Problemcentered learning

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Problem-centered learning

• Nithya Gogtay
• Department of Clinical Pharmacology
• Seth GS Medical College KEM Hospital, Mumbai
• njgogtay_at_hotmail.com

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Why PBL? The historical background

• 1969- McMaster University
• Traditional learning (TL) not satisfactory
• Basic sciences do not need to precede clinical
  sciences
• Students need to take greater responsibility for
  their learning

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• Thats the reason they are called lessons, the
  Gryphon remarked because they lessen from day
  to day.
• Lewis Carroll 1832-98 Alices Adventures in
  Wonderland (1865)

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What is PBL?

• A learning process based on the principle of
  using problems as a starting point for the
  acquisition and integration of new knowledge.
• HS Barrows, 1982

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Problem solving and Problem centered learning
versus PBL

• Problem solving arriving at decisions based on
  prior knowledge and reasoning- what is followed
  in most medical colleges in India
• PBL The process of acquiring new knowledge based
  on recognition of a need to learn
• Different, but inter-related

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Structure of a problem

• Title Guides the students in a particular
  direction
• Trigger material A story, description of
  phenomena, events
• Instructions For e.g, what would you do ?

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Don'ts of problem construction- 1

• A 40yr old man suffering from bronchial asthma
  for several years is diagnosed to have mild
  hypertension. Prescribe for this patient.
• What is your expectation? A prescription for
  asthma or hypertension?

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Don'ts of problem construction- 2

• A patient with CCF receiving treatment came to
  the casualty with complaints of vision changes.
  He had bradycardia. What is the possible cause of
  this reaction?
• Define expectation from students-
• CCF- Congestive cardiac failure or cough, cold
  and fever?
• What is the age of the patient?
• Do you expect the students to think of digoxin?

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Pre-preparation

• At what stage of learning are the students?
• How long should the problem be?
• How can I ensure that the students do not miss
  key concepts?
• How can I make the problem challenging and
  interesting?
• How much data should I provide?
• How open-ended should the problem be?

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How do I construct cases? Nature and types of
problems

• Relate to priority health needs of a defined
  population
• Represent important prototypical situations
• Simulate professional practice/real life
  situations
• Involve real patients
• Stimulate the need to know

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Constructing a problem- focus on a single
objective

• A 23 yr old male patient with a diagnosis of
  vivax malaria is given Injection metoclopramide
  prior to treatment with chloroquine. Ten minutes
  after the injection, the patient develops jerky
  movements of the limbs and uprolling of eyeballs.
• What is your diagnosis? - Oculogyric crisis

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Constructing a problem- focus on two objectives

• Topic- Pharmacokinetics
• Students IInd MBBS, 6 months completed, General
  pharmacology and CNS covered.
• Problem A patient of GTC epilepsy with a seizure
  frequency of 3/mth, is put on phenytoin sodium
  200mg/day. After 2 mths, he still complains of at
  least 1 episode/mth. The physician increases the
  dose to 400mg/d. Two weeks later, the patient
  presents with complaints of ataxia and giddiness
• Single objective Do they understand the
  difference between linear and non-linear
  kinetics?
• What do you think could have happened?

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• The single objective Phenytoin undergoes
  non-linear kinetics, thus the symptoms and signs
  of toxicity. the difference between constant
  amount excreted/ unit time versus constant
  fraction excreted/unit time
• Can we have more than 1 objective? Yes- assess
  students response
• For example- Which other drugs undergo non-linear
  kinetics?
• Or- In this patient what could have been done to
  prevent toxicity?

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Constructing a problem- multiple learning
objectives

• Topic Bronchial asthma
• Students Second Professional -Semester 4
• /II nd MBBS
• Object of test Test whether the students know
  the importance of diagnosis, which drug to choose
  for persistent bronchial asthma, which in turn in
  related to pathophysiology of the disease?

