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Library resources for problem-based learning: the program perspective
computer methods and programs in biomed'mcine ELSEVIER
Computer Methods and Programs in Biomedicine 44 (1994) 167-173
Library resources for problem-based learning: the program perspective Jennifer Blake MeMaster University, Health Sciences Centre 2E18, 1200 Main Street West, Hamilton, ON LSN 3Z5, Canada
Abstract The impact of a problem based curriculum has been the subject of increasing interest, as evidenced by several recent articles on the subject [ 1-4]. McMaster was able to design its library to serve a problem-based curriculum, but since there had been no prior experience with such a curriculum, the library was designed to meet needs that could only be guessed at [5]. In addition, the library serves the needs of a research intensive faculty. How the curriculum and the library have interacted over the past 25 years may be helpful to other schools considering problem-based learning. Key words: Problem-based learning; Small-group learning; Libraries
The role of the library in a problem-based, student-centered curriculum does indeed differ markedly from the role it plays in a traditional curriculum.
1. The history of problem-based learning at McMaster The Medical School at McMaster was founded in 1969. The goal of the founding fathers was to produce graduates who would be better able to meet the needs of their patients in an era of burgeoning information (Table 1) [6]. The objectives emphasize an active approach to learning,
* Corresponding author, Tel.: 905 525 9140 ext. 22141.
and the development of lifelong skills to serve future practitioners. The learning objectives specified are in 3 domains: (1) knowledge in 3 perspectives: biology, behavior, and population; (2) skills, both clinical and learning; and (3) attitudes and behavior that would be required of students. Traditionally, our libraries and standard resources have served the biological domain well; as more attention focuses on the broader determinants of health, students find increasing need for readily accessible information in other domains. To achieve these objectives, the founders decided to have small-group-centered, self-directed learning based on biomedical problems. The primacy of the library in the program was recognized from the outset. Beatrix Robinow, the founding
0169-2607/94/$07.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved SSDI 0169-2607(94)01575-Z
168
J. Blake / Comput. Methods Programs Biomed. 44 (1994) 167 173
Table 1 Objectives of the undergraduate medical programme • • • • • •
to be life-long, self-directed learners to recognize and confront problems and seek solutions to work effectively in groups to integrate scientific principles into clinical care to be effective communicators to have a community perspective in addition to a sound biologic and behavioural understanding • to learn to self-evaluate and take part in responsible peer evaluation • to contribute to the solutions of health care problems through new and innovative approaches
librarian, was instrumental in setting up the library in order to address the needs of a problembased, self-directed curriculum. Emphasis was placed on having the library placed in a large, central position in the Health Sciences building. Unlike most Canadian medical schools, the lines of accountability were set up to the Dean of Health Sciences, rather than to the University Librarian. Seating and study space were set up in a way that seemed wildly excessive (but was not). Space was dedicated to audiovisual materials, which figured quite heavily in the early years of the program [7]. Dr. Bill Walsh, one of our founders, tells how he handled town gown relationships for the impending school. Community physicians were asked to come up with a list of what students needed to know. They came up with massive lists on everything imaginable, sufficient for a subspecialist in each field. " G o o d , " answered Dr. Walsh, "now come on over here and make a slide tape show about each of these topics." He claims that the community was happy, and the library received a wealth of material [6]. Many of the slide tape shows developed in the early days of the school are still considered valuable resources. Editing and revising the outof-date material is a significant task. The premises on which this school was based have remained largely unchanged. The most significant change has been the recognition that problem solving is not a stand-alone skill, but is, to a considerable degree, knowledge dependent. As an example, in the early years, it was thought not to matter too much which problems students tackled: they would get the basic principles and be
able to apply these to solve other problems. Subsequently, we have realized that problem solving as such is largely knowledge dependent [8]. Research in medical education has, however, given us much theoretical support for a problem-based approach. This has been echoed in the General Professional Education of Physicians (GPEP) Report [9], and is reflected in the accreditation standards of the Liaison Committee on Medical Education (LCME) [10]. 2. Outcomes of the program
At McMaster we have tracked all of our graduates through annual surveys, and identified a number of attributes: 48% of all graduates are in family practice, of whom 27% are in rural settings. There is a balance of choices among the specialties. A surprisingly high proportion of the graduates hold academic appointments (40%), with 17% in full-time academic practice, and 10% holding grants. McMaster's graduates spend more time in educational, research, and community work than do graduates of other Canadian universities. They spend an equivalent amount of time in organized continuing medical education (CME) activities according to one report, but in another study, were more likely to be up to date on current management [11]. The relative merits of traditional vs. problembased learning is a subject of ongoing debate [12-14], but there is no doubt that it is a stimulating and enjoyable process for students and faculty alike. It is as a student that the most fundamental shifts in emphasis take place. No longer does it matter what the professor thinks, or wants to put on the exam. What counts is that twice a week you can contribute in a useful way to a discussion with peers in front of faculty. What matters is that during the week you work well and help one another. It is a system which drives you to learn from desire to know, and backs it up with peer pressure. As a result, our students tend to work inordinate hours; and the last job at night is to sweep the medical students out of the library. Problem-based learning has entered the mainstream of medical education and is enjoying a certain vogue, an astonishing development for
J. Blake / Comput. Methods Programs Biomed. 44 (1994) 167 173
169
UNIT 1 Christmas Break
ELECTIVE UNIT2
Holiday
UNIT 4
ELECTIVE (4 WEEKS)
(6 WEEKS)
UNIT 3
Christmas Break
UNIT 6 THE CLERKSHIP UNIT5
Unit 6 includes 2 - 8 week blocks( 16 weeks) of elective time, plus 4 weeks of holiday time Christmas Break
"i~i~i~!ii!~i,~i~i i~i~'~'~~i~!~iiiil!i!~ii.i~~i!ii!iiiiii!i!iiiilil ~i~ill i i;~iii~i!i!iii~~i!i~!i~i!i~i!i~i~i~~i~i~i~~iiiiii!iiiiiiiiiiii!ii~iii!? ~~~ii~!iilili!i~ii~il~i~!i~~i~!~!i!ii ~!~i~!~i~iii!i~i~ililiiiiill i!~iii~i!i!i/ UNIT 6
REVISION [GRADUATION
:
THE CLERKSHIP
(CONTINUED) Fig. 1. The curriculum plan.
