PROBLEM BASED SELF-DIRECTED LIFE LONG PARTICIPATORY LEARNING IN MEDICAL EDUCATORS AND THEIR AUDIENCE; REFLECTIVE LESSONS LEARNT FROM A LECTURE SERIES
**Rakesh Biswas, Shashikiran Umakanth, Mohit Shetty, Manjunath Hande and JS Nagra***
Melaka Manipal Medical College, Manipal academy of higher education, Melaka, Malaysia
* **Corresponding author:**
Department of Medicine, People's college of medical sciences, Bhanpur, Bypass road, Bhopal-462010 (M.P.) India Email: rakesh7biswas@gmail.com
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**Abstract**
**Aim.** this describes a process of how a medical educator and his audience may experience enhanced participatory learning in a didactic lecture set up comparing two different teaching methods. It has implications on how to improve communication between medical lecturers and their audience participants even in non-university large group continuing medical learning sessions.
**Design.** This was a qualitative study with ethnographic attention to process as well as quantitative and qualitative evaluation of student perceptions to illustrate the process.
**Method.** Two different lecture methods were used, over a period of 6 months, (one semester), by one lecturer (participant observer). The first method (with minimal audience participation) was applied for the first half of semester 8 medicine lectures and the second method (with maximal audience participation), was applied in the second half, for the same group of students, by the same lecturer (participant observer). Student feed back with particular emphasis on their perception of the second method was taken at the end of the second session using a structured as well as open-ended questionnaire.
**Results.** The process of lecture taking that evolved spontaneously in a problem oriented manner particularly to address the problem of student attention and participation in lecture sessions was described. This was also illustrated with student feedback. 106 students from a group of 117 responded (90%) to the questionnaire. An overwhelming 79% felt that inserting a patient narrative into the clinical query was stimulating. Many students (60%) also seemed to agree that there was no scope of learning without understanding in the second method. Substantial amount of students felt that the second method had enhanced their involvement and participation in the topic along with an improvement in their information finding abilities (53%).
On the down side only 26% felt the new method reduced their dependence on class notes with only 30% able to retain more information on the topic with this method and around 30% agreed to have received adequate feedback during the session. 48% agreed that this method would not better their university assessment performances.
**Conclusion. Inserting patient narratives with interjecting queries in lecture sessions** can stimulate students to participate but free participation may convert a lecture into a large group PBL with its attendant disadvantages. Controlled participation in a patient centered lecture augmented by portable information resources can promote participatory self-directed life long learning in health care givers of future.
**Keywords:** Problem based, self-directed life long learning, medical education, maximal audience participation.
*“Half of what you are taught as medical students will in ten years have been shown to be wrong. And the trouble is, none of your teachers know which half”*
> Sydney Burwell, Dean, Harvard Medical School 1956
Problem based learning (PBL) is a process of life long experiential learning. This write up is a process description of how medical educators learn utilizing problem based approaches to promote better learning among student participants even in a didactic lecture setting. Even as non-participatory didactic lectures become extinct in formal educational curricula they may still survive in large group conference addresses and other health care giver learning sessions. This write up aims to draw a parallel and address the issue of improving participatory communication between lecturers and audience even in large group non university medical learning sessions.
Traditional didactic lectures have been all but wiped out by PBLs in medical curricula. Many lecturers have little formal training in conducting didactic lecture sessions except from observations made on their own lecturers in their student past. Not all didactic lectures they may have had in their student careers would have been enjoyable though.
The most enjoyable didactic lecture sessions may have been the ones where the lecturer not only ensures full attention and participation from her students but also helps to integrate their past background knowledge with current foreground information provided in a practically applicable manner such that **it generates a healthy discussion** with raising and answering of queries. In short the traditional didactic lecture ceases to be a one way dynamic but multiple feedback loops are generated to create learning even for the lecturer conducting the session (1).
