Problemcentered learning Nithya Gogtay Department of Clinical Pharmacology

Problem-centered learning Nithya Gogtay Department of Clinical Pharmacology Seth GS Medical College & KEM Hospital, Mumbai njgogtay@hotmail. com NG JIPMER Problem-centered learning 16 Dec 2005

Why PBL? The historical background • 1969 - Mc. Master University • Traditional learning (TL) not satisfactory • Basic sciences do not need to precede clinical sciences • Students need to take greater responsibility for their learning NG JIPMER Problem-centered learning 16 Dec 2005

“ That’s the reason they are called lessons’, the Gryphon remarked: ‘ because they lessen from day to day. ’ Lewis Carroll 1832 -98: Alice’s Adventures in Wonderland (1865) NG JIPMER Problem-centered learning 16 Dec 2005

What is PBL? • “A learning process based on the principle of using problems as a starting point for the acquisition and integration of new knowledge. HS Barrows, 1982 NG JIPMER Problem-centered learning 16 Dec 2005

Problem solving and Problem centered learning versus PBL • Problem solving: arriving at decisions based on prior knowledge and reasoning- what is followed in most medical colleges in India • PBL: The process of acquiring new knowledge based on recognition of a need to learn • Different, but inter-related NG JIPMER Problem-centered learning 16 Dec 2005

Structure of a problem • Title: Guides the students’ in a particular direction • Trigger material: A story, description of phenomena, events • Instructions: For e. g, what would you do ………? NG JIPMER Problem-centered learning 16 Dec 2005

Don'ts of problem construction- 1 • A 40 yr old man suffering from bronchial asthma for several years is diagnosed to have mild hypertension. Prescribe for this patient. • What is your expectation? A prescription for asthma or hypertension? NG JIPMER Problem-centered learning 16 Dec 2005

Don'ts of problem construction- 2 • A patient with CCF receiving treatment came to the casualty with complaints of vision changes. He had bradycardia. What is the possible cause of this reaction? • Define expectation from students • CCF- Congestive cardiac failure or cough, cold and fever? • What is the age of the patient? • Do you expect the students to think of digoxin? NG JIPMER Problem-centered learning 16 Dec 2005

Pre-preparation • At what stage of learning are the students? • How long should the problem be? • How can I ensure that the students do not miss key concepts? • How can I make the problem challenging and interesting? • How much data should I provide? • How open-ended should the problem be? NG JIPMER Problem-centered learning 16 Dec 2005

How do I construct cases? Nature and types of problems • Relate to priority health needs of a defined population • Represent important prototypical situations • Simulate professional practice/real life situations • Involve real patients • Stimulate the “need to know” NG JIPMER Problem-centered learning 16 Dec 2005

Constructing a problem- focus on a single objective • A 23 yr old male patient with a diagnosis of vivax malaria is given Injection metoclopramide prior to treatment with chloroquine. Ten minutes after the injection, the patient develops jerky movements of the limbs and uprolling of eyeballs. • What is your diagnosis? - Oculogyric crisis NG JIPMER Problem-centered learning 16 Dec 2005

Constructing a problem- focus on two objectives • Topic- Pharmacokinetics • Students: IInd MBBS, 6 months completed, General pharmacology and CNS covered. • Problem: A patient of GTC epilepsy with a seizure frequency of 3/mth, is put on phenytoin sodium 200 mg/day. After 2 mths, he still complains of at least 1 episode/mth. The physician increases the dose to 400 mg/d. Two weeks later, the patient presents with complaints of ataxia and giddiness • Single objective: Do they understand the difference between linear and non-linear kinetics? • What do you think could have happened? NG JIPMER Problem-centered learning 16 Dec 2005

• The single objective: Phenytoin undergoes non-linear kinetics, thus the symptoms and signs of toxicity. the difference between constant amount excreted/ unit time versus constant fraction excreted/unit time • Can we have more than 1 objective? Yes- assess students’ response • For example- Which other drugs undergo non-linear kinetics? • Or- In this patient what could have been done to prevent toxicity? NG JIPMER Problem-centered learning 16 Dec 2005

Constructing a problem- multiple learning objectives • Topic – Bronchial asthma • Students – Second Professional -Semester 4 /II nd MBBS • Object of test: Test whether the students know the importance of diagnosis, which drug to choose for persistent bronchial asthma, which in turn in related to pathophysiology of the disease? NG JIPMER Problem-centered learning 16 Dec 2005

