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American Journal of Advances in Medical Science www.arnaca.com Vol-2: No-1: 18--27: 2014

Review Article

Task based learning, problem oriented learning and simulation based learning in medicine. A Review

Kartheek R Balapala1*, Sreekanth Talari2, Shamala Baskaran3

1Translational Research scholar, CRNCD, FMHS, University Tunku Abdul Rahman, Malaysia 2Post graduate researcher, Department of Pharmacology, Osmania Medical College and Hospital, Hyderabad, India 3Registered Nurse, FMHS, University Tunku Abdul Rahman, Malaysia

Abstract An effective mode of student centered learning is task-based learning. An increasing number of clinical schools today accept TBL as a better approach to learning in a student centered fashion. It provides a platform for integrated learning for various disciplines along with development of soft skills like professionalism and attitude. This serves as an intermediary link between theoretical knowledge and practical knowledge. Another state of art learning method in preclinical sciences is problem-based learning. This is mediated by a tutor who acts only like a facilitator, giving the appropriate triggers needed for the students to go forward in logical thinking and reasoning relevant to the given scenario. Demonstration of competence in these higher domains strongly implies that the needed prerequisite knowledge has been acquired by the student.

Keywords: PBL, TBL, student centered learning, medical curriculum

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Response of medical students to structured creativity tools An international survey reported important differences for staff and students between the disciplines of medicine and engineering regarding attitudes towards, and perceptions of, the relevance of interdisciplinary learning opportunities, and the role of creativity and innovation. There was agreement across groups concerning preferred learning, instructional styles and module content. Medical students showed greater resistance to the use of structured creativity tools and interdisciplinary teams [1]. In a retrospective experimental study in which male and female medical students were separated into single-gender tutorial groups, gender differences in the styles of participation and subjective experience of men and women in mixed gender and single gender tutorial groups were found. The women students noted an increased comfort level in the all women tutorial group and felt that learning about their own styles in this group helped them participate more effectively in coed groups and later on in other professional settings [2]. Application of PBL in psycho social learning and decision making The recognition of psychosocial data as germane disease variables was achieved more easily than the use of such data in a bio psychosocial formulation of traditional medical problems. A lack of sophistication and experience made the latter task difficult to accomplish for many second year medical students without using specific educational strategies. The mean numbers of psychosocial hypotheses and learning issues were highest in the PBL case units dominated by psychosocial material [3]. Informed cognitive training via laptop computer was found to be a promising treatment approach for cognitive dysfunction in early schizophrenia. An individual's baseline motivational system functioning (reward anticipation), and ability to engage in auditory processing speed improvement, represent important predictors of treatment outcome [4]. The

teaching of ethics in the field of medicine, particularly in psychiatry to be effective, it should be practical as opposed to theoretical and must be focused on the decision-making process sas opposed to the rote learning of concepts and eventually self-directed. An ideal method for reaching these goals is by incorporating problem-based learning approach in teaching and learning [5]. PBL enhances psychosocial learning. The study emphasized the important roles of small group interaction, exposure to diverse viewpoints, integrated presentation of psychosocial issues in cases, learning to adapt to uncertainty, and similarities with the process of psychotherapy as possible mediators for enhanced psychosocial learning through PBL in a medical curriculum [6]. Intervention Mapping was found to be a useful framework for formative data in program planning in the field of clinical guideline implementation. A decision aid to select determinants of guideline adherence identified in the formative research to analyze the problem increased the efficiency of the application of the Intervention Mapping process for the physical therapists and practice quality managers [7]. Continuing Medical Education The problem oriented model was quite enjoyable and useful for the students of dental education. The study results showed that this problem oriented course model helpedto achieve an integrated curriculum for dental school programs [8]. Both delivery methods i.e., Task Based Learning as well as Problem Oriented Lecture were found to be equally effective in Neurology Continuing Medical Education, showing statistically insignificant differences. Posttest mean scores were higher in TBL groups and radical increase in the posttest difficulty index demonstrated improved learning through TBL delivery [9]. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, in which the learning cycle is divided into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete

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experience, and reflective observation. The converging learning style involved problem solving and decision making, with the practical application of ideas and the use of hypothetical deductive reasoning. Learning through AE decreased with age, whereas learning through AC increased in a study done on orthopedics residency applicants,

residents, and faculty at an academic program. The most prevalent learning style among all participants was converging (53.5%). Others were followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) [10].

