Problem Based Learning at the Fiji School of Medicine

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Problem Based Learning at the Fiji School of
Medicine Presentation for
45th Annual Scientific Conference
Fiji Medical Association Joseph A.
Flear, MD MBBS Program Coordinator Fiji School of
Medicine
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Problem-Based Learning at the FSM History of
Problem Based Learning History of PBL at FSM
Overview of the MBBS Curriculum What is
Problem-Based Learning? How does PBL
work at FSM? Mr Kumar, a 38-year-old
with chest pain Assessment and
Evaluation Does PBL really work
at the FSM?
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The History of Problem Based Learning
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• History of Problem Based Learning
• McMaster University (Canada)
• University of Limburg, Maastricht
• 
  (Netherlands)
• University of Newcastle (Australia)
• University of New Mexico (US)

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• History of Problem Based Learning
• From its origin at McMaster . . .
• PBL has been adopted at other medical schools
  through the 1970's and 1980's.
• Medical schools in almost every country of the
  world use PBL
• PBL has spread into other disciplines nursing,
  dentistry, pharmacy, and veterinary medicine.

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• History of Problem Based Learning
• In the Pacific . . .
• Pacific Basin Medical Officers Training
• Program (Pohnpei) (late 1980s)
• John A Burns School of Medicine,
• University of Hawaii
• Fiji School of Medicine (early 1990s)
• University PNG Faculty of Medicine (2000)

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A Brief History of Problem-Based Learning at the
Fiji School of Medicine
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• History of PBL at FSM . . .
• 1987 coup
• departure of expatriate and local faculty
• withdrawal of regional students
• survival of the FSM at stake
• A Medical Education Task Force was commissioned
  by WHO in 1988

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• History of PBL at FSM . . .
• A major concern in 1970s and 80s
• high attrition rate among Year 1 students
  (especially regional and Fijian students)
• up to 70 exited the program after failing
  general science subjects
• of those progressing to Year 2, a further 40
  failed eventually to qualify

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• History of PBL at FSM . . .
• The Task Force recommended that FSM change its
  curriculum
• . . . from a multidisciplinary, non-integrated,
  sequentially-hurdled, and didactically-based
  educational approach
• . . . to an integrated, interdisciplinary,
  problem based learning curriculum.

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• History of PBL at FSM . . .
• WHO then commissioned the design of a new
  curriculum for FSM
• Consultants reviewed PBL models from Newcastle
  and the PBMOTP
• A new MBBS curriculum introduced in 1992

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• History of PBL at FSM . . .
• Primary Care Practitioner exit degree
• Diploma in Primary Care Practice conferred after
  3 years of schooling
• PCPs could be registered as practitioners after
  an internship year
• PCPs could return to FSM for an additional two
  years of hospital training, and be awarded the
  MBBS degree

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History of PBL at FSM . . . Support for
the new curriculum within FSM was generally
enthusiastic . . . . . . but there was also
vociferous opposition from some faculty and from
members of the medical profession outside
FSM. The new curriculum was introduced in 1992,
and ran until 1995.
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• History of PBL at FSM . . .
• The PCP experience was disappointing
• Health Ministries could not fit PCPs into
• their workforce
• What in heavens name is a PCP?
• Nurses fill this role already.
• PCP supervision poor or non-existent
• Returning PCPs deficient in the basics
• Scholarship funding agencies found a two-
• exit program difficult to accommodate

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• History of PBL at FSM . . .
• 1997 PCP exit degree formally abolished
• The Year 4 PCP internship was scrapped, to
  become a Year 6 Training Internship, and include
  both hospital and community training
• The first class of MBBS students to complete a
  Year 6 Training Internship did so in 2001.

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• History of PBL at FSM . . .
• 1998 Comprehensive curriculum review
• Undertaken with the assistance of two medical
  educationists from Australia
• Curriculum objectives were more clearly
  defined, with a better framework for delivery
• Major curriculum changes incorporated into all
  years of MBBS program from 1999.
• Students enrolled as MBBS-1 students in 1999 will
  graduate in 2004.

