Revitalizing Problem-Based Learning (PBL)

We started talking about PBL today as an extension of our discussion on case-based learning. PBL is a vital part of the medical school curriculum and yet it does not hold the esteemed position with our student body that it likely deserves. Mention of PBL is, sadly, more often met with groans than not. How did PBL become a lacklustre chore when it has the capacity to be so much more – the bridge between basic knowledge and the intricacies of the clinical realm? How can we restore it to its rightful place?

During my experience as a student with PBL, some of the biggest challenges I have seen were achieving realism and following through with the PBL process. Factors like improbable patient names,  monotonous case readings, and lack of visual images, each small in their own right, together can detract from the authenticity of a case and hinder engagement. In terms of process, focusing too much on finding the “right” research questions, as defined by that infamous last sheet in the facilitator package, rather than actual knowledge gap needed for the case and “presenting” research findings rather than “operationalizing” this information limits the learning potential from the PBL format.

Overall, in a large class, PBL is a precious opportunity to learn directly from clinical teachers and work with our peers. If properly applied and appreciated, it can be a wonderful tool for knowledge translation. Medical Teacher has an excellent 12-tips series for everyone interested in improving the PBL process - medical students, faciliator, and administrator alike. Perhaps it would be possible to make PBL more than Powerful But Lacking.

1.           Azer S a. Challenges facing PBL tutors: 12 tips for successful group facilitation. [Internet]. Medical teacher 2005 Dec;27(8):676-81.[cited 2012 Jan 7] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16451886

2.           Azer S a. Becoming a student in PBL course: twelve tips for successful group discussion. [Internet]. Medical teacher 2004 Feb;26(1):12-5.[cited 2011 Sep 6] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14744687

3.           Azer S a. Introducing a problem-based learning program: 12 tips for success. [Internet]. Medical teacher 2011 Jan;33(10):808-813.[cited 2011 Oct 3] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21942480

-Jenny

Reflections on a Learning Tool: MKSAP

Medical Knowledge Self Assessment Program (MKSAP) is a self-direct case-based learning program put forth by the American College of Physicians. MKSAP provides a review of internal medicine and its subspecialties. Regularly updated, it is currently in its 15^th iteration. The format of MKSAP consists of a basic syllabus on each of its 11 topics, ranging from internal medicine foundations to infectious disease to critical care, followed by multiple choice self-assessment questions and detailed well-referenced responses (Winter 2007).

For medical students, some of the benefits of supplementing our learning with MKSAP cases potentially includes rapid exposure to a variety of clinical scenarios, being guided through clinical reasoning, receiving immediate assessment and feedback on our decisions, and being connected with reputable references. I especially appreciate how questions are associated with an individual educational objectives so that we can see the relevance of each, otherwise disjointed, question and put them into context. I also like how the question discussions promote stepping back from the facts of the case so to cast a broader differential. For example, a stem like a “20-year-old man from Cambodia presenting with mild fever and neurological signs” in the Infectious Disease section may make us rightly suspicious of an infectious cause, but we should not forget about other important differentials like structural brain lesions and coagulation disorders.

There are certainly limitations to this format of learning. For one, these brief cases cannot fully mimic real clinical scenarios; rather, all the pertinent information is a little too nicely summarized. There is also, in these types of self-study cases, no opportunity for asking questions and clarification of responses. Finally, there is an odd lack of connection back to the syllabus for many of the questions, which may otherwise be useful.

Overall, MKSAP, with its myriad of cases, seems to be a good supplemental tool for learning. I hope to make more use of it in my studies in the future.

Winter DFJ. Review of MKSAP 14—Medical Knowledge Self-Assessment Program. Proceedings (Baylor University Medical Center) 2007;20(3):319-320.

