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An Overview of and Comparison among Three Current Approaches to Medical and Physiotherapy Undergraduate Education
91
SCHOLARLY PAPER
An Overview of and Comparison among Three Current Approaches to Medical and Physiotherapy Undergraduate Education Jennver Mom’s Key Wods Education, curriculum design, problem-based learning, problem solving.
summary In recent years there has been widespread evaluation and reappraisal of the design and outcomes of medical and paramedical undergraduate education. The so-called traditional approach has been found to be wanting in terms of both student learning and the demands of clinical practice. This approach is compared and contrasted with two alternative problem-based learning and problem-sdvlng approaches learning. Both alternative approaches are claimed to utilise design and methods which Improve students’ understanding and learning and foster development of the problem-solving skills believed to be central in effective patient management.
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Introduction A considerable amount of attention has been given in the literature on medical and paramedical education to the curriculum design which most successfullp produces clinicians with the skills and abilities required of them in professional practice. Concern with course design and undergraduate education is of interest to clinicians as well as to educators because clinical staff are often involved with students on clinical placements and the students’ school education will affect their clinical performance. In fact, current trends indicate that clinicians are functioning more as clinical educators than as clinical supervisors. Graduates also need to function as competent and ef€ective professionals in the real world and not simply possess academic knowledge. Physiotherapy has a n academic basis, but it requires practitioners who are able to apply their knowledge. The long-standing traditional approach has been widely criticised, although it is still in use in some schools. Alternative approaches which claim to be more successful have provided the philosophy upon which many new physiotherapy courses are based.
The Traditional Approach Until relatively recently, medical and physiotherapy education has been based on what is known as the traditional or conventional approach (Barrows and k b l y n , 1980). This approach is simply but aptly described by Coles (1989) .asa ‘pot-filling’ approach in which the students are ‘emptyvessels waiting to be filled by teachers who shower them with “liquid wisdom” ’.
In the traditional approach the teacher is active and the students mostly passive. Teaching is didactic and usually delivered by lectures to large groups. Subject areas are taught independently with little connection made between related topics. Theory is taught largely separately from practice and patient problems are presented only after the theory has been taught. Work loads for the students are large, and summative end-of-year examinations are the usual form of assessment (Barrows and k b l y n , 1980). Barrows and k b l y n believe that this approach d t s from an intention to ensure that studente acquire a sound knowledga Over the years, this determination has evolved into a one-sided focus on delivery of content and examination of recall of the imparted information, with little attention being given to how well or how much this often superficial learning could be used clinically. Results from research into learning styles and approaches (Newble and Entwistle, 1986) also raised valid questions as to the effectiveness of the traditional approach. Students tend to adopt learning strategies which are a response to the type ofteaching they receive (Newble and Clarke, 1986). Didactic teaching, in which students are passive, promotes rote learning with poor understanding and short-livedretention of what has been learned (Newble and Entwistle, 1986). In terms of the needs of clinical practice these authors argue that students need to adopt a deeper apprsach which promotes greater understanding and longer-term retention and that the traditional approach does not encourage this.
Weaknesses of Traditional Approach As long ago as 1910, Dewey stated that ‘science has been taught too much as a n accumulation of ready-made material with which students are to be made familiar, not enough as a method ofthinking, a n attitude of mind, after the pattern of which mental habits are to be transformed’ (Hamilton, 1976). A number of disadvantages of the traditional approach have been recognised and dem-ibed in recent yeara Coles (1989)argues that students d e r averload and decreased -motivation, fail to me the relevance of what they have been taught, and gain only superficial understanding, and that retention of knowledge over time is poor. Students ale0 find that there is poor correlation between theory and practice and that lack of integration of subject matter makes clinical practice M i c u l t (May,1977). Schmidt (1983)further claims that some ofthe knowledge acquired with the traditional approach is irrelevant, and that this approach does little to encourage postgraduate continuing education. This need for a continuum from undergraduate education through specialisation and
Phyrlothempy,February 1999, ~ 0 1 7 %no 2
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continuing education is also recognised by Harden (1988). Despite widespread awareness of the faults of the traditional approach, it is only in the last three decades or so that attention has been given to alternative approaches to medical and paramedical education. Apart from awareness of the inherent faults in the objectives and methods of the traditional approach, other pressures also encouraged re-appraisal of teaching approaches. There was concern that the needs of society and, thus, the needs of clinical practice had changed, while medical education had not (Hamilton, 1976). Concern was also expressed that the lack of correlation between theory and practice had led to health professionals not being equipped to cope with the problems presented by patients. A need for clinicians to be able to solve problems is believed to be central to effective patient management (May, 1977;Barr, 1977).
