 |
|
Impact of Problem-Based Learning on Residents' Self-directed Learning
Philip O. Ozuah, MD, MSEd;
Jane Curtis, MD;
Ruth E. K. Stein, MD
Arch Pediatr Adolesc Med. 2001;155:669-672.
ABSTRACT
| |
Objective To examine the effect of a problem-based learning (PBL) curriculum on
self-directed learning behaviors among a group of pediatric residents.
Methods A controlled comparison study was conducted with 80 pediatric residents
at a large urban academic medical center. Residents were observed over 3 distinct
but consecutive periods. First, all residents participated in a 3-month-long
daily lecture series (pre-exposure phase). Then, for another 3 months, 39
residents (PBL group) were exposed to twice-weekly PBL sessions while 41 residents
continued with the daily lectures (lecture-based group) and served as controls.
Problem-based learning was withdrawn after 3 months and all residents returned
to the lecture series (follow-up phase). Residents' self-directed learning
behaviors were assessed through self-administered questionnaires during the
pre-exposure, exposure, and follow-up phases.
Results There were no significant preexposure differences in self-directed learning
behaviors between the groups. During the exposure phase, the PBL group had
significantly higher self-directed learning: 5 or more hours of independent
study (2% vs 7%) (P= .001); 5 or more hours of medical discussions
(28% vs 4%) (P= .008); 2 or more computer literature searches
(51% vs 30%) (P= .005); and total hours of self-study per week
(6 vs 4 hours) (P<.05). At the 3-month follow-up, the PBL
group had returned to baseline levels of self-directed learning and there
were no significant differences between the groups.
Conclusion Residents exposed to PBL engaged in significantly higher levels of self-directed
learning than their counterparts.
INTRODUCTION
PROBLEM-BASED learning (PBL) has emerged as a prevalent teaching technique
in medical schools, especially during the preclinical years.1
Problem-based learning seeks to increase motivation for self-directed learning
by presenting a relevant problem to a group of learners. The process of solving
the problem requires that members of the group engage in independent reading
and research. Proponents of PBL maintain that during such a process, the innate
desire of a group of learners to solve a problem can be used as motivation
for self-directed learning. To date, very little has been published to support
this theory in the residency setting.
One of the goals of postgraduate medical education is to prepare physicians
to be lifelong learners, self-directing their own learning after residency.
Despite this, the use of PBL in postgraduate education has been sporadic and
limited.2, 3, 4, 5
The effect of PBL on self-directed learning among residents has not been studied.
Thus, this study was designed to test the hypothesis that the introduction
of a PBL curriculum would result in enhanced self-directed learning behaviors
among a group of pediatric residents.
MATERIALS AND METHODS
PROGRAM DEVELOPMENT
As a first step, one of us (J.C.) was trained in the PBL teaching method
by Howard Barrows, MD, at Southern Illinois University, Springfield. Subsequently,
an 8-hour-long faculty development course was developed at our institution.
All faculty members in our department were invited to volunteer to participate
in the course. All volunteers were accepted. One hundred five faculty members
took part in the course over a 4-year period. These trained facilitators served
as the pool of faculty for the residency PBL experience.
Using the established core lecture series as a template, we designed
a PBL curriculum by choosing topics that lent themselves to the PBL format.
Examples included "The Diagnostic Approach to the Child in Shock" and "The
Child With Fever and Rash." We searched our admission records and found actual
cases that illustrated these topic areas. For the selected cases, the medical
records were reviewed and summarized in a sequential written format that was
designed for the PBL exercise, beginning with the chief complaint and followed
by the history of present illness, medical history, family/social history,
review of systems, and the physical examination, in that order.
PBL SESSIONS
We employed the 2-part closed-loop reiterative model of PBL that has
been identified by Barrows6 as the best model
for promoting self-directed learning. In this model, learners are presented
with a clinical problem with no prior preparation. A faculty facilitator provides
no factual information, but helps the group probe their current knowledge
and stay on the task of solving the patient's problem.
