- Email: [email protected]
Case-oriented Self-learning and Review in Pharmacology Teaching
CLINICAL INVESTIGATION
Case-oriented Self-learning and Review in Pharmacology Teaching Siying Li, MD, Baoping Yu, PhD and Jiang Yue, PhD
Abstract: Background: To cultivate students’ ability to use the pharmacology principles in medical practice, case-oriented self-learning and review has partly replaced lecture-based teaching in our pharmacology course. The aim of this study is to investigate the effects of an innovative teaching model in pharmacology teaching on the performance of medical undergraduates. Methods: A total of 185 third-year medical students participated in the study in 2011 and 2012. The students were randomized into the study group (case-oriented self-learning and review) and control group (traditional lecture-based teaching). Examination performances between the students in the 2 groups were compared, and questionnaires were designed for both the students participating in the study group and the teachers to assess the new teaching method. Results: Mid-term examination performances in 2011 and 2012 were significantly better for the students in the study group than those in the control group (P , 0.01). On the final examination in 2011, significantly more students received an assessment of “excellent” in the study group than in the control group (P , 0.05). Moreover, students in the study group performed better than those in the control group on the final examination in 2012. The data from the questionnaires indicated that both teachers and students in the study group generally held positive attitudes toward the innovative teaching model. Conclusions: Case-oriented self-learning and review can improve students’ internalization of basic pharmacological principles and provide a greater opportunity for self-study and collaborative study. The examination composition can affect the efficacy of the assessment of problem solving abilities. Key Indexing Terms: Case-oriented self-learning and review; Pharmacology. [Am J Med Sci 2014;348(1):52–56.]
P
harmacology is the science of drugs that primarily concerns the interactions between drugs and the living systems. A pharmacology curriculum has 2 striking characteristics: applicability and changing periodicity. Most pharmacology textbooks that are used in medical colleges are drug oriented and are organized by body system; however, drug management in clinical practice is disease oriented. Appropriate drug application requires the internalization of pharmacological principles; yet, internalizing pharmacological principles is a considerable challenge for both students and teachers. Pharmacology course in medical school aspires not only to impart pharmacological knowledge to students but also to cultivate students’ ability to put the principles of pharmacology to use in medical practice.
From the Health Sciences Center, Wuhan University Medical School (SL, BY), Wuhan, China; and Department of Pharmacology (JY), Basic Medical School of Wuhan University, Wuhan, China. Submitted June 1, 2013; accepted in revised form August 26, 2013. The first two authors contributed equally to this work. The study received financial support in the form of a research grant from the Hubei educational agency in China (Foundation for Research Support of the State of Hubei, Grant 2008b005). The authors have no conflicts of interest to disclose. Correspondence: Jiang Yue, PhD, Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China (E-mail: [email protected]).
52
Traditional lecture-based teaching is an effective way of delivering knowledge but limits the independent thinking and learning space of students.1 Converting knowledge to application is difficult for students who receive traditional lecturebased instruction. Medical students often perceive a separation between theory and practice in clinical education on drug management. Thus, educators have to find practical instructional methods to promote critical inquiry and sustainable selfdirected learning.2 Over the past few decades, many innovative methods have been adopted in medical education, including problem-based learning, case-based learning (CBL) and the patient-oriented problem-solving system.2–5 The common feature of these methods is the application of clinical problems, and such application has been proved to be effective in improving students’ analytical skills and problem-solving abilities, promoting students’ self-directed life-long learning and reinforcing students’ collaborative and communication skills.4,6,7 But in developing countries especially in China, the application of these methods is limited due to reasons like faculty shortage and lack of resources.4 CBL is a long-established pedagogical method that focuses on case study teaching and inquiry-based learning; thus, CBL is on the continuum between structured and guided learning.8 CBL was 1st introduced by James Lorrain Smith, a pathology professor at the University of Edinburgh, as the “case method of teaching pathology” in 1912.9 CBL functions as a bridge between learning/knowledge and working life,8,10 strengthening the link between theory and practice11,12 and mirroring the decision-making process of the workplace.12 Drawing on the experience of CBL, an innovative teaching model that is designed for large student cohorts was applied in our pharmacology course. The lecture hours for the traditional topics were reduced by 30%, and 2 new topics were added in the course. We designed and prepared cases over the entire course. Two topics were chosen for case-oriented selflearning by the course director and the senior teachers based on an analysis of the teaching content in pharmacology and 3 caseoriented review sections were arranged during the course. Previous studies have shown that students’ reactions to CBL are overwhelmingly positive in pharmacology teaching; however, the effects of some similar methods on students’ academic performance were controversial.13–17 The effects of CBL on students’ academic performance in pharmacology teaching have rarely been evaluated in developing countries.18 In this study, a controlled and randomized study was conducted to assess the innovative teaching model in pharmacology teaching by analyzing students’ academic performance on examinations and data from questionnaires designed for both the participating students and teachers.