-Jenny

Ágoston Kecskés

992868991

January 5, 2012

Blog Entry #3: Questions worth asking, literature reviews worth doing

The agenda for today was dominated by my search for a research question, literature review, and teaching exercise, and figuring out how to integrate all three. Having recently purchased an iPhone 4, I am all too familiar with the gaping abyss separating the iPhone 4’s purported benefits and what it can actually deliver. My goal was to channel my frustrations with the iPhone 4 into a worthwhile, cutting edge research question. After a preliminary article search, I discovered that the literature on handheld devices in medicine consisted predominantly of articles on outdated devices. As the first iPhone was only released in 2007, there was a significant gap in the literature on more recent devices. Narrowing my search to the use of smartphones in medical education (and, specifically, in medical students) yielded essentially no articles. I know that students are not using Palm devices or Pocket PCs (at least not any more) in the clinical setting, so naturally I am forced to ask: “How are North American medical students using their smartphones as part of their education?” What better place to look for good hypotheses than in the literature on older devices? Fortunately, this literature is relatively limited and well bounded so it should be manageable within the given timeframe. An alternative would be to formulate hypotheses using the literature on resident and/or physician use of both older devices and more recent smartphones. For my teaching exercise, therefore, I plan to assemble an interactive seminar on tips for medical student smartphone users in medical education.

Ágoston Kecskés

992868991

January 4, 2012

Blog Entry #2: The plot thickens

As the second day of my CEEP selective kicks into high gear, the assigned readings[1] [2] [3] have served to deepen my understanding of the medical education literature.

One thing has become abundantly clear: details matter. For example, the details of definitions matter. Torgerson’s article is supposed to be an ardent defence of randomized control trials (RCTs) in the medical education literature. The argument quickly degenerates, however, in no small part owing to Torgerson’s failure to define RCTs. In fact, she uses the terms RCT and RCT methods interchangeably. While I recognize RCT methods as referring to a stylized stereotype of a gold standard for determining types and sizes of effects, Torgerson’s failure to clarify the terms simply serves to fuel the fires of her detractors. For example, blinding is not a necessary condition of RCTs. The same is not true of ‘RCT methods,’ assuming blinding is possible and practical. The details of quotes also matter. Half or more of the assigned readings over the last two days have featured arguments triggered or at least spurred on by misquotes or quotes taken out of context. These quotes are clearly useful in establishing the extremeness of the author’s position. However, they often also lead to rehashing of old familiar debates with little or no progression of thought. For instance, Krupat dedicates half a page of his article to describing Kurt Lewin’s ‘action research.’ Besides the fact that Lewin’s ‘action research’ is little more than a call for increased focus on practice over theory, Krupat’s blurb is essentially a focused job description. On the other hand, Krupat makes no such efforts to detail exactly what he means by ‘serious conceptual analysis’ and how it is supposed to advance the medical education literature.

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[1] Carole Torgerson, “Educational research and randomized trials,” Medical Education, http://www.mendeley.com/research/educational-research-randomised-trials/; accessed 4 January 2012

[2] Geoff Norman, “RCT = results confounded and trivial: The perils of grand educational experiments,” Medical Education, http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2923.2003.01586.x/abstract; accessed 4 January 4, 2012

[3] Edward Krupat, “A call for more RCTs (Research that is Conceptual and Thoughtful),” Medical Education, http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2010.03682.x/abstract; accessed 4 January 4, 2012

Ágoston Kecskés

992868991

January 3, 2012

Blog Entry #1: The more things change, the more they stay the same

When I started today’s readings[1] [2] [3] [4] I expected to be diving headfirst into a body of literature completely foreign to me. Halfway through the second article, I found myself revisiting many of the familiar themes of my undergraduate and graduate studies. The old familiar qualitative versus quantitative methods debate made a triumphant comeback. It appears that this debate is as vibrant in the medical education as it is in the public policy and administration literature. Likewise, Thomas Kuhn and Descartes made their mark on our discussion of metaphors used to guide the medical education research agenda. It was also nice to see that the ‘heavy hitters’ of the medical education literature like Geoff Norman had just as strong personalities as those in other budding, controversial fields of academia. Despite these similarities, or rather because of them, I think I can learn a lot during this CEEP selective. Given my familiarity with the themes found in the background reading, I feel poised to tackle some of the higher-level themes in the medical education literature. Likewise, having written a few literature reviews (both formal and informal) I feel poised to move beyond basics to focus on style and structure. That being said, this CEEP selective only lasts three weeks so I will have to work quickly. My research question will have to be narrow and focused to allow for adequate exploration of the relevant issues. To work efficiently, I will attempt to focus my learning by integrating my teaching exercise with my research question and literature review.