#### **The Problem**
Didactic lecture classes have evolved dramatically over the last century that has seen a profusion of visual aids to impart factual information and yet student attention spans during lectures are abysmal. As soon as the PowerPoint slides are switched on many brains automatically switch off to sleep (induced by unseen sedatives radiating from the slides).
Lecture handouts are another fallout of the PowerPoint movement in didactic lecturing and there is a strong suspicion that they may be nothing but short term memorizing tools very often discarded and forgotten after assessments and have little value in developing skills like ability to best utilize available information for medical problem solving. Very often they dissuade students from reading a variety of evidence-based resources that exist in textbooks, CDs or online and preparing their own notes. This constitutes a serious impediment to inculcating self-directed life long learning in medical students.
The effort which the lecturer puts into preparing her lecture notes serves to enhance her own self directed learning on the topic and the by product of this transferred to students (In the form of notes) may encourage rote memorization rather than thoughtful learning.
One of us (SU) often compares self-directed learning to a multi-course dinner and lecture notes to the partially/completely digested food material in the lecturer’s distal ileum. While the former is delicious and enjoyable while consuming, the latter is definitely not so. This comparison is to give the students a fair idea about the ‘advantages’ of self-directed learning and reading from textbooks and other authentic resources.
Undergraduate students dependant on short term lecture note memories may feel overwhelmed when they step into a post graduate environment that demands greater information handling for smoother medical problem solving activities.
Very often the didactic lecture session may run the danger of becoming just an avenue for students to collect the handouts/notes with preference given to utilize the rest of the lecture session for catching up on the much needed sleep.
#### **Possible Solutions**
Over the years lecture sessions have evolved in terms of structure so much so that it has been successfully broken into small group PBL sessions that have radically transformed learning into a maximal student participation phenomena with the role of a lecturer suitably tuned down to a facilitator.
In our institute the number of scheduled lecture classes in medicine (taught in 6 semesters) have been brought down from 200 hours to 90 hours over a period of 3 years along with an overall reduction in number of didactic lecture hours for all other subjects taught in 10 semesters (see figure 1) and yet for a lecturer who has to take 20 lectures for a semester spaced out as one lecture per week, the challenge of holding students attention during the lecture classes remains significant.
#### **Design**
This was a qualitative study with ethnographic attention to process as well as quantitative and qualitative evaluation of student perceptions to illustrate the process.
#### **Method**
Two different lecture methods were used, over a period of 6 months, (one semester), by one lecturer (participant observer). The first method (with minimal student participation) was applied for the first half of semester 8 medicine lectures and the second method (with maximal student participation), was applied in the second half, for the same group of students, by the same lecturer (participant observer). Student feed back with particular emphasis on their perception of the second method was taken at the end of the second session using a structured as well as open-ended questionnaire.
##### **First Method (Minimal Audience participatory)**
The lecture starts with a disease scenario, preferably an engaging narrative that also stimulates the student's affective domain other than the cognitive and psychomotor domains so that the emphasis is not just on content knowledge and factual recall [2].
Throughout the lecture factual information is also inserted at relevant points in the narrative.
##### **Inadequacies in the first method**
Although 15 minutes were earmarked at the end of the presentation for student participation in the form of queries or comments regarding the topic, there was none. This method was mostly a one-way delivery by the lecturer with little student participation and in spite of the narrative, few students still managed to doze off.
**Need for student participation**
It was this lack of students’ participation that gave birth to the necessity for a different method at the middle of the semester. One of the main reasons for students’ lack of participation was unavailability of information on the topic. It was there fore decided to let them use their own information resources to answer the questions raised by the topic during the class. The majority used textbooks as their information sources with one or two using electronic resources (Portable digital assistants). This it was hypothesized would lead to initiation of independent self-directed learning on the topic instead of pure dependence on the lecture handouts for factual memorization.
##### **Second Method (Maximal Audience Participatory)**
The lecture still begins with the disease scenario/narrative but at each step in the presentation student participation is invited with a query.
