PBL교육과정에서 조기 환자대면에 대한 학생의 인식

Students’ perceptions of early patient encounters in a PBL curriculum: A first evaluation of the Maastricht experience

AGNES D. DIEMERS1, DIANA H. J. M. DOLMANS1, MARIJKE VAN SANTEN2, SCHELTUS J. VAN LUIJK3, AMEIKE M. B. JANSSEN-NOORDMAN1 & ALBERT J. J. A. SCHERPBIER1

1Maastricht University, 2University Hospital Maastricht, 3VUmc, Amsterdam, at the time of the study Maastricht University, The Netherlands

Introduction: Real patient encounters before the clinical phase of undergraduate medical education are recommended to stimulate integration of theory and practice. Such encounters are not easy to integrate into the three phases of the problem-based learning cycle, i.e. preparation, self-study and reporting. The authors studied students’ perceptions of problem-based learning with real patient encounters as the starting point for learning.

Method: Students’ perceptions of the programme with real patients were evaluated by means of a questionnaire. Mean item scores on a five-point Likert scale and 95% confidence intervals were calculated.

Results: Students showed satisfaction with the patient encounters and said they learned a lot from them. Reporting was also highly rated, particularly the integration of theory and practice. Preparation and self-study received lower scores.

Discussion: The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students’ and teachers’ views and behaviours in respect of this type of learning.

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Introduction

PBL의 취지와 예상되는 이점에도 불구하고, 학생들은 이론적 지식을 실제 환자에 연결시키기 어려워하고 있으며, 실제 환자를 임상실습교육기간보다 이전에 만나는 것이 이 문제의 해결법으로 제시되었다.

Problem-based learning (PBL) is increasingly being used as an educational approach in medical education. It is supposed to ‘promote the transfer of concepts to new problems and the integration of basic science concepts into clinical problems’ (Norman & Schmidt 1992). Despite this assumed benefit, students in a PBL curriculum have reported difficulty in applying theoretical knowledge to real patient problems when making the transition from preclinical, mainly theoretical courses to clinical training during the clerkships (Prince et al. 2000; 2005). Contacts with real patients during the preclinical phase have been proposed as a solution to this problem (Prince et al. 2000; 2005).

문헌을 통해서도 조기 환자접촉의 효과가 확인되고 있다. 실제 환자의 맥락 속에서 이론을 배울때 'more relevant'해지고 'easier to learn'해진다. 또한 학습의 강력한 원동력이다.

Reports in the literature concerning the use of early patient encounters in PBL have confirmed the beneficial effects of such encounters (O’Neill et al. 2000; 2002; Dammers 2001). New knowledge is better internalized when students can relate it to a real patient (Prince et al. 2000). When students learn theory within the context of real patients, it becomes ‘more relevant’, and is ‘easier to learn’ and easier to remember (Norman & Schmidt 1992; Dornan & Bundy 2004; Littlewood et al. 2005). Furthermore, when real patients are used as the starting point for learning, they act as a powerful driving force for meaningful and profound learning (Norman & Schmidt 1992; Prince et al. 2000; Parsell & Bligh 2001; Dornan & Bundy 2004; Littlewood et al. 2005).

그러나 실제로 환자 접촉을 의학 교육과정에 넣는 것은 가볍게 될 일도 아니고, 그 성공이 담보되는 것도 아니다. 주요하게 거론되는 문제로는 환자의 문제를 교육과정의 주제와 맞추기도 어렵고, 핵심 교육과정을 포괄할만큼 충분한 사례를 확보하는 것도 어렵다.

The actual implementation and integration of patient contacts in medical curricula is an undertaking that should not be embarked upon lightly and success is not to be taken for granted. The main problems reported in the literature are matching patient problems to course themes and expected difficulties in selecting sufficient numbers of suitable cases to ensure coverage of the core curriculum (Bokhoven et al. 1998; O’Neill et al. 2000; 2002; Mainhard et al. 2004). 

또 다른 문제는 학생들이 이론과 실제의 의미있는 연결고리를 찾기를 어려워한다는 것이다. 실제 환자를 만나게 하는 것이 자동적으로 학생들로하여금 환자가 가진 문제의 기전(병태생리)를 학습하게 하지는 않았다. 이 연구에서 학생들은 환자와 학습을 적절하게 연결시키지 못했다고 말했으며, 그 연결이 어떤 것인지가 '제시될' 필요가 있다고 했다. 또한 Eva는 학생들이 자동적으로 analytic reasoning을 사용하지 않으며, 환자의 문제가 어떻게 기초과학과 연결되는지 분명한 교육을 받을 필요가 있고, 여러 문제간 비교를 해줄 필요가 있다고 주장했다.