those of us who were at McMaster in the early years. It is important to remember that problembased learning (PBL), self-directed learning (SDL), and small-group learning (SGL) are means to achieve a set of objectives, and are not objectives in themselves.
3. Implementation of problem-based learning at McMaster 3.1. Problem -based learning At McMaster the heart and soul of the curriculum is problem based, and the only mandatory activity prior to clerkship is attendance at tutorial. Tutorial groups of 5 to 6 students meet twice weekly, and work through a series of health care problems which have been prepared to meet specific unit objectives. The units are all integrated. After an introductory unit there are 3 'body system' units (Cardio/Resp/Renal, Hemo/Gastro/ Endo, Neuro/Psycho/Loco), followed by a life cycle, community-based unit, then a year long clerkship (Fig. 1). There are 26 weeks of elective
time available to students, distributed across all years of the program. Presentations to the class as a whole are specifically not designed to 'cover' the curriculum, but deal with particular issues, or bring multidisciplinary views together. Problem-based learning is an educational strategy in which the problem is presented to the student first, to trigger the acquisition and integration of knowledge necessary for the student to resolve the problem. The cognitive basis of PBL has been the subject of much careful study. The work of Dr. Henk Schmidt and Dr. Geoff Norman, among others, has been particularly helpful [15-19]. Following presentation of the problem, students activate old knowledge [15]. This enables understanding of the current problem, and facilitates acquisition of new knowledge. Old knowledge may be theoretical or experiential. We have all had the experience of entering a conversation in process, and feeling mystified by what is being said. Suddenly you hear a clue as to what is under discussion and 'it all makes sense now'. Often we
170
J. Blake ] Comput. Methods Programs Biomed. 44 (1994) 167 173
will ask to hear the discussion again; our memory is not as good if we have not activated our prior knowledge. Students then elaborate on the subject, manipulating their knowledge and bringing it to bear on the current problem, exploring the boundaries of their understanding, This aids in mastery or ownership of knowledge. Students then list issues for further study and set objectives. In the second phase, students engage in an active information search. In this process the library is the key, though not the only resource. Students make extensive use of print materials, as well as computerized databases. A reserve collection contains multiple copies of materials known to be in high demand. Students will consult with resource people or agencies and arrange field trips or laboratory experiences as needed. In the final step, the group reconvenes for resolution of the problem, and sharing of information gathered. One of the premises of PBL is that information acquired in this manner will be more accessible later in a clinical setting: you have not 'had' biochemistry, you have 'used' it to facilitate understanding of, for example, diabetes. Learning in context is a powerful educational strategy which aids recall. It is further hoped that the habit of learning around health care problems will facilitate life-long learning. The health care problems are all written by faculty to address curricular objectives, and in accordance with a procedure coordinated through a central learning resources office. The problems are reviewed annually, and are placed in the library for access by students. The tutors are faculty members who have been trained through workshops and through cotutoring. They are not content experts, although they are generally familiar with the content area, or with the unit. To assist them in their role, a tutor guide is provided which highlights the key issues embedded in each problem. Since 1982, there has also been a problem resource bluesheet prepared, which students can refer to in order to assist them with their independent study. Students quickly develop their own approach to self-directed study which may include general texts and reference texts, resources listed on the
'blue sheets' and on reserve in the library, consultations with faculty and resource people, and primary literature searches. Because of the emphasis on collaborative learning and working as a group, students tend to work together in the library. If one student in the group finds a useful resource they will seek out their fellows to share the reference. The skill of particular students in finding and sharing materials is acknowledged in the tutorial meetings. Hiding or vandalizing library materials would be deeply censored as antithetical to the prevailing culture of cooperative learning. 3.2. Self-directed learning Self directed learning is not synonymous with problem-based learning, but is another of the key underpinnings to our educational system, and meshes seamlessly with PBL. Self-directed learning was chosen in order to develop learning skills and, more importantly, habits that would influence behavior throughout their careers. The development of computer-based information systems has triggered a major expansion in this aspect of library skills. Computer searching, popular with students, must be balanced by the ability to use the full range of resources provided by a contemporary library. 3.3. Small-group learning McMaster students can always be recognized because they travel in packs. This carries through into the library, where students will want and need to work, share and debate as a group. Ten small-group study rooms are provided for this purpose. The emphasis on small-group cooperative learning is deliberate. While McMaster stresses self-directed learning, it is not an independent study program. Effective small groups accelerate learning, and prepare students for their future careers in which team work and interprofessional relationships are critical. McMaster graduates are more likely to enter group as opposed to solo practice [11]. Work in the field of continuing education has further supported this strategy, as social isolation has been found to be a major predictor of substandard practice [ 16,17].
