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MONTHLY FeaTURE IDEAS FOR MEDICAL EDUCATION Gerald J. Kelliher, PhD, 1996 Associate Editor* A Pilot Course as a Model for Implementing a PBL Curriculum Jean Vincelette, MD, MSc, Raymond Lalande, MD, MA, Pierre Delorme, MD, MSc, Johanne Goudreau, MSc, Viateur Lalonde, MD, and Pierre Jean, MD, PhD Abstracts Many medical schools are shifting to a prob- Jem-based learning (PBL) curriculum, some without any transition period, others using periods of paralel-track curricula. The authors report on and discuss a thid strat gy for implementing PBL: using a pilot course asa model to facilitate the transition. After the Université de Mon- tréal Faculty of Medicine chose to switch to PBL, one course in the third year ofthe traditional curiculur was changed to a PBL format 11 months before the new cur- riculum was to startin September 1993. This was done to develop local expertise, wo gain confidence, to test the feasibility ofthe method, to produce a showcase, to assess rmore accurately the resources required, and to provide a practice ground for the curriculum planners and managers and the faculty-development training team. The authors discuss the planning of the pilot course, the taining of the faculty in various aspects of PBL (writing problems, tutoring methods, ete.), the course implementation, and the course evaluation. Overall, the pilot course was well received by both the faculty and the students and pro- ‘vided much beneficial information that assisted the uni versity in its transition to a new PBL curriculum. ‘Acad, Med.1997;72:698-701. any medical schools are shifting to a problem- based learning (PBL) curriculum, implying a drastic change in educational philosophy. How they are handling this shift, though, depends largely on local circumstances. Two main strategies are being used: an abrupt change to a PBL curriculum without any transition period, as was done at the Université de Sher brooke! and the University of Hawaii John A, Burns School of Medicine? and a period of dual curriculum streams, also called parallel track, as was done at Harvard Medical School.! The former method was perceived as risky for the Université de Moneréal Faculty of Medicine, a large public school that makes use of many teaching hospitals; the later method was considered both unaffordable and counterpro- ductive. In this article we report on a third strategy for im- plementing a PBL curriculum: using a pilot course as a model to facilitate the transition. “Eidos ne: This paper by Vinclete al. wa alice by Dt Keliher in 1996 during his tere motte eto fr Ide for Metical Edition. Beau of unsooidale delays inthe svi proces, we were unable to publish che paper une noe 698 Acapemie Mapicixt vou. 12 BACKGROUND Each year the university recruits some 170 new medical stu- dents. Up until 1991 the five-year traditional curriculum for fan MD degree consisted of three primarily lecture-based pre- clinical years and two years of clerkship. Two yeats in a post: doctoral program in family medicine or five to six years in specialty taining were required for licensure. In the fall of 1991, after chece successive program-revision proposals had been drafted by three different curriculum committees, and after much discussion and hesitation, the Faculty Council f rally decided that a new, four-year undergraduate program ‘would be implemented in September 1993. The first two, preclinical, years would be broken down as follows: 70% PBL alter the Maastrich model! 10% various other forms of teaching, and 20% introduction to clinical medicine. The f- nal ewo years would be devoted to the usual clerkship rota In 1991 PBL was still thought to be a very risky business by many council members, teachers, and administrator. Confidence in the ability of the students to lear efficiently by themselves without “real teaching” was low. Only a few teachers had the opportunity to witness PBL in action else- No.8/AuousT 1997 where; the rest had either a very theoretical knowledge of it ‘, worse, a vague and often distorted view of the method, with all che uncertainties and fears imaginable. Many teach- crs had the impression that they were being set apart, either because of their specialization or because their topics were integrated in another course. Shortly before the Faculty Council made its resolution, the vice dean of pregraduate education and the Curriculum ‘Committee decided that one course of the traditional cur. riculum should he transformed into a PBL course that would be taken by an entire class of students; this pilot course would occur 11 months before the new curriculum was scheduled to begin. The pilot course was not created to guide the council's decision, but it was agreed by all chat it could be used to aid in the transition to the new PBL cur- riculum. By experimenting with PBL on a small scale we hoped to develop local expertise and gain confidence; to test the feasibility of the method in our school and produce a showcase for teachers, students, and administrators; €0 assess ‘more accurately the resources required for PBL; and to pro- vide a practice ground forthe curriculum planners atd man agers and the faculty-development training team to adjust the planning process and refine the faculty-development program, ‘Tue Por PBL Course The five-week course on the respiratory system, scheduled forthe fall of the third year, was selected to be the pilot PBL course because of the course director's interest as well as the appropriate timing of the course. The new course consisted of eight problems, three hours of lectures, two three-hour question-and-answer sessions, a panel on smoking, a selfin- structional package on respiratory allergy, and four half-day sessions in hospitals for an introduction to clinical skills. Af ter the pilot course the students retumed to the traditional curriculum (the medical students at Montréal take one course ata time). Because of the experimental nature of the course, a passfail grading system was used instead of the usual AF grading system. Written problem-analysis ques- tions (PAQs)* were introduced in the course's examination, ‘There