President's Message - Practice Based Learning
by Mike Fotis, ICHP President
January 9, 2014
You have probably worked with or served as a preceptor for pharmacy students and recent grads who completed courses in pharmacy school that followed a Practice Based Learning (PBL) teaching strategy. If you are a PGY-1 or PGY-2 resident preceptor who has completed Residency Learning System (RLS) training, you have likely been at least introduced to this concept. Many of the medical students and recent medical graduates that you interact with every day were taught using PBL methods. It is very likely that your kids, and for a few of us, your grandchildren are being taught by this method right now!
Once we entered college most of us were taught by the traditional lecture based strategy. In a four credit hour course, 3 one hour lectures were supplemented by a one hour discussion session led by a graduate student. The professor presented material in an organized and often (but not often enough) interesting manner. The grad students answered our questions, and led discussions that often helped us apply the information to structured situations. Attending a lecture is an effective way to gather facts, but students end up in a passive rather than active mode, and if you now serve as faculty or as a preceptor, you might have noticed that students might not remember these facts for very long after the final exam. As a preceptor I can attest that fact-based learning doesn't help very much with application and analysis skills, doesn't promote working as a part of a team, and doesn't help to develop the learning skills needed to be successful in experiential training.
For the past couple of years I have had the opportunity to serve as a tutor for Clinical Medicine using PBL methods. This year I also have PBL experience for parts of Pharmacology and for Medical Decision Making courses. In PBL the responsibility for learning rests squarely on the student. Each week in Clinical Medicine, an unstructured real life clinical case serves as the basis for our three weekly discussions. There are also lectures that help to introduce the material needed to address the patient case. In the first PBL session, students interview a virtual patient to gather data, formulate a problem and generate hypotheses. A virtual exam is conducted in the second session and the students use this information to rank and test hypotheses while later in the week lab tests and imaging are used to re-rank hypotheses. In the third session, hypotheses undergo further testing, and if an intervention is needed, a treatment plan is developed which may or may not include medications.
As you might expect, since the material is new to the students there are numerous issues that require further study. The students determine whether or not there is a “learning issue” (LI) and each student presents a summary of the learning issues at the next class. The students are dependent on each other to prepare a timely, thorough, and well referenced learning issue at each PBL class session. In the first year of this experience I was also serving as a preceptor for pharmacy students and often found myself pointing out in discussion with the pharmacy students that I thought the students had an LI and asked which of them were going to take responsibility for the LI. The pharmacy students looked at me in amazement wondering if having an LI was a healthy or unhealthy diagnosis! Believe it or not, the pharmacy students tended to like working in this manner (once I explained an LI was a Learning Issue), so I tended to use a modified PBL technique quite often.
It’s not easy serving as a PBL tutor, especially for me. As the teacher, you need to keep your mouth shut much more frequently than I am used to doing. It is best to let the students work together to solve the patient case, even though as an instructor, I am sorely tempted to help them. Many times you need to provide hints, but even though I had completed some formal and experiential PBL training provided by the University, I found that my hints alternated from too obvious, giving away the answer, to so obscure the students had no idea what I was talking about. Last year I was better at providing hints, and this year I think I have it figured out. The trickiest scenario is when the students have overlooked an important issue, or have misunderstood the physiology, pharmacology or have misunderstood Evidence Based Medicine. Asking the students to discuss the further implications of their hypothesis usually leads to recognition that they are on the wrong path. Don’t forget to use this method once in a while when the students are correct.
Another advantage of the PBL method is that students are better prepared for their clerkship experiences as many of the methods used in PBL are the methods used during their experiential education. Students take responsibility for their own learning, learn to work in groups and to trust one another, and I really appreciate when they develop a questioning and critical approach to the presented material. Most importantly, students are highly engaged in their coursework, take responsibility for their virtual patient, avoid simply memorizing material and instead develop their own understanding of each topic rather than repeating the instructor’s statements. I also want to point out that all of our students tend to prefer the PBL method.
Is PBL a panacea that will automatically solve all of our educational issues? Of course not. But even though I had always considered myself to be an excellent lecturer, I am so glad I had the additional opportunity to learn to use the PBL method. If your team has a tendency to focus on facts and tasks and might be missing the overall picture, you might want to learn more about the PBL strategy. If you or any of your residents would like to see PBL methods in action, please contact me. I would love to have the opportunity to have you on campus for a couple of classes.
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