J. Blake / Comput. Methods Programs Biomed~ 44 (1994) 167 173
3.4. Evaluation of student learning Student progress and performance is evaluated continuously through the program by the students themselves, their peers, the tutor, and the program. Self-evaluation is expected to be ongoing, and students are expected to self-evaluate briefly at the end of each tutorial, commenting on success of learning strategies, contributions to the group, and progress with respect to their objectives. At the midpoint and end of each unit, students self-assess following the categories of knowledge, skills, and attitudes. Self-evaluation is followed by feedback from their peers and from the tutor. Tutors have a vital role in ensuring that the feedback given is honest, helpful, and fair. During each unit, there are 2 formal exercises, which differ between units. Triple jumps are particularly helpful in the early units. These are brief problem scenarios which assess problem identification, information retrieval and synthesis, and problem resolution skills. They are time-limited exercises (usually 2 - 4 h search time) which throw the students into the library and test their efficiency. They also test the ability of the library to cope with students on a mission. There are longer exercises in units 4 and 5 which ask the students to make much more extensive use of the library and its resources, and include epidemiologic and critical appraisal skills, such as the McMaster Community Oriented Problem Exercise (McCope). In 1992 the program introduced progress testing of knowledge by objective examination [4]. This is administered in a way which emphasizes personal performance and progress for the purpose of formative evaluation. It is not a test that students can, or do, study for. We do not, therefore, experience peaks of library use around progress testing.
3.5. The role of the library The library becomes the key resource to students in our program. Students come to us with widely diverse backgrounds, from those with PhDs in immunology to those with degrees in music or engineering, and no natural science. Self-directed learning is the only logical approach, as what is new to one student is old hat to
171
another. With every problem, students must devise their own, as well as their group's, learning objectives. The library contains the bulk of the print and audiovisual resources that students will need to consult, cataloged with print materials, but housed in a separate area. The audiovisual room has videos or slide tape shows that fill the role of lectures in a more traditional curriculum, with the advantage that they can be viewed when the material is relevant to the problem at hand. Computer-based instructional material is also stored in the audiovisual area. The reserve desk houses principal texts, reprints, and other materials that may be identified by the unit planners. Students are oriented to the library during their first weeks of medical school, and may avail themselves of organized instruction on the use of library resources, or may follow the self-help materials which are produced by the library staff. A computer instructional room is available for teaching literature computer-based searches. Because the bulk of the day is unstructured, there is heavy use of the library during the working day, and ample opportunity for students to interact with the professional library staff. Students are generally on a first name basis with the librarians. With a medical school class of 100 each year, and a total health sciences enrollment of 650 per year, there is seating for 651 in a comfortable, well-lit facility. The hours of operation are longer for the Health Sciences Library than for any other library on campus, closing at 11:30 h most nights, a total of 97.5 h weekly. Because there is no extended summer break, there is no opportunity to reduce hours during a summer term. In order to accommodate the intensive nature of the off-hours use of the facility, the library has provided for enhanced training of the nonprofessional staff, so that they are able to assist students with requests that would otherwise have to be deferred until the next day. Students in the PBL curriculum rely heavily on the library. In a study conducted between McMaster and our two neighboring traditional schools, a number of differences emerged (Table 2). PBL students use the library more often, an average of 54 visits per student each month, corn-
172
J. Blake ! Comput. Methods Programs Biomed. 44 (1994) 167-173
Table 2 Selected characteristics of participating libraries and medical schools McMaster Facilities and services Hours open per week Study seating capacity Square feet of space Professional staff (M.L.S.) Public microcomputers or terminals
103.5 549 38 905 9 20
Western
87.3 671 40 394 5.25 9
Toronto
90 336 61 850 11.8 17
Collection Volumes Current serial titles
129 375 1823
360 019 not reported
791 490 3240
Use and users Circulation Reserve or short-term loan circulation Gate count N u m b e r of medical students N u m b e r of medical faculty (full-time and part-time)
55 438 112 667 576 278 297 908
172 319 7641 569 035 415 1062
250 474 4323 not reported 1002 1260
With the exception of the number of medical students and the number of medical faculty, the figures are those submitted for publication in the Annual Statistics of Medical School Libraries in the U.S. and Canada, 1990-1991, 19th ed.
pared to 12-16 at the comparison schools. Each of the visits was longer on average, 157 min versus 71-103 [4]. This means that PBL students were in the library about twice a day for 2.5 h each trip. While there, students searched databases, used reference reserve and audiovisual collections, photocopied, studied and socialized more than their peers in traditional schools. This leads to a busy, often noisy library. When asked what more they wanted from the library, students requested a cappuccino bar.
