|Year : 2012 | Volume
| Issue : 2 | Page : 98-103
Effects of problem-based learning along with other active learning strategies on short-term learning outcomes of students in an Indian medical school
Reem R Abraham1, Komattil Ramnarayan2, Bincy M George3, Indira Adiga4, Girija R Kumari5, Niveditha Suvarna2, Vasudha Devi6, Shobha Karabylu Lakshminarayana5, Madeeha B Mamot7, Wan Nasyitah BW Jamil7, Nai'mah BA Haripin7
1 Department of Physiology, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
2 Department of Pathology, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
3 Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
4 Department of Biochemistry, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
5 Department of Microbiology, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
6 Department of Pharmacology, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
7 Undergraduate MBBS students, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka state, India
|Date of Web Publication||27-Sep-2012|
Reem R Abraham
Associate Professor, Department of Physiology, Melaka Manipal Medical College (Manipal Campus), International Centre for Health Sciences, Manipal 576 104, Karnataka State
Source of Support: None, Conflict of Interest: None
Background: Problem-based learning (PBL) is reported to improve general competencies such as problem solving. It also fosters the development of a scientific attitude in medical students. The present study explored perceptions of students at Melaka Manipal Medical College (MMMC), Manipal Campus, India regarding the extent to which PBL along with other active learning strategies has succeeded in improving a few short-term learning outcomes. We also determined graduation and attrition rates of seven and six batches of first- and second-year students, respectively, who were enrolled in MBBS program before and after the implementation of PBL. Materials and Methods: Students (n = 120) were requested to indicate their responses on a Likert scale in a questionnaire focusing on the 12 short-term learning outcomes. Additionally, a retrospective analysis of graduation and attrition rates of seven batches of first year and six batches of second-year students who were enrolled in MBBS program was done. Results and Conclusion: Out of the 12 learning outcomes, all were found to have a median score of 4, except time management, motivation for lifelong learning, and interest in pursuing medical profession. The graduation and attrition rates were found to be significantly high and low respectively for PBL students compared to non-PBL students in first year. In the second year too, PBL students outnumbered non-PBL students in terms of graduation rate. The attrition rate was found to be low for PBL students compared to non-PBL students. The present study revealed that PBL along with other active learning strategies such as self-directed learning (SDL) sessions employed in the curriculum right from first year culminated in improvement of almost all short-term outcomes.
Keywords: Attrition rate, graduation rate, problem-based learning, short-term learning outcomes
|How to cite this article:|
Abraham RR, Ramnarayan K, George BM, Adiga I, Kumari GR, Suvarna N, Devi V, Lakshminarayana SK, Mamot MB, Jamil WB, Haripin NB. Effects of problem-based learning along with other active learning strategies on short-term learning outcomes of students in an Indian medical school. Int J Health Allied Sci 2012;1:98-103
|How to cite this URL:|
Abraham RR, Ramnarayan K, George BM, Adiga I, Kumari GR, Suvarna N, Devi V, Lakshminarayana SK, Mamot MB, Jamil WB, Haripin NB. Effects of problem-based learning along with other active learning strategies on short-term learning outcomes of students in an Indian medical school. Int J Health Allied Sci [serial online] 2012 [cited 2020 Jan 17];1:98-103. Available from: http://www.ijhas.in/text.asp?2012/1/2/98/101703
| Introduction|| |
In Indian medical schools, a large proportion of subject content is delivered through the traditional lectures. Avenues for improving generic skills such as critical thinking, problem solving, communication skills, and team work are minimal. Learning is supposed to be taking place in the classroom through the teacher-centered teaching strategies whatsoever. Active learning strategies do not find a place in the typical schedule of medical students, mainly due to the concern that such activities will take away the valuable time for lectures and laboratory sessions. By and large, students get less number of opportunities to apply their learning in appropriate contexts. This practice could hamper their learning in the future years of the medical course, when they encounter patients.