Problem-based Learning In response to the perceived failures of the traditional approach in preparing medical students for the reality of clinical practice, the alternative approach of problembased learning (PBL) was devised. PBL was pioneered at McMaster University medical school in Canada in the late 1960s. It is almost diametrically opposed to the traditional approach in design and method. Barrow and ‘Igmblyn (1980)state that there are two fundamental postulates in PBL. One is that learning through problem-solving is more effectivethan memorybased learning in creating a usable body of knowledge and the other is that problem-solving skills are more important than memory in clinical practice. Menahem and Paget (1990)define PBL as ‘learning that results from the process of working towards the understanding or resolution of a problem’. Schmidt (1983)states that PBL claims to solve many of the problems of conventional medical education. The core of PBL is that the patient problem is presented before any theory is learned and that the students build up their knowledge base on the patient problems with which they have been presented rather than learning pathologies and treatments theoretically. This method also focuees on development of problem-solvingskills and the reasoning used by clinicians in solving patient problems (Barrows and Thmblyn, 1980). Apart from this pivotal change in philosophy, the design of PBL is very different. Learning is student-centred, not teachercentred. The students are actively responsible for their own learning and the teacher acts as a facilitator. Subjects are integrated and patient problems are looked at as a whole rather than in fragmented form. The lecture and large group format are dropped in favour of students working in small tutorial groups. Assessment is formative and continuous rather than summative (Barrows and ‘hmblyn, 1980;Hamilton, 1976;Titchen, 1987a; Ellis, 1988;Menahem and Paget, 1990;Schmidt, 1983). The methods of teaching and learning are also very different in PBL. The problems presented should be baaed on real patients so that students perceive their relevance. They can be presented in many ways ranging through a written description of problems, video, simulation, roleplay and real patients. Resources can be print, video, computer-baaed and so on (Barrows and ‘Igmblyn, 1980).
Phydothenpy,February 1993, vol79, no 2
Justification for PBL Barrows and ’Igmblyn and other supporters of PBL (Hamilton, 1976)believe that students trained under PBL have effective clinical problem-solving skills, a relevant and well-retained body of knowledge, a desire to continue with their education after graduation and a well-established ability for independent study and maximal use of resources. Proponents of PBL accept that this approach is radically different from what has been considered to be the norm, and agree that both teachers’ and students’ attitudes have to be changed. Barrows and Thmblyn (1980)agree that if PBL is to be successful its implementation needs the full support of all staff, students and involved clinicians. They also acknowledge that PBL needs more resources than the traditional approach, but believe that once the resource base has been established it is a very cost-effective method. They disagree that smaller groups make increased demands on teacher time and argue that, because the students do most of the learning themselves, teaching commitments are little changed. Researchers in learning theory also favour the PBL approach. Coles (1989)describes PBL as an example of ‘making connections’ in which learning is satiafying and the approach of practice coming before theory helps ‘the learner learn how to learn’. PBL is also concluded to be better than the traditional approach in promoting the desirable deep approach to learning (Newble and Clarke, 1986;Coles, 198Ei).
Weaknesses of Problem-based Learning Even if PBL is largely successfulin fulfilling its objedive of producing clinicians who are able to solve patients’ problems, there are perceived areas of weakness. Woodward and Ferrier (1983)questioned graduates of the McMaster course on how well they felt they had been prepared for clinical practice. In comparison with graduates from traditional schools the McMaster graduates felt more competent in areas like independent study, problem-solving and ability to gather data and keep records, but felt badly prepared in basic medical sciences which, they believed, needed more attention. This raises the possibility of a need for provision of core material classes before students are given patients’ problems on which to work. Such an approach would involve a move away from the pure form of PBL into an area between the two extremes of the traditional approach and PBL. This large middle area is the context for the third approach to medical and paramedical education - problem-solving learning.
