58% of the third-year class and 50% of the fourth-year class).
Willingness to participate. An encouraging number of respondents (Table 3) volunteered to participate in focus group discussions (40%, 37%, and 28% of students, respectively) and in a test of basic physiological concepts (48%, 36%, and 38% of students).
Over a third of the respondents (36% and 39%) volunteered additional comments (Table 3). The majority of these reaffirmed their perceived need for expert explanations of basic physiological concepts, the essential role of physiology for the understanding of clinical and pathological conditions, and the importance of a suitable intervention to address these perceived needs.
Student comments. Specific examples of basic physiology/medical science concepts provided by the students are shown in Table 5. The top three concepts identified by students as being the most challenging are highlighted and ranked accordingly.
Additional comments made by the students are shown in Table 6. As with the results shown in Table 5, the top three specific issues raised are highlighted and ranked accordingly.
DISCUSSION
The present study documents student perceptions and experiences of their learning of physiology during the first 4 yr of study in a problem-based environment that is predominantly case based and student centered. To date, despite there being a general shift in South Africa of medical curricula from a traditional didactic and discipline-based approach to a multidisciplinary problem-based approach, there has been, to the best of our knowledge, no data published on the impact of such curricular changes on the teaching and learning of physiology in the South African context. The only published work found emanating from the South Africa context was that by Mitchell in 1988 (22), which documents a novel approach to the teaching and learning of physiology using problems and clinically relevant data. It is important to note that this approach was used to teach physiology in a clinical context but not to teach clinical medicine in an integrated and multidisciplinary fashion.
The participants of the present study represented the first three cohorts of students that entered into the new PBL curriculum at the NRMSM. As part of the pioneering group, they were subjected to numerous questionnaires, as highlighted by McLean (17) and Singaram et al. (28). It is therefore not surprising that not all of the students were willing to participate in the present study. According to information on the website of the Division of Instructional Innovation and Assessment of the University of Texas at Austin (6), a response rate of >50% is considered good for this type of survey. We thus believe that our results, based on an overall response rate of >45% (257 of 569 students) (Table 3), are a reasonable reflection of the opinions and experiences of the students as a whole. Furthermore, it is interesting to note that Singaram et al. (28) also reported a low response rate of <50% in their study of the 2004 NRMSM student cohort.
It is our understanding that many PBL schools either give a didactic or PBL foundation course (14, 25) composed of various science subjects or select graduate students into PBL medical curricula. At NRMSM, students in the traditional curriculum were exposed to a year of chemistry, physics, and biology together with a short introductory course in anatomy and physiology before a full-year course in anatomy and physiology in their second year of study. This year was abolished when the PBL curriculum was introduced. Instead, a limited number of LGRSs were offered during the first year on various basic science topics. This meant that students largely had to rely on their knowledge of science and biology that they had acquired while at school for their understanding of basic concepts. The results of our study support this view in that only a small proportion of the respondents stated they had completed a physiology (<20%) and biology (<30%) course after leaving school, respectively, demonstrating that some of the basic scientific foundations required for the full appreciation of physiology and its application to medicine were potentially missing in the bulk of the students entering the PBL program at the NRMSM. It is worthwhile noting that in a subsequent study (28), Singaram et al. reported that only 38% of students at the NRMSM had any any postsecondary school education. This favorably compares with the findings in the present study.
With the implementation of PBL at NRMSM, there was also a shift away from the traditional didactic lecture to small-group tutorials and self-study. As shown in Table 3, there was a surprising number of students (7%, 14%, and 10% of the second-, third-, and fourth-year respondents, respectively) who claimed that they never used a dedicated textbook. When students were asked to list the various texts that they used, the majority of students who responded, not unexpectedly, listed the prescribed text: Guyton and Hall's Textbook of Medical Physiology (97%, 93%, and 93% for second-, third-, and fourth-year students, respectively). Despite this, it is worthwhile noting that up to 60% of students cited using various physiology texts in combination with the Textbook of Medical Physiology, as shown in Table 4. This suggests to us that students did not necessarily have the conceptual framework that they needed to understand the information they were encountering in a comprehensive physiology text, such as that by Guyton and Hall. This is corroborated by the fact that >50% and >70% of all respondents indicated that they had experienced difficulty in studying physiology on their own and found the reading of physiology texts much easier after attending LGRSs, respectively. This viewpoint is further substantiated in this study, in that the majority of respondents indicated that they had difficulty in understanding the concepts that were referred to in LGRSs by both physiologists and clinicians and requested additional enrichments sessions in physiology (>50% and >75% for all students, respectively; Table 3).
