This is a guide to Year One of Curriculum 2000 at Southern Illinois University School of Medicine. Many of the concepts discussed here originated with the Problem-Based Learning Curriculum. I have written it in a form that is brief, practical and essentially free!
|Beginning a unit|
|Opening a case|
|Wrapping up a case|
|Tutor group assessments|
PBL is an educational creation that focuses attention on process as a mechanism to acquire content within the context of a patient case. It is substantially different from traditional lecture-based curricula that most of us have experienced during schooling, which concerned content with the eventual acquisition of process. A number of books and articles have appeared that describe the curricula, approaches, and challenges to the underlying theory. However, these are intellectual readings that generally ignore the day to day workings and consequences of putting people together in small groups.
The purpose of this document is to highlight the important features of PBL as seen from the eyes of a tutor (me), which may be useful for students. I will attempt to provide a brief outline of the important features of PBL in simple practical language.
When you are invited to participate in a PBL program (accepted to SIU-SOM), more than likely you have agreed to certain ground rules. At SIU-SOM, these ground rules require that you work within a small-group setting, carry out specific activities outlined in curricular unit documents, and contribute to the tutor group assessment process. We strive for student-centered, active-learning activities (with some gentle tutor modeling of approaches and behaviors). The tutors you will encounter will vary in style and experience. As a result, you should be flexible and tolerant of different approaches and ideas.
There are at present, three objective areas for C2000.
Understanding what each of these objectives means and what the expectations are will make your participation worthwhile and rewarding.
Self-directed learning and articulation - You want to build your understanding of both the clinical and basic sciences important to the presenting problem, whether it's a patient case (ePBLM), a simulated patient, or alternative educational experience. Some have argued that a strong foundation is tantamount to developing the ability to reason. It is important that you be able to express yourself within tutor group, to your peers, and to faculty and health care professionals. Therefore, the ability to articulate is key in meeting this objective. Quiet group members must learn to articulate and actively participate in group discussions. You should also ask yourself if you are genuinely discussing learning issues or simply reading prepared notes that have been abstracted from the various resources.
How do you go about identifying appropriate resources that you will use to learn the content that will enable you to understand the patient case? Although textbooks are a common and important source of information, there are other resources that may be appropriate, especially when the topic is in an active field (i.e., molecular genetics of some human disease, clinical treatments, ethical issues). Are you able to reflect on your learning strategy and make an assessment as to its effectiveness? Are you learning anything? Do you need to reevaluate your approach?
Reasoning - During the evolution of a clinical case, you will use your knowledge to reason through the patient's problem. You develop hypotheses, consider differential diagnoses (alternatives), choose appropriate physical examinations and order clinical laboratory tests. Be proactive in your approach; be bold; take chances with your thinking. The group environment is perfect for using information to develop your reasoning skills and learning from other group members. Tutors pose questions to encourage you to think about the information that has been collected. Discovering that your understanding may be right or wrong is important in making progress.
Interpersonal and group skills - The tutor group appears at times a-home-away-from-home. Your behavior will enable effective achievement of objectives and goals. Be cooperative, flexible and tolerant of others. There is nothing wrong with challenging someone during group discussions, but be polite and assume ignorance rather than malice. Remember that everyone perceives situations differently. Share group tasks, take your turn as scribe, reader, summarizer, computer operator, and scheduler of additional lab and resource sessions. Listen actively to each group member. You will need to provide information to each person about how they are progressing from your perspective. Information is the key to progress. Therefore, developing your ability to provide constructive feedback is important and will be crucial to working with a team of professionals in the near future. Ask yourself if you are providing valuable constructive information or simply stating positive affirmations to get through the process.
It's important to know who you will be working with for the next four months. Make sure you introduce yourself and find out information about other group members and the tutor. Exchange phone numbers and addresses. This will allow everyone to stay informed about bad weather, emergencies, and schedule changes. After the first day, you'll know the basic science background of your group mates and whether they possess clinical expertise and other forms of experience.