were four interrelated steps to the pilot PBL course course planning, faculty development, course implementa- ton, and course evaluation, Course Planning ‘An interdisciplinary pilot-course committee—consisting of ‘two chest specialists, pediatric chest specialist, an internist, a family physician, a cardiologist, and a pathologist —was appointed one year before the course was to be given. In ad- dition, a microbiologist, a hematologist, and a radiologist as Acannsic MEpteite, Vou well as two students (chosen by the vice dean after consult ing with teachers) were invited tothe committees meetin; the cardiologist and the hemacologist were also appointed to direct future courses in the new curriculum. Fifteen addi- tional tutors (drawn from the university campus, the five university hospitals, and one affliated hospital) were se- lected during the following months. Approximacely half were chest specialists; the other half were family physicians, various medical specialists, und laboratory physicians. The committee's planning of the course, wich included writing the problems and devising the examination, was paced by the ongoing faculty development taking plaee in anticipae tion of the new curriculum, Faculty Development ‘The Unité de recherche et de développement en édueation médicale (URDEM), the universtys office of medical edu cation,’ was mandated (© train 300 tutors for the new eur riculum and also to provide every PBL course committee ‘member with problem-building and -asessment capabilities. As the PBL field was quite new to the faculty, the vice dear half of the Course Committee, and members of URDEM at- tended a four-day workshop on PBL at the Université de Sherbrooke. URDEM devised a faculty-development pro- ram after consulting with Sherbrooke’sofice of medical ed ucation. ‘The members of the pilot-course committee were intto- dluced to PBL with a two-hour workshop during their frst meeting. In March, a three-day workshop was held to intro- luce the committee and the other tutors to the general prin- ciples of medical education, The 25 artenilees participated in an intensive guided exercise in the systematic planning of ‘continuous medical education activity that solicited their teaching experience as it revealed basic pedagogical con- cepts. On the fist day the attendees were resistant to partic~ ipating, but on the second and thint days they became in- ‘creasingly enthusiastic about their emerging understanding ‘of student-centered education. The training of the pilot-course committee members in specific PBL skills began seven months prior to the course's stare with a one-day workshop on problem writing that was based on the course's content, which the committee had pre- viously defined. One month Inter followup workshop pro- vided the opportunity to make farther revisions in the prob- lems. Similarly, two one-day workshops were devoted 10 training the committee the writing of PAQs Preliminary versions of the eases to be used in the course were tested with students. ‘One month before the beginning of the course, the tutors were trained for their specific tasks: guiding the students through the PBL process, supervising learning, using “teach- 12, No.8/AuousT 1997 699) able moments,” furthering group interaction, and evaluating the students’ involvement. The two-day workshop eulmi- nated in a live demonstration of a PBL session using one of the problems developed by the pilot-course committee. The demonstration was led by one memther of URDEM who had no prior tutoring experience, with eight students from the class that was to be part of the pilot course. The demonstra tion (which was videotaped for use in future training) was success with the tutors. During the pilot cours, every tutor was observed by a member of URDEM for at least one tutorial session and was given feedback on his or her performance. ‘Course Implementation ‘A ovumber of students were involved in the designing of the pilot course, working with the committee and participating in the validation of the problems as well asthe live demon- stration for the tutors. The entire class was introduced to PL with a one-day workshop including a lecture, an edited video of the live demonstration, a panel discussion with the eight students involved in the demonstration, and a prnctice PBL session. The students met twice weekly in small groups with a tue tor for PBL sessions. The first 90 minutes were spent dis- cussing a new problem, generating explanatory hypotheses, and defining learning objectives that the students liad to ful- fill for the next session. During the first four weeks, day was spent in a hospital for an introduetion to elinical skills in respirology, and other half-days were spent in the classroom for a lecture (one moming), x question-and wer session (two mornings), or a panel on smoking. A self instructional package on respiratory allergies was provided at the beginning of the course. ‘The course director and tutors held meetings once a week prior to each tutorial sesion. PBL sessions were scattered all cover the university campus, employing all types of class- rooms to accommodate 21 groups of eight students. The ‘course director and an assistant in each building were ncces- sible by cellular phone in case of logistical problems (locked doors, missing chairs or tables, delayed tuto, etc). Course Evaluation As judged by their examination performances—a mean score of 88% on the multiple-choice—question component and a mean score of 76% on the PAQ component —the stu dents seemed to have mastered the contents of the pilot PBL course. Despite their lower performances on the PAQs, the students recommencled that this new type of question format be used in every examination, The evaluation of the course was based on a survey of the 100 Acanemic Mipieise, Vor students, 2 complementary report by the students (at the re- quest of the vice dean the stulent association appointed 2 group of students co comment on the pilot course), a survey of the tutors, ve with the tures and URDEM. The course was well received hy the students, with only 9% preferring the traditional form of teaching. A thint