Teaching Formats for the Pre-clerkship Curriculum

1. Teaching Formats for the Pre-clerkship Curriculum Overview And Presentation of Hybrid Model HMS Academy

2. Professional Competencies “competency” – “an individual’s ability to make deliberate choices from a repertoire of behaviors for handling situations and tasks in specific contexts of professional practice” Govaerts MJB. Medical Education, 2008;42:234 How do we best achieve this for physicians? HMS Academy

3. Goals Today At the end of the session, you should be able: • To describe the educational principles underlying PBL, CBL and TBL • To link these principles to the goals of the new HMS curriculum • To explain how CBCL blends elements of each of the other teaching approaches • To design a teaching session that uses some or all of these elements. HMS Academy

4. Our Curricular Goals • Enhance accountability and responsibility of students for learning • Enhance student preparation for learning sessions • Shift bulk of “transfer of content” from faculty to self-study and small group study • Emphasize creation of frameworks, application of knowledge and problem solving/analysis in teacher-student interactions HMS Academy

5. Expertise and Creativity Cognitive process Dimension HMS Academy

6. Problem-based Learning HMS Academy

7. Problem-Based Learning: Theory • Open inquiry • Exploration/journey: students generate learning objectives and means to reach them • Construct knowledge HMS Academy

8. PBL PrinciplesNorman and Schmidt, Acad Med, 67:557, 1992 • Student’s prior knowledge of the problem is insufficient to understand it in depth • Questions arise which serve as learning goals for self-directed learning • Teacher as “guide” • Learning knowledge in setting of problems fosters retention • Enhanced motivation to learn HMS Academy

9. PBL and Cognitive Theory • Activation of prior knowledge facilitates subsequent processing of new information • Elaboration of knowledge at the time of learning (e.g., discussion, answering questions) enhances subsequent retrieval • Transfer: “….concept or principle learned in one context can be transferred or applied to a problem…different in initial appearance…requires the same principles for solution.” HMS Academy

10. Enhancing Transfer Expt: A) Solve a problem and receive feedback about the approach taken to solve the problem vs. B) read and remember a problem and have the solution explained to you • Group A – transferred concept to new problem 90% of time • Group B – transferred concept to new problem 60% of time HMS Academy

11. Thinking ApproachesModified from Pottier et al. Med Ed 2010 Inductive Reasoning Deductive Reasoning

12. Analytical Reasoning Boshuizen and Schmidt 1990 • PBL vs traditional curriculum • Task: Example: explain how a metabolic deficiency and a specific disease could be related • Groups: students, biochemists, internists • PBL students and biochemists  explored underlying biochemical principles, then linked to clinical prob (inductive; reasoning) • Traditional students/internists  searched memory for direct answer to question (pattern recognition) • PBL students and biochemists more accurate HMS Academy

13. Problem-Based Learning: Concerns • Content gaps • Tutors: content vs. process experts (facilitators) –studies show more errors possibly linked to limited knowledge of “guides” • Only do this for few sessions/week – will it really have an impact? HMS Academy

14. Case-based Learning HMS Academy

15. Case-Based Learning • Guided inquiry • Tutor as discussion leader • Teacher > student determines learning goals • More focused discussion HMS Academy

16. Principles of Case-Based Teaching • Creative problem-solving with some advanced preparation • Students and facilitators share responsibility coming to closure in key learning points • Students may ask clarifying questions of faculty during session • Guided inquiry; elaboration of knowledge HMS Academy

17. Comparison of PBL and CBL PBL • Preparation: None for students; lots for faculty • Control: student direct discussion; faculty provide no direction • Data seeking: students lots of additional data sought; faculty some CBL • Preparation: some to lots for student; lots for faculty • Control: students provide some direction; faculty provide some direction • Data seeking: students some; faculty no additional data sought Srinivasan et al. Acad Med 82:74;2007 HMS Academy

18. Case-Based: pros/cons Pros • Open-ended discussion, debate • Efficient, goal directed • Focus learners on key points • Structured approach to problem-solving Cons • Stifles curiosity? • Requires intensive faculty development • Spoon feeding mentality (always expect experts to have answers)? HMS Academy