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History of PBL at FSM . . . Current MBBS
Program at FSM 3 years of Problem-Based
Learning 2 years of Clinical and Community
Medicine attachments 1 year Training Internship
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Overview of the MBBS Curriculum
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MBBS Curriculum Overview MBBS-1 PBL -
Systems modules Orientation 3
weeks Homeostasis 2 weeks Musculoskeletal
System 6 weeks Blood/Immune System 8
weeks Cardiovascular System 7 weeks Ear, Nose,
Throat 2 weeks Respiratory System 7 weeks
35 weeks
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MBBS Curriculum Overview . . . MBBS-2
PBL - Systems modules Gastrointestinal
System 9 weeks Urinary System 5 weeks Endocrine
System 6 weeks Reproductive System 4
weeks Nervous System 10 weeks Eye 2
weeks 36 weeks
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MBBS Curriculum Overview . . . MBBS-3
PBL - Aetiologies, Management Genetics 3
weeks Cancer 3 weeks Immunology 3
weeks Respiratory 4 weeks Infectious
Diseases 5 weeks Gastrointestinal / Nutrition 2
weeks . . .
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• MBBS Curriculum Overview . . .
• MBBS-3 PBL - Aetiologies, Management. . .
• Endocrine 3 weeks
• Renal 1 week
• Musculoskeletal 3 weeks
• Cardiovascular 4 weeks
• Psychiatry 4 weeks
• Gynaecology 1 week
• 36 weeks

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• MBBS Curriculum Overview . . .
• MBBS 4/5 Eight 9-week Attachments
• Paediatrics
• Surgery
• Medicine
• Obstetrics / Gynaecology
• Psychiatry
• Special Topics (Ophthalmology, Radiology,
  Dietetics, Physiotherapy, Anaesthesia)
• Community Health 1
• Community Health 2
• 72 weeks

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MBBS Curriculum Overview . . . MBBS 6
Training Internship Lautoka Hospital (18
weeks) Hospital-based tertiary care
experience Community Health Centre (18
weeks) Primary care and public health
experience 36 weeks
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What is Problem-Based Learning?
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• What is Problem Based Learning?
• In the PBL learning process . . .
• Students attempt to solve a problem
• . . . with information they already possess,
• allowing them to appreciate what they already
  know
• . . . and identifying what they need to learn,
• to better understand the problem and how to
  resolve it

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• What is Problem Based Learning?
• In the PBL learning process . . .
• . . . engaging in self-directed study,
• to research the information needed
• . . . using a variety of information sources
• books, journals, online information, etc.
• people with relevant expertise

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• What is Problem Based Learning?
• In the PBL learning process . . .
• . . . returning to the problem to apply what they
  learned
• . . . in order more fully to understand and
  resolve the problem.

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What is Problem Based Learning? How does
teaching / learning in a PBL curriculum differ
from that in the traditional curriculum?
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• What is Problem Based Learning?
• Traditional . . .
• Rote learning
• Memorisation of facts
• vs PBL . . .
• Understanding of concepts
• Reasoning, from hypotheses, to testing
• of hypotheses, to solution
• Facts are learned in the context of
• clinical reasoning

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What is Problem Based Learning?
Traditional . . . Excessive details, which
often turn out to be irrelevant (though we dont
realize that until years later) vs PBL . .
. Information relevant to the solution of the
problem
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What is Problem Based Learning?
Traditional . . . Basic sciences are taught
in isolation, emphasising coherence within each
discipline, and integrity of the discipline vs
PBL . . . A clinical frame of reference is the
starting point, and all of the disciplines are
integrated in solving a clinical problem.
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What is Problem Based Learning?
Traditional . . . Public Health disciplines
(Epidemiology, Environmental Health, Health
Promotion, Health Services Management, etc) are
taught separately, stressing discipline
coherence vs PBL . . . A clinical or community
health frame of reference integrates all of the
disciplines in solving a problem.
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• What is Problem Based Learning?
• The role of teacherin traditional curriculum
• the center of attention
• provides direct instruction
• disseminates information, to be received by
  the students

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• What is Problem Based Learning?
• The role of the teacher (tutor) in PBL
• Guide asks students not so much what
• they know, as how they know it
• Skeptic asks students to examine their
• thinking
• Not a teacher as such . . .
• does not provide the "right answer"
• is not the primary source of information

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• What is Problem Based Learning?
• The role of the student in PBL
• Do-er suggests solutions
• Skeptic questions and critiques
• Instructor explains ideas, clarifies
• puzzling issues
• Scribe records what transpires
• Conciliator resolves conflicts

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How does Problem-Based Learning work at the Fiji
School of Medicine?
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• How does PBL work at the FSM?
• The Tutorial Group
• Years 1 to 3 classes contain 70 students
• about 60 from Fiji
• the rest from regional countries
• Each class is divided into 7 groups, 10 students
  per group
• each group balanced by gender, country
• for those from Fiji, by ethnic background