Ask and discover the available resources in the tutor room, the building, and libraries. Learn to use the computer, along with its associated software and e-mail. This will save you time and will get you into the modern age of electronic communications. Find the faculty and keep talking to them. You'll find that they can provide a combination of information about process and content.
The formal mechanism that drives the curriculum is the Internet-based Problem-Based Learning Module (ePBLM). In order to acquire information that will be useful to understanding a case, you'll need someone to read the book (reader) and someone to write on the board (scribe). Everyone in the group will be expected to take a reasonable share of these two activities. Some groups like to compile information on the computer, but this tends to slow the group down and is best left for after the tutor group meeting.
Information that is read from an ePBLM should be summarized on a white writing board. Most groups do this by following a format for History and Physical as described in Bates or other manuals. Typically, the left side of the board begins with the patient's identity and presenting situation (including the chief complaint). History information appears below that and in organized sections (history of present illness, past medical history, family history, psychosocial information, etc). A Review of Systems is summarized after that. Results of your Physical Exam may be listed in the next column. In an adjacent column appears Hypotheses and under that Actions/Tests. The rest of the space on the board is used for listing Learning Issues and Actions/Test Results. Many variations exist for organizing this information. The important point is to choose a method that allows you to become familiar with the data collection.
Even if you have terrible handwriting, you will be expected to develop satisfactory skills as the scribe. It is considered bad manners to hide behind poor handwriting, especially if you're the only one. Learn to share reading responsibilities. A useful mechanism is to create a chart of group activities and indicate how many times each person has performed a task during the unit.
Many tutor groups (as well as the Doctoring Committee) find it useful to summarize the case at the beginning of each new group meeting. This serves several purposes. It provides a mechanism for you to get to know the patient. Some groups have even taken this a step further by having one person become the patient, while the others practice speaking to her or him. It facilitates assessment by the tutor group of your summary skills. You are also gaining experience for clinical years when you will be expected to provide an assessment of important information to your peers, the residents and physicians, and the faculty while on rounds.
One of the most significant challenges to group process and individual progress in PBL is the concept of learning issues (LIs). LIs are actual topics or questions that begin to define the basic science necessary to understand patient problems. As you work your way through each patient case, you should ask yourself questions concerning your level of understanding of the present problem. Are you and the tutor group at the same point? Are you considering the important aspects of the case? Typically you will tend to ignore an issue and the tutor will ask some simple question that focuses you on that particular aspect. These tend to be very simple questions, which illustrate the fact that you are making some serious assumptions about your learning. Don't avoid topics simply because you think you can avoid them. The purpose of the PBL is to be able to build a foundation in each of the basic and clinical science disciplines. Use the patient cases to begin this process and fill in appropriate information as dictated by the specific patient case. Remember that you should be determining what you want to remember forever, not just for today or tomorrow.
How do you formulate a learning issue? This is a very good question and different tutors and tutor groups have different approaches. You may find it effective to simply form a short phrase that defines the topic. For example, you could write glycolytic pathway, beta-oxidation, citric acid cycle, and electron transport chain as learning issues concerning how cardiocytes power their cellular activities. You could take a different approach and post the question "How does a cardiocyte power its contraction?" The same approach can be applied to other cells as you move from one C2000 unit to another. For examples, "How does a neuron power its cellular activities? or "How does a hepatocyte process the monosaccharides glucose and fructose?" The bottom line is that you should provide sufficient detail to defining the learning issues so that you have a very clear idea of what you need to research, learn, and apply for that specific patient case. Remember that there are experienced faculty present who can assist you in developing learning issues.
