PBL for the Novice
You are a pre-medical student shadowing an ER physician at the Grouse Mountain Medical Center. Two paramedics wheel in an unconscious 23 year-old Caucasian male, accompanied by the patient’s friend who introduces himself as Alex. After the patient has been admitted, you interview Alex under the watchful eye of Dr. Johnson.
Alex begins: ‘Well, Jim and I decided to hike the Grouse Grind, a hiking trail that runs up (and down) Grouse Mountain, that takes about two hours roundtrip, as you may know. About 10 minutes into the climb, Jim said his nose was getting stuffy, probably due to the tree pollen, since his allergies are always bothering him. I keep a first aid kit in my bag, and I found an old package of Seldane®. Jim took four tablets, and we continued hiking. As we neared the lodge, it started to rain, so we began to hurry. This was when Jim said that he felt dizzy. He passed out at the lodge, and the paramedics brought him down right away.’
A quick check of Jim’s pockets reveals a nearly empty bottle of erythromycin, recently prescribed. “Uh oh,” Dr. Johnson remarks, “this is likely the reason he passed out. We’d better start an electrocardiogram and monitor his heart, as his condition could get much worse.”
What happened to Jim? Discuss and identify any learning issues.
Welcome to Problem-Based-Learning (PBL)! As you can see, the curriculum is taught in a manner unlike what you encountered in your undergraduate years. The UBC Faculty of Medicine uses a combination of lectures and PBL small-group tutorials to teach the large volume of information that must be mastered in medical school. The first two years of the program, where most theory is learned, is divided into a number of blocks each concentrating on a specific body system. This “new” hybrid curriculum was instituted in September 1997, and the medical Class of 2004 will be the fourth class initiated into this program.
The fundamental goal of PBL is to encourage team exploration of new concepts, allowing each member of the group to contribute. Each group is composed of eight medical (and dental) students, and is facilitated by a tutor, usually a clinical or academic doctor. Each PBL group meets in the morning for two hours every Monday, Wednesday, and Friday. There, they begin the process of analyzing and dissecting the week’s case, which is based on a specific focus within a body system. The details of each case are gradually revealed (in a progressive manner) using provided narratives, clinical data, and supplemental images (i.e. x-rays, histological images) that stimulate discussion resulting in student generated learning objectives. So, material learned in the Monday tutorial will be used to build on concepts taught in the Wednesday tutorial. The Friday tutorial is used to wrap-up any remaining details in the case.
The basis of PBL attempts to use the expertise of individual group members to build a framework of understanding for the case. Imagine a diverse group composed of a microbiologist, a kinesiologist, an immunologist, a physiologist, an animal biologist, a bio-psychologist, a biochemist, and a geneticist and there you have my (Ian’s) first PBL group in September 1999. Each one of my PBL classmates had the academic knowledge necessary to be accepted into medical school, and with the broad spectrum of knowledge we possessed, I think that there is little in medicine we could not have mastered. It truly is a marvel to see the interdisciplinary approach, and cooperative team learning that is the hallmark of PBL.
During the Monday session, you will receive the case introduction, and be asked to generate learning issues surrounding the case. These learning issues are unknown pieces of information that are crucial to understanding the case. Your job after each PBL session will be to do research on these topics so that you can discuss the learning issues in your group during the next PBL tutorial. For example, one learning issue for the (above mentioned) case would be to find the actions of Seldane and erythromycin, as well as the resulting drug interactions when taken together. Furthermore, you may wish to explore the scenarios and circumstances in which a physician might prescribe erythromycin, or a patient might use Seldane, which might help identify the target sub-group in the population who would be most at risk for combining Seldane and erythromycin.
The lectures given on Monday and Tuesday following the Monday PBL tutorial reinforce the important ideas of the theme. For instance, Tuesday’s lectures might well describe the cytochrome P450 detoxification enzymes in the liver, and they may mention that erythromycin and Seldane are detoxified and removed from the body using the same enzyme. This information could be useful in the Wednesday PBL tutorial where an astute group member recognizes that this competition for the detoxification enzyme will cause a bottleneck and decrease overall drug metabolism, leading to dangerously high levels of Seldane in the bloodstream. Now, back to the Wednesday PBL tutorial session:
Dr. Johnson takes you aside, and commends you for knowing that together, Seldane and erythromycin can be a lethal combination. He notes that Seldane is no longer sold over-the-counter for that reason, and he adds that Alex should not have kept the old package of Seldane that expired in 1996.
He then adds that the heart arrhythmia and syncope (fainting) suffered by Jim was likely due to a high blood plasma concentration of Seldane as a result of consuming erythromycin simultaneously. He asks, “Since Seldane is a histamine H1 antagonist, what other areas of Jim’s body should we be worried about?” He also reminds you that since erythromycin is commonly prescribed to treat pneumonia, Jim’s respiratory system should be closely monitored. Finally, he asks to you do literature research to determine Jim’s chances for a full long-term recovery.
Explore the learning issues raised by Dr. Johnson. Propose mechanisms for why a high blood plasma level of Seldane could cause cardiac arrhythmia and syncope.
The lectures on Wednesday and Thursday will further support the PBL case, giving you further information to answer your learning issues for Friday. An important part of PBL is the ability to work together in a team, and to share information liberally with other students. In the hands of a classmate, a seemingly insignificant piece of information you read the night before might be the trigger that links pieces of the anatomical, biochemical, and physiological jigsaw puzzle forming the week’s case.
In this fashion, PBL tests the ability to analyze and apply concepts derived from the basic sciences. Yes, there is still memorization, but there is an increased stress on the ability to understand a logical flow of information as it relates to a medical case. Furthermore, you will rotate groups every 5 weeks, so you meet and collaborate with different class members and tutors. This is an excellent way to familiarize yourself with your classmates. Finally, since PBL learning is inherently less structured than lecture-based teaching, you are free to use whatever resources are necessary to further your learning.
Students in the Class of 2003 use everything from lecture notes and medical textbooks to journal articles and the Internet to research their learning issues. This ability to find information is most relevant will certainly be useful after medical school graduation; it aids each professional in staying educated in the ever-evolving complexity that is medicine.
The PBL/lecture hybrid curriculum will be in its fourth year of use in September 2000. The PBL portion allows for a very exciting, dynamic and interactive curriculum that emphasizes teamwork, interdisciplinary learning, and the use of many different educational resources on a daily basis. Simultaneously, the lecture portion allows each medical student to gain a common grounding in the basic sciences that can then be applied in the PBL tutorials. Using realistic scenarios in PBL ensures that relevant material is constantly being taught while also preparing each student for the problem-solving skills and the ability to think and reason in a way that will make them successful physicians and life long learners.
Dr. Johnson greets you as you return to the Emergency Center on Friday. He asks if you have done any research on Jim’s prognosis. After you explain your reasoning, you ask Dr. Johnson to confirm your findings. His face crinkles into a wide grin as he replies, “Well, now, that’s something I’m not allowed to reveal just yet. If you want to find out, you’ll have to join UBC Medicine this September…”
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