Another potential problem is students having difficulty identifying meaningful links between theory and practice. One study reported that confrontation with real patients in the curriculum did not automatically result in medical students studying the pathophysiology underlying patients’ problems (van der Wiel et al. 1999). In that study, students said that they did not make the connection between patients and learning of their own accord and that they needed ‘to be shown those links’ (van der Wiel et al. 1999). Additionally, Eva (2004) argues that students do not spontaneously use analytic reasoning, but should be explicitly instructed to link the problems presented by the patient to basic science and make comparisons across problems.

조기 환자접촉과 PBL이 가진 교육적 잠재력을 합해내려면 환자 접촉을 PBL사이클에 적절하게 포함시킬수 있는 방법이 필요하다. PBL 사이클을 세 단계로 이뤄진다. 준비-자습-보고. 우리는 준비 단계 이후에 환자를 접촉하는 과정에 대한 연구를 했고, 연구의 목적은 이 4단계 PBL사이클에 대한 학생들의 평가는 어떠한지 보고자 하는 것이다.

In order to realize the combined educational potential of early patient encounters and PBL, a way has to be found to effectively integrate real patient encounters into the PBL cycle. The PBL cycle generally comprises three phases: preparation, self-study and reporting. We studied a course in which real patient encounters were incorporated into the PBL cycle immediately after the preparation phase (Figure 1). The aim of our study was to evaluate students’ perceptions of their learning organized around this four-phase PBL cycle, in which a real patient encounter was introduced as a driving force for student learning.

교육적 배경 Educational background

2001년 Maastricht 의과대학의 6년제 PBL교육과정에 전방위적 개혁이 이뤄졌다. '낡은'교육과정은 명확히 구분되는 두 개 시기로 나눠져있었다 (4년 전임상실습, 2년 임상실습). 새로운 교육과정의 목적은 학생들이 실제 환자와의 경험을 조기에 할 수 있도록 하는 것이다.

In 2001, extensive innovations were introduced into the six-year PBL curriculum of Maastricht Medical School, the Netherlands. The ‘old’ curriculum consisted of two distinct phases: a four-year preclinical phase in which PBL tutorials were the predominant educational method and two years of mainly hospital-based clinical clerkships. One of the aims of the new curriculum is to offer students experiences with real patients earlier in the curriculum. 

이를 위해 3학년에서 실제 환자와의 잦은 접촉 기회를 포함시켰고, 새로운 3학년 교육과정의 주제는 '만성질환' 이었다. 이 주제는 크게 네 개의 클러스터로 나눠진다. 매주 학생들은 외래 클리닉에서 환자를 본다. 환자와의 접촉은 PBL사이클의 시작점이고, 각 사이클은 일주일간 진행되며 10명의 학생과 학생들의 코치가 함께하는 4시간짜리 tutorial, 모든 학생들의 환자 접촉, 환자 접촉과 다음 tutorial 사이의 자습시간으로 구성된다. 

In Year 3 this is realized by the introduction of frequent real patient encounters. The theme of the new Year 3 is Chronic Diseases. This theme is divided into four subject clusters, i.e. abdominal region, locomotor system, circulation & lungs and psychomedical problems & mental healthcare. Every week students see a patient in the teaching outpatient clinic at University Hospital Maastricht. The patient encounters are the starting point for learning in the PBL cycle. Each cycle lasts a week and comprises one four-hour tutorial attended by 10 students and their coach, patient encounters for all students, and self-study between the patient encounter and the next tutorial. 

우리는 PBL의 첫 phase를 둘로 나누었다. 하나는 준비시기로, 학생들이 환자 대면을 준비하고 사전 지식을 모으는 단계이다. 환자 대면 시기는 학생들이 짝을 이뤄서 실제 환자를 만나는 것이다. 이 환자 대면으로부터 학생들은 자습할 학습 주제를 찾는다. 

We divided the original first phase of PBL tutorials into two phases: the ‘preparation phase’ in which students prepare for the patient encounter and activate prior knowledge and the ‘patient encounter phase’ in which students, in pairs, meet a real patient instead of a paper patient. From this encounter students derive learning issues for self-study. 

그 결과 네 개의 연속된 시기가 PBL사이클을 구성한다.

As a result, four consecutive phases can be discerned in the PBL cycle. 

The preparation phase takes up the last hour of the tutorial, 

the patient encounter phase is scheduled one or two days after the tutorial, (튜터리얼 1~2일 후)

the self-study phase covers the time between the patient encounter and the tutorial in the next week, and 

the reporting phase takes place during the first three hours of the tutorial. 

PBL사이클은 3학년의 주요한 교육요소이며, 강의자, 술기훈련, 그 외 다른 교육활동으로 보충된다. 이 네 phase의 내용은 아래에서 더 자세히 다룬다.