**For Example:**
**_(For the complete example see web link:_**
http://www.medspan.info/component/option,com__smf/Itemid,84/topic,104.0
_Also all the other lectures taken for this semester have been posted on to this web link for reference:_
http://www.medspan.info/medical-downloads/powerpoint-presentations/student-participation-lecture-series/
The following example demonstrates a one-hour lecture session using a PowerPoint modification of an Internet patient narrative interspersed with queries to invite student participation. Patient consent was established by email (later the same has been taken as a signed document).
**A Chronic Bleeding Disorder**
**PowerPoint Slide 1**
Patient’s diary— (http://www.itppeople.com/joany.htm)
*It all started in the summer of... when I returned from a long weekend ... it was cool and rainy there. I ate too many gravy coated potato fries, drove home in damp clothes, and caught what I thought was the flu.*
**PowerPoint slide 2**
*It didn’t respond to my usual cure of lying on the sofa and watching four rented videos. In a few weeks I noticed some black and blue marks on my arm and panicked when I didn’t stop bleeding from a small cut. My days became a struggle to continue life, as I once knew it and understand why my body was betraying me.*
As the slides are self-explanatory narratives, the lecturer is silent while displaying them but after letting them go through the slides and their books for 5-10 minutes the lecturer interjects a query:
*What are the natural/physiologic mechanisms for preventing spontaneous bleeds or normal quick cessation of any bleed?*
At the end of the five-minute gap for the student to find out the answer from his/her information resource the microphone is passed around either in a linear or random sequence and students are encouraged to verbalize their thoughts. After 3-4 responses the next PowerPoint projects the possible best response.
**PowerPoint slide 3**
**Physiology of Hemostasis**
The cessation of bleeding from damaged blood vessel. After vessel injury, process of hemostasis takes place in 2 phases: Primary:
1. Vessel wall contraction
2. Platelet aggregation & plugging of injured area
Secondary:
3. Formation of an insoluble fibrin clot due to activation of clotting system
In addition, there is a fibrinolytic system, which actively removes the clot
*What are the abnormalities of hemostasis that may have caused abnormal bleeding in this patient?*
**PowerPoint slide 4**
**Haemorrhagic diseases**
Can result from abnormalities of:
* Blood vessels
* Platelets
* Clotting systems
Lecturer interjects:
Diseases affecting the smaller blood vessels & platelets produce the clinical picture of purpura. Clinical differences in variety of skin bleeds: Petechiae, Purpura, Eschymosis—based on size of the bleed—Petechiae-1-2 mm, Purpura<or=5mm, Eschymosis>5 mm (See Clinical Image)
As this patient’s discussion is going to evolve around thrombocytopenia there is another slide on clotting disorder mentioned in passing (a separate class is generally required to discuss any of them in detail)
**PowerPoint Slide 5**
**Diseases of Clotting System**
* Congenital (Hemophilia, von-Willebrand’s disease)
* Acquired Deficiency of Vitamin K dependent clotting factors - severe liver disease, anticoagulant therapy; Hypofibrinogenemia –DIC, destruction of liver
**PowerPoint Slide 6**
Patient’s diary— (http://www.itppeople.com/ioany.htm)
*After a short stint in the hospital for tests, the diagnosis was confirmed... The hematologist wrote it down so I could remember what it stood for. My count was 6,000, a severe case, potentially fatal. I didn’t know what a platelet was.*
Lecturer interjects: What could be the possible reasons for a low platelet count in this patient?
