Playing House

Problem-Based Learning Approach Successful at UTMB

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Medical Education – June 2011

Tex Med. 2011;107(6):45-58.

By Ken Ortolon
Associate Editor

You wouldn't think real-world medical education would emulate the techniques of TV's fictional Dr. House. But first-year medical student Samuel Mathis says that's exactly what the faculty at The University of Texas Medical Branch (UTMB) in Galveston is doing. 

Each week on the hit TV series "House, M.D.," the cantankerous Dr. House and his associates face a difficult diagnosis. Dr. House outlines the patient's symptoms on a marker board, the team members discuss possible diagnoses, and then they reach a conclusion and treat the patient. 

Mr. Mathis says that's pretty much what happens in small group, problem-based learning sessions that are a key component of the curriculum at UTMB. 

"Basically, we play House, like the TV show," Mr. Mathis says. "We're told a patient has a cough and a low-grade fever. That's all we're given initially. We will then have to come up with a differential diagnosis, put all the problems up on the board, put our differential up like House does, and then slowly but surely, as new information comes in, we cross it off." 

Those small group, problem-based learning sessions began in the late 1990s when UTMB administrators overhauled the school's curriculum. Steven Lieberman, MD, vice dean for academic affairs, says the integrated medical curriculum was intended to shift medical education at UTMB away from passive learning and toward active learning. 

"We undertook a series of changes beginning in the late '90s to focus our students more on their ability to apply information to solve clinical problems," Dr. Lieberman said. 

That curriculum reform effort also included a shift from organizing teaching around traditional disciplines, such as pathology and physiology, to teaching organ systems. Administrators revamped student assessment and student counseling and support programs, as well. 

The results have been dramatic. UTMB students' mean scores on Step 1 of the United States Medical Licensing Exam (USMLE) had been lagging well behind the national mean. Now they are substantially higher than the national mean, with scores among underrepresented minorities and women – groups that traditionally scored lower – improving the most. And, four- and five-year graduation rates also have risen. 

In a 2010 article in the journal Medical Education, Dr. Lieberman and his coauthors concluded that the performance improvements shown through UTMB's curriculum reform efforts are the largest reported in recent medical education literature. 

Ditching Flexner

Dr. Lieberman says UTMB revamped its curriculum after realizing the state's oldest medical school "had been following the same general model" of education since Abraham Flexner's groundbreaking 1910 report fueled a wave of medical education reform.  

With rapid advancement in medical knowledge and technology meaning educators had to cram more information into the curriculum, UTMB administrators decided they could not continue relying primarily on "a sage on the stage spouting information for 50 minutes and expecting students to be able to learn it, remember it, and know how to use it," Dr. Lieberman said. 

"The first change we made was in the way we taught, which was to move from primarily a lecture-based curriculum to a curriculum that emphasized small group, problem-based learning," he added. 

Patricia Beach, MD, professor of pediatrics and chair of UTMB's Curriculum Committee, says traditional medical school curricula have up to 40 hours of contact time between student and faculty per week, with as many as 25 to 30 hours of lectures, particularly in the first two years when students are learning the basic sciences. 

"We listened to lectures, and then we took tests on it," Dr. Beach said. "Basically, you went to lecture, you memorized facts, and you spit them out on tests." 

At UTMB, lecture classes usually total less than 21 hours per week, and students spend about six hours in small group sessions. Dr. Lieberman says those small groups normally pair one faculty member with eight or nine students. The teacher lays out a clinical problem, and the students discuss potential diagnoses. 

"They are presented with a patient with a problem, and they don't know how to solve the problem," Dr. Lieberman said. "But they ask questions, they identify the gaps in their knowledge, they spend a couple of hours talking about different aspects of the patient's problem. Then they have a couple of days to go out and research the information, find out what they need to know to answer those questions they asked, and then come back a couple of days later and discuss what they learned." 

Typically, the small group sessions discuss a different case each week, Dr. Lieberman says. Lectures, laboratory sessions, computer-based learning modules, and other activities take up the rest of the instructional time.  

Overall contact time between students and faculty is limited to allow students the time necessary for the self-directed study required for the small group sessions, he adds.

"Part of the goal here is certainly for them to learn to apply information, be able to use it, but also to help them develop lifelong learning skills," Dr. Lieberman says. That, he adds, is important, because "half of what we teach them in the four years they are here will be obsolete or just flat wrong 10 years after they graduate." 

Where's the Discipline?

Small group, problem-based learning was just the first step in a much broader effort to revamp how medicine is taught at UTMB. One of the reasons it's called "integrated" medical curriculum is the fact that faculty have integrated instruction in the various disciplines into courses that focus on organ systems. 