Problem-solvingLearning The need for problem-solvinghas been widely recognised in physiotherapy as well as medicine. May and Newman (1980)state that ‘problem-solvingis an integral part of effective physiotherapy practice’. Concern about physiotherapy students’ ability in problem-solving has also been raised, as students are the clinicians of the future and will need to be able to analyse what they have learned in relation to managing patients’ problems (Slaughter et al, 1989). The need for problem-solving
93
skills in physiotherapists is illustrated by Henry (1985) Discussion who describes how students or therapists who are unable to solve problems cannot be effective clinicians, because Much of the literature on PBL is based on medical if they cannot recognise patients' problems they will find education. However, Titchen (1987b)confirms the link it difficult, even impossible, to plan or implement between approaches to medical and physiotherapy education. PBL has not been fully adopted in any successful management and treatment. physiotherapy school in Britain, but such schools do exist As already stated, problem-solving learning (PSL) lies in other countries including Holland, Australia, USA and between the traditional and PBL approaches. Its design Canada. Van Langenberghe(1988)and Titchen and Cola can be very flexible, but the curriculum must be designed (1991)argue that PBL is a more successful approach to around development of problem-solving skills. These physiotherapy education than the traditional approach, skills can be developed within both the theoretical and in terms of fostering desirable learning styles and the clinical parts of the student training and would then skills and abilities needed clinically by graduates. be taken into the clinical situation by the qualified A PSL approach to physiotherapy education has been physiotherapists (Barr, 1977). widely reported on outside Britain and conclusions A problem-solving curriculum generally introduces the have been positive in terms of expected outcomes and patients' problems a t the same time as the theory. The fulfilment of objectives (Burnett et al, 1986;Barr, 1977; teacher acts at certain times as an information giver and Slaughter et al, 1989;May, 1977). at others as a facilitator, and small-group work is used, as well as sessions for the whole class. Learning is more The move towards writing new independent and degree physiotherapy courses in Britain in recent years provided student-centred than in the traditional approach and an opportunity for current thinking on medical and problem-solving is incorporated into a curriculum in paramedical education to be considered in course design. which subjects are integrated. Because students are more involved in their learning and do more independent study The extent of use of problem-solving, integration of than in the traditional approach, there is said to be subjects, and active involvement of students in their learning varies, but it appears, from informal murc8s, greater understanding and longer-term retention of that there has been a move away from the traditional knowledge (May, 1977). Evaluation tends to be summative, but formative assessment may be recognised approach towards a PSL approach in physiotherapy education in this country. as contributing towards the final mark. The changes in focus and design in physiotherapy education in Britain must have required marked changes Structure of PSL Teaching. in expectations and attitudes in educators, students The extent to which students are involved in PSL, the and clinicians. Although research into the design, sue of teaching groups, and whether other teaching implementation and evaluation of PSL in physiotherapy methods are used in preference to lectures,depend on the education is indicated, no literature has been found which has investigated whether graduates of this new design of individual course units. Some may argue that current pressures make student-centred learning very approach, as it exists in Britain, are more able than Hicult because lectures are the most cost-ef€ectiveway clinicians trained in the traditional way, in solving of teaching. Butler (1992)agrees that current financial patients' problems, coping with the demands of modern pressures mean that the lecture format is unlikely to be professional practice or continuing their education. replaced by small group teaching, but believes that the lecture need not be a didactic, one-way experience in Conclusion which the students are passive. "baching methods which At present, the three approaches to medical and are student-centred can be &ectively used within a largephysiotherapy education described and compared in this group lecture format. paper are available to educators as possible models of curriculum design. It seems, in light of research into Summary learning styles, the perceived faults with the traditional approach and the modern demands on clinicians in a The three approaches presented can be conveniently rapidly changing health service that a PBL or PSL compared and contrasted in the following table: approach is to be preferred over the traditional one. Similarities and differences among the objectives, Treditional Problem-based Problem solving design and methodology of all three approaches have approach learning learning been outlined 80 that they can be evaluated in terms of Teacher active Teacher facilitates Teacher teaches and desired learning and professional outcomes in facilitates physiotherapists. Students passive Students active Students active Author and Address for Correspondence Subjects not integrated Subjects integrated Subjects integrated Jennifer Morris BA MCSP DipTP is a teacher at Cardiff School Teaching didactic Active learning Active learning of Physiotherapy, Institute of Health Care Studies, University Hospital of Wales, Heath Park, Cardiff CF4 4XN. large group format Small group format Variable group size Superficial rote learning Deep understanding Greater understanding References Barr, J S (1977). 'A problem-solvingcurriculum design in physical Poor retention Long-term retention Longer-term retention therapy', Physical Therapy, 57, 3, 262-272. Summative assessment Formative assessment Summative assessment Barrows, H Sand Tamblyn, R M (1980). PrOblem-besedLeeming: Patients' problems Patients' problems Patients' problems An approach to medical education, Springer Publishing Co, presented after theory presented beforetheory presented with theory New York.
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Burnett, C N, Mahoney, P J, Chidley, M J and Pierson, F M (1986). ‘Problem-solvingapproach to clinical education’, Phpical Therapy, 66, 11, 1730-33. Butler, J A (1992). ‘Use of teaching methods bhhin the lecture format’, Medical Teecher, 14, 1, 11-25. C o b , C R (1985). ‘Differences between conventional and problem-based curricula in their students’ approaches to studying’, Medical Education, 19, 308-309. Coles, C R (1989). ‘Diabetes education: Theories of practice’, Practical Diabetes, 6, 5. 119-202. Ellis, R (ed) (1988). Professional Competence and Quelity Assurance in the Caring Professions, Chapman Hall, London. Hamilton, J D (1976). ‘The McMaster curriculum: A critique’, British Medical Journal, 1, 1191-96. Harden, R M (1988). ‘Some dilemmas in curriculumdevelopment’, Medical Teacher, 10, 1, 129-131. Henry, J N (1985). ‘Identifying problems in clinical problem-sohring: perceptions and interventions with non-problem-solvingclinical behaviours’, Physical Therapy, 65, 7, 1071-74. May, B J (1977). ‘An analytical problem-solvingcurriculum design for physical therapy education’, Physical Therapy, 57, 7, 807-813. May, B J and Newman, J (1980). ‘Developing competence in problem solving: A behavioural model’, Physical Therapy, 60,9, 1140 45.