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Problem- Bronchial asthma

• A 16 year old male patient recently diagnosed as
  having bronchial asthma had been advised to take
  MDI salbutamol as and when needed. The patient
  reports back to his physician after 2 mths,
  saying that he has been taking 2-3 puffs of
  salbutamol everyday for the past 2 mths and is
  still symptomatic.
• What could be the probable reason for the patient
  not responding to the treatment?

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What are the characteristics of this case?

• Positive aspects
• Relevant, realistic, logical
• Not too complex
• Progressive disclosure/step by step
• Points which need attention
• Use of abbreviations e.g. MDI, mths
• Expects student to know the difference between
  intermittent and persistent bronchial asthma
  check whether it has been taught

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Bronchial asthma- learning objectives

• What would be your drug of choice in persistent
  asthma?-inhaled corticosteroids.
• Why inhaled corticosteroids?- Pathophysiology
  -Because it is now known that bronchial asthma is
  a chronic inflammatory disease, where
  corticosteroids are the drugs of choice and ß2
  agonists only provide symptomatic relief

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Bronchial asthma- learning objectives

• If student says that maybe the patient did not
  know how to use the MDI and so instructions on
  proper use of MDI or use of spacer then what?
• He/she should be given additional marks for
  thinking beyond the prescription (therefore this
  problem permits differentiating between good and
  very good students)

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Pre- preparation

• Check problems and scenarios with clinicians
• Dry run problems with residents and interns
• Focus on must know areas
• Pre define learning objectives for each session

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• You cannot teach a man anything you can only
  help him find it within himself.
• Galileo Galilei (1564-1642) Italian physicist and
  astronomer.

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Group task 1 -Coronary artery disease

• A 58 year old man with a recent diagnosis of
  coronary artery disease has the following lipid
  profile- LDL 134mg, TG-166mg, HDL-40mg, and
  total cholesterol-205mg. What should be his line
  of treatment?
• Identify the characteristics of this case- what
  does it have and what does it not have?
• Identify the learning objectives for this problem.

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Group task - 2

• Instructions
• You are teaching pharmacology to IInd MBBS
  medical students who have completed at least 1
  medicine post and have had orientation in the
  Emergency medical services.
• Construct a problem on anaphylaxis
• Identify the learning objectives of the problem.

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Group task - 3

• Instructions
• You are teaching physiology to first MBBS medical
  students who have completed eight months in
  physiology and have had the theory and practical
  classes related to hematology.
• Formulate any problem related to iron deficiency
  anemia
• Define what the students must know at the end
  of the problem centered learning session for that
  problem.

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Group task 1- solution- What are the
characteristics of this case?

• What does it have?
• Opening scenario
• History of present illness
• Investigations
• What does it not have?
• Past history, personal history, family history
• Physical examination
• Management

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Group task 1- solution-Coronary artery disease-
learning objectives

• Define and understand target lipid profiles-
  lt200mg for total chol, and lt150mg for TGs, HDL
  gt 40mg
• Define which is the most important lipid- LDL
• In this case, what should be its value?- This
  depends on whether or not the patient has CAD
• With CAD- target LDL lt 100mg, 1-2 risk factors
  130mg or less, otherwise lt 160mg
• Would this patient require drug therapy? If yes,
  which drug?
• If only the TGs were raised, would your advice
  have been any different?

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Sample Problem for group task 2

• Mrs Sunanda, a 26 year old married female
  presents to the Emergency medical services (EMS)
  of the KEM hospital with h/o fever, difficulty in
  swallowing and sore-throat for four days. On
  examination she is found to have acute follicular
  tonsillitis. She is asked whether she has had
  penicillin before to which she replies in the
  affirmative. She is given an injection of
  procaine penicillin and suddenly she complains of
  difficulty in breathing and faints. Her BP is
  very low.

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Sample Problem for group task 2 contd

• What could be the reason for her reaction?
• What is the treatment?
• What is the pharmacological basis for the
  selection of drugs?
• How could it have been prevented?
• If the student answers these questions one may
  ask how a test dose of penicillin is prepared or
  how many units should injected (for test dose) /
  what is the site of injection / what to look for
• This question should not be given early on as it
  will provide a clue.