The first PBL meeting occurred at the beginning of the week and began
with the presentation of the chief complaint of the patient. This was followed
by a discussion of the differential diagnoses. Next, a summary of the rest
of the history was read. Then there was a group discussion aimed at generating
a list of problems, defining learning issues, and ranking the differential
diagnoses. After this, the findings on physical examination were then made
known; this helped the group in refining the differential diagnosis. Finally,
there was the self-assignment of the learning issues that had been generated
during the session. These learning issues involved further information that
the group felt it needed to have to solve the patient's problem. After a break
of several days to allow for research and reading, the second meeting began
with reports on the self-assigned learning issues. There was further discussion
of the differential diagnosis based on the new information. The group generated
an action plan of laboratory tests and patient treatment. Laboratory reports
for the planned tests were then revealed and a final discussion ensued. After
the group committed to a specific diagnosis, the patient's actual diagnosis
was made known. The sessions ended with a review of the case and a discussion
of any errors that the group might have made along the way.
During the study period, residents completed 4 PBL cases per month.
SETTING/DESIGN
The study was based in a large tertiary academic medical center with
85 pediatric residents. Eighty pediatric residents on active rotations were
enrolled in the study. We performed a time-series cohort analysis of an intervention
group with a comparison group. A self-administered questionnaire was developed
to measure the self-directed learning behaviors of each resident according
to our operational definition described below. The study was designed to include
3 distinct periods of observation each of 3 months' duration: pre-exposure,
exposure, and follow-up.
During the pre-exposure period (July-September 1998), all 80 residents
participated in a lecture series. Baseline self-directed learning behaviors
were assessed in September 1998. During the exposure phase (October-December
1998), 39 residents (PBL group) were exposed to twice-weekly PBL sessions.
The PBL group was made up of residents on inpatient rotations at the central
residency site. For this group, PBL was substituted for noon lectures and
occurred twice weekly. This group had weekly self-assigned learning issues
derived from the PBL meetings and includes residents with a minimum of 1 and
a maximum of 3 months of PBL. At the end of each monthly rotation, self-directed
learning was measured using the same questionnaire. Forty-one residents on
other concurrent rotations served as a comparison group. These residents continued
to receive daily noon didactic lectures and were designated as the lecture-based
learning group. The lecture-based learning group consisted of residents on
ambulatory rotations at the central site plus residents on rotations at another
training facility affiliated with the residency program. The lecture-based
learning group had no formal self-assigned research topics. Self-directed
learning behaviors were assessed at the end of each month.
The PBL intervention was withdrawn in December 1998. During the follow-up
period (January-March 1999), all residents returned to the daily lecture series.
Self-directed learning behaviors were reassessed in March 1999.
In addition, we assessed residents' satisfaction and opinions about
PBL and the lecture series using a 5-point Likert scale. Complete data were
available on all 80 subjects.
DEFINITIONS
Self-directed learning was operationally defined as the average time
per week that a resident spent in (1) independent study of medical text and
journals; (2) medical discussions with colleagues, outside of scheduled didactics
(including PBL) and teaching rounds; and (3) performing computer literature
searches. The period of recall assessed was the preceding month. For example,
each resident was asked to answer the following question: "On average over
the past 1 month, how many hours per week did you spend in performing computer
literature searches?"
STATISTICAL METHODS
Data were maintained in SPSS 9.0 statistical software (SPSS Inc, Chicago,
Ill). Comparisons of percentages between PBL and lecture-based learning groups
were done using  2 or Fisher exact test as appropriate for
dichotomous variables. Cut points for statistical analysis were determined
prospectively based on pilot data on residents' self-directed learning while
field-testing the questionnaire.