Problem- Bronchial asthma • A 16 year old male patient recently diagnosed as having bronchial asthma had been advised to take MDI salbutamol as and when needed. The patient reports back to his physician after 2 mths, saying that he has been taking 2 -3 puffs of salbutamol everyday for the past 2 mths and is still symptomatic. • What could be the probable reason for the patient not responding to the treatment? NG JIPMER Problem-centered learning 16 Dec 2005

What are the characteristics of this case? Positive aspects • Relevant, realistic, logical • Not too complex • Progressive disclosure/step by step Points which need attention • Use of abbreviations e. g. MDI, mths • Expects student to know the difference between intermittent and persistent bronchial asthma – check whether it has been taught NG JIPMER Problem-centered learning 16 Dec 2005

Bronchial asthma- learning objectives • What would be your drug of choice in persistent asthma? -inhaled corticosteroids. • Why inhaled corticosteroids? - Pathophysiology Because it is now known that bronchial asthma is a chronic inflammatory disease, where corticosteroids are the drugs of choice and ß 2 agonists only provide symptomatic relief NG JIPMER Problem-centered learning 16 Dec 2005

Bronchial asthma- learning objectives • If student says that maybe the patient did not know how to use the MDI and so instructions on proper use of MDI or use of spacer then what? • He/she should be given additional marks for thinking beyond the prescription (therefore this problem permits differentiating between good and very good students) NG JIPMER Problem-centered learning 16 Dec 2005

Pre- preparation • Check problems and scenarios with clinicians • Dry run problems with residents and interns • Focus on “must know” areas • Pre define learning objectives for each session NG JIPMER Problem-centered learning 16 Dec 2005

• You cannot teach a man anything; you can only help him find it within himself. – Galileo Galilei (1564 -1642) Italian physicist and astronomer. NG JIPMER Problem-centered learning 16 Dec 2005

Group task 1 -Coronary artery disease • A 58 year old man with a recent diagnosis of coronary artery disease has the following lipid profile- LDL 134 mg%, TG-166 mg%, HDL 40 mg%, and total cholesterol-205 mg%. What should be his line of treatment? • Identify the characteristics of this case- what does it have and what does it not have? • Identify the learning objectives for this problem. NG JIPMER Problem-centered learning 16 Dec 2005

Group task - 2 • Instructions • You are teaching pharmacology to IInd MBBS medical students who have completed at least 1 medicine post and have had orientation in the Emergency medical services. • Construct a problem on anaphylaxis • Identify the learning objectives of the problem. NG JIPMER Problem-centered learning 16 Dec 2005

Group task - 3 • Instructions • You are teaching physiology to first MBBS medical students who have completed eight months in physiology and have had theory and practical classes related to hematology. • Formulate any problem related to iron deficiency anemia • Define what the students “must know” at the end of the problem centered learning session for that problem. NG JIPMER Problem-centered learning 16 Dec 2005

Group task 1 - solution- What are the characteristics of this case? What does it have? • Opening scenario • History of present illness • Investigations What does it not have? • Past history, personal history, family history • Physical examination • Management NG JIPMER Problem-centered learning 16 Dec 2005

Group task 1 - solution-Coronary artery disease- learning objectives • Define and understand target lipid profiles- <200 mg% for total chol, and <150 mg% for TGs, HDL > 40 mg% • Define which is the most important lipid- LDL • In this case, what should be its value? - This depends on whether or not the patient has CAD • With CAD- target LDL < 100 mg%, 1 -2 risk factors 130 mg% or less, otherwise < 160 mg% • Would this patient require drug therapy? If yes, which drug? • If only the TGs were raised, would your advice have been any different? NG JIPMER Problem-centered learning 16 Dec 2005

Sample Problem for group task 2 • Mrs Sunanda, a 26 year old married female presents to the Emergency medical services (EMS) of the KEM hospital with h/o fever, difficulty in swallowing and sore-throat for four days. On examination she is found to have acute follicular tonsillitis. She is asked whether she has had penicillin before to which she replies in the affirmative. She is given an injection of procaine penicillin and suddenly she complains of difficulty in breathing and faints. Her BP is very low. NG JIPMER Problem-centered learning 16 Dec 2005

Sample Problem for group task 2 contd… • What could be the reason for her reaction? • What is the treatment? • What is the pharmacological basis for the selection of drugs? • How could it have been prevented? • If the student answers these questions – one may ask how a test dose of penicillin is prepared or how many units should injected (for test dose) / what is the site of injection / what to look for • This question should not be given early on as it will provide a clue. NG JIPMER Problem-centered learning 16 Dec 2005