**PowerPoint Slide 7**
**Thrombocytopenia**
**Causes**
Impaired production: Marrow aplasia, Leukemia, Infiltration, Megaloblastic anemia, Myeloma, Myelofibrosis
Excessive destruction: ITP, Secondary Immune: SLE, CLL, viruses, Drugs eg. Heparin
Sequestration: Hypersplenism
Dilutional: Massive transfusion
Other: DIC, TTP
(For complete class see supplement 1) It may be pertinent to note that method alone is not adequate. What matters is what happens within the method. [2]
**Table 1. Summarizes the lecture content in terms of PowerPoint, lecturer and audience inputs**
| PowerPoint◯ input | Lecturer’s input | Audience input |
| :--- | :--- | :--- |
| 1) Begins with a projection of patient data in the form of an evocative narrative. | 1) Lecturer develops and interjects relevant queries with respect to pathophysiology, clinical features and management derived from the disease narrative at appropriate intervals explaining and elaborating at the same time on the key word answers projected on the PowerPoint slides. | 1) Respond to queries developed in the patient narrative after accessing their appropriate information resources (books, PDA, colleagues etc) |
| 2) Develops queries based on the patient narrative with regards to patho-physiology clinical features and management. | 2) S/he controls the timing of the PowerPoint slides leaving appropriate time for the students to access their information resources before they respond to the queries. | 2) Add their own queries to the lecturer’s as well as their own comments/opinions on the case scenario. |
| 3) Projects answers to those queries in the form of keywords. | | |
An anonymous student questionnaire was circulated at the end of the semester relating to their feelings on the second method of lecture taking (Supplement 2). The questionnaire contained 13 structured statements related to effect on student participation, classroom stress, enjoyment of group activity, attention spans, effect of patient narrative, dependence on lecture notes, independent reading, understanding vs. memorization, retention, information finding abilities, teacher feedback, assessments and if they looked forward to more such sessions. The responses were obtained on a Likert scale (strongly agree = 5 to strongly disagree=1) to indicate their degree of agreement with the statements in the questionnaire. Three open-ended questions about the positive and negative aspects of the teaching method, and any other free comments were also part of the questionnaire. The quantitative data were entered in Microsoft Excel and averages and percentages were calculated.
#### **Results**
106 students from a group of 117 responded (90%) to the questionnaire. On evaluation of the structured questionnaire responses it was found that the average score for each parameter was positive for most parameters suggesting that the average respondent agreed with most of the statements.
An overwhelming 79% felt that inserting a patient narrative into the clinical query was stimulating. Many students (60%) also seemed to agree that there was no scope of learning without understanding in the second method. Substantial amount of students felt that the second method had enhanced their involvement and participation in the topic along with an improvement in their information finding abilities (53%). Increased stress because of pressure to perform during the session was reported only by 47% of students. 47% felt the new method made them learn more independently and 46% felt they were more attentive as result of it. Only 40% enjoyed working with the whole class as a group.
On the down side only 26% felt the new method reduced their dependence on class notes (which meant that they still needed class notes) with only 30% able to retain more information on the topic with this method and around 30% agreed to have received adequate feedback during the session. 48% agree that this method would not better their university assessment performances. Only 33% of respondents looked forward to more such lecture sessions because of important (but not irreversible) disadvantages in the second method as elaborated in the open ended responses of the 41% who did not look forward to such student participatory sessions.
Following is a summary of positive and negative feelings the students had about the lectures as jotted down in their **open-ended responses**-
##### **Disadvantages**
1. Student participation is still not total.
2. At times I felt lost and didn’t like the clinical scenario or the queries (one respondent).
3. The discussion dragged as students repeated viewpoints in their responses
4. It was difficult to hear their colleagues at times mumbling into the microphone at the other end of the room
5. Difficult to take notes
##### **Advantages**
1. Hearing their student colleague voice their thoughts on the topic encouraged them to think more on it themselves.
2. No scope of sleeping, more lively and active learning.
3. Boosted confidence in their ability to verbalize
4. Initiated healthy reading into the topic without which some of them admittedly would never have opened their text books and only depended on lecturer notes
5. Promoted critical thinking, exposure to different clinical scenarios and may help them in facing real world patients.
#### **Discussion**
A discussion of the down sides to the second new method needs to be made first and this has again been elaborated very well in the open ended student responses.
