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# (PBL-SGT)-Fusion

MMedSci Medical Education (Distinction), University of Nottingham, 2015

An active-learning method that adapts each session to the learners in the room.

### In plain English

(PBL-SGT)-Fusion combines problem-based learning with small-group teaching, and adds one crucial ingredient: a pre-test diagnostic before each session, so the difficulty adapts to the people actually in the room rather than to an imagined average student.

I evaluated it with psychometrics, item difficulty and score reliability, and with Kirkpatrick's framework, across 35 students. The result that mattered: junior-phase (CP1) students mastered material written for senior-phase (CP3) students. When teaching adapts, learners outperform their stage.

The thesis also proposed a follow-on model, 'Theory, Simulation, Practise' (TSP).

This was adaptive learning built by hand, a decade before AI made personalisation cheap. The principle transfers directly.

### Abstract & Supervisors

**Background**

In recent times there has been a clamour against 'spoon feeding' (1) in medical education, something that has coincided with a drive to encourage medical students to participate in self-directed learning (SDL). This is all well and good; however an important variable should not be overlooked. The environment in which we are placing medical students is by no means a perfect arena for learning. The ward environment has changed dramatically since the introduction of the European Working Time Directive (2) (EWTD). The firm based structure, which supported undergraduates so well, is no longer present. The combinations of shift-working and ward-based teams have resulted in a transient workforce. Consequently there can be a lack of continuity in care for patients throughout their hospital stay. From personal experience, I have witnessed the adverse effects this environment has on educational opportunities for medical students. There is a new breed of junior doctors known as Clinical Teaching Fellows (CTFs), doctors who are specifically devoted to teaching medical students. CTFs are a fantastic resource and provide an opportunity to bridge the gap between classrooms and clinical environments.

**Objectives**

This dissertation will look at incorporating active learning methodologies into Small Group Teaching (SGT), and to determine if this can help prepare clinical medical students for life on the wards. This preparation will entail equipping students with core knowledge that is readily retrievable. The term I have applied to this process is (PBL-SGT)-Fusion, as I have taken elements from traditional Problem Based Learning (PBL) and Small Group Teaching (SGT) when developing this style. (PBL-SGT)-Fusion can help prepare students for life in a challenging learning environment in order to maximise their learning opportunities. The primary objective of this study was to determine if implementing active learning techniques would translate into improved student performance on a 'Post-test' paper. The initial cohort included Clinical Phase 3 (CP3) students. A secondary objective was looking at whether this kind of teaching could also be implemented with Clinical Phase 1 (CP1) students. Across both objectives, I wanted to ensure I developed a teaching process that was both psychometrically sound yet still enjoyed by the students. The overarching research questions therefore are as follows:

1. 'Can a new teaching methodology incorporating active learning techniques be successfully developed and delivered?'
2. 'Does this translate into increased student performance in a written exam?'
3. 'Can the same method be used to deliver CP3 material to CP1 students?'

**Methods**

This study was performed as part of the Trauma & Orthopaedic teaching delivered to University of Nottingham Medical Students on placement at Lincoln County Hospital. A convenience sampling method (3) was used to enroll CP3 students to the study. Students were on the Musculoskeletal Diseases & Disorders (MDD) block for 8 weeks per rotation, with a maximum of 10 students per group. Due to this set up, SGT was always going to be a heavily utilised teaching methodology. The SGT environment is well suited to the (PBL-SGT)-Fusion approach as it permits incorporation of constructivist (4) approaches to learning. Students were exposed to active learning techniques including mind mapping the case and group Case Based Discussion (CBD). A total of 35 students (15 CP1 and 20 CP3) participated in this study.

A 'Pre-test' paper was given to students at the start of sessions to introduce the subject material. This also allowed for the activation of prior knowledge whilst identifying weaknesses and deficiencies in students' understanding. On completion, the 'Pre-test' papers were handed in and reviewed by the teacher to rapidly identify the baseline level of knowledge within the group, and adjust session difficulty accordingly. Following tutor review, the tutor facilitated a group CBD between the students. This took the salient elements of the case and summarised the group discussion on to a mind map. Finally, towards the end of their placement six weeks later, students sat a 'Post-test' paper covering all the cases under examination conditions. It is worth noting students were not allowed to keep the 'Pre- or Post-' test papers, and that they were unaware the same cases would be used in the 'Post-test' scenario. The reasons for distributing the 'Post-test' paper are three fold; to assess the impact of the teaching intervention and its effect on learning, to allow students to consolidate their knowledge via recall under examination conditions, and finally, to enable the teacher to check students are not leaving the placement with gaps in their knowledge or understanding.