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[1] Geoff Norman, “Sample sizes, scoops and educational science,” Advances in Health Science Education, http://www.springer.com/education+%26+language/journal/10459; accessed 2 January 2012.

[2] Glenn Regehr, “It’s NOT rocket science: Rethinking our metaphors for research in health professions education,” Medical Education, http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2009.03418.x/full; accessed 2 January 2012.

[3] Geoff Norman, “Chaos, complexity and complicatedness: Lessons from rocket science,” Medical Education, http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2011.03945.x/abstract; accessed 2 January 2012.

[4] Glenn Regehr, “Highway spotters and traffic controllers: Further reflections on complexity,” Medical Education, http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2011.04007.x/abstract; accessed 2 January 2012.

Importance of Medical Genetics

Excellent Grand Rounds today by Dr. Hanna Faghfoury titled “Why should Internal Medicine care about Medical Genetics?” According to Dr. Faghfoury, the importance of Medical Genetics lies in the fact that even rare diagnosis will at times appear and accurate diagnosis can lead to appropriate treatment, monitoring of other associated organ systems, and screening of family members. Three cases, each presenting with neurological findings, led to discussions on Classical Homocysteinuria, Fabry’s Disease, and Ehler-Danlos Type IV.

Dr. Faghfoury emphasized that we should not forget that common is common (i.e. don’t miss horses for the zebras), but we should keep genetic diseases in our differential. Important hints that we may be dealing with genetic disorders includes:

1. working diagnosis does not explain clinical picture: e.g. there is atypical features, young age, refractory to treatment, recurrent presentation, unexplained multi-systemic issues
2. dysmorphism or developmental delay in patient
3. suspicious family history: can ask about development delay, consanguinity, ethnicity, childhood/ early adulthood hospitalization/ surgery/ death

For an interesting example of Fabry’s disease, please see:  

Kopp JB, Schiffmann R. Images in clinical medicine: Fabry’s disease [Internet]. New England Journal of Medicine 2003 Jan;349(21):e20.Available from: http://www.ncbi.nlm.nih.gov/pubmed/14627801

-Jenny

Nature of Educational Research

Today, we were introduced to the wonderful world of medical education research. By juxtaposing the positions of Dr. Geoff Norman (Norman, 2011) and Dr. Glenn Regehr (Regehr, 2011), we glimpsed one of the hottest ongoing debates in medical education research – what is the nature of education science and how should we go about conducting educational research? Does our current approach overly resemble a “search for proofs of simple generalisable solutions” to truly appreciate the complexity of medical education? Or is the reductionist approach a valid method for extracting meaningful and practical information about this complicated system? The truth may lie somewhere in between. Perhaps we can start to reconcile the two sides by applying scientific methods with greater appreciation of the multivariate nature of medical education and carefully reflecting on study results.

Good journals on the topic of medical education, for future reference, includes:
·         Academic Medicine
·         Medical Education
·         Advances in Health Science Education
·         Medical Teacher
·         Teaching and Learning in Medicine

Norman, G. (2011). Chaos, complexity and complicatedness: lessons from rocket science. Medical Education, 45(6), 549-59. doi:10.1111/j.1365-2923.2011.03945.x
Regehr, G. (2011). Highway spotters and traffic controllers: further reflections on complexity. Medical education, 45(6), 542-3. doi:10.1111/j.1365-2923.2011.04007.x


- Jenny