METHODS Basic pharmacology has traditionally been taught in the 5th semester of the 5-year medical program at Wuhan University. In all, 103 and 82 third-year medical students volunteered to participate in the study in 2011 and 2012,
The American Journal of the Medical Sciences
Volume 348, Number 1, July 2014
Case-Oriented Self-Learning and Review
respectively. The Excel software program was used to generate random numbers that were assigned to each student. Then, the students were randomized to either the study group (49 in 2011 and 47 in 2012) or the control group (traditional lecture-based teaching) (54 in 2011 and 35 in 2012). The course scheme for the study group has been developed by the course director and senior teachers. The reform plan was approved by the Health Science Center of Wuhan University. In the study group, the students received 44 hours of case-oriented lectures (including 4 hours of lectures concerning the toxicology and pharmacology of the immune system that were not given in the control group), 4 hours of case-oriented discussion and 6 hours of review (Table 1). In the control group, the students received 57 hours of lectures in basic pharmacology. In the study group, the students were divided into 10 small teams (4–5 students on each team) and were asked to work as a team throughout the semester. To facilitate students’ critical thinking toward pharmacological principles in medical practice, we designed and prepared cases that demonstrate a number of key issues over the entire course. During lectures, teachers provided 1 or 2 cases with questions for each chapter, which will guide the students to study the new topic. The students were required to learn selected chapters (“Factors affecting the drug effect” and “Rational use of antimicrobial drugs”) from a pharmacology textbook by themselves before the scheduled case-oriented discussion, and the related cases with questions were distributed to the class 2 weeks before the class discussion. During these 2 weeks, the students had to search for and read related references and discuss the applicable pharmacological theory and questions within their team. In class, each group explained their understanding of the cases and responded to criticisms from other students of their analysis of the cases. During the discussion, the teachers (1 teacher for 5 groups) were required to make no comments. At the end of the discussion, the teachers provided a brief summary of the important issues in the case. Therefore, the students led the class discussion. Case-oriented review sections were arranged to enhance students’ understanding of the key principles and their capability of applying these principles in clinical practice. In review classes, the teachers led the class discussion, providing a considerable number of clinical questions concerning the topics that
TABLE 1. Topics for 2 groups Topics Traditional lecture-based teaching (57 h) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
General principles (8 h)
Peripheral neuropharmacology (10 h) Cardiovascular pharmacology (8 h) Anticoagulants (2 h) Central neuropharmacology (10 h) Endocrine pharmacology (6 h) Chemotherapy drugs (13 h)
were discussed in previous courses to help students adapt to professional working conditions and to strengthen students’ understanding and application of the knowledge. During the semester, the students took a mid-term examination and a final examination. These examinations covered the topics learned by both groups. The mid-term and final examinations were, respectively, designed by the course director and a senior teacher. The examinations were not made available to the teachers before they were administered to the students. Before grading the students’ examination papers, all of the teachers (8 people) who participated in this study met to discuss the answers of the short-answer questions and to create an answer key. The short-answer questions in the paper were graded by several teachers, and each short-answer question was graded by a single teacher to ensure consistency. Teachers scoring the examinations were blinded as to the identity and group of the students. The mid-term examination was designed to evaluate the learning process by encouraging students to use their knowledge to solve problems rather than to just recall their knowledge of the subject. The final examination was based on the Chinese Medical License Examination. The mid-term examination was more difficult than the final examination. Both examinations were worth 100 points. Comprehensive problems were worth 50 to 60 points on the mid-term examination and 20 to 30 points on the final term. In 2011, the students in both groups took the same mid-term examination, which had 30 multiple-choice questions and 2 short-answer questions, and the same final examination, which had 60 multiple-choice questions and 6 short-answer questions. In 2012, the students were required to take a mid-term examination, which had 40 multiple-choice questions and 3 short-answer questions, and a final examination, which had 60 multiple-choice questions and 9 shortanswer questions. Based on the examination score, the students were categorized into 4 performance ranges: (1) excellent (scoring 86–100); (2) very good (scoring 76–85); (3) good (scoring 60–75) and (4) insufficient (failing the examination). Questionnaires were designed for both the students in the study group and the teachers who participated in the study in 2011 (Tables 2 and 3).15,16,19 Answers were provided on 5-point Likert-type scales ranging from 1 (strongly disagree) to 5 (strongly agree).
Case-oriented self-learning (54 h) General principles (6 h) Toxicology (2 h) (Discussion) Factors affecting the drug effect (2 h) Peripheral neuropharmacology (6 h) Review (2 h) Cardiovascular pharmacology (6 h) Anticoagulants (2 h) Central neuropharmacology (8 h) Review (2 h) Endocrine pharmacology (4 h) Chemotherapy drugs (8 h) Pharmacology of the immune system (2 h) (Discussion) Rational use of antimicrobial drugs (2 h) Review (2 h)
The content added in the new teaching model is marked as the italics.
Ó 2013 Lippincott Williams & Wilkins
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Li et al
The mean scores of the examination were analyzed, and an unpaired Student’s t test was used to test the differences between 2 groups. The percentage of the students in each of the 4 performance ranges was calculated, and the x2 test was used to analyze the differences between 2 groups in terms of their distribution among these 4 performance ranges. Data analysis was performed using SPSS statistical software (Version 16.0; SPSS, Chicago, IL, USA), and a P value less than 0.05 was considered to be statistically significant.
RESULTS All the participating students were between the ages of 19 to 21 years old. We found that the students in the study group (24 male and 25 female) performed significantly better compared with students in the traditional lecture-based teaching group (26 male and 28 female) (74 6 8.52 versus 61 6 13.10; P , 0.01) on the mid-term examination in 2011. Compared with the traditional lecture-based teaching group, a higher percentage of students received an assessment of “very good” (P , 0.01) and a lower percentage of students received an assessment of “insufficient” (P , 0.01) in the study group (Figure 1A). There was no significant difference in the final examination performance in 2011 between the 2 groups, but the study group shows a trend toward higher mean scores compared with the traditional lecture-based teaching group (84 6 8.00 versus 81 6 8.88; P 5 0.06). The percentage of students who received an assessment of “excellent” was significantly higher in the study group than in the traditional lecture-based teaching group (P , 0.05; Figure 1B). In 2012, the mean score for the mid-term examination was significantly higher for the study group (21 male and 26 female) than for the traditional lecture-based teaching group (16 male and 19 female) (81 6 16.24 versus 62 6 16.37; P , 0.01). The percentage of the students who received an assess-
ment of “excellent” was significantly higher (P , 0.01) and the percentage of students who received an assessment of “insufficient” was lower (P , 0.01) in the study group than in the traditional lecture-based teaching group (Figure 1C). However, in 2012, there was no significant difference in the mean score for the final examination between the 2 groups (83 6 8.03 versus 80 6 9.62; P 5 0.18). The study group showed a trend toward a higher percentage of the students who received an assessment of “excellent” compared with the traditional lecture-based teaching group (43% versus 31%), although this difference was not significant (Figure 1D). Meanwhile, all of the students in the study group passed the final examination, and 2.9% of the students in the control group failed the examination. The results of the questionnaires indicated that both the students in the study group and the teachers generally held positive attitudes toward case-oriented discussion and review. Among the 8 teachers, 7 completely agreed that the cases could stimulate students’ interest in thinking and exploring the course material. Among 47 students in the study group, 36% of the students completely agreed and 47% of the students partly agreed with the same statement. Seven teachers completely agreed that the cases in the review class could guide students to reconsider pharmacological knowledge, and only 1 teacher was neutral. Among the students, 55% of the students completely agreed and 32% of the students partly agreed with this same statement. In addition, the teachers believed that the course planning workload increased significantly after the change in the teaching mode (Table 2). Moreover, 5 teachers believed that their interaction with students increased, whereas 2 teachers were neutral and 1 teacher did not agree with that. Meanwhile, the students recognized that the encouragement and guidance of the teachers increased their interest in solving the problems presented in the discussion. The new teaching mode improved the students’ critical and creative thinking abilities (Table 3).