3.6. Interaction between library staff and the program There are a number of opportunities for formal interaction. The director of the library, Dorothy Fitzgerald, sits on the undergraduate medical education committee and is aware of major trends within the program. There is a working relationship between library staff and each of the unit planners, which may include membership on planning committees. One of our librarians has co-tutored in the program to become better aware of the needs of students, and is now working with the curriculum committee to develop offerings that will assist students in developing information retrieval and storage systems. There is representa-
tion from the faculty on the library committee. A classroom was recently equipped within the library in recognition of this increasing role for professional librarians. More profound than these interactions is the close relationship students feel to their library. At the heart of this is that the seat of learning is no longer a bench in a lecture hall, but is the Health Sciences Library. Students identify the professional staff as among the most supportive people they encounter in the course of the degree program. When asked where to hang the photographs of the graduating classes, the students selected a corner of the library and dubbed it 'Mary's Corner' after a secretary who had acted as a den mother to the students. This centrality in the lives of students is a single most striking aspect of self-directed learning in a problem-based curriculum, and has a lot to do with why, whenever you need to find a student, the library is the first place to look. In planning our new student home base, space opposite the library was chosen because that is where the students want to be. As more and more schools adopt this educational format, it seems inevitable that the linkage students have to the library will become increas-
J. Blake/Comput. Methods Programs Biomed. 44 (1994) 167 173
ingly close, and essential. Proximity of the library to the students, involved staff, accessible hours, and adequate study space are all essential; advanced technologic support is a bonus.
4. Summary McMaster has had 25 years of experience as a problem-based medical school. The role of the library has proved central to the success of the curriculum. Many of the original features of the library were specifically to meet the needs of the medical school, while at the same time serving a research intensive faculty. Although problembased learning varies between schools, the system at McMaster is described with its foundation of problem-based, self-directed learning in smallgroup tutorials. Problem-based students have been found to make much more extensive and intensive use of the library. Perhaps more important to the students is the attachment they form to their library. Vandalism or misuse of the library is very rare. The needs of students in PBL curricula to search databases, and to employ effective information management and retrieval systems provides major opportunities for the librarians to interact directly in the students' learning.
References [1] J.D. Eldridge, A problem-based learning curriculum in transition: the emerging role of the library, Bull. Med. Libr. Assoc. 81 (1993) 310-315. [2] M.C. Watkins, Characteristics of services and educational programs in libraries serving problem-based curricula: a group self-study, Bull. Med. Libr. Assoc. 81 (1993) 306 309. [3] J.A. Rankin, Highlighting problem-based learning and medical libraries, Bull. Med. Libr. Assoc. 81 (1993) 293. [4] J.G. Marshall, D. Fitzgerald, L. Bushby and G. Heaton, A study of library use in problem-based and traditional medical curricula, Bull. Med. Libr. Assoc. 81 (1993) 299 305.
173
[5] B.H. Robinow, The Health Sciences Library, McMaster University, Hamilton, Ontario, Bull. Med. Libr. Assoc. 60 (1972) 559-565. [6] W.B. Spaulding, Revitalizing medical education: McMaster medical school the early years 1965-1974 (B.C. Decker Inc., Hamilton, Ontario, 1991). [7] B.H. Robinow, Audiovisuals and non-print learning resources in a health sciences library, J. Biocommun. 6 (1979) 14-19. [8] G.R. Norman, Problem-solving skills, solving problems and problem-based learning, Med. Educ. 22 (1988) 279286. [9] Association of American Medical Colleges, Physicians for the twenty-first century: report of the panel on the General Professional Education of the Physician and College Preparation for Medicine (Association of American Medical Colleges, 1984). [10] Liaison Committee on Medical Education, Functions and structure of a medical school: accreditation and the Liaison Committee on Medical Education, standards for accreditation of medical education programs leading to the MD degree (Association of American Medical Colleges and the American Medical Association, 1991). [11] C.A. Woodward, The effects of the innovations in medical education at McMaster: a report on follow-up studies, Medicus 2 (1989) 64-68. [12] L. Berkson, Problem-based learning: have the expectations been met? Acad. Med. 68 (1993) $79 $88. [13] M.A. Albanese and S. Mitchell, Problem-based learning: a review of literature on its outcomes and implementation issues, Acad. Med. 68 (1993) 52 81. [14] D.T.A. Vernon and R.L. Blake, Does problem-based learning work? A meta-analysis of evaluative research, Acad. Med. 68 (1993) 550 563. [15] H.G. Schmidt, Foundations of problem-based learning: some explanatory notes, Med. Educ. 27 (1993) 422 432. [16] G.R. Norman, D.A. Davis and S. Lamb, Competency assessment of primary care physicians as a component of a peer review program, J. Am. Med. Assoc. 270 (1993) 1046-1051. [17] J.M. Last, Maintenance of competence, Ann RCPSC 24 (1991) 7-8. [18] G.R. Norman and H.G. Schmidt, The psychological basis of problem-based learning: a review of the evidence, Acad. Med. 67 (1992) 557 565. [19] H.G. Schmidt, M.L. De Voider, W.S. DeGrave and J.H.C. Moust, Explanatory models in the processing of science text: the role of prior knowledge activation through small-group discussion, J. Educ. Psychol. 81 (1989) 610 619.