"In the traditional curriculum, we had courses by 'ologies,'" Dr. Lieberman said. "So there was a course of physiology and pathology and pharmacology and so forth and so on. Now we have courses based on organ systems. When you take the gastrointestinal and nutrition course, for instance, you get the physiology of the GI system, you get the pathology, the pharmacology, and so on." 

Dr. Lieberman says this integrated approach helps the students build a "coherent mental model" of organ systems and the specific diseases that relate to it. 

In addition to the instructional changes, UTMB administrators revamped examinations to assess problem-solving abilities rather than rote memorization skills. 

"We also secured the exams and made them much more like the national [licensing] board exams in terms of the type of questions so that the students are getting very used to seeing those kinds of questions and getting used to solving problems on exams rather than just regurgitating information," Dr. Lieberman said. "And they have lots of practice tests to gauge where they are, to assess themselves in terms of how well they're learning the material before they take their higher-stakes exams." 

Finally, student support programs also were revamped specifically to address the type of learning and testing UTMB students are experiencing. "The type of learning and the type of testing that we do is different from what the students are used to from their college days, and so our student support activities specifically target the skills that students need to be successful in this curriculum," Dr. Lieberman said. 

Among those student support efforts are professional counseling and peer tutoring. Mr. Mathis says a group of second-year students are his tutors. They usually meet in small groups to discuss issues the first-year students may be having, and they help direct the younger students' study efforts. 

"They've been through the course, so they know what we're going through," he said. "They can put the pieces together for you." 

Getting Mean

Dr. Lieberman says UTMB faculty would like to take credit for "brilliant insight" and an "amazing innovative capability." But, he says, virtually everything they are doing at UTMB has been tried elsewhere. The difference in UTMB's results may be the fact that it took a broad-based approach toward curriculum reform rather than trying problem-based learning or increased student support efforts in isolation. 

The results, he says, speak for themselves. In the Medical Education article, Dr. Lieberman and his coauthors compared two groups of UTMB graduating classes. They included students who matriculated between 1995 and 1997 and between 2003 and 2005. They found that USMLE Step 1 failure rates declined by 69 percent, mean test scores rose 14 points, and four- and five-year graduation rates went up 7.1 percent and 5.8 percent, respectively.

Perhaps more important, USMLE Step 1 scores improved among all demographics, but improvements were greatest among women and underrepresented minorities. 

Dr. Lieberman says those test score improvements are important for a number of reasons. 

"It tells us that they know how to use the information that they've learned to solve problems. And I think that's critical," he said. "It's one thing to know a lot of 'stuff,' but if you cannot use that to the betterment of patients, then obviously the value of all the 'stuff' you know is much less. 

"The other thing it does for the students is it puts them in a more competitive position for residency programs," he continued. "Step 1 scores are one of the high-profile qualifications that residency program directors look for." 

While the success of the integrated curriculum has been dramatic, Dr. Lieberman and Dr. Beach say faculty and students did not immediately accept the new approach. 

"Initially, there was a lot of resistance" among the faculty, Dr. Beach said. "It's a lot more efficient for a faculty member to stand in front of a group of 200 students and spout facts, do that one time, maybe a couple of hours a year, and be done." 

The small group sessions are much more demanding on faculty members' time, she adds. "There were concerns that it would reduce their productivity in other required activities, such as doing their research, and that's a very real consideration. On the other hand, if you are producing physicians who are much better qualified, it's hard to turn your back on that." 

Once they got familiar with the new curriculum, though, many faculty members found they actually enjoyed the increased interaction with the students, Dr. Beach says.

Pathologist Sharon Fuentes, MD, who was a student at UTMB when the new curriculum was instituted, says students also had serious trepidations. 

"We were all a little nervous because we all pretty much had learned under the standard teaching modality where students sat in a lecture hall listening to what the professor wanted you to learn, supplemented it occasionally with reading, but knew that the tests would entail mostly what came from the lecture," she said. The new curriculum required the students to "take ownership" in obtaining information and being self-directed in much of their studies, she adds. 

Once the students got more experience with the new system, a lot of the initial anxieties went away, says Dr. Fuentes, who currently is doing a fellowship in Connecticut. 

"The take-home message at the end of the day was measured by success in passing their examinations," she said. "We had probably less than 5 percent of the class that was critical, no matter what. They were diehard critics, and no matter what you said they were not going to be happy. But the other 95 percent of the students went through the process, they took out what they could, and got what they could from the curriculum. They passed their board. Most of us got the residencies of our choice." 

Now, the integrated curriculum is a selling point for some UTMB students, such as Mr. Mathis. 

"In all honesty, I love it," he said. "It was one of the reasons why UTMB was one of my top choices. And our board scores speak to the effectiveness of this." 

  Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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