19. PBL vs CBL Srinivasan et al. Acad Med 82:74;2007 PBL CBL Focus on the journey or the destination or both? HMS Academy

20. Team-based Learning HMS Academy

21. Team-Based Learning • Practice using concepts to solve problems • Requires explicit preparation – Readiness assessment process (RAP) with frequent “tests” and feedback • Allows for fewer faculty; peer instruction HMS Academy

22. TBL – Key principles • Accountability: students must be accountable for preparation & quality of individual and group work • Feedback: students must receive frequent and timely feedback • Assignment design: group assignments must promote learning and team development Michaelsen et al. Team-based Learning: Small group learning’s next big step, 2008 HMS Academy

23. TBL Sequence • Preparation: learners study an advance assignment • Readiness assessment: learners demonstrate knowledge through individual and group readiness exercises • Application: learners apply concepts to problem-solving exercises Koles et al. Acad Med 85:1739;2010 HMS Academy

24. TBL Process Michaelsen et al. 2008 HMS Academy

25. TBL: Nature of Tasks • Stimulate higher-level cognitive skills (student makes a judgment based on application of a concept, not just identify a concept) • Requires broad participation within small group to achieve consensus • Leads to competing solutions among groups Haidet et al. Acad Med 77:40;2002 HMS Academy

26. TBL Advantages • Preparation and accountability • Mandates commitment to an answer • Peer instruction • Debate and defense of solutions to problems; enhance thinking skills, analysis • May be particularly useful for weaker students (Koles et al., 2010) HMS Academy

27. Is there one right pedagogical approach? “From a cognitive perspective, to achieve the goal of acquiring facts and concepts, it may be equally efficient to have students approach written problems individually or in small groups without a tutor, and then use faculty teachers for synthesis and explanation of the problems’ solutions.” Norman and Schmidt, Acad Med 1992 HMS Academy

28. CBCL HMS Academy

29. Case-Based Comparative Learning (CBCL) CBL PBL TBL Peer instruction HMS Academy

30. Elements of CBCL - Proposed • Self study: explicit assignment for study of content with “thought questions”/task(s) –must have answer (commit) • Readiness assessment (personal) – content based, MCQ (delivered electronically in evening) • Small group (next morning, tutorless, PBL-like) – 45 mins. Review assignment, achieve consensus on task • Intermediate group – 90 mins • Simultaneous reveal by group; discussion – 15 mins • New case vignette: TBL approach (individual, small group consensus, large group discussion) – 30 mins • Additional cases(s) discussed CBL format – 45 mins HMS Academy

31. Gas Exchange – An example • Assignment (afternoon and night): • Read syllabus notes and think about embedded quests • Review virtual histology of lung tissue and path slides of emphysema and pulmonary fibrosis; review anatomy of pulmonary circulation; concept videos: A) CO2 elimination; B) hypoxemia • Do readiness assessment exercise • Answer thought question: Create a physiological hypothesis to explain why a patient with V/Q mismatch is more likely to have hypoxemia than hypercapnia. HMS Academy

32. Gas Exchange – An example • Small group (tutorless session) • Discuss readings and anatomy/histology/pathology assignment; review anatomy models/resources as needed • Discuss answers to thought question; achieve group consensus HMS Academy

33. Gas Exchange – An example • Intermediate size group • Discuss answers to assigned task – simultaneous reveal of group hypotheses • New TBL assignment: Create a physiological hypothesis to explain why chronic hypercapnia would reduce dyspnea in a patient with emphysema. • Additional CBL discussion: Breathing pattern and gas exchange; EtOH intoxication/vomiting/gas exchange HMS Academy

34. Our Curricular Goals • Enhance accountability and responsibility of students for learning • Enhance student preparation for learning sessions • Shift bulk of “transfer of content” from faculty to self-study and small group study • Emphasize creation of frameworks, application of knowledge and problem solving/analysis in teacher-student interactions HMS Academy

35. Summary • Keep our eye on key principles • Demand preparation by students • Accountability for their learning • Value of peer/team learning • Readiness assessment; frequent feedback • Push for understanding, application, analysis • A hybrid model (PBL + CBL +TBL = CBCL) or variants thereof can work. HMS Academy