FIGURE 1. The distribution of the students in different performance ranges (excellent, scoring 86–100; very good, scoring 76–85; good, scoring 60–75; insufficient, failing the examination) on examinations in 2011 and 2012. Compared with the traditional lecture-based teaching group, the percentage of students who received an assessment of “very good” was higher and the percentage of students who received an assessment of “insufficient” was lower in the study group for the mid-term examination in 2011 (A); the percentage of students who received an assessment of “excellent” was significantly higher in the study group on the final examination in 2011 (B); the percentage of the students who received an assessment of “excellent” was significantly higher and the percentage of students who received an assessment of “insufficient” was lower in the study group for mid-term examination in 2012 (C); the study group showed a trend toward a higher percentage of the students who received an assessment of “excellent” on the final examination in 2012 (D), (*P , 0.05, **P , 0.01).
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Case-Oriented Self-Learning and Review
TABLE 2. Questionnaire for teachers Statement (n 5 8)
5, n (%)
4, n (%)
3, n (%)
2, n (%)
1, n (%)
Cases allows students to achieve learning goals Cases stimulate students’ interest to think and explore Cases help students to learn the basic theory or skills Cases guide the students to review previous knowledge and experience Cases promote students to collect a variety of information Cases promote students to exchange information Workload for course planning increased significantly Interaction with students increased Exchanges between teachers increased
5 7 3 7 6 4 5 3 4
3 (37.5) 1 (12.5) 5 (62.5) 0 2 (25) 4 (50) 3 (37.5) 2 (25) 0
0 0 0 1 (12.5) 0 0 0 2 (25) 4 (50)
0 0 0 0 0 0 0 1 (12.5) 0
0 0 0 0 0 0 0 0 0
DISCUSSION Our results demonstrate that the innovative teaching model assessed in this study not only provides a greater chance for self-study and collaborative study but also improves students’ academic performance. There were significant differences in the students’ examination performance between the study group and the control group in mid-term examination in 2011 and 2012, and the study group showed a trend toward a higher performance on the final examination in 2011 and 2012 compared with the control group. Moreover, case-oriented selflearning and review requires fewer teaching resources compared with the classic CBL/problem-based learning, allowing use with large student cohorts. In contrast to traditional lecture-based teaching, caseoriented self-learning and review enables teachers to effectively guide students to critically think about pharmacology principles by designing a series of questions that follow clinical cases. The innovative teaching model not only allows students to direct their learning experiences but also makes the teaching target clear. The discussion can effectively facilitate students’ internalization of the basic course principles and improve their critical thinking skills. Similar research has shown that CBL promotes active learning, enhances motivation and helps avoid a focus on irrelevant and less useful parts of teaching curriculums.20,21 In the review classes, we summarize the important problems and challenges that may arise in clinical practice to deepen students’ understanding of the concepts.22 We try to
(62.5) (87.5) (37.5) (87.5) (75) (50) (62.5) (37.5) (50)
help students adapt to professional working conditions and strengthen students’ understanding of and ability to apply the knowledge that they acquire using case-based discussions. In this study, significant differences in mid-term examination performance were found between the study group and the traditional teaching group, whereas the differences in the final examination performance were smaller between the groups. An explanation for the smaller difference between the groups on the final examination may be the different composition of questions between the mid-term examination and the final examination. A higher percentage of the questions focused on knowledge application on the mid-term examination than on the final examination. Additional analyses showed that the students in the study group had a lower error rate in the applied part of the final examination (data not shown). As the examination composition can affect the efficacy of the assessment of problem solving abilities, future studies may focus on developing a reliable and valid written test for effective evaluation. In addition, the data from the questionnaires suggest that not all the teachers agree that the interaction between the teachers and the students increased. One possible reason may be that the teachers who were not involved in the discussion and review section might feel little change in the interaction with students. Nevertheless, the results may have been affected by interference between the groups. Students in the 2 teaching groups could freely exchange information and review each other’s learning materials during this study, which may make it
TABLE 3. Questionnaire for students Statement (n 5 47) Cases allows students to achieve learning goals Cases stimulate students’ interest to think and explore Cases help students to learn the basic theory or skills Cases guide the students to review previous knowledge and experience Cases promote students to collect a variety of information Cases promote students to exchange information The new course promotes me self-learning The new course model inspirits me to solve problems independently The new course improved students’ self-assessment of their ability for critical and creative thinking. Teachers are familiar with the process and task of teaching Teachers can grasp the process of teaching Teachers can create a good atmosphere for learning Teachers provide feedback to us in a timely manner Teachers are enthusiastic to carry out discussions
Ó 2013 Lippincott Williams & Wilkins
5, n (%) 4, n (%) 3, n (%) 2, n (%) 1, n (%) 20 17 21 26 22 24 30 27 26