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• How does PBL work at the FSM?
• The Tutorial Group . . .
• remains together for half the year
• is assigned a tutor from the pool of
  dedicated tutors
• meets with the tutor for a two-hour tutorial
  twice each week, on Tuesdays and Fridays
• and again together on their own, without the
  tutor, twice each week

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• How does PBL work at the FSM?
• The Tutorial Process
• In the first tutorial, the students . . .
• . . . receive a Trigger
• . . . identify cues to focus their thinking
• . . . generate hypotheses to explain the
  problem, focusing on mechanisms to describe
  possible causes, and effects

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• How does PBL work at the FSM?
• In the first tutorial, the students . . .
• . . . recall knowledge they already have, figure
  out what they still need to know
• . . . ask the tutor for further specific
  information from the patients history (or
  physical exam, or investigations), in an attempt
  to prove or disprove their hypotheses

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• How does PBL work at the FSM?
• In the first tutorial, the students . . .
• . . . re-evaluate and re-rank their hypotheses
  based on the new information
• . . . identify learning issues for study and
  exploration in the next few days, before the next
  session.

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• How does PBL work at the FSM?
• Between sessions (3 days)
• independent self-directed study
• formal resource sessions, to help grasp the
  more complicated concepts
• a self-directed tutor-less group meeting, to
  discuss the learning issues and prepare for the
  next formal tutorial

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• How does PBL work at the FSM?
• In the second tutorial, the students . . .
• . . . discuss what theyve discovered of the
  learning issues from the first session

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• How does PBL work at the FSM?
• In the second tutorial, the students . . .
• . . . discuss what theyve discovered of the
  learning issues from the first session
• . . . apply what theyve learned to the case,
  re-evaluating and re-ranking their hypotheses
• . . . identify their need for more information
  about the patient

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• How does PBL work at the FSM?
• In the second tutorial, the students . . .
• . . . obtain this information from the tutor,
  and justify their need for it (as the case
  scenario unfolds incrementally over the four
  sessions)
• . . . identify a new set of learning issues for
  study and exploration before the next session

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• How does PBL work at the FSM?
• Between sessions (3-4 days)
• . . . as earlier . . .
• In the third and fourth tutorials . . .
• . . . discussion of new learning issues
• . . . re-evaluating hypotheses
• . . . further patient information is given
• . . . continued unfolding of the case

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• How does PBL work at the FSM?
• In the final tutorial . . .
• . . . students present a full summary of the
  case
• . . . describe the mechanisms which link the
  cause of the problem to findings on history,
  physical exam, and investigations
• . . . and how treatment and management further
  reflect what theyve learned of mechanisms

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• How does PBL work at the FSM?
• The PBL tutors at FSM
• a dedicated tutor pool of PBL tutors
• current pool all have a medical degree
• receive an orientation to PBL tutoring
• are mentored by an experienced PBL
• tutor for several weeks
• before being assigned a tutorial group

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• How does PBL work at the FSM?
• The PBL tutors . . .
• receive a tutor pack one week ahead
• Patient Data Sheet case details on the
  history, physical, investigations, etc.
• Tutor Guide extensive instructions on the
  incremental unfolding of the case
• with numerous suggested how and why
  questions to pose to students

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• How does PBL work at the FSM?
• At the conclusion of each PBL problem, the tutors
  meet with the Program Coordinator for a
  de-briefing meeting . . .
• to discuss any problems with the PBL scenario
  just concluded
• to review the new PBL scenario which is to
  start
• to keep tabs on any problem students

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How does PBL work at the FSM? Learning
Issues Each PBL case is constructed such
that a set of Core Learning Issues, which form
part of the overall curriculum objectives,
inevitably arise out of the particulars of the
case.
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How does PBL work at the FSM? Learning
Issues Each discipline has devised a set of
curriculum objectives, its discipline
map These learning issues are woven through
the PBL problems in Years 1 to 3 (and then on
into Year 4 to 6) . . . The spiral concepts
introduced in early problems become prior
knowledge for concepts introduced later
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How does PBL work at the FSM? Learning
Issues Depending on the individual case,
Learning Issues may be identified in Anatomy,
Physiology, Biochemistry, Microbiology,
Pathology, Pharmacology Medicine, Paediatrics,
Obstetrics, Surgery, Psychiatry
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How does PBL work at the FSM? Learning
Issues Learning Issues may be identified in
. . . Public Health disciplines Epidemiology,
Environmental Health, Nutrition, Health
Promotion, Health Services Management,
etc. Personal / Professional Development
(Ethics, Forensic Medicine, etc)
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How does PBL work at the FSM? Learning
Issues A study guide outlining the topic
has been devised by the discipline
expert Highlights key points, sets boundaries
for how deeply or widely to probe the
topic Distributed to students at the end of the
tutorial
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How does PBL work at the FSM? Resource
Sessions Formal sessions, conducted by the
discipline experts, to explain the more
complicated concepts Ideally interactive
answer student queries, address student
puzzlement, rather than simply provide
information which the students have most likely
already found and read on their own
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• How does PBL work at the FSM?
• Resource Sessions
• Consist of
• interactive full class sessions
• practical laboratory sessions
• Microbiology
• Anatomy
• Pathology
• Haematology