I used a mix of descriptive and inferential statistics to analyze the data obtained in this study. The psychometric properties of items have been calculated including item difficulty and the reliability of test scores.

**Results**

This study was universally well received by students of all ability and stage. Many of whom would like more teaching in this style elsewhere in their medical curriculum. CP1 students found the process enjoyable and were able to comprehend and retain material traditionally taught at CP3 level. Interestingly there was no significant difference between performances of Undergraduate (UG) students on 'Pre-test' papers when compared to Graduate Entry Medical (GEM) students. One might expect GEM students to out-perform their UG colleagues, given their experience doing PBL on the GEM course, this was not the case. These findings for UG and GEM students were replicated in the 'Post-test' paper, in that there was no significant difference between their results. CP3 students generally outperformed their CP1 colleagues. However, a particularly interesting result is the CP1 students scoring a higher median mark on their 'Post-test' paper than CP3 students achieved on their 'Pre-test' papers.

**Discussion**

Given the current climate (5) within the NHS, a typical ward environment is far from an optimal setting for teaching. As medical educators, the temptation can be to increase classroom based teaching to compensate, however, I would argue we need to develop innovative ways of using time with students in the classroom to maximise their learning opportunities in clinical environments. We must be mindful of the environment we are preparing students to enter and learn in, as there is often a conflict between service provision and training. (PBL-SGT)-Fusion is an example of how innovative approaches can improve student engagement and attainment. Kirkpatrick's model has been applied when evaluating this curriculum intervention, for which the combined use of constructivist learning theory (6, 7) and implementation of active learning techniques have been central to its creation.

**Conclusion**

It is worth bearing in mind this innovative teaching technique so far has only been implemented by one teacher at one site with 35 students. Nevertheless, this study has proved that the introduction of active learning methodologies within SGT is both enjoyed by students and translates into improved performance in written examinations. (PBL-SGT)-Fusion has an advantage over traditional teaching methods, as active learning methodology is engrained throughout the educational process. Anecdotally students have reported a desire to alter their approach to learning having been introduced to such techniques.

An argument could be made for introducing this type of teaching earlier in students' clinical phases, then building on it by incorporating simulation. I have termed this approach 'Theory, Simulation, Practise' (TSP) and is introduced in 'Chapter 7.0) Recommendations & Suggestions for Future Research.' The idea behind the TSP approach is creating environments where students' learning maps with their curriculum, in a way we are actively preparing them for life as junior doctors. I believe this will lead to increased levels of engagement and satisfaction.

**References**

1. Dornan T, Hadfield J, Brown M, Boshuizen H, Scherpbier A. How can medical students learn in a self-directed way in the clinical environment? Design-based research. Medical Education. 2005;39(4):356-64.
2. Breen K, Hogan A, Mealy K. The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience. Irish Journal of Medical Science. 2013;182(3):383-7.
3. Tavakol M, Sandars J. Quantitative and qualitative methods in medical education research: AMEE Guide No 90: Part II. Medical Teacher. 2014;36(10):838-48.
4. Schmidt HG, Van der Molen HT, Te Winkel WW, Wijnen WH. Constructivist, problem-based learning does work: A meta-analysis of curricular comparisons involving a single medical school. Educational Psychologist. 2009;44(4):227-49.
5. Wood H. Mid Staffs shows what's wrong with NHS management. BMJ. 2013;346:25.
6. Phillips DC. The good, the bad, and the ugly: The many faces of constructivism. Educational Researcher. 1995:5-12.
7. Hein G, editor. Constructivist learning theory. The Museum and the Needs of People, CECA (International Committee of Museum Educators) Conference, Jerusalem, Israel; 1991.

Supervisors: [Prof Reg Dennick](https://www.linkedin.com/in/reg-dennick-9186a4343/), [Prof Catherine Haines](https://www.linkedin.com/in/catherine-haines-12310532/)