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

HMS Academy 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?

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

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

Expertise and Creativity Cognitive process Dimension

Problem-based Learning HMS Academy

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

PBL Principles Norman 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

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

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

Thinking Approaches Modified from Pottier et al. Med Ed 2010 Inductive ReasoningDeductive Reasoning

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

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?

Case-based Learning HMS Academy

Case-Based Learning Guided inquiry Tutor as discussion leader Teacher > student determines learning goals More focused discussion

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

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 HMS Academy Srinivasan et al. Acad Med 82:74;2007

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

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

Team-based Learning HMS Academy

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

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

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 HMS Academy Koles et al. Acad Med 85:1739;2010

TBL Process HMS Academy Michaelsen et al. 2008

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 HMS Academy Haidet et al. Acad Med 77:40;2002

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

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

CBCL HMS Academy

Case-Based Comparative Learning (CBCL) PBL CBL TBL Peer instruction

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

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

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

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

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

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