1. PBL in the clinic Hong Kong 2004 Associate Professor Liz Farmer Co chair PBL Expert Advisory Group Flinders University

2. overview  Review PBL process  Clinical environment  Theoretical concepts in clinical PBL  Concepts of clinical expertise and PBL  One approach  Conclude and discuss

3. Definition of PBL  PBL is the learning that results from the process of understanding and resolving a problem-  the problem comes first in the learning process

4. Steps in the tutorial process Identify key information Generate / rank hypotheses

5. Identify key information Generate / rank hypotheses Explore and explain information QUESTIONSQUESTIONS KNOWLEDGE BASEKNOWLEDGE BASE

6. Identify key information Generate / rank hypotheses Explore and explain information QUESTIONSQUESTIONS KNOWLEDGE BASEKNOWLEDGE BASE

7. Identify key information Generate / rank hypotheses Explore and explain information QUESTIONSQUESTIONS KNOWLEDGE BASEKNOWLEDGE BASE Learning Issues Self-directed learning

9. Clinical environments  Clinical environments are increasingly stressed by service pressures but offer unparalleled opportunities for independent self directed learners:

10. Clinical PBL: theoretical aspects  Foley suggests Barrows’ 4 key elements must be present: Clinical context to facilitate recall and application Clinical context to facilitate recall and application Develop clinical reasoning processes Develop clinical reasoning processes Increases motivation for learning Increases motivation for learning Allows SDL Allows SDL

11. Constructivist learning  PBL is a form of constructivist learning  “Information-processing constructivism”  Savery and Duffy  “Eight instructional principles”

12. 8 Principles  Anchor learning activities to larger task or problem  Support ownership of problem  Authentic task  Design task to reflect complexity of environment the learner should be able to function in at completion  Ownership of process to develop solution  Design environment to challenge thinking  Encourage testing of alternative views and contexts  Provide opportunity for and support reflection on content learned and the learning process

13. Evidence for Claims of PBL Schmidt  Problem is context for learning  Problem is activator of prior knowledge  Small-group discussion as means of elaboration and knowledge construction  Learning is intrinsically motivated  Learning is self-directed

14. Why context?  Context facilitates and affects recall: “grocery store”  Royal navy divers Baddely 1976

15. Context dependent memory   Learned on landLearned underwater 0 5 10 15 20 25 30 35 40 45 50 Percentage of words recalled Recalled on land  Recalled underwater

16. Role of context in expertise (Hobus et al, 1995)

18. Activating prior knowledge  Activating prior knowledge facilitates processing of new information  Activation and elaboration at time of learning enhances recall and transfer of that knowledge (Schmidt 1993)

19. Activating means problem first plus discussion  recall is context dependent  Students presented with problem first plus attempts to solve and explain do better in long term recall than those where problem presented and explained all at once

20. A theory of clinical knowledge A theory of clinical knowledge  George Bordage 1. Reduced: absent or inaccessible 2. High / dispersed lacks organization 3. High / elaborated organized, modelled or structured to more global and accessible representations of the problem 4. High / compiled elaborated networks condensed by experience, does not engage in detailed reasoning, uses other factors such as pattern recognition

21. Dispersed: Flight Connections SIB Airlines Maastricht - Amsterdam vv Maastricht - Brussels vv Amsterdam - Hamburg vv Amsterdam - Edinburgh vv Amsterdam - Brussels vv Amsterdam - London (Gatwick) vv Brussels - Paris vv Brussels - London (Heathrow) vv Manchester - London (Heathrow) vv

22. Elaborated Flight Connections SIB Airlines

23. Diagnostic accuracy of medical students: Schmidt Subjects: 205 medical students Material: 30 cases covering major organ systems

24. Expertise growth as a result of experience 010203040 0 2 4 6 8 10 12 14 r =.68 Diagnostic Accuracy Years of Experience

25. Memory and Expertise Possible PositionBizarre Position

26. The Results 0 25 50 75 100 % Correct GrandmasterMasterNovice Level of Expertise Class A player

27. expertise  Extensive application allows knowledge to be compiled and subsumed  When faced with non-routine problems experts’ causal models are more coherent, account for more data and are more accurate (Norman 1994)

28. Why focus on explanatory structures?  Aim is to bring students to high elaborated knowledge levels in each context

29. A theory of clinical knowledge A theory of clinical knowledge  George Bordage 1. Reduced: absent or inaccessible 2. High / dispersed lacks organization 3. High / elaborated organized, modelled or structured to more global and accessible representations of the problem 4. High / compiled elaborated networks condensed by experience, does not engage in detailed reasoning, uses other factors such as pattern recognition

30. One approach: “Live clinical PBL”  Lead student sees patient chosen with tutor  Lead student presents case as PBL Tut 1  Group discuss hypotheses and further information required (? Tutor required)  Group SDL while lead student follows up patient  Tutorial 2 group presents work in context, student offers follow up data, progress and actual management  Tutor present; gives clinical feedback only at the end of the session

31. conclusions  Clinical expertise is complex  Theory and evidence can underpin our approach to the learning environment: PBL process PBL process Nature of expertise Nature of expertise  Clinical PBL helps to integrate these domains  Exciting opportunities for GP educators