Computer Methods and Programs in Biomedicine 44 (1994) 167-173
Library resources for problem-based learning: the program perspective Jennifer Blake MeMaster University, Health Sciences Centre 2E18, 1200 Main Street West, Hamilton, ON LSN 3Z5, Canada
Abstract The impact of a problem based curriculum has been the subject of increasing interest, as evidenced by several recent articles on the subject [ 1-4]. McMaster was able to design its library to serve a problem-based curriculum, but since there had been no prior experience with such a curriculum, the library was designed to meet needs that could only be guessed at [5]. In addition, the library serves the needs of a research intensive faculty. How the curriculum and the library have interacted over the past 25 years may be helpful to other schools considering problem-based learning. Key words: Problem-based learning; Small-group learning; Libraries
The role of the library in a problem-based, student-centered curriculum does indeed differ markedly from the role it plays in a traditional curriculum.
1. The history of problem-based learning at McMaster The Medical School at McMaster was founded in 1969. The goal of the founding fathers was to produce graduates who would be better able to meet the needs of their patients in an era of burgeoning information (Table 1) [6]. The objectives emphasize an active approach to learning,
* Corresponding author, Tel.: 905 525 9140 ext. 22141.
and the development of lifelong skills to serve future practitioners. The learning objectives specified are in 3 domains: (1) knowledge in 3 perspectives: biology, behavior, and population; (2) skills, both clinical and learning; and (3) attitudes and behavior that would be required of students. Traditionally, our libraries and standard resources have served the biological domain well; as more attention focuses on the broader determinants of health, students find increasing need for readily accessible information in other domains. To achieve these objectives, the founders decided to have small-group-centered, self-directed learning based on biomedical problems. The primacy of the library in the program was recognized from the outset. Beatrix Robinow, the founding
0169-2607/94/$07.00 © 1994 Elsevier Science Ireland Ltd. All rights reserved SSDI 0169-2607(94)01575-Z
168
J. Blake / Comput. Methods Programs Biomed. 44 (1994) 167 173
Table 1 Objectives of the undergraduate medical programme • • • • • •
to be life-long, self-directed learners to recognize and confront problems and seek solutions to work effectively in groups to integrate scientific principles into clinical care to be effective communicators to have a community perspective in addition to a sound biologic and behavioural understanding • to learn to self-evaluate and take part in responsible peer evaluation • to contribute to the solutions of health care problems through new and innovative approaches
librarian, was instrumental in setting up the library in order to address the needs of a problembased, self-directed curriculum. Emphasis was placed on having the library placed in a large, central position in the Health Sciences building. Unlike most Canadian medical schools, the lines of accountability were set up to the Dean of Health Sciences, rather than to the University Librarian. Seating and study space were set up in a way that seemed wildly excessive (but was not). Space was dedicated to audiovisual materials, which figured quite heavily in the early years of the program [7]. Dr. Bill Walsh, one of our founders, tells how he handled town gown relationships for the impending school. Community physicians were asked to come up with a list of what students needed to know. They came up with massive lists on everything imaginable, sufficient for a subspecialist in each field. " G o o d , " answered Dr. Walsh, "now come on over here and make a slide tape show about each of these topics." He claims that the community was happy, and the library received a wealth of material [6]. Many of the slide tape shows developed in the early days of the school are still considered valuable resources. Editing and revising the outof-date material is a significant task. The premises on which this school was based have remained largely unchanged. The most significant change has been the recognition that problem solving is not a stand-alone skill, but is, to a considerable degree, knowledge dependent. As an example, in the early years, it was thought not to matter too much which problems students tackled: they would get the basic principles and be
able to apply these to solve other problems. Subsequently, we have realized that problem solving as such is largely knowledge dependent [8]. Research in medical education has, however, given us much theoretical support for a problem-based approach. This has been echoed in the General Professional Education of Physicians (GPEP) Report [9], and is reflected in the accreditation standards of the Liaison Committee on Medical Education (LCME) [10]. 2. Outcomes of the program
At McMaster we have tracked all of our graduates through annual surveys, and identified a number of attributes: 48% of all graduates are in family practice, of whom 27% are in rural settings. There is a balance of choices among the specialties. A surprisingly high proportion of the graduates hold academic appointments (40%), with 17% in full-time academic practice, and 10% holding grants. McMaster's graduates spend more time in educational, research, and community work than do graduates of other Canadian universities. They spend an equivalent amount of time in organized continuing medical education (CME) activities according to one report, but in another study, were more likely to be up to date on current management [11]. The relative merits of traditional vs. problembased learning is a subject of ongoing debate [12-14], but there is no doubt that it is a stimulating and enjoyable process for students and faculty alike. It is as a student that the most fundamental shifts in emphasis take place. No longer does it matter what the professor thinks, or wants to put on the exam. What counts is that twice a week you can contribute in a useful way to a discussion with peers in front of faculty. What matters is that during the week you work well and help one another. It is a system which drives you to learn from desire to know, and backs it up with peer pressure. As a result, our students tend to work inordinate hours; and the last job at night is to sweep the medical students out of the library. Problem-based learning has entered the mainstream of medical education and is enjoying a certain vogue, an astonishing development for
J. Blake / Comput. Methods Programs Biomed. 44 (1994) 167 173
169
UNIT 1 Christmas Break
ELECTIVE UNIT2
Holiday
UNIT 4
ELECTIVE (4 WEEKS)
(6 WEEKS)
UNIT 3
Christmas Break
UNIT 6 THE CLERKSHIP UNIT5
Unit 6 includes 2 - 8 week blocks( 16 weeks) of elective time, plus 4 weeks of holiday time Christmas Break
"i~i~i~!ii!~i,~i~i i~i~'~'~~i~!~iiiil!i!~ii.i~~i!ii!iiiiii!i!iiiilil ~i~ill i i;~iii~i!i!iii~~i!i~!i~i!i~i!i~i~i~~i~i~i~~iiiiii!iiiiiiiiiiii!ii~iii!? ~~~ii~!iilili!i~ii~il~i~!i~~i~!~!i!ii ~!~i~!~i~iii!i~i~ililiiiiill i!~iii~i!i!i/ UNIT 6
REVISION [GRADUATION
:
THE CLERKSHIP
(CONTINUED) Fig. 1. The curriculum plan.