(43) (36) (45) (55) (27) (51) (64) (58) (55)
25 22 21 15 22 17 14 18 18
(53) (47) (45) (32) (27) (36) (30) (38) (38)
1 7 5 6 3 4 3 2 3
(2) (15) (10) (13) (6) (9) (6) (4) (6)
0 0 0 0 0 2 (4) 0 0 0
1 (2) 1 (2) 0 0 0 0 0 0 0
28 22 23 24 28
(60) (47) (49) (51) (59)
17 18 18 18 14
(36) (38) (38) (38) (30)
2 7 4 4 4
(4) (15) (9) (9) (9)
0 0 2 (4) 1 (2) 1 (2)
0 0 0 0 0
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Li et al
more difficult to show differences between the groups. Certainly, the effectiveness of our study may be limited to a certain extent since examination performance is a short-term outcome reflecting the learning activity. Before further use of this innovative teaching model, some problems or challenges should be addressed. With a greater number of students learning through this method, more teachers will be involved in the case-oriented discussion and review, and consensus regarding the teaching philosophy and curriculum goals should be made. Appropriate cases that can effectively guide students in learning core knowledge in pharmacology should be selected. The time required for case discussions in class limits the ability for students to engage in more in-depth discussions, and the students may feel uneasy about this new approach since they have become accustomed to the traditional mode of learning and being told what is right and wrong.23 Changing student’s learning behavior is thus also a vital step during the teaching reform. Now, our evaluation system for students in the study group comprises 2 parts: examination grades and performance in discussions (data not shown). However, 1 question that remains concerns how to assess the long-term outcome from the innovative teaching model. In current context of global medical education, there are considerable differences among countries. It is difficult to find a teaching mode that is suitable for all courses or schools, especially in developing countries. CBL can help develop students’ ability to apply their knowledge in clinical practice; however, further research is necessary to determine how to use CBL for basic medicine teaching with fewer resources. Caseoriented self-learning and review may be a suitable teaching method for improving students’ ability to internalize basic principles and for providing self-study and collaborative study. ACKNOWLEDGMENTS The authors would to thank the participating 3rd-year students and teachers for their help and willingness to contribute to this study. REFERENCES 1. Tisonova J, Hudec R, Szalayova A, et al. Experience with problem oriented teaching in pharmacology. Bratisl Lek Listy 2005;106:83–7. 2. Srinivasan M, Wilkes M, Stevenson F, et al. Comparing problembased learning with case-based learning: effects of a major curricular shift at two institutions. Acad Med 2007;82:74–82. 3. Husain A. Problem-based learning: a current model of education. Oman Med J 2011;26:295. 4. Zhang Z, Liu W, Han J, et al. A trial of patient-oriented problemsolving system for immunology teaching in China: a comparison with dialectic lectures. BMC Med Educ 2013;13:11. 5. Sherer R, Dong H, Yunfeng Z, et al. Medical education reform in wuhan university, china: a preliminary report of an international collaboration. Teach Learn Med 2013;25:148–54.
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6. Tsou KI, Cho SL, Lin CS, et al. Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school. Kaohsiung J Med Sci 2009;25:282–93. 7. Malher X, Bareille N, Noordhuizen J P, et al. A case-based learning approach for teaching undergraduate veterinary students about dairy herd health consultancy issues. J Vet Med Educ 2009;36:22–9. 8. Thistlethwaite JE, Davies D, Ekeocha S, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 2012;34:e421–44. 9. Sturdy S. Scientific method for medical practitioners: the case method of teaching pathology in early twentieth-century Edinburgh. Bull Hist Med 2007;81:760–92. 10. Hansen WF, Ferguson KJ, Sipe CS, et al. Attitudes of faculty and students toward case-based learning in the third-year obstetrics and gynecology clerkship. Am J Obstet Gynecol 2005;192:644–7. 11. Hudson JN, Buckley P. An evaluation of case-based teaching: evidence for continuing benefit and realization of aims. Adv Physiol Educ 2004;28:15–22. 12. Stewart SR, Gonzalez LS. Instruction in professional issues using a cooperative learning, case study approach. Commun Disord Q 2006;27: 159–77. 13. Rich SK, Keim RG, Shuler CF. Problem-based learning versus a traditional educational methodology: a comparison of preclinical and clinical periodontics performance. J Dent Educ 2005;69:649–62. 14. Dyke P, Jamrozik K, Plant AJ. A randomized trial of a problembased learning approach for teaching epidemiology. Acad Med 2001;76: 373–9. 15. Antepohl W, Herzig S. Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study. Med Educ 1999;33:106–13. 16. Grauer GF, Forrester SD, Shuman C, et al. Comparison of student performance after lecture-based and case-based/problem-based teaching in a large group. J Vet Med Educ 2008;35:310–7. 17. Zgheib NK, Simaan JA, Sabra R, Using team-based learning to teach clinical pharmacology in medical school: student satisfaction and improved performance. J Clin Pharmacol 2011;51:1101–11. 18. Tayem YI, The Impact of small group case-based learning on traditional pharmacology teaching. Sultan Qaboos Univ Med J 2013;13:115–20. 19. Kingsbury MP, Lymn JS, Problem-based learning and larger student groups: mutually exclusive or compatible concepts—a pilot study. BMC Med Educ 2008;8:35. 20. Marin-Campos YL, Mendoza-Morales, Navarro-Hernandez JA. Students’ assessment of problems in a problem-based learning pharmacology course. Adv Health Sci Educ Theory Pract 2004;9:299–307. 21. Gwee MC. Globalization of problem-based learning (PBL): cross-cultural implications. Kaohsiung J Med Sci 2008;24(suppl 3):S14–22. 22. Hudec R, Tisonova J, Bozekova L, et al. Modified problem-based learning in pharmacology. Bratisl Lek Listy 2009;110:732–5. 23. Michel MC, Bischoff A, Jakobs KH. Comparison of problem-and lecturebased pharmacology teaching. Trends Pharmacol Sci 2002;23:168–70.