RESULTS
Compared with the lecture group, a significantly higher percentage of
residents in the PBL group studied for 5 or more hours per week (26% vs 7%)
(P = .001); engaged in 5 or more hours of medical
discussions per week (28% vs 4%) (P = .008); and
performed 2 or more computer literature searches per week during the exposure
phase (51% vs 30%) (P = .005). At follow-up, self-directed
learning in the PBL group had returned to baseline and there were no significant
differences between the groups (Table 1).
|
|
|
|
Table 1. Comparison of Self-Directed Learning Behaviors Between the
Groups*
|
|
|
Table 2 shows that for the
PBL group during exposure, there was a significant increase in the mean total
weekly self-directed learning hours (6 vs 4 hours) (P<.05).
|
|
|
|
Table 2. Comparison of Mean Total Self-directed Learning Hours per
Week*
|
|
|
On a 5-point satisfaction scale (with 5 as the best score), residents
gave the PBL series a rating of 4.6, while the lecture series was rated as
3.3.
COMMENT
This is the first report to demonstrate that participation in PBL resulted
in significant increases in self-directed learning behaviors in the postgraduate
setting. We found that a group of residents who were exposed to PBL showed
significant increases in the amount of time devoted to independent study,
the amount of time spent in medical discussions, and the number of computer
literature searches that were done. However, our findings also suggest that
the gains in self-directed learning behaviors might be short lived. It is
unclear whether residents who have prolonged or ongoing exposure to PBL would
sustain the improvement in self-directed learning behaviors. In addition,
it would be of interest to study whether the enhanced self-directed learning
behaviors would resurface if another mechanism for self-assignment of research
topics were instituted in the ambulatory setting.
The percentage of residents from both groups performing computer literature
searches dropped during the follow-up period. We are not sure why this happened.
A speculation might be that the fatigue and increased clinical demands associated
with the winter months were contributing factors. We did not ask residents
to identify the location from which they performed their literature searches.
However, in addition to the medical center's library resources, we have computer
terminals with Internet access located on the wards and in the ambulatory
setting.
Outcome variables that have been used to assess PBL in the past have
included student satisfaction, student performance on standardized tests or
problem-solving paradigms, student motivation to learn as demonstrated by
topics covered, and self-directed learning as demonstrated by use of library
and other materials.4, 5, 7, 8, 9, 10
In the residency setting, Schwartz et al4 showed
a high level of satisfaction among surgical residents engaged in PBL. In another
study, attendance at PBL was highly correlated with performance on the American
Board of Surgery In-Service In Training Exam.5
Itani et al5 speculated that this finding might
have been the result of enhanced self-study on the part of residents engaged
in PBL, but they did not establish this link. Our findings strongly support
the association between PBL and enhanced self-directed study.
A limitation of our study is that we relied on self-reports by residents
and could not independently verify the behaviors that were being reported.
However, we believe that this limitation is partially controlled for by the
fact that we administered the same questionnaire to the same group of residents
at several intervals both preintervention and postintervention. Moreover,
the residents were unaware of the study hypothesis. We found that residents
were very willing to report low levels of self-directed learning behaviors.
As an example, approximately 30% of residents in both groups consistently
reported studying for less than 1 hour per week. The fact that residents were
quite willing to report such low levels of self-directed learning activity
gives us some confidence in the honesty of the self-reports. We believe that
this level of reporting was encouraged by the fact that the questionnaires
were anonymous.
This was not a randomized study, but rather a convenience sample of
residents based on rotation assignments. However, we were unaware of any bias
in the way that residents were assigned to various rotations. We do not believe
that the changes observed were a result of rotation assignments because during
the follow-up period, the group rotation assignments were essentially reversed.
Despite this fact, we found no significant differences in self-directed learning
behaviors during this period.
Overall, we found very low levels of baseline self-directed learning
behaviors among residents. This lends some validity to the general consensus
among residency educators about the need for finding ways to enhance self-directed
learning. However, the demonstrated effectiveness of PBL in improving self-directed
learning among residents in this report challenges the presumption that the
enormous time demands of residency may preclude the attainment of this goal.
This study demonstrates that it is in fact possible to increase residents'
self-directed learning in spite of heavy clinical demands. Based on our findings,
further use and study of the PBL technique in residency is warranted.
AUTHOR INFORMATION
Accepted for publication February 5, 2001.
Presented in part at the annual meetings of the Pediatric Academic Society,
San Francisco, Calif, May 3, 1999, and Boston, Mass, May 16, 2000.