Figure -1: Domains of learning while carrying out a task

Active learning systems and algorithms: The use of native like distance maps was able to reproduce 3D structures that were identical to the targets, giving an average RMSD of 0.5Å. It was concluded that the methodology used in this study, if complemented by more complex reconstruction protocols, can represent a possible path to improve machine learning algorithms for 3D protein structure prediction. This can also be used as an intermediary step in protein structure predictions either on its own or complemented by NMR restraints [11].To solve the non-convex optimization problem, a MultiStage MultiTask Feature Learning (MSMTFL) algorithm was proposed. A detailed theoretical analysis showed that MSMTFL achieved a better parameter estimation error bound than the convex formulation. Empirical studies done on synthetic and real world data sets demonstrated the effectiveness of MSMTFL in comparison with the state of the art multitask sparse feature learning algorithms [12]. Virk, an active learning (AL) system while being trained, simultaneously learns a classification model and identified documents having information of interest for a knowledge base. This approach used a support vector machine (SVM) classifier with input features derived from neuroscience related publications from the primary literature. Using this new approach, it was possible to increase the size of the Neuron Registry, a knowledge base of neuron-related information by a factor of 90%, in a short duration of 3 months, in contrast to standard biocuration methods taking quite a longer period of time [13]. Undergraduate research (UR) and problem based learning (PBL) sessions were found to be almost similar with respect to the type of skills gained through each. In the study, it was concluded that appropriate modification of PBL sessions contributed to enhanced UR experience [14]. A series of related questions examining how monkeys, apes, and humans encode, internally represent, and integrate spatial, temporal, and quantity information in efficiently locating and relocating productive feeding sites in both small scale and large scale space were studied and clarified in a study on primates. To study wild and captive primates, a range of methods and approaches were used including computer and mathematical modeling, virtual reality, and detailed examinations of animal movement using global positioning system (GPS) and GIS analyses to understand primate cognitive ecology and species differences in decision making.

WHY MUST IT BE PERFORMED?

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Figure -2:Domains of learning process

Species specific differences in primate spatial cognition were documented [15]. Webbased delirium learning was found to be an effective and satisfying method of information delivery for registered nurses suggesting needed future research to investigate clinical outcomes as a result of this web-based education [16]. A hermeneutic phenomenological study that sought to understand the scholarly writing development of nurses enrolled in a clinical doctoral programme, revealed that there were three themes: learning throughout life, influence of emotions, and getting through the gate. Thus recommendations for further development of doctoral student writing were suggested so that students can disseminate their knowledge in a scholarly manner, improve practice, and contribute to the nursing and teaching profession [17]. In the context of simulationbased teaching in anesthesia, the learning outcome depended on knowledge, practical skills and motivational variables but also was found to depend on the presence of negative feelings, ability self-concepts and various personality traits. A trend was identified showing that simulation in the field of anesthesiology and emergency medicine must be set up with the theoretical basis first in order to avoid negative feelings [18]. The studies done on dental students revealed that PBL did not negatively influence the acquisition of