Volume 348, Number 1, July 2014
Case-oriented Self-learning and Review in Pharmacology Teaching Siying Li, MD, Baoping Yu, PhD and Jiang Yue, PhD
Abstract: Background: To cultivate students’ ability to use the pharmacology principles in medical practice, case-oriented self-learning and review has partly replaced lecture-based teaching in our pharmacology course. The aim of this study is to investigate the effects of an innovative teaching model in pharmacology teaching on the performance of medical undergraduates. Methods: A total of 185 third-year medical students participated in the study in 2011 and 2012. The students were randomized into the study group (case-oriented self-learning and review) and control group (traditional lecture-based teaching). Examination performances between the students in the 2 groups were compared, and questionnaires were designed for both the students participating in the study group and the teachers to assess the new teaching method. Results: Mid-term examination performances in 2011 and 2012 were significantly better for the students in the study group than those in the control group (P , 0.01). On the final examination in 2011, significantly more students received an assessment of “excellent” in the study group than in the control group (P , 0.05). Moreover, students in the study group performed better than those in the control group on the final examination in 2012. The data from the questionnaires indicated that both teachers and students in the study group generally held positive attitudes toward the innovative teaching model. Conclusions: Case-oriented self-learning and review can improve students’ internalization of basic pharmacological principles and provide a greater opportunity for self-study and collaborative study. The examination composition can affect the efficacy of the assessment of problem solving abilities. Key Indexing Terms: Case-oriented self-learning and review; Pharmacology. [Am J Med Sci 2014;348(1):52–56.]
P
harmacology is the science of drugs that primarily concerns the interactions between drugs and the living systems. A pharmacology curriculum has 2 striking characteristics: applicability and changing periodicity. Most pharmacology textbooks that are used in medical colleges are drug oriented and are organized by body system; however, drug management in clinical practice is disease oriented. Appropriate drug application requires the internalization of pharmacological principles; yet, internalizing pharmacological principles is a considerable challenge for both students and teachers. Pharmacology course in medical school aspires not only to impart pharmacological knowledge to students but also to cultivate students’ ability to put the principles of pharmacology to use in medical practice.
From the Health Sciences Center, Wuhan University Medical School (SL, BY), Wuhan, China; and Department of Pharmacology (JY), Basic Medical School of Wuhan University, Wuhan, China. Submitted June 1, 2013; accepted in revised form August 26, 2013. The first two authors contributed equally to this work. The study received financial support in the form of a research grant from the Hubei educational agency in China (Foundation for Research Support of the State of Hubei, Grant 2008b005). The authors have no conflicts of interest to disclose. Correspondence: Jiang Yue, PhD, Department of Pharmacology, Basic Medical School of Wuhan University, Wuhan 430071, China (E-mail: [email protected]).
52
Traditional lecture-based teaching is an effective way of delivering knowledge but limits the independent thinking and learning space of students.1 Converting knowledge to application is difficult for students who receive traditional lecturebased instruction. Medical students often perceive a separation between theory and practice in clinical education on drug management. Thus, educators have to find practical instructional methods to promote critical inquiry and sustainable selfdirected learning.2 Over the past few decades, many innovative methods have been adopted in medical education, including problem-based learning, case-based learning (CBL) and the patient-oriented problem-solving system.2–5 The common feature of these methods is the application of clinical problems, and such application has been proved to be effective in improving students’ analytical skills and problem-solving abilities, promoting students’ self-directed life-long learning and reinforcing students’ collaborative and communication skills.4,6,7 But in developing countries especially in China, the application of these methods is limited due to reasons like faculty shortage and lack of resources.4 CBL is a long-established pedagogical method that focuses on case study teaching and inquiry-based learning; thus, CBL is on the continuum between structured and guided learning.8 CBL was 1st introduced by James Lorrain Smith, a pathology professor at the University of Edinburgh, as the “case method of teaching pathology” in 1912.9 CBL functions as a bridge between learning/knowledge and working life,8,10 strengthening the link between theory and practice11,12 and mirroring the decision-making process of the workplace.12 Drawing on the experience of CBL, an innovative teaching model that is designed for large student cohorts was applied in our pharmacology course. The lecture hours for the traditional topics were reduced by 30%, and 2 new topics were added in the course. We designed and prepared cases over the entire course. Two topics were chosen for case-oriented selflearning by the course director and the senior teachers based on an analysis of the teaching content in pharmacology and 3 caseoriented review sections were arranged during the course. Previous studies have shown that students’ reactions to CBL are overwhelmingly positive in pharmacology teaching; however, the effects of some similar methods on students’ academic performance were controversial.13–17 The effects of CBL on students’ academic performance in pharmacology teaching have rarely been evaluated in developing countries.18 In this study, a controlled and randomized study was conducted to assess the innovative teaching model in pharmacology teaching by analyzing students’ academic performance on examinations and data from questionnaires designed for both the participating students and teachers.