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Menahem, S and Paget, N (1990). ‘Role play for the clinical tutor: towards problem-based learning’. Medical Teach84 12, 1, 57-61.
Waiting to See? In touch with cataracts by Margaret Ford. Broadcasting Support Services, 1992,large print, Braille and audiocassette. f2.50from PO Box 7. London W3 6XJ.
More than 120,000 cataract operations are carried out in Britain every year, and most patients have to live with increasingly blurred vision for many months beforehand. This booklet aims to make the waiting period less unpleasant and frustrating. It also answers the questions that haunt many patients: What will happen when Igo into hospital? What does the operation invoke? What is a lens implant? Will Ineed thick glasses? How soon will I be able to see again? It seeks to reassure and inform elderly people and their carers, relieving their anxiety at a difficult time.
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Newble, D Iand Clarke, R M (1966). ‘The approaches to learning of students in a traditional and in an innovative problem-based medical school’, Medical Education, 20, 267-273. Newble, 0 I and Entwlstle, N J (1986). ‘Learning styles and approaches: implications for medical education’, Medical Education, 20, 162-175. Schmidt, H G (1983). ‘Problem-based learning: Rationale and description’, Medical Education, 17, 11-16 Slaughter, D S, Brown, D S, Gardner, D L and Perritt, L J (1989). ‘Improving physical therapy students’ clinical problem-solving skills: An analytical questioning model’, Physical Therapy, 69, 6, 441-447. Titchen, A C (1987a). ‘Design and Implementationof a problembased continuing education programme: A guide for clinical physiotherapists’, Physiotherapy, 73, 7, 319-323. Titchen, A C (1987b). ‘Problem-based learning: The rationalefor a new approach to physiotherapy continuing educetion’, Physiotherapy, 73, 7,324-327. Titchen, A C and Coles C R (1991). ‘Comparative study of physiotherapy students’ approaches to their study in subjectcentred and problem-based curricula’, PhySiohempy Theory and Practice, 7, 127-133. Van Langenberghe, H V K (1988). ‘Evaluation of students’ approaches to studying in a problem-based physical therapy curriculum’, Physid Therapy, 68, 4, 522-527. Woodward, C A and Ferrier, B M (1983). ‘The content of the medical curriculum at McMaster Unhrersity: Graduates’ evaluation of their preparation for postgraduate training’, MedicalEducaffon, 17,54-60.
publication only one case of HIV was attributed to a sporting conflict in Italy but even then the source was not certain. Nevertheless 10 million people worldwide are infected with HIV so the measures outlined in this booklet must be a wise precaution.
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A Charter for Disabled People using Hospitals pmpared by the Royal Collegeof Physicians and the Prince d Wales’Advisory Group on D W l & 1992. 24 pages. 6 . f including postage from RCGe 11 S t Andrew’s Place, Regent’s park. London NW1 4LE.
Sport and HIV A kitbag for managers, coaches and players published by the Health Education Authoritx 1992 (ISBN 1 85448 471 0).30 pages. fl plus SAE from HEA Distribution Unit, Hamilton House, Mabledon Place, London WClH 9TX.
This small-format booklet deals with issues such as HIV testing, the risk of infection from communal showers, and whether people who are HIV positive should take part in sport. Vigorous contact sports which can break the skin and cause bleeding may present a risk of infection, although at the time of
Consultation between members of the Royal Collegeof General Practitioners and representatives of people with a variety of disabilities resulted in this detailed and specific report. Two main principles are that hospital staff need to distinguish between managingan illness and working with a disabled person, and that someone who has learned to live with a disability is usually much better informed about coping with it than anyone else. It also takes into account the many hospital users who have temporary impairments. It lays stress on simple matters like clear signposting, seats in long corridors and accessible toilets. It points out that adjustable examination couches and bath fittings to enable patients to help themselves will also contribute to
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Phyrlotherapy, February 1993, vol79, no 2
preventing back strain among staff. Several physiotherapistswere members of the working group which producedthis glossy A4 booklet, which can be used at many different stages of planning either comprehensively or in detail, and by several different types of hospital staff.
Stroke: A handbook for the patient’s family by Orahem Mulky DM FRCR The stroke Association, 1992. 32 pages. Sop from Publications Department, CHSA House, whitecraps Street, London EClY IUI.
The Stroke Association states that 1OOpoO people in Britain suffer a RIM stroke every yeat They can beof any age and this booklet alms to help them come to terms with their new situation and its devastating effect on their families. Professor Mulley describes in slmple terms the causes and effects of stroke, stressing that every patient is different. The hospital rehabilitation team is introduced and the booklet explains what to expect in the recovery stage and how the family can help. The most difficult time for the family may come when the patient is discharged, and the booklet suggests haw to preparefor this stage, identifies sources of practical help, and outlines ways in which to continue the rehabilitation process at home. There is straightforward advice on common problems and a complete section on money problems. Carers are urged to consider their own needs, and reassured that help can be made available.