Typically, groups will begin to accumulate anywhere from a 6 to a 12 LIs during a patient case and there comes a point when students become overwhelmed and question whether there is enough time to cover all the material, especially when the group is meeting again in two days. Many tutors find it convenient to introduce the process of breaking down a problem into more manageable pieces and dividing the work among the group members. This is what we call "dividing learning issues." One approach is for the entire group to do a quick first-pass on a particular topic with one or more members responsible for thoroughly investigating the LI. When one or two students are responsible for processing a smaller amount of information for the larger group, the collective effort of the group generates quite a large amount of research. Using this method, the entire group can actively participate in group discussions.
More recently, tutor guides have been developed. The purpose of these guides, which vary from unit to unit, is to provide the non-expert tutors with an outline of the clinical case and prioritized learning issues. The advent of tutor guides has led to both a dramatic decrease in the number of learning issues and an increase in group-to-group consistent learning issues.
What many students have trouble with is the concept that even though LIs are divided, the collective information generated is still the responsibility of each individual group member. Thus, it is far easier to build a house with eight people than it is with one person and if those eight people then take an interest in what each person has done and ask appropriate questions, the result is that each person has increased his or her knowledge base tremendously. This does not prevent individuals from looking at each LI nor excuse them from understanding what the group is doing as a whole. Implicit in this process is the exchange of resource information and appropriate handouts and summary sheets.
A second approach is based upon prioritizing the LIs. Some tutor groups compile all their LIs during the first tutor group session of a patient case. The tutor group then decides which LIs to discuss in each of the subsequent sessions. It may be helpful to consider what you need to learn and at what depth for the present patient case. Begin by painting the landscape and then as you encounter the same or similar LI in another case, fill in more information. It is just as important to know something as it is to know what is missing. The more you know, the better you will reason through unfamiliar situations.
Over the past several years, I have favored the latter approach (prioritizing LIs). This method has resulted in more thorough, more sophisticated, and better focused discussions. I have found discussions to work more effectively for each student in a particular tutor group with some students being able to ask questions about a topic or point they don't understand while other students being able to provide effective explanations. Even with larger tutor group sizes (8 people), discussions have been richer in content and concepts and have involved all members of the group.
A special note should be made for disciplines such as biochemistry (see the C2000 biochemistry resource page) and behavioral science that stream through all the clinical patient cases. While it may not be the most effective method of approaching these learning issues, their constant presence throughout the curriculum should encourage you to revisit these topics time and again. A tacit assumption has been made by the faculty that you already possess (or are actively developing) the maturity to build a solid foundation (see Web Lessons for basic information) on which to add case specific complexities.
Another note should be made for the concept of learning issue relevance. It is sheer lunacy for medical students-in-training and faculty leading this training to think about the relevance of any learning issue. Relevance cannot be determined in the short term; it is something that is realized later in the profession. What is relevant is building a strong foundation in the basic and clinical sciences. It is this foundation knowledge that will allow you to reason through patient problems and assess conditions far too complex for other health-care workers.
Textbooks are the traditional and an important resource for learning material. PBL is an active-learning curriculum, so textbooks may be a first step in obtaining information. Many topics have been undergoing significant changes with enhancement of our knowledge occurring at a relatively quick pace. As a result, learn to use other resources. Use the Medical Resource Center and the University's Morris Library. Discuss topics with resource faculty. Remember that tutors aren't supposed to be experts for your tutor group when it's in session. They can be used during resource sessions, which sometime overlap with tutor group meetings.
The best method for two-legged resources is to have done some active research on a topic and if there are some questions about the information or lack of information, bring in an expert. Although faculty enjoy talking when asked a question, it will be far more important for you to know more than them and to use them for putting together concepts. Faculty vary, some remember few details but are excellent processors, others are experts on narrow topics.
C2000 uses a hybrid of the old curricula. While we define the curriculum as problem-based and active learning, there are scheduled optional resource sessions with the basic science faculty. Some faculty enjoy lecturing (a passive experience for you) and think that they should provide you with everything you need to know. Other faculty desire to create a more active learning experience. They challenge your knowledge and ability to apply what you have learned. You will need to accept both approaches and trust that the faculty have your best interests at heart in both the short and long term.