METHODS Basic pharmacology has traditionally been taught in the 5th semester of the 5-year medical program at Wuhan University. In all, 103 and 82 third-year medical students volunteered to participate in the study in 2011 and 2012,
The American Journal of the Medical Sciences
Volume 348, Number 1, July 2014
Case-Oriented Self-Learning and Review
respectively. The Excel software program was used to generate random numbers that were assigned to each student. Then, the students were randomized to either the study group (49 in 2011 and 47 in 2012) or the control group (traditional lecture-based teaching) (54 in 2011 and 35 in 2012). The course scheme for the study group has been developed by the course director and senior teachers. The reform plan was approved by the Health Science Center of Wuhan University. In the study group, the students received 44 hours of case-oriented lectures (including 4 hours of lectures concerning the toxicology and pharmacology of the immune system that were not given in the control group), 4 hours of case-oriented discussion and 6 hours of review (Table 1). In the control group, the students received 57 hours of lectures in basic pharmacology. In the study group, the students were divided into 10 small teams (4–5 students on each team) and were asked to work as a team throughout the semester. To facilitate students’ critical thinking toward pharmacological principles in medical practice, we designed and prepared cases that demonstrate a number of key issues over the entire course. During lectures, teachers provided 1 or 2 cases with questions for each chapter, which will guide the students to study the new topic. The students were required to learn selected chapters (“Factors affecting the drug effect” and “Rational use of antimicrobial drugs”) from a pharmacology textbook by themselves before the scheduled case-oriented discussion, and the related cases with questions were distributed to the class 2 weeks before the class discussion. During these 2 weeks, the students had to search for and read related references and discuss the applicable pharmacological theory and questions within their team. In class, each group explained their understanding of the cases and responded to criticisms from other students of their analysis of the cases. During the discussion, the teachers (1 teacher for 5 groups) were required to make no comments. At the end of the discussion, the teachers provided a brief summary of the important issues in the case. Therefore, the students led the class discussion. Case-oriented review sections were arranged to enhance students’ understanding of the key principles and their capability of applying these principles in clinical practice. In review classes, the teachers led the class discussion, providing a considerable number of clinical questions concerning the topics that
TABLE 1. Topics for 2 groups Topics Traditional lecture-based teaching (57 h) 1 2 3 4 5 6 7 8 9 10 11 12 13 14
General principles (8 h)
Peripheral neuropharmacology (10 h) Cardiovascular pharmacology (8 h) Anticoagulants (2 h) Central neuropharmacology (10 h) Endocrine pharmacology (6 h) Chemotherapy drugs (13 h)
were discussed in previous courses to help students adapt to professional working conditions and to strengthen students’ understanding and application of the knowledge. During the semester, the students took a mid-term examination and a final examination. These examinations covered the topics learned by both groups. The mid-term and final examinations were, respectively, designed by the course director and a senior teacher. The examinations were not made available to the teachers before they were administered to the students. Before grading the students’ examination papers, all of the teachers (8 people) who participated in this study met to discuss the answers of the short-answer questions and to create an answer key. The short-answer questions in the paper were graded by several teachers, and each short-answer question was graded by a single teacher to ensure consistency. Teachers scoring the examinations were blinded as to the identity and group of the students. The mid-term examination was designed to evaluate the learning process by encouraging students to use their knowledge to solve problems rather than to just recall their knowledge of the subject. The final examination was based on the Chinese Medical License Examination. The mid-term examination was more difficult than the final examination. Both examinations were worth 100 points. Comprehensive problems were worth 50 to 60 points on the mid-term examination and 20 to 30 points on the final term. In 2011, the students in both groups took the same mid-term examination, which had 30 multiple-choice questions and 2 short-answer questions, and the same final examination, which had 60 multiple-choice questions and 6 short-answer questions. In 2012, the students were required to take a mid-term examination, which had 40 multiple-choice questions and 3 short-answer questions, and a final examination, which had 60 multiple-choice questions and 9 shortanswer questions. Based on the examination score, the students were categorized into 4 performance ranges: (1) excellent (scoring 86–100); (2) very good (scoring 76–85); (3) good (scoring 60–75) and (4) insufficient (failing the examination). Questionnaires were designed for both the students in the study group and the teachers who participated in the study in 2011 (Tables 2 and 3).15,16,19 Answers were provided on 5-point Likert-type scales ranging from 1 (strongly disagree) to 5 (strongly agree).
Case-oriented self-learning (54 h) General principles (6 h) Toxicology (2 h) (Discussion) Factors affecting the drug effect (2 h) Peripheral neuropharmacology (6 h) Review (2 h) Cardiovascular pharmacology (6 h) Anticoagulants (2 h) Central neuropharmacology (8 h) Review (2 h) Endocrine pharmacology (4 h) Chemotherapy drugs (8 h) Pharmacology of the immune system (2 h) (Discussion) Rational use of antimicrobial drugs (2 h) Review (2 h)
The content added in the new teaching model is marked as the italics.
Ó 2013 Lippincott Williams & Wilkins
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The mean scores of the examination were analyzed, and an unpaired Student’s t test was used to test the differences between 2 groups. The percentage of the students in each of the 4 performance ranges was calculated, and the x2 test was used to analyze the differences between 2 groups in terms of their distribution among these 4 performance ranges. Data analysis was performed using SPSS statistical software (Version 16.0; SPSS, Chicago, IL, USA), and a P value less than 0.05 was considered to be statistically significant.
RESULTS All the participating students were between the ages of 19 to 21 years old. We found that the students in the study group (24 male and 25 female) performed significantly better compared with students in the traditional lecture-based teaching group (26 male and 28 female) (74 6 8.52 versus 61 6 13.10; P , 0.01) on the mid-term examination in 2011. Compared with the traditional lecture-based teaching group, a higher percentage of students received an assessment of “very good” (P , 0.01) and a lower percentage of students received an assessment of “insufficient” (P , 0.01) in the study group (Figure 1A). There was no significant difference in the final examination performance in 2011 between the 2 groups, but the study group shows a trend toward higher mean scores compared with the traditional lecture-based teaching group (84 6 8.00 versus 81 6 8.88; P 5 0.06). The percentage of students who received an assessment of “excellent” was significantly higher in the study group than in the traditional lecture-based teaching group (P , 0.05; Figure 1B). In 2012, the mean score for the mid-term examination was significantly higher for the study group (21 male and 26 female) than for the traditional lecture-based teaching group (16 male and 19 female) (81 6 16.24 versus 62 6 16.37; P , 0.01). The percentage of the students who received an assess-
ment of “excellent” was significantly higher (P , 0.01) and the percentage of students who received an assessment of “insufficient” was lower (P , 0.01) in the study group than in the traditional lecture-based teaching group (Figure 1C). However, in 2012, there was no significant difference in the mean score for the final examination between the 2 groups (83 6 8.03 versus 80 6 9.62; P 5 0.18). The study group showed a trend toward a higher percentage of the students who received an assessment of “excellent” compared with the traditional lecture-based teaching group (43% versus 31%), although this difference was not significant (Figure 1D). Meanwhile, all of the students in the study group passed the final examination, and 2.9% of the students in the control group failed the examination. The results of the questionnaires indicated that both the students in the study group and the teachers generally held positive attitudes toward case-oriented discussion and review. Among the 8 teachers, 7 completely agreed that the cases could stimulate students’ interest in thinking and exploring the course material. Among 47 students in the study group, 36% of the students completely agreed and 47% of the students partly agreed with the same statement. Seven teachers completely agreed that the cases in the review class could guide students to reconsider pharmacological knowledge, and only 1 teacher was neutral. Among the students, 55% of the students completely agreed and 32% of the students partly agreed with this same statement. In addition, the teachers believed that the course planning workload increased significantly after the change in the teaching mode (Table 2). Moreover, 5 teachers believed that their interaction with students increased, whereas 2 teachers were neutral and 1 teacher did not agree with that. Meanwhile, the students recognized that the encouragement and guidance of the teachers increased their interest in solving the problems presented in the discussion. The new teaching mode improved the students’ critical and creative thinking abilities (Table 3).