those of us who were at McMaster in the early years. It is important to remember that problembased learning (PBL), self-directed learning (SDL), and small-group learning (SGL) are means to achieve a set of objectives, and are not objectives in themselves.
3. Implementation of problem-based learning at McMaster 3.1. Problem -based learning At McMaster the heart and soul of the curriculum is problem based, and the only mandatory activity prior to clerkship is attendance at tutorial. Tutorial groups of 5 to 6 students meet twice weekly, and work through a series of health care problems which have been prepared to meet specific unit objectives. The units are all integrated. After an introductory unit there are 3 'body system' units (Cardio/Resp/Renal, Hemo/Gastro/ Endo, Neuro/Psycho/Loco), followed by a life cycle, community-based unit, then a year long clerkship (Fig. 1). There are 26 weeks of elective
time available to students, distributed across all years of the program. Presentations to the class as a whole are specifically not designed to 'cover' the curriculum, but deal with particular issues, or bring multidisciplinary views together. Problem-based learning is an educational strategy in which the problem is presented to the student first, to trigger the acquisition and integration of knowledge necessary for the student to resolve the problem. The cognitive basis of PBL has been the subject of much careful study. The work of Dr. Henk Schmidt and Dr. Geoff Norman, among others, has been particularly helpful [15-19]. Following presentation of the problem, students activate old knowledge [15]. This enables understanding of the current problem, and facilitates acquisition of new knowledge. Old knowledge may be theoretical or experiential. We have all had the experience of entering a conversation in process, and feeling mystified by what is being said. Suddenly you hear a clue as to what is under discussion and 'it all makes sense now'. Often we
170
J. Blake ] Comput. Methods Programs Biomed. 44 (1994) 167 173
will ask to hear the discussion again; our memory is not as good if we have not activated our prior knowledge. Students then elaborate on the subject, manipulating their knowledge and bringing it to bear on the current problem, exploring the boundaries of their understanding, This aids in mastery or ownership of knowledge. Students then list issues for further study and set objectives. In the second phase, students engage in an active information search. In this process the library is the key, though not the only resource. Students make extensive use of print materials, as well as computerized databases. A reserve collection contains multiple copies of materials known to be in high demand. Students will consult with resource people or agencies and arrange field trips or laboratory experiences as needed. In the final step, the group reconvenes for resolution of the problem, and sharing of information gathered. One of the premises of PBL is that information acquired in this manner will be more accessible later in a clinical setting: you have not 'had' biochemistry, you have 'used' it to facilitate understanding of, for example, diabetes. Learning in context is a powerful educational strategy which aids recall. It is further hoped that the habit of learning around health care problems will facilitate life-long learning. The health care problems are all written by faculty to address curricular objectives, and in accordance with a procedure coordinated through a central learning resources office. The problems are reviewed annually, and are placed in the library for access by students. The tutors are faculty members who have been trained through workshops and through cotutoring. They are not content experts, although they are generally familiar with the content area, or with the unit. To assist them in their role, a tutor guide is provided which highlights the key issues embedded in each problem. Since 1982, there has also been a problem resource bluesheet prepared, which students can refer to in order to assist them with their independent study. Students quickly develop their own approach to self-directed study which may include general texts and reference texts, resources listed on the
'blue sheets' and on reserve in the library, consultations with faculty and resource people, and primary literature searches. Because of the emphasis on collaborative learning and working as a group, students tend to work together in the library. If one student in the group finds a useful resource they will seek out their fellows to share the reference. The skill of particular students in finding and sharing materials is acknowledged in the tutorial meetings. Hiding or vandalizing library materials would be deeply censored as antithetical to the prevailing culture of cooperative learning. 3.2. Self-directed learning Self directed learning is not synonymous with problem-based learning, but is another of the key underpinnings to our educational system, and meshes seamlessly with PBL. Self-directed learning was chosen in order to develop learning skills and, more importantly, habits that would influence behavior throughout their careers. The development of computer-based information systems has triggered a major expansion in this aspect of library skills. Computer searching, popular with students, must be balanced by the ability to use the full range of resources provided by a contemporary library. 3.3. Small-group learning McMaster students can always be recognized because they travel in packs. This carries through into the library, where students will want and need to work, share and debate as a group. Ten small-group study rooms are provided for this purpose. The emphasis on small-group cooperative learning is deliberate. While McMaster stresses self-directed learning, it is not an independent study program. Effective small groups accelerate learning, and prepare students for their future careers in which team work and interprofessional relationships are critical. McMaster graduates are more likely to enter group as opposed to solo practice [11]. Work in the field of continuing education has further supported this strategy, as social isolation has been found to be a major predictor of substandard practice [ 16,17].