of the students reported experiencing more stress ding the course, but a eorresponding third reported less stress. There were problems with the course, but no more than eight he expected, and those involved suggested such improvements as limiting the number of eoncepts covered in the course. The students were pleased with the tutors performances, but they expressed strong concer for uniform interventions among the tutors, especially in guiding students toward learning objectives, giving feedback on learning, and provide inyg explanations. There was a fear that some groups of st clonts might receive better help from their tutors than oth~ cers. The tutors observed that course objectives and tasks were achieved, although there were some pitfalls, which were identified and corrected. The overall evaluation of the course showed that the most appropriate course of the dis- cussion following personnel study needed to be clarified, ancl feedback on group performance had to be more systematic. Discussion, Many have reported introducing a PBL course in a trai sional cursiculum with the hope of leading che school to- wand an all-PBL curriculum.?-» This has often been che i ¢ of a small yroup of teachers and, for the most part, it thas remained limited to those teachers. By contrast, our pie lot course followed the decision to switeh to a PBL curse tum. Te was created to facilitate the implementation process—a springboard to ease the lane step planned for the following year Because they were involved and evaluating the coun, the tutors created momentum among the faculy and a wider ownership of PBL, Knowl tc about the course spread where those teachers involved in the course became eredible witnesses and models of a change in the perspective of teaching. The course sent a strong signal to the entite faculty thar it was time to get ine volved Asa result of the course, URDEM checked! and adjusted its feeuley-development progeam. For instance, in the tutor ‘workshop the time spent on the general principles of med- ical education was condensed in onder to incorporate the ine troduction to PBL, and the links bewween education prinei- ples and PBL were discussed more explicitly. The systematic ‘observation of PBL sessions by members of URDEM pro- vided the opportunity to identify critical issues in the applic cation of the metho! and revealed mistakes thar needed! 10 12, No.s/Auoust 1997 be prevented. It also provides! firsthand experience and ex: amples from the university itself that could be used in the faculty-development program (as ently as the final week of the pilot course). The troubleshooting that happened during the course and the feedback to the tutors helped clarify the ‘educational concepts of PBL and what instruction t0 pro idle to tutors. We could not expect to see a major change in the students? bbchavior after such a short exposure to PBL, Four months af- ter the course a survey of the stuxlents revealed that they re- tured to tational ceaching without much disturbance. Nevertheless, about a fourth of the students reported some difficulties with going back: they resented the curriculum overload (leading to surface learning), the passivity, the loss cof autonomy, and the shortage of time for reading; they ques- tioned the pertinence of some teaching, and they lost some motivation. On the other hand, a fifth of the students felt more moxivated because they had changed their perspective ‘on medical studies oF because they had adopted a deep-learn- ing approach. Overall, after the course the students used more reference sources, were more critical of lectures, and perceived the importance of the basic sciences slightly more nd the importance of the clinical sciences much more. The course was implemented without largely affecting the ongoing traditional curriculum courses. The Faculty Council rade the proposal for an all-PBL curriculum while the course planning and faculty development were proceeding smoothly. The council members were reasured that the PBL method would he pretested on a small par of the curriculum with an entire class prior to the implementation of the new curticur lum, providing the opportunity to stop che project in the ‘event of a major problem. A significant part of the anxiety re- lated to the implementation process was focused on the pilot course, The success of the course confirmed the Faculty Coun- «il in its decision to move toward PBL, and the new curticu- Jun was incited on schedule with much greater confidence Ie was clear ehat in a lange, dispersed school, students could lear this way, and that they would accept the method posi- tively and, for the most part, enthusiastically, Also, it demon- strated that the faculty could adapt to PBL and that the uni- versity had the capacity to create this rype of curriculum, The pilot course provided an excellent practice field and en- abled the university to assess more accurately the resources re- quired for PBL. Testing the logistics of the implementation process resulted in a detailed and realistic timetable for the planning of each new PBL course, for which the faculty- development workshops constituted the milestones and set the pace. Also, the Curriculum Committee clarified its expecta- tions for the PBL courses and developed a monitoring process. Acammne Mepiensé, Vou ‘Two directors of furure PBL courses took the opportunity t0 gztin experience with planning and managing such a program by working on the pilot-course committee; others became fi milar with the method as tutors for the course. In brief, our pilot course proved a useful and efficient strategy for the university as it proceeded toward PBL. The new curriculum began in September 1993 as planned and has thus far run smoothly, with only the small bumps and missteps expected in any new endeavor. De, Vincelett is lial asite profesor of mira an una fin [lage st the citer, the Uni de vecherhe ola delet tn ddueaton médicale (URDEM), Universé de Monréal Facey of Meine, Montes, Canada; Dr. Lalande i ical esac profexinof medine, UR” DEM: Dr. Delrme i ase profes of edit aned dec of URDEM; Me. 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