FIGURE 1. The distribution of the students in different performance ranges (excellent, scoring 86–100; very good, scoring 76–85; good, scoring 60–75; insufficient, failing the examination) on examinations in 2011 and 2012. Compared with the traditional lecture-based teaching group, the percentage of students who received an assessment of “very good” was higher and the percentage of students who received an assessment of “insufficient” was lower in the study group for the mid-term examination in 2011 (A); the percentage of students who received an assessment of “excellent” was significantly higher in the study group on the final examination in 2011 (B); the percentage of the students who received an assessment of “excellent” was significantly higher and the percentage of students who received an assessment of “insufficient” was lower in the study group for mid-term examination in 2012 (C); the study group showed a trend toward a higher percentage of the students who received an assessment of “excellent” on the final examination in 2012 (D), (*P , 0.05, **P , 0.01).
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Case-Oriented Self-Learning and Review
TABLE 2. Questionnaire for teachers Statement (n 5 8)
5, n (%)
4, n (%)
3, n (%)
2, n (%)
1, n (%)
Cases allows students to achieve learning goals Cases stimulate students’ interest to think and explore Cases help students to learn the basic theory or skills Cases guide the students to review previous knowledge and experience Cases promote students to collect a variety of information Cases promote students to exchange information Workload for course planning increased significantly Interaction with students increased Exchanges between teachers increased
5 7 3 7 6 4 5 3 4
3 (37.5) 1 (12.5) 5 (62.5) 0 2 (25) 4 (50) 3 (37.5) 2 (25) 0
0 0 0 1 (12.5) 0 0 0 2 (25) 4 (50)
0 0 0 0 0 0 0 1 (12.5) 0
0 0 0 0 0 0 0 0 0
DISCUSSION Our results demonstrate that the innovative teaching model assessed in this study not only provides a greater chance for self-study and collaborative study but also improves students’ academic performance. There were significant differences in the students’ examination performance between the study group and the control group in mid-term examination in 2011 and 2012, and the study group showed a trend toward a higher performance on the final examination in 2011 and 2012 compared with the control group. Moreover, case-oriented selflearning and review requires fewer teaching resources compared with the classic CBL/problem-based learning, allowing use with large student cohorts. In contrast to traditional lecture-based teaching, caseoriented self-learning and review enables teachers to effectively guide students to critically think about pharmacology principles by designing a series of questions that follow clinical cases. The innovative teaching model not only allows students to direct their learning experiences but also makes the teaching target clear. The discussion can effectively facilitate students’ internalization of the basic course principles and improve their critical thinking skills. Similar research has shown that CBL promotes active learning, enhances motivation and helps avoid a focus on irrelevant and less useful parts of teaching curriculums.20,21 In the review classes, we summarize the important problems and challenges that may arise in clinical practice to deepen students’ understanding of the concepts.22 We try to
(62.5) (87.5) (37.5) (87.5) (75) (50) (62.5) (37.5) (50)
help students adapt to professional working conditions and strengthen students’ understanding of and ability to apply the knowledge that they acquire using case-based discussions. In this study, significant differences in mid-term examination performance were found between the study group and the traditional teaching group, whereas the differences in the final examination performance were smaller between the groups. An explanation for the smaller difference between the groups on the final examination may be the different composition of questions between the mid-term examination and the final examination. A higher percentage of the questions focused on knowledge application on the mid-term examination than on the final examination. Additional analyses showed that the students in the study group had a lower error rate in the applied part of the final examination (data not shown). As the examination composition can affect the efficacy of the assessment of problem solving abilities, future studies may focus on developing a reliable and valid written test for effective evaluation. In addition, the data from the questionnaires suggest that not all the teachers agree that the interaction between the teachers and the students increased. One possible reason may be that the teachers who were not involved in the discussion and review section might feel little change in the interaction with students. Nevertheless, the results may have been affected by interference between the groups. Students in the 2 teaching groups could freely exchange information and review each other’s learning materials during this study, which may make it
TABLE 3. Questionnaire for students Statement (n 5 47) Cases allows students to achieve learning goals Cases stimulate students’ interest to think and explore Cases help students to learn the basic theory or skills Cases guide the students to review previous knowledge and experience Cases promote students to collect a variety of information Cases promote students to exchange information The new course promotes me self-learning The new course model inspirits me to solve problems independently The new course improved students’ self-assessment of their ability for critical and creative thinking. Teachers are familiar with the process and task of teaching Teachers can grasp the process of teaching Teachers can create a good atmosphere for learning Teachers provide feedback to us in a timely manner Teachers are enthusiastic to carry out discussions
Ó 2013 Lippincott Williams & Wilkins
5, n (%) 4, n (%) 3, n (%) 2, n (%) 1, n (%) 20 17 21 26 22 24 30 27 26
(43) (36) (45) (55) (27) (51) (64) (58) (55)