Specific examples of the basic medical science/physiology concepts that students listed as not knowing and/or understanding during LGRSs are shown in Table 5. Not unexpectedly, the majority of physiology topics cited by students as being difficult were common to both physiology and clinical LGRSs. The three most common problematic areas, ranked 1–3, included ECG analysis and interpretation (1), gastrointestinal and hepatic physiology (2), and renal physiology (3), biochemistry (3), and neurophysiology and the central nervous system (3). An analysis of possible reasons why this may be so led us to discover that the students received little formal exposure to those basic concepts required by the students for an understanding of these topics. These concepts include, for example, introductory physics concepts (such as electricity and vectors), basic cellular and receptor biology, and biochemistry. It was also apparent that there was limited exposure to basic chemistry principles such as acids and bases and the processes by which ions equilibrate themselves. It is interesting to note that Abu-Hijleh and coworkers (3), in their study of the effectiveness of a PBL module on the cardiovascular system, reported that 90% of their student group was aware of gaps in their knowledge. Unfortunately, this finding was not probed further by these authors, as the cardiovascular knowledge gaps may well have been similar to those identified by students in the present study.
It is generally accepted that students find physiology hard to learn. Michael (20) reported that at least 50% of his students indicated that this was so when they were informally questioned. In Michael's survey of faculty members (20), the key issues identified by physiology teachers for the learning of physiology and what makes it difficult to learn included a required understanding of physics and chemistry, an understanding of physiological phenomena at different organizational levels simultaneously, a failure of students to appreciate the integrative nature of physiological mechanisms, and the tendency for students to compartmentalize. As teachers of physiology, we can fully relate to these observations. Our study of student perceptions corroborates Michael's findings as our results show that the students' most frequently stated difficulties (Table 5) involve those topics that require either an understanding of physics (ECG), chemistry (acid-base reactions), and biochemistry (gastrointestinal physiology) or an ability to integrate (e.g., renal physiology).
In their study (14), Kaufman and Mann found that students in a preclinical PBL curriculum had positive attitudes as to the importance and relevance of basic sciences. Our findings also show that students are keenly aware of the importance of physiology for their mastering of pathology and clinical medicine. Over 90% of them recognized that physiology is essential for their understanding of pathology and interpretation of not only patients' signs and symptoms but also laboratory results (Table 3). This is borne out by the student comments shown in Table 6. As shown in Table 5, the issues raised by the respondents were ranked according to frequency. The importance of physiology (including anatomy and biochemistry) and student unhappiness with their situation were the two top matters enumerated. Interestingly, the need for foundation material as well as more formal contact was highlighted by the respondents. It is noteworthy that 50% of the negative comments were made by members of the fourth-year student cohort. The high level of discontent expressed by this group is perhaps not surprising given the fact that they represent the pioneering cohort of the new PBL curriculum at NRMSM and that they were continually being compared with their traditional curriculum counterparts. Their perceptions could also be related to the fact that as fourth-year students, they had had greater clinical exposure than the other year groups and were perhaps realizing that they had gaps in their knowledge of basic sciences, including physiology. Interestingly, the fourth-year students, as a group, seemingly had a greater lack of prior exposure to physiology and/or biology at a tertiary level compared with the other year groups. The significance of this observation is unclear.
We were encouraged to note that over 80 (>25%) of the students who participated in the study indicated their willingness to participate in focus group discussions and undergo a test of their knowledge of some of the basic essential concepts underpinning physiology/medical science. Unfortunately, no followup of the students was done as originally planned due to unforeseen circumstances. These included the merger of our previous institution with another, with us physically moving to a location away from NRMSM to another faculty, and the consequent exposure to numerous other Allied Health Science courses requiring physiology input and the expansion of our postgraduate program.
At NRMSM, the student population is diverse not only in terms of culture, language, gender, and race but also in terms of educational and financial background (28). In view of this diversity, a potential limitation of the present study is whether or not, due to lack of suitable demographic data, the respondents' views reported here are in fact representative of those of the classes as a whole. A second potential limitation of the present study is that while physiology teaching and learning was spread throughout the first 4 yr of the curriculum (Table 2), we are uncertain as to whether the third- and fourth-year student responses reflect their experiences of their present year only or that of their overall exposure to physiology. It is noteworthy, however, that similar responses were obtained for all the year cohorts for the majority of the issues probed in the questionnaire. Two notable exceptions relate to the prior exposure of the fourth-year students to physiology and/or biology at the tertiary level (Table 3) and the considerably higher percentage of negative comments volunteered by the fourth-year students (Table 6).