SCHOLARLY PAPER
An Overview of and Comparison among Three Current Approaches to Medical and Physiotherapy Undergraduate Education Jennver Mom’s Key Wods Education, curriculum design, problem-based learning, problem solving.
summary In recent years there has been widespread evaluation and reappraisal of the design and outcomes of medical and paramedical undergraduate education. The so-called traditional approach has been found to be wanting in terms of both student learning and the demands of clinical practice. This approach is compared and contrasted with two alternative problem-based learning and problem-sdvlng approaches learning. Both alternative approaches are claimed to utilise design and methods which Improve students’ understanding and learning and foster development of the problem-solving skills believed to be central in effective patient management.
-
Introduction A considerable amount of attention has been given in the literature on medical and paramedical education to the curriculum design which most successfullp produces clinicians with the skills and abilities required of them in professional practice. Concern with course design and undergraduate education is of interest to clinicians as well as to educators because clinical staff are often involved with students on clinical placements and the students’ school education will affect their clinical performance. In fact, current trends indicate that clinicians are functioning more as clinical educators than as clinical supervisors. Graduates also need to function as competent and ef€ective professionals in the real world and not simply possess academic knowledge. Physiotherapy has a n academic basis, but it requires practitioners who are able to apply their knowledge. The long-standing traditional approach has been widely criticised, although it is still in use in some schools. Alternative approaches which claim to be more successful have provided the philosophy upon which many new physiotherapy courses are based.
The Traditional Approach Until relatively recently, medical and physiotherapy education has been based on what is known as the traditional or conventional approach (Barrows and k b l y n , 1980). This approach is simply but aptly described by Coles (1989) .asa ‘pot-filling’ approach in which the students are ‘emptyvessels waiting to be filled by teachers who shower them with “liquid wisdom” ’.
In the traditional approach the teacher is active and the students mostly passive. Teaching is didactic and usually delivered by lectures to large groups. Subject areas are taught independently with little connection made between related topics. Theory is taught largely separately from practice and patient problems are presented only after the theory has been taught. Work loads for the students are large, and summative end-of-year examinations are the usual form of assessment (Barrows and k b l y n , 1980). Barrows and k b l y n believe that this approach d t s from an intention to ensure that studente acquire a sound knowledga Over the years, this determination has evolved into a one-sided focus on delivery of content and examination of recall of the imparted information, with little attention being given to how well or how much this often superficial learning could be used clinically. Results from research into learning styles and approaches (Newble and Entwistle, 1986) also raised valid questions as to the effectiveness of the traditional approach. Students tend to adopt learning strategies which are a response to the type ofteaching they receive (Newble and Clarke, 1986). Didactic teaching, in which students are passive, promotes rote learning with poor understanding and short-livedretention of what has been learned (Newble and Entwistle, 1986). In terms of the needs of clinical practice these authors argue that students need to adopt a deeper apprsach which promotes greater understanding and longer-term retention and that the traditional approach does not encourage this.
Weaknesses of Traditional Approach As long ago as 1910, Dewey stated that ‘science has been taught too much as a n accumulation of ready-made material with which students are to be made familiar, not enough as a method ofthinking, a n attitude of mind, after the pattern of which mental habits are to be transformed’ (Hamilton, 1976). A number of disadvantages of the traditional approach have been recognised and dem-ibed in recent yeara Coles (1989)argues that students d e r averload and decreased -motivation, fail to me the relevance of what they have been taught, and gain only superficial understanding, and that retention of knowledge over time is poor. Students ale0 find that there is poor correlation between theory and practice and that lack of integration of subject matter makes clinical practice M i c u l t (May,1977). Schmidt (1983)further claims that some ofthe knowledge acquired with the traditional approach is irrelevant, and that this approach does little to encourage postgraduate continuing education. This need for a continuum from undergraduate education through specialisation and
Phyrlothempy,February 1999, ~ 0 1 7 %no 2
92
continuing education is also recognised by Harden (1988). Despite widespread awareness of the faults of the traditional approach, it is only in the last three decades or so that attention has been given to alternative approaches to medical and paramedical education. Apart from awareness of the inherent faults in the objectives and methods of the traditional approach, other pressures also encouraged re-appraisal of teaching approaches. There was concern that the needs of society and, thus, the needs of clinical practice had changed, while medical education had not (Hamilton, 1976). Concern was also expressed that the lack of correlation between theory and practice had led to health professionals not being equipped to cope with the problems presented by patients. A need for clinicians to be able to solve problems is believed to be central to effective patient management (May, 1977;Barr, 1977).
