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Problem-Based Learning: An Approach to Medical Education

BACKGROUND Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear. OBJECTIVES This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence. METHODS Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software. RESULTS Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters. CONCLUSION Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.

Influence of clerkship experiences on clinical competence.

Objective Logbooks are widely used in medical schools as an evaluation tool to assess students' progress towards objectives. To estimate whether students fill in their logbooks reliably, we measured interobserver agreement by comparing doctors' data and students' data. Method Completed logbooks were collected at two subdivisions of the department of Internal Medicine at the University Hospital of Groningen. The logbook contains 231 preprinted diseases. Doctors and students recorded the diseases they had encountered. Interobserver agreement, expressed by the Jaccard coefficient (J), was calculated for the complete set of diseases and for a subset of core diseases. To assess the kinds of errors which students made, sensitivity and specificity were determined. Results Logbook data of doctors and students are not fully consistent (mean J for the complete set of diseases was .23 and for the core diseases .36). The quality of the logbook data is high in the sense that students do not record many false identifications (mean specificity for the complete set of diseases and for the core diseases were .96 and .93, respectively); the quality is poor in the sense that students do not record all the diseases which could be seen at the department (mean sensitivity for the complete set of diseases is .36 and for the core diseases it is .51). Conclusion This study shows inconsistencies in recording diseases in a logbook by students compared with doctors. In particular the diseases which are present at a department are under-reported by students. Supervision and feedback are important mechanisms to optimize the students' use of (1) all diseases which could be encountered and (2) the logbook.

The reliability of logbook data of medical students: an estimation of interobserver agreement, sensitivity and specificity.

Background: Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients a...

https://www.tandfonline.com/doi/pdf/10.3109/0142159X.2013.797570

A systematic review of the relationship between patient mix and learning in work-based clinical settings. A BEME systematic review: BEME Guide No. 24

Background: Logbooks are used by clinical clerkships in undergraduate medical education as tools for individual student guidance, programmatic evaluation, and Liaison Committee on Medical Education (LCME) accreditation The purpose of this narrative review was to summarize the published literature on the form and function of logbooks and to review logbook validity and reliability We performed a literature search from 1980 through 2004 and reviewed 50 articles on logbook use during clinical clerkships Summary: Articles were categorized into 5 themes: description and feasibility of logbooks (27 articles), accuracy and completeness of logbook entries (14 articles), utility to student education (11 articles), utility to program evaluation (26 articles), and connecting logbook process measures to clerkship outcomes (2 articles) Conclusions: A feasible and acceptable logbook system is an attainable goal, although students usually did not complete logbooks unless required The available literature does not es

Narrative review: use of student-generated logbooks in undergraduate medical education.

An international summer school session, Oncology for Medical Students, was held in 1996 at Groningen University Hospital in The Netherlands. It was sponsored and organized by the WHO Collaborating Centre for Cancer Education-Groningen. The central focus of the two-week course was cancer in general health care. Various teaching techniques were used, but interaction between students and patients, and students and faculty, was considered a prerequisite. The approach was multidisciplinary, with a variety of clinical disciplines participating, including patient organizations and the Comprehensive Cancer Center North Netherlands. The students, from all over the world, presented posters about oncology topics in their countries. Evaluation showed that the course was highly appreciated by the students; in particular, the students felt they had benefitted from the multidisciplinary approach, the patient encounters, the psychosocial concern, the poster sessions, the quality of the teaching, and meeting other students from all over the world.

Report of an international summer school--oncology for medical students--in 1996 in Groningen, The Netherlands.

The Dutch national objectives for the education of medical doctors (in terms of diseases), expressed in the form of a student compiled logbook, must be attained at the time of graduation. The diseases that are required are divided into the categories 'essential' and 'compulsory choice'. The aim of this study is to investigate whether the inpatient department of internal nedicine offers medical students sufficient diseases during two four-week periods in the clerkship, such that the required diseases related to Internal Medicine as described in our logbook can be met. At five subdivisions, medical doctors recorded the diseases available for students. Of the 37 'essential' diseases students may be expected to encounter during one four-week stay in the department: 57% in internal medicine-I; 55% in internal medicine-II; 47% in nephrology; 41% in respiratory medicine; 13% in oncology. Of the 65 'compulsory choice' diseases the number of diseases encountered is respectively: 78%; 57%; 41%; 34%; 33%. We conclude that a considerable number of the diseases required by the Blueprint and therefore by the government is available in two four-week periods in the inpatient clerkship, when this comprises a stay at a general subdivision and a specialist-oriented subdivision. To be more precise about the fulfilment of the logbook requirements, further research is necessary.

The availability of diseases for medical students in a university hospital

Background: The Dutch Blueprint 1994 (Raamplan 1994) describes the objectives of undergraduate medical education. The Blueprint, developed in order to improve medical education in the Netherlands, is accepted by all Dutch medical schools and has been legislated Aim: Translation of global objectives of the Blueprint into specific requirements of a Logbook (guideline and evaluation tool) far the internship Internal Medicine. Description: The Blueprint as such is impracticable as a guideline during the Internal Medicine internship. The content covers the objectives for the entire field of medicine, and the volume dedicated to Internal Medicine is too large to fit in with a twelve week internship. The practicability of the Blueprint leaves much to be desired because it is complex, and not easily accessible. So, the Blueprint was adapted on three points: (1) selecting those objectives out of the whole content, which are specifically relevant to Internal Medicine; (2) decreasing the volume Internal Medicine by clustering and defining the requirements; (3) making the Logbook usable as a guideline and evaluation instrument. Conclusion: The Logbook is a good starting-point to evaluate whether students meet the objectives of the Blueprint related to the discipline internal Medicine. (C) 1999 Elsevier Science B.V. All rights reserved.

Objectives for an internship internal medicine: from the Dutch Blueprint (Raamplan 1994) to implementation into a practical logbook.

Because medical students in The Netherlands should achieve common national objectives, it is important to know whether clinical experiences in different hospitals are comparable. The research questions were: (1) Do students achieve learning experiences of the required diseases during the internship in Internal Medicine and to what extent do they achieve these experiences? (2) Are there differences between the diseases experienced at a university hospital and at community hospitals? Completed logbooks of students were analysed; the percentage of students that achieved the required diseases and the mean number of experiences of diseases were calculated. A t-test was done to test for differences. Medical students in the university and in community hospitals get broad experience (76-131%) of the required diseases. In both hospitals there are many students who are not achieving the requirements, but the mean number of experiences of students at the community hospitals is higher than those at the university hospital. To eliminate the differences between students from the university hospital and the community hospitals, the educational programmes within both hospitals should be adjusted.

W Bender

Papers

The reliability of logbook data of medical students: an estimation of interobserver agreement, sensitivity and specificity.

Report of an international summer school--oncology for medical students--in 1996 in Groningen, The Netherlands.

The availability of diseases for medical students in a university hospital

Objectives for an internship internal medicine: from the Dutch Blueprint (Raamplan 1994) to implementation into a practical logbook.

Medical students' experiences of diseases in internal medicine in university and community hospitals