25 22 21 15 22 17 14 18 18
(53) (47) (45) (32) (27) (36) (30) (38) (38)
1 7 5 6 3 4 3 2 3
(2) (15) (10) (13) (6) (9) (6) (4) (6)
0 0 0 0 0 2 (4) 0 0 0
1 (2) 1 (2) 0 0 0 0 0 0 0
28 22 23 24 28
(60) (47) (49) (51) (59)
17 18 18 18 14
(36) (38) (38) (38) (30)
2 7 4 4 4
(4) (15) (9) (9) (9)
0 0 2 (4) 1 (2) 1 (2)
0 0 0 0 0
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more difficult to show differences between the groups. Certainly, the effectiveness of our study may be limited to a certain extent since examination performance is a short-term outcome reflecting the learning activity. Before further use of this innovative teaching model, some problems or challenges should be addressed. With a greater number of students learning through this method, more teachers will be involved in the case-oriented discussion and review, and consensus regarding the teaching philosophy and curriculum goals should be made. Appropriate cases that can effectively guide students in learning core knowledge in pharmacology should be selected. The time required for case discussions in class limits the ability for students to engage in more in-depth discussions, and the students may feel uneasy about this new approach since they have become accustomed to the traditional mode of learning and being told what is right and wrong.23 Changing student’s learning behavior is thus also a vital step during the teaching reform. Now, our evaluation system for students in the study group comprises 2 parts: examination grades and performance in discussions (data not shown). However, 1 question that remains concerns how to assess the long-term outcome from the innovative teaching model. In current context of global medical education, there are considerable differences among countries. It is difficult to find a teaching mode that is suitable for all courses or schools, especially in developing countries. CBL can help develop students’ ability to apply their knowledge in clinical practice; however, further research is necessary to determine how to use CBL for basic medicine teaching with fewer resources. Caseoriented self-learning and review may be a suitable teaching method for improving students’ ability to internalize basic principles and for providing self-study and collaborative study. ACKNOWLEDGMENTS The authors would to thank the participating 3rd-year students and teachers for their help and willingness to contribute to this study. REFERENCES 1. Tisonova J, Hudec R, Szalayova A, et al. Experience with problem oriented teaching in pharmacology. Bratisl Lek Listy 2005;106:83–7. 2. Srinivasan M, Wilkes M, Stevenson F, et al. Comparing problembased learning with case-based learning: effects of a major curricular shift at two institutions. Acad Med 2007;82:74–82. 3. Husain A. Problem-based learning: a current model of education. Oman Med J 2011;26:295. 4. Zhang Z, Liu W, Han J, et al. A trial of patient-oriented problemsolving system for immunology teaching in China: a comparison with dialectic lectures. BMC Med Educ 2013;13:11. 5. Sherer R, Dong H, Yunfeng Z, et al. Medical education reform in wuhan university, china: a preliminary report of an international collaboration. Teach Learn Med 2013;25:148–54.
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6. Tsou KI, Cho SL, Lin CS, et al. Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school. Kaohsiung J Med Sci 2009;25:282–93. 7. Malher X, Bareille N, Noordhuizen J P, et al. A case-based learning approach for teaching undergraduate veterinary students about dairy herd health consultancy issues. J Vet Med Educ 2009;36:22–9. 8. Thistlethwaite JE, Davies D, Ekeocha S, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 2012;34:e421–44. 9. Sturdy S. Scientific method for medical practitioners: the case method of teaching pathology in early twentieth-century Edinburgh. Bull Hist Med 2007;81:760–92. 10. Hansen WF, Ferguson KJ, Sipe CS, et al. Attitudes of faculty and students toward case-based learning in the third-year obstetrics and gynecology clerkship. Am J Obstet Gynecol 2005;192:644–7. 11. Hudson JN, Buckley P. An evaluation of case-based teaching: evidence for continuing benefit and realization of aims. Adv Physiol Educ 2004;28:15–22. 12. Stewart SR, Gonzalez LS. Instruction in professional issues using a cooperative learning, case study approach. Commun Disord Q 2006;27: 159–77. 13. Rich SK, Keim RG, Shuler CF. Problem-based learning versus a traditional educational methodology: a comparison of preclinical and clinical periodontics performance. J Dent Educ 2005;69:649–62. 14. Dyke P, Jamrozik K, Plant AJ. A randomized trial of a problembased learning approach for teaching epidemiology. Acad Med 2001;76: 373–9. 15. Antepohl W, Herzig S. Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study. Med Educ 1999;33:106–13. 16. Grauer GF, Forrester SD, Shuman C, et al. Comparison of student performance after lecture-based and case-based/problem-based teaching in a large group. J Vet Med Educ 2008;35:310–7. 17. Zgheib NK, Simaan JA, Sabra R, Using team-based learning to teach clinical pharmacology in medical school: student satisfaction and improved performance. J Clin Pharmacol 2011;51:1101–11. 18. Tayem YI, The Impact of small group case-based learning on traditional pharmacology teaching. Sultan Qaboos Univ Med J 2013;13:115–20. 19. Kingsbury MP, Lymn JS, Problem-based learning and larger student groups: mutually exclusive or compatible concepts—a pilot study. BMC Med Educ 2008;8:35. 20. Marin-Campos YL, Mendoza-Morales, Navarro-Hernandez JA. Students’ assessment of problems in a problem-based learning pharmacology course. Adv Health Sci Educ Theory Pract 2004;9:299–307. 21. Gwee MC. Globalization of problem-based learning (PBL): cross-cultural implications. Kaohsiung J Med Sci 2008;24(suppl 3):S14–22. 22. Hudec R, Tisonova J, Bozekova L, et al. Modified problem-based learning in pharmacology. Bratisl Lek Listy 2009;110:732–5. 23. Michel MC, Bischoff A, Jakobs KH. Comparison of problem-and lecturebased pharmacology teaching. Trends Pharmacol Sci 2002;23:168–70.
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