A further limitation of our study is that we are unable to assess how effective the small-group facilitation was in terms of the learning of physiology as the cases in the small-group sessions are multidisciplinary in nature and learning objectives are likely to have differed from group to group. In addition, Singaram et al. (28), working with students at the NRMSM, highlighted that up to 30% of first-year students responded negatively to group work and that further research was required to establish the reasons why. The facilitator plays a important role in determining the small-group tutorial learning environment. This has been highlighted by numerous authors, including more recently in our context by McLean (15). McLean conducted a study in 2001/2002 on the same cohort of students that comprised the fourth-year group in our study. From McLean's study (15), it is evident that the students perceived some facilitators to be "a key part of the group," while others were described as "a real waste of time." This may also explain some of the difficulties that students highlighted in our study and that 50% of the negative comments were made by members of the fourth-year student cohort.
In 2003, Glew (12), a biochemist and a previously strong proponent of PBL, highlighted his concern about the shallow nature of the grasp and poor knowledge that fourth-year medical students at his institution have of the basic sciences that underpin clinical conditions. He furthermore states that this view is corroborated by the students themselves, who perceive that they are being graduated with inadequate grasp of basic science. He also expresses concerns about the fact that, at his institution, students are being given too many clinically orientated lectures by clinicians and too few basic science lectures. He cites two main possible reasons for this: 1) that clinicians are not supportive of the basic science content of the curriculum and are too busy with their clinical workload and 2) that there are basic scientists in his institution who have never really embraced PBL and, consequently, have elected to spend very little time "teaching" on the program and conducting lectures and tutorials. Furthermore, he raises the highly pertinent and contentious issue regarding the disparity in the recognition and rewards for teaching as opposed to research. As potential solutions, Glew (12) not only reaffirms that faculty staff who specialize in teaching should be rewarded but also stresses, as does Savin-Baden (26), the need for staff and curriculum organizers/administrators to critically analyze and evaluate their curricula, including their pedagogical approaches. The present study does not attempt to address the merits of PBL per se but, rather like Glew (12) and Savin-Baden (26), to highlights some potential stumbling blocks that may be encountered with respect to the teaching and learning of basic sciences, in particular, physiology, during implementation of a PBL-based medical curriculum.
Although we are aware that the present study only details the experiences at our institution (NMRSM) and within our specific curriculum, we nevertheless trust that our findings, together with those of others, will contribute to the debates around medical curricular change so as to ensure that students are adequately equipped to master the study of physiology in the PBL context. It also provides evidence of the sort of challenges faced by students of diverse backgrounds during the early implementation years. We would advocate, in our context, that a foundation course be introduced that encompasses basic cellular physiology and autonomic and endocrine control of systemic physiological processes to facilitate students' mastering of physiology in a PBL context. Interestingly, our recommendations are similar to those proposed by Modell (23), who suggested that students need a basic foundation in control systems, transport of substances across membranes, basic molecular concepts, and cell-to-cell communication to assist their understanding of physiology. More recently, Michael and coworkers (19) have expanded on Modell's work and identified a number of core principles that relate to the general models proposed by Modell (23), which, in their opinion, can serve as the foundation for understanding physiology.
As we reflect 7 yr after the initial introduction of the new curriculum at NRMSM, it is gratifying to report that there is an increasing recognition by the faculty of the issues highlighted by this study and that a faculty curriculum task team is planning the implementation of a full-year foundation course incorporating some of these concepts from 2010 onward.
To conclude, let us heed the voices of our students:
The fact that we straight away embark on clinical concepts without medical/clinical/physiological basical science basically make life very difficult for us. I am also wondering what kind doctors are gonna be without medical basic sciencies. Please do something about this lest we regret in future for coming to this medical school.An understanding of Physiology is imperative to comprehend the signs/presenting symptoms. It provides one with a basis to "think", "figure" and "work out" outcomes without lists. First year prove challenging w/o having this understanding. Now at 2nd year level I am having more of those "Ah Ha" moments as things (some) finally make more sense
I think this is an excellent move, hope it continues & starts soon. We are really battling to understand some complex texts (e.g., Pathology) due to a lack of general basic sciences. It will help the coming years countlessly.
Too late!!! We needed this 4 years ago!!!
Acknowledgments
The authors thank all the students for participating in the study and for giving them valuable insights into student perceptions and experiences in physiology in a PBL curriculum.
Footnotes
* M. A. Tufts and S. B. Higgins-Opitz contributed equally to this work. 
1 Supplemental material for this article is available online at the Advance in Physiology Education website.
Received for publication December 12, 2008. Accepted for publication May 18, 2009.
REFERENCES
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