Problem-based Learning In response to the perceived failures of the traditional approach in preparing medical students for the reality of clinical practice, the alternative approach of problembased learning (PBL) was devised. PBL was pioneered at McMaster University medical school in Canada in the late 1960s. It is almost diametrically opposed to the traditional approach in design and method. Barrow and ‘Igmblyn (1980)state that there are two fundamental postulates in PBL. One is that learning through problem-solving is more effectivethan memorybased learning in creating a usable body of knowledge and the other is that problem-solving skills are more important than memory in clinical practice. Menahem and Paget (1990)define PBL as ‘learning that results from the process of working towards the understanding or resolution of a problem’. Schmidt (1983)states that PBL claims to solve many of the problems of conventional medical education. The core of PBL is that the patient problem is presented before any theory is learned and that the students build up their knowledge base on the patient problems with which they have been presented rather than learning pathologies and treatments theoretically. This method also focuees on development of problem-solvingskills and the reasoning used by clinicians in solving patient problems (Barrows and Thmblyn, 1980). Apart from this pivotal change in philosophy, the design of PBL is very different. Learning is student-centred, not teachercentred. The students are actively responsible for their own learning and the teacher acts as a facilitator. Subjects are integrated and patient problems are looked at as a whole rather than in fragmented form. The lecture and large group format are dropped in favour of students working in small tutorial groups. Assessment is formative and continuous rather than summative (Barrows and ‘hmblyn, 1980;Hamilton, 1976;Titchen, 1987a; Ellis, 1988;Menahem and Paget, 1990;Schmidt, 1983). The methods of teaching and learning are also very different in PBL. The problems presented should be baaed on real patients so that students perceive their relevance. They can be presented in many ways ranging through a written description of problems, video, simulation, roleplay and real patients. Resources can be print, video, computer-baaed and so on (Barrows and ‘Igmblyn, 1980).
Phydothenpy,February 1993, vol79, no 2
Justification for PBL Barrows and ’Igmblyn and other supporters of PBL (Hamilton, 1976)believe that students trained under PBL have effective clinical problem-solving skills, a relevant and well-retained body of knowledge, a desire to continue with their education after graduation and a well-established ability for independent study and maximal use of resources. Proponents of PBL accept that this approach is radically different from what has been considered to be the norm, and agree that both teachers’ and students’ attitudes have to be changed. Barrows and Thmblyn (1980)agree that if PBL is to be successful its implementation needs the full support of all staff, students and involved clinicians. They also acknowledge that PBL needs more resources than the traditional approach, but believe that once the resource base has been established it is a very cost-effective method. They disagree that smaller groups make increased demands on teacher time and argue that, because the students do most of the learning themselves, teaching commitments are little changed. Researchers in learning theory also favour the PBL approach. Coles (1989)describes PBL as an example of ‘making connections’ in which learning is satiafying and the approach of practice coming before theory helps ‘the learner learn how to learn’. PBL is also concluded to be better than the traditional approach in promoting the desirable deep approach to learning (Newble and Clarke, 1986;Coles, 198Ei).
Weaknesses of Problem-based Learning Even if PBL is largely successfulin fulfilling its objedive of producing clinicians who are able to solve patients’ problems, there are perceived areas of weakness. Woodward and Ferrier (1983)questioned graduates of the McMaster course on how well they felt they had been prepared for clinical practice. In comparison with graduates from traditional schools the McMaster graduates felt more competent in areas like independent study, problem-solving and ability to gather data and keep records, but felt badly prepared in basic medical sciences which, they believed, needed more attention. This raises the possibility of a need for provision of core material classes before students are given patients’ problems on which to work. Such an approach would involve a move away from the pure form of PBL into an area between the two extremes of the traditional approach and PBL. This large middle area is the context for the third approach to medical and paramedical education - problem-solving learning.