factual knowledge in dental students and PBL enhanced the ability of students in applying their knowledge to the relevant clinical situations. PBL positively affected students perceived preparedness [19]. Video cases were associated with significantly higher mean scores compared to the other measures and were effective in helping students achieve cognitive goals like facilitating good discussions, identifying public health problems, realizing how health disparities will impact their future role as dentists and affective goals like empathizing with vulnerable individuals, appreciating how health disparities impact real people. Video cases significantly improved cognitive, affective, and overall learning outcomes for dental students compared to the paper based cases [20]. Understanding animal interactions A veterinary course should take a multidisciplinary approach and highlight contentious areas of animal law and trends within the wider societal framework of human-animal interactions. From a pedagogical standpoint, a variety of integrated teaching methods and assessment techniques must be included in the curriculum. A problem based learning approach to encourage the assimilation of facts and promote higher order learning is favored [21]. Among the contexts used to generate the single event based goals, the

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posterior parietal cortex provided the new prefrontal areas with information about relational metrics such as order, number, duration, length, distance and proportion, which play a crucial role in foraging choices needed for the humans. This specialized network later became adapted to support the human capacity for reasoning and general problem solving, which is not so well developed in anthropoid primates [22]. Inquiry based approach in biochemistry and anatomy The guided inquiry based approach that used a single laboratory activity for undergraduate Introductory Biochemistry promoted student learning and engagement. Student surveys reported a higher level of course satisfaction with a statistically significant improvement in the quality of the student work [23]. Students completing the course demonstrated increased attainment of course outcomes and confidence in their ability to evaluate a patient case and make pharmaco-therapeutic recommendations in a 3-credit hour elective for third year pharmacy students that included problem based learning (PBL), journal club and case presentations, and drug information activities [24].A full description of the alleged factors was done revealing the needed recommendations for improving anatomy education and teaching in medical curriculum by promoting recognition for teaching in institutions. This is obtained by enhancing the professional recognition of anatomists through the implementation of a national postgraduate training program and by encouraging anatomists to participate in educational research [25].Periodic quality improvement (QI) interventions were effective in reframing inter-professional communication dynamics to enable needed changes in practice. The prospective design provided insights into communication content and frequency associated with collective learning and changes in the culture. The study identified evidence-based management strategies for positive practice

change at the unit level [26]. Traditional anatomy education based on topographical structural anatomy taught in lectures and gross dissection classes has been replaced by a multiple range of study modules, including problem based learning, plastic models or computer-assisted learning, and curricula integration, thus giving a basis for understanding pathologic and clinical problems in relation to the structure of the human body [27]. A new design of a multisource evaluation tool based on the coaching competencies enabled more rigorous study of the Doctor Coach framework and training programs and provided a richer feedback mechanism for participants. The framework facilitate dgreater faculty development needed to implement the milestones and entrust able professional activities in the medical education ,suggesting the need for restructuring the approach to teaching and learning across the continuum of medical education [28]. In a study done on the benefits of externally parallelizing a series of independent learning classifier system, (LCS) runs such that permutation testing with cross validation becoming more feasible to complete on a single multi-core workstation, testing of python implementation of the strategy in the context of a simulated complex genetic epidemiological data mining problem was done. The evaluations indicated that so long as the number of concurrent processes did not exceed the number of CPU cores, approximately linear speedup was achieved [29]. Simulation based training and nursing Students who received the simulation based training, outperformed those who received usual teaching with an overwhelmingly positive feedback and a vast majority of consensus that the session had a positive impact on their perceptions of geriatric medicine [30].

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Figure-3: PBL process

In a review study done by Bate E et al, it was stated that students and Faculty share the responsibility for learning and there are several factors that influence its success in an educational institution. They include student motivation for PBL and the various ways in which they respond to being immersed in the process. Faculty need to consider the way in which the learning environment supports the students, so that they can develop the habit of lifelong learning, and the skills and attitudes that will help them become competent reflective practitioners in the society after graduation [31]. In year one nursing undergraduates, artistic activities encouraged to relate the arts to their daily lives thus making them show consideration for patients through the arts.There was not full consensus among the participants on the relation between artistry and the sciences/nursing, but most of the students gained a better understanding of artistry and were able to link nursing care with artistry. The study results encouraged nursing educators to think beyond the boundaries of traditional teaching approaches and nurture their students with the artistry of clinical practice [32]. The psycho-pedagogical and physiological-