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3.4. Evaluation of student learning Student progress and performance is evaluated continuously through the program by the students themselves, their peers, the tutor, and the program. Self-evaluation is expected to be ongoing, and students are expected to self-evaluate briefly at the end of each tutorial, commenting on success of learning strategies, contributions to the group, and progress with respect to their objectives. At the midpoint and end of each unit, students self-assess following the categories of knowledge, skills, and attitudes. Self-evaluation is followed by feedback from their peers and from the tutor. Tutors have a vital role in ensuring that the feedback given is honest, helpful, and fair. During each unit, there are 2 formal exercises, which differ between units. Triple jumps are particularly helpful in the early units. These are brief problem scenarios which assess problem identification, information retrieval and synthesis, and problem resolution skills. They are time-limited exercises (usually 2 - 4 h search time) which throw the students into the library and test their efficiency. They also test the ability of the library to cope with students on a mission. There are longer exercises in units 4 and 5 which ask the students to make much more extensive use of the library and its resources, and include epidemiologic and critical appraisal skills, such as the McMaster Community Oriented Problem Exercise (McCope). In 1992 the program introduced progress testing of knowledge by objective examination [4]. This is administered in a way which emphasizes personal performance and progress for the purpose of formative evaluation. It is not a test that students can, or do, study for. We do not, therefore, experience peaks of library use around progress testing.
3.5. The role of the library The library becomes the key resource to students in our program. Students come to us with widely diverse backgrounds, from those with PhDs in immunology to those with degrees in music or engineering, and no natural science. Self-directed learning is the only logical approach, as what is new to one student is old hat to
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another. With every problem, students must devise their own, as well as their group's, learning objectives. The library contains the bulk of the print and audiovisual resources that students will need to consult, cataloged with print materials, but housed in a separate area. The audiovisual room has videos or slide tape shows that fill the role of lectures in a more traditional curriculum, with the advantage that they can be viewed when the material is relevant to the problem at hand. Computer-based instructional material is also stored in the audiovisual area. The reserve desk houses principal texts, reprints, and other materials that may be identified by the unit planners. Students are oriented to the library during their first weeks of medical school, and may avail themselves of organized instruction on the use of library resources, or may follow the self-help materials which are produced by the library staff. A computer instructional room is available for teaching literature computer-based searches. Because the bulk of the day is unstructured, there is heavy use of the library during the working day, and ample opportunity for students to interact with the professional library staff. Students are generally on a first name basis with the librarians. With a medical school class of 100 each year, and a total health sciences enrollment of 650 per year, there is seating for 651 in a comfortable, well-lit facility. The hours of operation are longer for the Health Sciences Library than for any other library on campus, closing at 11:30 h most nights, a total of 97.5 h weekly. Because there is no extended summer break, there is no opportunity to reduce hours during a summer term. In order to accommodate the intensive nature of the off-hours use of the facility, the library has provided for enhanced training of the nonprofessional staff, so that they are able to assist students with requests that would otherwise have to be deferred until the next day. Students in the PBL curriculum rely heavily on the library. In a study conducted between McMaster and our two neighboring traditional schools, a number of differences emerged (Table 2). PBL students use the library more often, an average of 54 visits per student each month, corn-
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Table 2 Selected characteristics of participating libraries and medical schools McMaster Facilities and services Hours open per week Study seating capacity Square feet of space Professional staff (M.L.S.) Public microcomputers or terminals
103.5 549 38 905 9 20
Western
87.3 671 40 394 5.25 9
Toronto
90 336 61 850 11.8 17
Collection Volumes Current serial titles
129 375 1823
360 019 not reported
791 490 3240
Use and users Circulation Reserve or short-term loan circulation Gate count N u m b e r of medical students N u m b e r of medical faculty (full-time and part-time)
55 438 112 667 576 278 297 908
172 319 7641 569 035 415 1062
250 474 4323 not reported 1002 1260
With the exception of the number of medical students and the number of medical faculty, the figures are those submitted for publication in the Annual Statistics of Medical School Libraries in the U.S. and Canada, 1990-1991, 19th ed.
pared to 12-16 at the comparison schools. Each of the visits was longer on average, 157 min versus 71-103 [4]. This means that PBL students were in the library about twice a day for 2.5 h each trip. While there, students searched databases, used reference reserve and audiovisual collections, photocopied, studied and socialized more than their peers in traditional schools. This leads to a busy, often noisy library. When asked what more they wanted from the library, students requested a cappuccino bar.