Restructuring the didactic lecture to promote more student participation ran the danger of turning the lecture into a large group PBL. Many problems highlighted by the students in their open-ended responses like at times feeling lost and dragged, difficulty hearing their colleagues mumbling into the microphone at the other end of the room are in fact problems associated with large group PBLs.
Our solution for this (which the lecturer has already implemented in subsequent classes) is to let the lecturer keep the control over the microphone and restrict student responses to 2-3 without any repetitions so that the session doesn’t drag and there is more utilization of time. In short there may be just a token participation of students in didactic lectures (as far as student verbalization is concerned). On the other hand some students who wanted the second new pattern to continue mentioned in their open ended responses that hearing their student colleague voice their thoughts on the topic encouraged them to think more on it themselves. With more time (2-3 hour sessions with hourly 10 minute breaks) more audience participation verbalization can easily be accommodated. In a similar virtual lecture session this whole problem of time can be eliminated altogether.
The other feature of this method that encourages them to look for information as the clinical scenario is being presented with queries was received better in the open-ended responses. Most of them agree that it initiated healthy reading into the topic (without which some of whom admittedly would never have opened their text books and only depended on lecturer notes). However here too one of the important situational downside to this method (as viewed by many in the open ended responses) was the inconvenience of carrying heavy textbooks to the classroom (which is incidentally an hours drive away form the main campus). This problem can be easily circumvented using portable electronic information sources like PDAs.
The table 2 summarizes the important differences between the first and second methods:
**Table 2. Differences in the first (minimal student participatory) and second (maximal student participatory) methods**
| Minimal student participatory (first method): | Maximal student participatory (second method): |
| :--- | :--- |
| 1) Clinical scenario/narrative presented without interjected queries<br>2) No information searching stimuli/ time allowed throughout the lecture<br>3) Student participation invited at the end of the session (10-15 minutes) in the form of comments or queries | 1) Queries interspersed throughout the lecture narrative inviting student responses<br>2) Students invited to search their information resources (books, PDAs) for 5-10 minutes following the query generated by the narrative.<br>3) Student participation begins early during the lecture in the form of a) Grasping the narrative generated queries b) Searching answers from their information resources c) Organizing the information in the form of an answer and verbalizing it to share it with the rest of the class. |
The most embraced salient feature of this lecture series (79% of students) was the narrative introduction to the topic and this was a feature common to both the methods (which essentially differed in student participation).
In some instances as in the example, we used virtual patients who had voluntarily posted their stories on the net and were even accessible by email through which they often communicated their willingness to be of help. Students who are natural self directed learners may even be able to communicate with such patients on their own and keep their own follow up in a way getting exposed to ‘continuity of care’ an important aspect of healing. [3]
All education evaluation studies where questionnaire feedback is the only outcome measure would naturally tend to have limitations (these studies are often berated as using student happiness indices). Opinion tends to change and may not be a true measure of what is actually efficacious depending again on what the aims are. Also as part of an ethnographic approach we haven’t really concentrated on the outcome but have tried to detail the process of experiential learning in medical educators and students [4].
The aim of these lectures were to predominantly develop self directed learning in the audience by stimulating them to read more variety of information sources on a given topic and other than their own opinion the other way to assess the variety of learning they have been through would be for the lecturer/mentor to participate in a daily feedback session with them where students email their learning narratives to their mentor for daily guidance and approval. We are working on developing such a mentoring system at present in the curriculum.
The most meaningful outcome would be to witness our students grow up to be selfdirected learners so much so that they can actually teach their lecturers a thing or two.
From an individual or health professional perspective medical learning may need to be more bottom up user driven. They may require knowing only what is meaningful to their given situation or problem at hand at that particular point of time. In such a situation outcomes may be seldom generalized. Formal assessment outcomes that represent tests of factual information retaining abilities and are learnt by many students only to clear the assessments may not represent real life health caregiver behavior [5].