From the Department of Pediatrics, Albert Einstein College of Medicine
and the Children's Hospital at Montefiore, Bronx, NY.
Corresponding author: Philip O. Ozuah, MD, MSEd, Montefiore Medical
Center, 3544 Jerome Ave, Bronx, NY 10467 (e-mail: pozuah{at}pol.net).
REFERENCES
| |
1. Barrows HS, Tamblyn RM. Problem-Based Learning: An Approach to Medical Education. New York, NY: Springer Publishing; 1980.
2. Foley RP, Polson AL, Vance JM. Review of the literature on PBL in the clinical setting. Teach Learn Med. 1997;9:4-9.
3. Schwartz RW, Donnelly MB, Mayo WP, Strodel WE. Problem-based learning: a formal curriculum for postgraduate surgical
education. Curr Surg. 1993;50:285-290.
4. Schwartz RW, Donnelly MB, Sloan DA, Strodel WE. Residents' evaluation of a problem-based learning curriculum in a general
surgery residency program. Am J Surg. 1997;173:338-341.
FULL TEXT
|
ISI
| PUBMED
5. Itani KM, Miller CC, Church HM, McCollum CH. Impact of a problem-based learning conference on surgery residents
in training exam (ABSITE) scores: American Board of Surgery in Training Exam. J Surg Res. 1997;70:66-68.
FULL TEXT
|
ISI
| PUBMED
6. Barrows HS. A taxonomy of problem-based learning methods. Med Educ. 1986;20:481-486.
ISI
| PUBMED
7. Thomas RE. Problem-based learning: measurable outcomes. Med Educ. 1997;31:320-329.
FULL TEXT
|
ISI
| PUBMED
8. Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcome and implementation
issues. Acad Med. 1993;68:52-81.
ISI
| PUBMED
9. Vernon DT, Blakc RL. Does problem-based learning work? a meta-analysis of evaluative research. Acad Med. 1993;68:550-563.
ISI
| PUBMED
10. Saunders K, Northup DE, Mennin SP. The library in a problem-based curriculum. In: Kaufman A, ed. Implementing Problem-Based Medical
Education: Lessons From Successful Innovations. New York, NY: Springer
Publishing; 1985.
RELATED ARTICLES
Can We Train a Lifelong Learner?
Thomas DeWitt
Arch Pediatr Adolesc Med. 2001;155(6):637-638.
EXTRACT
| FULL TEXT
Evidence-Based Medicine Journal Club: What's It All About and What's in It for Me?
Harold P. Lehmann
Arch Pediatr Adolesc Med. 2001;155(6):639-640.
EXTRACT
| FULL TEXT
Does Problem-Based Learning Improve Residents' Self-directed Learning?
Naya Juul-Dam, Stephanie Brunner, Rachel Katzenellenbogen, Michael Silverstein, and Dimitri A. Christakis
Arch Pediatr Adolesc Med. 2001;155(6):673-675.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
From DSME to DSMS: Developing Empowerment-Based Diabetes Self-Management Support
Funnell et al.
Diabetes Spectr. 2007;20:221-226.
ABSTRACT
| FULL TEXT
Transforming the Marketing Curriculum Using Problem-Based Learning: A Case Study
Wee et al.
Journal of Marketing Education 2003;25:150-162.
ABSTRACT
Problem-Based Learning: An Approach to Dermatology Resident Education
Stratman and Dyer
Arch Dermatol 2002;138:1299-1302.
FULL TEXT
More on Problem-Based Learning and Self-directed Learning
Ozuah and Stein
Arch Pediatr Adolesc Med 2001;155:1278-1278.
FULL TEXT
Can We Train a Lifelong Learner?
DeWitt
Arch Pediatr Adolesc Med 2001;155:637-638.
FULL TEXT
Evidence-Based Medicine Journal Club: What's It All About and What's in It for Me?
Lehmann
Arch Pediatr Adolesc Med 2001;155:639-640.
FULL TEXT
Does Problem-Based Learning Improve Residents' Self-directed Learning?
Juul-Dam et al.
Arch Pediatr Adolesc Med 2001;155:673-675.
FULL TEXT
|