hygienic aspects of improvement of student's learning in radiation hygiene within a framework of the requirements of the new Federal State Educational Standard - 3,were considered at the Health prophylactic Faculty of the medical institution, in a study done by Minnibaev TS et al [33]. Tutor less PBL sessions were comparable to tutored PBL sessions only in the early stages. Students in these tutor less PBL groups performed well in the written examinations, whereas those in the tutored PBL groups, achieved this and reported better self contentment with their learning experience [34]. The 31 - item Quality Improvement Confidence Instrument (QICI) offered a psychometrically rigorous approach to evaluating medical residents' confidence levels suggesting it to be used to gauge the appropriateness of a trainee's confidence against actual QI performance [35]. Asian countries and Middle East The study done on Asian medical students reported the first application of the health education technology, content analysis (CA) to a Japanese web-based seminar (webinar). The report was the first to describe the application of CA to a multi-university real

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time audio and video PBL medical student clinical training webinar in two Japanese medical schools. These results were preliminary, limited by a small sample size and a limited time frame of four sessions. CA technology had the required potential to improve clinical thinking for medical students [36]. In a cadaver biopsy project (CBP), the researchers involved clinical and basic science faculty and senior medical students in a collaborative project to design and implement an integrated curriculum through which students revisited at several different points, the microscopic structure and patho-physiology of common diseases. These were used to develop clinical cases for courses in histology, pathology and radiology, thereby linking students' first experiences in basic sciences with other basic science courses and later with clinical courses [37]. To select approaches with the greatest utility to demonstrate superior outcomes, instructors must carefully align conditions of the learning context with the learning approaches under consideration. Further, it is important that modifications are made with caution and do not impede the desired cognitive activities needed to support meaningful collaborative learning [38]. In a cross sectional study conducted at the College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia, the most unsatisfied elements for traditional learning (TL) students were supervision, teaching, and course organization, which demonstrated the disadvantages of the traditional system. The PBL was considered a potentially successful method in enhancing medical education [39]. Results indicated that a PBL approach alone was not enough to ensure adequate learning of anatomy. The educational principles like time on task and repetition have a stronger impact on students' perceived and actual anatomical knowledge than the educational approach underpinning a curriculum. To

improve anatomy education, innovations in teaching and assessment like spiral curriculum, teaching in context, teaching for transfer and assessment for learning (rewarding understanding and higher order cognitive skills) are required [40]. In a case study of the Distributed e-Library at the Weill Cornell Medical College in Qatar in Doha, to teach and develop the medical humanities, developing an information literacy course with course guides for specific courses, the 100 Classic Books Project, collection development of doctors' stories related to the practice of medicine including medically oriented movies and TV programs and workshops to teach the analytical and critical thinking skills that form the basis of humanistic approaches to knowledge, best practices approach was out lined in developing the medical humanities in collaboration with the medical library, faculty and administrative stakeholders [41]. Student peer assessment (SPA) training and the application of the skills by the intervention group resulted in higher scores on formative tests compared to those in the control group, a difference approaching statistical significance. This suggests that the extra effort expended by librarians, other personnel, and medical students must be factored into the decision to use SPA in any specific educational context [42]. Unlike lecturing that mainly disseminates knowledge and activates the left brain, PBL encourages whole brain learning. But PBL has got some other disadvantages as well such as its inefficiency, lack of adequately trained preceptors, and the in-depth, silo learning within a relatively small number of cases. As different schools tend to utilize PBL in different ways, either the curriculum designer or the learning strategy, it is important to maximize the advantages of a PBL session. Then only it is possible to make PBL an ideal format for refining students' ethical decisions and behaviors in a competency driven education system [43].

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