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• How does PBL work at the FSM?
• Fixed Resource Sessions
• Bones and anatomy models
• Pathology specimens
• X-rays
• Microscope slides and culture plates
• etc.

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• How does PBL work at the FSM?
• Clinical skills
• A discipline map of learning objectives threads
  its way through the problems
• Students learn history-taking and physical
  examination skills in the context of the PBL
  problems
• A didactic demonstration session is followed by
  a hands-on practice session where students
  practice on each other

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• How does PBL work at the FSM?
• Early clinical exposure
• Clinic attachments in the Suva area . . .
• Maternal and Child Health Clinics
• Family Planning Clinics
• Outpatients Clinics
• Antenatal Clinics (Nausori)
• Specialty Clinics Oxfam, Diabetes,
• Eye, Skin, TB, Physiotherapy,
• Rehabilitation Clinics

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• How does PBL work at the FSM?
• Early clinical exposure . . .
• Objectives for the students
• to experience genuine clinical situations
• to interact with patients and staff
• to become familiar with the services
• offered at the health centres
• to set their own learning goals based on
• the clinics they attend and patients
• they see

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• How does PBL work at the FSM?
• Early clinical exposure . . .
• Objectives for the students
• to use their experience in the clinics in the
  tutorials, in order to enrich their study of the
  clinical problems in the curriculum
• to use what they learn in the tutorials in the
  clinics, to enrich their learning there as well

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The first tutorial of a recent MBBS-1 PBL problem
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Mr. Kumar, a 38-year-old man, is
brought to the Health Centre with severe chest
pain for the past several hours, which started
while he was doing some heavy work in his shop.
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• Mr Kumar, a 38-year-old with chest pain
• During this 3-week problem, the students will
  study such Core Learning Issues as
• What is the anatomy of the chest and structures
  inside the chest?
• What is the blood supply of the heart?
• What happens when the blood supply of the heart
  is blocked? The pathology of infarction
• What are the effects of myocardial ischaemia
  and infarction on the function of the heart?
• . . .

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• Mr Kumar, a 38-year-old with chest pain
• How do we assess a patient with chest pain, and
  confirm the diagnosis of myocardial infarction?
  Clinical features and investigations
• How do we measure the electrical activity of
  the heart? An introduction to the ECG
• Principles of management of a patient with a
  myocardial infarction
• Nutritional aspects of non-communicable
  diseases diet, body weight, and Body Mass
  Index and their relation to the risk of NCDs

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• Mr Kumar, a 38-year-old with chest pain
• As well as the following Core Learning Issues in
  Public Health
• Types of epidemiological study Descriptive and
  cross-sectional designs.
• What is a cohort study (with the Framingham
  study as a model)? What is a relative risk?
• Epidemiology of coronary artery disease in Fiji
  and the Pacific
• The concept of burden of illness using
  cardiovascular disease as a model

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• Mr Kumar, a 38-year-old with chest pain
• Principles of prevention as applied to NCD's
  primary, secondary, and tertiary prevention
• Nutritional interventions to prevent NCDs
• How do we change peoples behaviour or
  lifestyle in order to prevent lifestyle diseases
  issues of culture, belief, and practices as
  related to food and activity

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Mr Kumar, a 38-year-old with chest pain Core
Learning Issue What is the blood supply of
the heart? Built on prior knowledge . . . . .
. 4 weeks previously Gross anatomy and
histology of the heart, in a fight or flight
reaction PBL problem . . . just previously
Anatomy / histology of arteries and veins, in
a two-scenario PBL problem of peripheral
arterial disease and deep vein thrombosis
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• Mr Kumar, a 38-year-old with chest pain
• Core Learning Issue
• What happens to heart function in infarction?
• Built on prior knowledge . . .
• . . . in the fight or flight reaction PBL
  problem
• Physiology of the normal heart, including
• Starlings Law, contractility, force of
  contrac-
• tion, its relation to end-diastolic volume,
  etc
• Physiology of the sympathetic NS, what
• stimulates it, and its effect on heart rate,
  
• contractility, peripheral resistance, etc.