It has also been observed that while teaching strategies that foster learner-to-learner interactions and self directed learning lead to more active engagement among learners, the learners themselves may not value the session much (6). This was also observed in our present study (depicted as disadvantages of the maximal student participatory method).
It has been suggested that it is the unprepared/ ill prepared student who often faces difficulty in situations like this where peer-to-peer interaction is involved. While situational approach facilitates active learning, the unprepared (naïve) students may have difficulty with the process. (7)
To reduce student unprepared ness we allowed them to utilize their information resources before they responded to the clinical scenario generated queries and found (lecturer’s personal observations in class) that students who were otherwise classified as bad (based on their past assessment performances) were able to participate rather meaningfully well in the discussion.
In real life, health carers practicing evidence-based medicine need to continually keep themselves updated by looking up and appraising the variety of evidence based literature stimulated by clinical queries raised in their day-to-day practice. They need to attend CME workshops with their portable information sources (PDAs) so that they can achieve full participation in meaningful discussion with the presenter.
Our teaching method has been a modest effort to replicate this real life health care professional behavior that would prepare our undergraduate medical students to make a smoother transition when they step into real world medicine.
Our experience with didactic lectures may even benefit educational cultures where they are almost extinct (like in some universities) but still survive disguised, often making their presence felt in large group conference addresses and health care giver learning sessions in various forms.
#### **Summary Points**
**What is Already Known on This Topic**
1. In medical education “There is no teacher or student only different categories of medical learners.”
2. Medical educators also need to use PBL techniques along with their students to further their own learning in medical education
3. A common problem identified is the lack of audience attention and participation in didactic lectures.
**What This Study Adds**
1. This ethnographic study with the lecturer as a participant observer describes a process of lecture taking that evolved in response to the problem identified.
2. A lecture method was devised that projected evocative Internet narratives aimed at both the cognitive and affective domains of the audience.
3. The projected narrative generated queries that encouraged the audience to search their information sources before verbalizing their thoughts, sharing it with the class.
4. This may help to simulate real life health care professional behavior that would prepare undergraduate medical students to make a smoother transition when they step into real world medicine. It also highlights the issue of improving participatory communication between lecturers and their audience even in nonuniversity medical learning sessions.
#### **Acknowledgements**
**Contributors:** RB was involved in the conception and design of the study, collected all data, and contributed to the analysis and interpretation of the data along with drafting the paper. SU, MS, MH and JSN were involved in the conception and design of the study, supervised data collection, and contributed to the analysis of the data and final version of the paper. In addition SU was instrumental in drafting the paper.
**Competing interests:** None
**Funding received:** None
#### **References**
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* [2] Azila NM, Problem based learning: does it matter what we call it? _Journal of the University of Malaya Medical Center_, 2006; Supplement 1: 5-8
* [3] Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R., _Continuity of care: a multidisciplinary review_. BMJ. 2003 Nov 22; 327(7425):1219-21.
* [4] Savage J. Ethnography and health care. _BMJ_ 2000; 321: 1400-1402
* [5] McManus IC, Richards P, Winder BC, Sproston KA. Clinical experience, performance in final examinations, and learning style in medical students: prospective study. _BMJ_ 1998; 316: 345-350
* [6] Haidet P, Morgan RO, O'Malley K, Moran BJ, Richards BF. A Controlled Trial of Active Versus Passive Learning Strategies in a Large Group Setting. _Advances in Health Sciences Education_ 2004; 9(1):15-27
* [7] Richardson D. Using situational physiology in a didactic lecture setting. _Advan Physiol Educ_ 1996; 271:61-67
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*In: Journal of Education Research, Volume 3, Issue 4, pp. 1–14. ISSN: 1935-052X. © 2009 Nova Science Publishers, In.*
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