The PBL cycle is the main educational component of Year 3 and is complemented by lectures, skills training and other educational activities. The content of the four phases will now be discussed in some detail.

1. Preparation phase

The students are given the GP’s letter of referral or a vignette (Box 1) describing the problem (or a similar problem) of the patient they will see in the outpatient clinic. The patient problems are elaborated on by the group in order to activate the knowledge gained during the preceding two years of the curriculum. During elaboration, attention is also being paid to history-taking and physical examination. The students then generate learning issues and decide what to study in preparation for the patient encounter.

2. Patient encounter phase

One or two days after the preparation phase, student pairs go to the outpatient clinic where they take a history and perform a physical examination of a patient. After about 30 minutes, when history and physical examination are finished, the students consult the patient’s attending physician, who acts as their ‘clinical supervisor’. The students and the clinical supervisor then return to the patient to complete the consultation. The role of the clinical supervisor is to guide the students in generating learning issues on the basis of the problem presented by the patient and to give the students feedback on their performance.

3. Self-study phase

During the self-study phase the students work on the learning issues derived from the patient encounter. They make use of a variety of learning resources, such as books, skills training, lectures and so on. The student pairs prepare a clinical presentation on ‘their patient’ to present to the group during the reporting phase.

4. Reporting phase

This phase is partly devoted to the patient presentations, which consist of a report on history, physical examination, differential diagnosis and management plan. The presentation is followed by a discussion of what the students have learned during the patient encounters and self-study phase. The purpose of this phase is to promote integration of theory and practice. Students apply their newly acquired knowledge to the patient problems.

The coach and the clinical supervisor are both clinical staff members of the disciplines involved in the Year 3 programme. Both have had two hours’ training in advance in which it is explained to them how to guide the session as a coach and clinical supervisor.

Instruments

For this study we analysed the results of the anonymous questionnaire of the regular curriculum evaluation, which is administered routinely to all students at the end of each cluster (Appendix 1). This means that each student could complete four questionnaires over the course of the year. The questionnaire is identical for the four clusters and consists of 10 statements with a five-point Likert scale (1=fully disagree, 5=fully agree): two statements about the preparation phase, three about the patient encounter phase, two about the self-study phase and three about the reporting phase. An example of a statement about the preparation phase is: ‘The tutorials provided sufficient preparation for the patient encounters.’ An example of a statement about the patient encounter phase is: ‘I learned much from the patient encounters.’

Analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS version 12.0.1). Mean item scores across all students were calculated for each cluster separately. In this way 10 scores were obtained for each of the four subject clusters. Mean scores below 3.0 were considered unsatisfactory and indicative of a strong need for improvement. Mean scores of 3.0–3.4 were considered borderline, i.e. necessitating some improvement and mean scores of 3.5 or higher were considered good. We determined 95% confidence intervals (95% CI) for the mean item scores to determine whether a score differed significantly (p < 0.05) from 3.5.

Conclusions and discussion

Overall, students appear to be satisfied with the patient encounter phase and indicate that they learn a great deal from it. This supports Dornan’s (Dornan & Bundy 2004) findings that early patient contacts have the potential to enhance learning. The reporting phase is also rated highly. Students strongly agree that the patient encounters are discussed adequately during this phase. This positive view is reinforced by the relatively high scores concerning connecting theory and practice. These results are indicative of positive effects of the early introduction of real patient encounters in a PBL curriculum (Dornan & Bundy 2004). This can be seen as support for the view that real patient encounters can act as a powerful driving force for meaningful and profound learning (Norman & Schmidt 1992; Prince et al. 2000; Dornan & Bundy 2004; Littlewood et al. 2005). It should be taken into account, though, that further research is needed to further investigate the value-added of real patients in PBL.

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Med Teach. 2007 Mar;29(2-3):135-42.

Students' perceptions of early patient encounters in a PBL curriculum: a first evaluation of the Maastrichtexperience.

Diemers AD1, Dolmans DH, Van Santen M, Van Luijk SJ, Janssen-Noordman AM, Scherpbier AJ.

Author information

Abstract

INTRODUCTION:

Real patient encounters before the clinical phase of undergraduate medical education are recommended to stimulate integration of theory and practice. Such encounters are not easy to integrate into the three phases of the problem-based learning cycle, i.e. preparation, self-study and reporting. The authors studied students' perceptions of problem-based learning with real patient encounters as the starting point for learning.

METHOD:

Students' perceptions of the programme with real patients were evaluated by means of a questionnaire. Mean item scores on a five-point Likert scale and 95% confidence intervals were calculated.

RESULTS:

Students showed satisfaction with the patient encounters and said they learned a lot from them. Reporting was also highly rated, particularly the integration of theory and practice. Preparation and self-study received lower scores.

DISCUSSION:

The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students' and teachers' views and behaviours in respect of this type of learning.