Problem-solvingLearning The need for problem-solvinghas been widely recognised in physiotherapy as well as medicine. May and Newman (1980)state that ‘problem-solvingis an integral part of effective physiotherapy practice’. Concern about physiotherapy students’ ability in problem-solving has also been raised, as students are the clinicians of the future and will need to be able to analyse what they have learned in relation to managing patients’ problems (Slaughter et al, 1989). The need for problem-solving
93
skills in physiotherapists is illustrated by Henry (1985) Discussion who describes how students or therapists who are unable to solve problems cannot be effective clinicians, because Much of the literature on PBL is based on medical if they cannot recognise patients' problems they will find education. However, Titchen (1987b)confirms the link it difficult, even impossible, to plan or implement between approaches to medical and physiotherapy education. PBL has not been fully adopted in any successful management and treatment. physiotherapy school in Britain, but such schools do exist As already stated, problem-solving learning (PSL) lies in other countries including Holland, Australia, USA and between the traditional and PBL approaches. Its design Canada. Van Langenberghe(1988)and Titchen and Cola can be very flexible, but the curriculum must be designed (1991)argue that PBL is a more successful approach to around development of problem-solving skills. These physiotherapy education than the traditional approach, skills can be developed within both the theoretical and in terms of fostering desirable learning styles and the clinical parts of the student training and would then skills and abilities needed clinically by graduates. be taken into the clinical situation by the qualified A PSL approach to physiotherapy education has been physiotherapists (Barr, 1977). widely reported on outside Britain and conclusions A problem-solving curriculum generally introduces the have been positive in terms of expected outcomes and patients' problems a t the same time as the theory. The fulfilment of objectives (Burnett et al, 1986;Barr, 1977; teacher acts at certain times as an information giver and Slaughter et al, 1989;May, 1977). at others as a facilitator, and small-group work is used, as well as sessions for the whole class. Learning is more The move towards writing new independent and degree physiotherapy courses in Britain in recent years provided student-centred than in the traditional approach and an opportunity for current thinking on medical and problem-solving is incorporated into a curriculum in paramedical education to be considered in course design. which subjects are integrated. Because students are more involved in their learning and do more independent study The extent of use of problem-solving, integration of than in the traditional approach, there is said to be subjects, and active involvement of students in their learning varies, but it appears, from informal murc8s, greater understanding and longer-term retention of that there has been a move away from the traditional knowledge (May, 1977). Evaluation tends to be summative, but formative assessment may be recognised approach towards a PSL approach in physiotherapy education in this country. as contributing towards the final mark. The changes in focus and design in physiotherapy education in Britain must have required marked changes Structure of PSL Teaching. in expectations and attitudes in educators, students The extent to which students are involved in PSL, the and clinicians. Although research into the design, sue of teaching groups, and whether other teaching implementation and evaluation of PSL in physiotherapy methods are used in preference to lectures,depend on the education is indicated, no literature has been found which has investigated whether graduates of this new design of individual course units. Some may argue that current pressures make student-centred learning very approach, as it exists in Britain, are more able than Hicult because lectures are the most cost-ef€ectiveway clinicians trained in the traditional way, in solving of teaching. Butler (1992)agrees that current financial patients' problems, coping with the demands of modern pressures mean that the lecture format is unlikely to be professional practice or continuing their education. replaced by small group teaching, but believes that the lecture need not be a didactic, one-way experience in Conclusion which the students are passive. "baching methods which At present, the three approaches to medical and are student-centred can be &ectively used within a largephysiotherapy education described and compared in this group lecture format. paper are available to educators as possible models of curriculum design. It seems, in light of research into Summary learning styles, the perceived faults with the traditional approach and the modern demands on clinicians in a The three approaches presented can be conveniently rapidly changing health service that a PBL or PSL compared and contrasted in the following table: approach is to be preferred over the traditional one. Similarities and differences among the objectives, Treditional Problem-based Problem solving design and methodology of all three approaches have approach learning learning been outlined 80 that they can be evaluated in terms of Teacher active Teacher facilitates Teacher teaches and desired learning and professional outcomes in facilitates physiotherapists. Students passive Students active Students active Author and Address for Correspondence Subjects not integrated Subjects integrated Subjects integrated Jennifer Morris BA MCSP DipTP is a teacher at Cardiff School Teaching didactic Active learning Active learning of Physiotherapy, Institute of Health Care Studies, University Hospital of Wales, Heath Park, Cardiff CF4 4XN. large group format Small group format Variable group size Superficial rote learning Deep understanding Greater understanding References Barr, J S (1977). 'A problem-solvingcurriculum design in physical Poor retention Long-term retention Longer-term retention therapy', Physical Therapy, 57, 3, 262-272. Summative assessment Formative assessment Summative assessment Barrows, H Sand Tamblyn, R M (1980). PrOblem-besedLeeming: Patients' problems Patients' problems Patients' problems An approach to medical education, Springer Publishing Co, presented after theory presented beforetheory presented with theory New York.
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Burnett, C N, Mahoney, P J, Chidley, M J and Pierson, F M (1986). ‘Problem-solvingapproach to clinical education’, Phpical Therapy, 66, 11, 1730-33. Butler, J A (1992). ‘Use of teaching methods bhhin the lecture format’, Medical Teecher, 14, 1, 11-25. C o b , C R (1985). ‘Differences between conventional and problem-based curricula in their students’ approaches to studying’, Medical Education, 19, 308-309. Coles, C R (1989). ‘Diabetes education: Theories of practice’, Practical Diabetes, 6, 5. 119-202. Ellis, R (ed) (1988). Professional Competence and Quelity Assurance in the Caring Professions, Chapman Hall, London. Hamilton, J D (1976). ‘The McMaster curriculum: A critique’, British Medical Journal, 1, 1191-96. Harden, R M (1988). ‘Some dilemmas in curriculumdevelopment’, Medical Teacher, 10, 1, 129-131. Henry, J N (1985). ‘Identifying problems in clinical problem-sohring: perceptions and interventions with non-problem-solvingclinical behaviours’, Physical Therapy, 65, 7, 1071-74. May, B J (1977). ‘An analytical problem-solvingcurriculum design for physical therapy education’, Physical Therapy, 57, 7, 807-813. May, B J and Newman, J (1980). ‘Developing competence in problem solving: A behavioural model’, Physical Therapy, 60,9, 1140 45.