3.6. Interaction between library staff and the program There are a number of opportunities for formal interaction. The director of the library, Dorothy Fitzgerald, sits on the undergraduate medical education committee and is aware of major trends within the program. There is a working relationship between library staff and each of the unit planners, which may include membership on planning committees. One of our librarians has co-tutored in the program to become better aware of the needs of students, and is now working with the curriculum committee to develop offerings that will assist students in developing information retrieval and storage systems. There is representa-
tion from the faculty on the library committee. A classroom was recently equipped within the library in recognition of this increasing role for professional librarians. More profound than these interactions is the close relationship students feel to their library. At the heart of this is that the seat of learning is no longer a bench in a lecture hall, but is the Health Sciences Library. Students identify the professional staff as among the most supportive people they encounter in the course of the degree program. When asked where to hang the photographs of the graduating classes, the students selected a corner of the library and dubbed it 'Mary's Corner' after a secretary who had acted as a den mother to the students. This centrality in the lives of students is a single most striking aspect of self-directed learning in a problem-based curriculum, and has a lot to do with why, whenever you need to find a student, the library is the first place to look. In planning our new student home base, space opposite the library was chosen because that is where the students want to be. As more and more schools adopt this educational format, it seems inevitable that the linkage students have to the library will become increas-
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ingly close, and essential. Proximity of the library to the students, involved staff, accessible hours, and adequate study space are all essential; advanced technologic support is a bonus.
4. Summary McMaster has had 25 years of experience as a problem-based medical school. The role of the library has proved central to the success of the curriculum. Many of the original features of the library were specifically to meet the needs of the medical school, while at the same time serving a research intensive faculty. Although problembased learning varies between schools, the system at McMaster is described with its foundation of problem-based, self-directed learning in smallgroup tutorials. Problem-based students have been found to make much more extensive and intensive use of the library. Perhaps more important to the students is the attachment they form to their library. Vandalism or misuse of the library is very rare. The needs of students in PBL curricula to search databases, and to employ effective information management and retrieval systems provides major opportunities for the librarians to interact directly in the students' learning.
References [1] J.D. Eldridge, A problem-based learning curriculum in transition: the emerging role of the library, Bull. Med. Libr. Assoc. 81 (1993) 310-315. [2] M.C. Watkins, Characteristics of services and educational programs in libraries serving problem-based curricula: a group self-study, Bull. Med. Libr. Assoc. 81 (1993) 306 309. [3] J.A. Rankin, Highlighting problem-based learning and medical libraries, Bull. Med. Libr. Assoc. 81 (1993) 293. [4] J.G. Marshall, D. Fitzgerald, L. Bushby and G. Heaton, A study of library use in problem-based and traditional medical curricula, Bull. Med. Libr. Assoc. 81 (1993) 299 305.
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[5] B.H. Robinow, The Health Sciences Library, McMaster University, Hamilton, Ontario, Bull. Med. Libr. Assoc. 60 (1972) 559-565. [6] W.B. Spaulding, Revitalizing medical education: McMaster medical school the early years 1965-1974 (B.C. Decker Inc., Hamilton, Ontario, 1991). [7] B.H. Robinow, Audiovisuals and non-print learning resources in a health sciences library, J. Biocommun. 6 (1979) 14-19. [8] G.R. Norman, Problem-solving skills, solving problems and problem-based learning, Med. Educ. 22 (1988) 279286. [9] Association of American Medical Colleges, Physicians for the twenty-first century: report of the panel on the General Professional Education of the Physician and College Preparation for Medicine (Association of American Medical Colleges, 1984). [10] Liaison Committee on Medical Education, Functions and structure of a medical school: accreditation and the Liaison Committee on Medical Education, standards for accreditation of medical education programs leading to the MD degree (Association of American Medical Colleges and the American Medical Association, 1991). [11] C.A. Woodward, The effects of the innovations in medical education at McMaster: a report on follow-up studies, Medicus 2 (1989) 64-68. [12] L. Berkson, Problem-based learning: have the expectations been met? Acad. Med. 68 (1993) $79 $88. [13] M.A. Albanese and S. Mitchell, Problem-based learning: a review of literature on its outcomes and implementation issues, Acad. Med. 68 (1993) 52 81. [14] D.T.A. Vernon and R.L. Blake, Does problem-based learning work? A meta-analysis of evaluative research, Acad. Med. 68 (1993) 550 563. [15] H.G. Schmidt, Foundations of problem-based learning: some explanatory notes, Med. Educ. 27 (1993) 422 432. [16] G.R. Norman, D.A. Davis and S. Lamb, Competency assessment of primary care physicians as a component of a peer review program, J. Am. Med. Assoc. 270 (1993) 1046-1051. [17] J.M. Last, Maintenance of competence, Ann RCPSC 24 (1991) 7-8. [18] G.R. Norman and H.G. Schmidt, The psychological basis of problem-based learning: a review of the evidence, Acad. Med. 67 (1992) 557 565. [19] H.G. Schmidt, M.L. De Voider, W.S. DeGrave and J.H.C. Moust, Explanatory models in the processing of science text: the role of prior knowledge activation through small-group discussion, J. Educ. Psychol. 81 (1989) 610 619.