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• Mr Kumar, a 38-year-old with chest pain
• Core Learning Issue
• What is a cohort study?
• Built on prior knowledge . . .
• . . . in a Semester 1 PBL problem on Anaemia
• proportions, ratios, rates within populations
• the concept of distribution and determinants
• of disease (using the Fiji National
  Nutrition
• survey)
• . . . in the Peripheral Vascular Disease problem
• the concept of risk factors
• the concept of the web of causation

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• Mr Kumar, a 38-year-old with chest pain
• Core Learning Issue
• How do we change peoples behaviour?
• Built on prior knowledge . . .
• . . . in a Semester 1 PBL problem, of a child
  with a
• fracture after being struck by an
  automobile
• the Ottawa Charter, and its five elements of
• health promotion
• Built on current events and personal experience
• How do we deal with a Coca-Cola machine
• on the FSM Tamavua campus?

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Assessment and Evaluation
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• Assessment and Evaluation
• Assessment
• Written Exams several times during the year,
  plus an end-of-year final exam
• case scenario-based
• integrated across all disciplines
• set and vetted by an integrated team (anatomy,
  physiology, pathology, microbiology,
  biochemistry, public health, etc)

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• Assessment and Evaluation
• Assessment . . .
• Practical / Clinical Exams once during the
  year, plus an end-of-year final exam
• Practical stations in anatomy, pathology,
  microbiology, public health
• Clinical stations in history-taking, physical
  examination techniques

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• Assessment and Evaluation
• Formative assessment
• Attendance at tutorials, resource sessions
• Tutor assessment of tutorial performance
• Learning Portfolio
• Student presentations

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Assessment and Evaluation Assessment . .
. Students with a poor attendance record, or who
fail an exam, are issued a formal letter, and
requested to meet with the Program Coordinator
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• Assessment and Evaluation
• Evaluation
• Exam results analysed for deficiencies
• students caught up in a later problem
• the problem is changed in future
• the exam is altered in future
• the discipline spiral is reshuffled
• External examiners evaluate assessment
• procedures, provide recommendations

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Assessment and Evaluation Evaluation . . .
Students submit an evaluation for each PBL
problem Study guides, resource sessions,
web-based resources, etc. Students provide
written feedback on their tutors twice a
year Students meet with the Program Coordinator
at the end of each year
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Does PBL work at the FSM?
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• Does PBL work at the FSM?
• A marked decrease in the attrition
• rates of the 1970s and 1980s
• Anecdotal reports
• FSM graduates of the early 1980s and 1990s who
  return as faculty report a change for the better
• Faculty at overseas hospitals which accept FSM
  Year 4 and Year 5 elective students express
  satisfaction

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• Does PBL work at the FSM?
• WHO-sponsored World Federation of Medical
  Education team (Deans from University of
  Queensland, James Cook University, UPNG)
  evaluated MBBS Curriculum in 2002, and reported
  favorably
• External examiners evaluate end-of-year
  assessments of MBBS 1 to 3 students each year,
  and report favorably

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• Does PBL work at the FSM?
• In the years since the turbulent 90s
• The PBL curriculum has settled, with few new
  changes in recent years
• Curriculum objectives and mode of delivery are
  now clearly defined, with only minor alterations
  from year to year
• The students are no longer troubled by frequent
  curriculum changes

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• Does PBL work at the FSM?
• In the years since the turbulent 90s . . .
• A dedicated tutor pool has contributed greatly
  to stability within the PBL curriculum
• Current group of discipline experts are nearly
  all physicians, are enthusiasts of the PBL mode
  of curriculum delivery, and more readily now run
  their own sessions interactively rather than
  didactically

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• Does PBL work at the FSM?
• In the years since the turbulent 90s . . .
• Weekly clinic attachments for MB 1-3 students
  in the greater Suva area have enriched the
  students clinical experience beyond the
  classroom, with a marked improvement in student
  self-confidence in the end-of-year OSCE.

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• Does PBL work at the FSM?
• In the years since the turbulent 90s
• Students complain now of the didactic resource
  session which only repeats information they
  already know the references they cant find in
  the library their inability to access useful
  internet sites from the schools computers
• BUT, almost without exception praise the
  tutorials where we learn so much.

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Oooh . . . that is SO cool !