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Menahem, S and Paget, N (1990). ‘Role play for the clinical tutor: towards problem-based learning’. Medical Teach84 12, 1, 57-61.
Waiting to See? In touch with cataracts by Margaret Ford. Broadcasting Support Services, 1992,large print, Braille and audiocassette. f2.50from PO Box 7. London W3 6XJ.
More than 120,000 cataract operations are carried out in Britain every year, and most patients have to live with increasingly blurred vision for many months beforehand. This booklet aims to make the waiting period less unpleasant and frustrating. It also answers the questions that haunt many patients: What will happen when Igo into hospital? What does the operation invoke? What is a lens implant? Will Ineed thick glasses? How soon will I be able to see again? It seeks to reassure and inform elderly people and their carers, relieving their anxiety at a difficult time.
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Newble, D Iand Clarke, R M (1966). ‘The approaches to learning of students in a traditional and in an innovative problem-based medical school’, Medical Education, 20, 267-273. Newble, 0 I and Entwlstle, N J (1986). ‘Learning styles and approaches: implications for medical education’, Medical Education, 20, 162-175. Schmidt, H G (1983). ‘Problem-based learning: Rationale and description’, Medical Education, 17, 11-16 Slaughter, D S, Brown, D S, Gardner, D L and Perritt, L J (1989). ‘Improving physical therapy students’ clinical problem-solving skills: An analytical questioning model’, Physical Therapy, 69, 6, 441-447. Titchen, A C (1987a). ‘Design and Implementationof a problembased continuing education programme: A guide for clinical physiotherapists’, Physiotherapy, 73, 7, 319-323. Titchen, A C (1987b). ‘Problem-based learning: The rationalefor a new approach to physiotherapy continuing educetion’, Physiotherapy, 73, 7,324-327. Titchen, A C and Coles C R (1991). ‘Comparative study of physiotherapy students’ approaches to their study in subjectcentred and problem-based curricula’, PhySiohempy Theory and Practice, 7, 127-133. Van Langenberghe, H V K (1988). ‘Evaluation of students’ approaches to studying in a problem-based physical therapy curriculum’, Physid Therapy, 68, 4, 522-527. Woodward, C A and Ferrier, B M (1983). ‘The content of the medical curriculum at McMaster Unhrersity: Graduates’ evaluation of their preparation for postgraduate training’, MedicalEducaffon, 17,54-60.
publication only one case of HIV was attributed to a sporting conflict in Italy but even then the source was not certain. Nevertheless 10 million people worldwide are infected with HIV so the measures outlined in this booklet must be a wise precaution.
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A Charter for Disabled People using Hospitals pmpared by the Royal Collegeof Physicians and the Prince d Wales’Advisory Group on D W l & 1992. 24 pages. 6 . f including postage from RCGe 11 S t Andrew’s Place, Regent’s park. London NW1 4LE.
Sport and HIV A kitbag for managers, coaches and players published by the Health Education Authoritx 1992 (ISBN 1 85448 471 0).30 pages. fl plus SAE from HEA Distribution Unit, Hamilton House, Mabledon Place, London WClH 9TX.
This small-format booklet deals with issues such as HIV testing, the risk of infection from communal showers, and whether people who are HIV positive should take part in sport. Vigorous contact sports which can break the skin and cause bleeding may present a risk of infection, although at the time of
Consultation between members of the Royal Collegeof General Practitioners and representatives of people with a variety of disabilities resulted in this detailed and specific report. Two main principles are that hospital staff need to distinguish between managingan illness and working with a disabled person, and that someone who has learned to live with a disability is usually much better informed about coping with it than anyone else. It also takes into account the many hospital users who have temporary impairments. It lays stress on simple matters like clear signposting, seats in long corridors and accessible toilets. It points out that adjustable examination couches and bath fittings to enable patients to help themselves will also contribute to
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Phyrlotherapy, February 1993, vol79, no 2
preventing back strain among staff. Several physiotherapistswere members of the working group which producedthis glossy A4 booklet, which can be used at many different stages of planning either comprehensively or in detail, and by several different types of hospital staff.
Stroke: A handbook for the patient’s family by Orahem Mulky DM FRCR The stroke Association, 1992. 32 pages. Sop from Publications Department, CHSA House, whitecraps Street, London EClY IUI.
The Stroke Association states that 1OOpoO people in Britain suffer a RIM stroke every yeat They can beof any age and this booklet alms to help them come to terms with their new situation and its devastating effect on their families. Professor Mulley describes in slmple terms the causes and effects of stroke, stressing that every patient is different. The hospital rehabilitation team is introduced and the booklet explains what to expect in the recovery stage and how the family can help. The most difficult time for the family may come when the patient is discharged, and the booklet suggests haw to preparefor this stage, identifies sources of practical help, and outlines ways in which to continue the rehabilitation process at home. There is straightforward advice on common problems and a complete section on money problems. Carers are urged to consider their own needs, and reassured that help can be made available.