On a personal note, Dr. David King has designed, developed, and maintained a histology resource page for C2000. I have done the same for biochemistry and cell and molecular biology.
We encourage the use of flowcharts in understanding the patient problem. Flowcharts are simply diagrams that incorporate the information that has been collected about the patient case. The tutor group begins with some feature of the problem (sometimes the diagnosis, sometimes a symptom) and works through a logical thought process that connects each of the individual thoughts (primarily the LIs). The flow chart below illustrates what one might do with a soft tissue injury that results in swelling.
If you remember those computer flowcharts that begin with input, go to formulas and conditional statements, and finally arrive at a solution, you'll see the relationship. Be creative! Each individual step should focus on some aspect of the LIs and the underlying basic and clinical sciences.
For a nice example, see the flowchart (pdf 57K) developed by Scott Gilmore (Class of 2004).
After spending some time on an individual ePBLM, anywhere from 3 to 6 sessions, depending on the time of the year and the complexity of the case, you will get to a point where no more learning is perceived to take place. Most tutors and many students recognize when the group gets to this point and begin to suggest that the group wrap-up and prepare to move on to a new presenting situation or chief complaint (i.e., a new ePBLM). When this occurs, it is important to be able to summarize the learning and understanding that has taken place, using either a flowchart or stimulating group discussions of the learning issues. Groups will discuss their approaches to managing the patient case and consider what will be necessary for the patient in terms of long-term care, additional clinical procedures, social services, family interventions, etc.
But the excitement that surrounds the case typically focuses on what the ePBLM wrap-up section indicates was done for that particular patient. You will naturally want to know what the physicians did and their reasoning for performing specific physical examinations and clinical tests. The patient progress portion of the ePBLM contains this information, along with any consultant reports that were requested by the physician. There may be additional questions or LIs that result from the information that you receive. You will want to note that these LIs should be pursued and added to your on-going list of important topics. Remember that learning takes place before, during and after each case. The wrap-up is simply a convenient marker for reflecting on your progress during the unit.
The key to assessing yourself and the members of the tutor group is honesty, constructive criticism, and active listening. You are expected to become well-versed in this area because both your progress and that of your group mates depends on the richness of the information provided by you to your colleagues and the tutors. This is probably the most undeveloped and neglected activity during tutor group sessions and leads to differences of opinion between students and select tutors. If you are unable to contribute, you have not been fair to yourself and the group. Follow the Tutor Group Assessment Forms. They're well designed and contain valuable information that may assist you when you participate in group sessions. Read them ahead of time. Once you're familiar with the anticipated TGA categories, you can spend time in group listening to the other students and consider how they are addressing each area.
Remember that you should emphasize the importance of receiving feedback in the spirit intended by this curriculum. Be honest, constructive, and non judgmental! Glowing positive appraisals that lack descriptive information are relatively (even absolutely) worthless. You should act upon the information from your tutor group and use it to improve yourself as well as your interactions in the group.
C2000 uses objective assessments to gauge your on-going learning of important concepts and content. With the conclusion of each patient case, you will have assess to a collection of self-assessment questions (SAQs) written by faculty. The questions are designed to indicate the breathe and depth that you need to go in your learning. In addition, during each unit, resource sessions will be available to complement the work that you will be doing. Each of these activities should give you a fairly good idea of what you should learn in terms of content and concepts.
The end-of-unit assessment is a compilation of questions (primarily multiple-choice questions developed by faculty, although some older-style questions have not been culled from C2000) based upon the consensus LIs. The consensus LIs overlap significantly with the material associated with resource sessions. Select students may complain that we ask questions that do not result from the LIs associated with a particular patient case. While this may be an valid perception, it typically is a result of the resulting breathe and depth that a tutor group has taken with a particular LI. It would be unfair to you, to the curriculum, and to society to not challenge you with questions that prepare you for both the National Boards and a career in medicine.
Biochemistry and Molecular Biology Resources
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