Problem-based learning (PBL) is reported to improve general competencies such as problem solving,  scientific attitude,  and te amwork  in medical students PBL is known to demand a lot of self-direction from the students provided appropriate guidance is given by the faculty facilitators.  Previous studies have compared competencies acquired by PBL and non-PBL graduates and found that PBL graduates were perceived to have better interpersonal skills,  problem solving,  communication skills, and teamwork. , Additionally, a few studies have explored the graduation rates and study duration of students in a PBL program. ,, This paper describes perceptions of students at Melaka Manipal Medical College (MMMC), Manipal Campus, India, regarding the extent to which PBL along with other active learning strategies have succeeded in improving the short-term learning outcomes (outcomes which students are intended to achieve at the end of two and a half years of training in the medical school). In addition to that, we attempted to conduct retrospective analyses of the graduation and attrition rates  (defined as the number of students who enrolled in the program but did not complete the course within the specified time) of seven batches of first-year students who enrolled in the MBBS program before and after the implementation of PBL and six batches of second-year students who enrolled in the MBBS program before and after the implementation of PBL.
| Materials and Methods|| |
Our medical school offers the Bachelor of Medicine and Bachelor of Surgery (MBBS) program in two campuses; one in India and the other in Malaysia. The program envisages two and a half years of preclinical training in India and the remaining two and a half years at Malaysia. The first-year subjects include anatomy, physiology, and biochemistry whereas pathology, microbiology, pharmacology, and forensic medicine are taught in the second year. The first- and second-year curriculum is divided into four blocks each of 10 weeks duration as follows.
Block 1: Basic Concepts, Muscle, Blood
Block 2: Cardiovascular System, Respiratory System, Gastrointestinal System
Block 3: Endocrine System, Reproductive System, Renal System
Block 4: Central Nervous System, Special Senses
Block 1: Basic Concepts, Infection, Inflammation, Blood, Immunity, and Neoplasia
Block 2: CNS, ANS, Special Senses, Skin, Muscle, Bones, and Joints
Block 3: CVS, RS, GIT, and Hepatobiliary System
Block 4: Endocrine, Reproduction, and Renal System
After completing two years of preclinical training, students enter 6 months of clinical training phase in Manipal. Upon successful completion of this phase, students pursue the remaining part of their course in Malaysia. There are two admission intakes per year; one in March and another in September. Majority of the students are from Malaysia (98%) and the rest are from Seychelles, Bahrain, Australia, and Singapore. PBL was implemented in the curriculum from September 2006 admissions onwards. Prior to this, the curriculum comprised lectures, self-directed learning sessions, and laboratory sessions.
At Melaka Manipal Medical College (MMMC), student-centered teaching and learning strategies have occupied a dominant place in the curriculum in both first and second years in the form of self-directed learning (SDL) and PBL sessions in first year, self-directed learning, PBL, and independent learning (IL) sessions in second year. In the typical SDL session, students are divided into small groups (n = 35 to 40) and they are required to present a topic (known to the students at the beginning of a block) after learning the topic independently or via collaborative learning. A faculty member facilitates these sessions. In IL sessions, there will not be any facilitator to guide the discussion. Students have to learn the topics allotted for IL sessions themselves.
The PBL process
At present, three PBL sessions are conducted per block in first year. In the second year, three PBL sessions are conducted per block in the first three blocks. By the end of second year, students would have completed 20/21 PBL sessions altogether. PBL is conducted in the traditional pattern consisting of both brainstorming and presentation sessions with five to six PBL groups, each group led by a subject expert who functions as facilitator. In the brainstorming session, students work together in small groups of 10-12 to bring out the unknown terms, learning issues, hypotheses, and learning objectives. PBL groups are encouraged to engage in collaborative learning before they come for the presentation session. In the presentation session, students in each PBL group present the learning objectives. The students are assessed both in the brainstorming and presentation sessions based on their active participation, presentation style, and accuracy of the content presented.
To monitor and supervise the smooth progress of PBL sessions, a PBL committee was formed with Dean as the chairperson and 6 members from each of the six departments (excluding forensic medicine). The PBL committee takes initiative in conducting evaluation of the PBL program. One such initiative was to determine the extent to which PBL has been successful in improving 12 short-term learning outcomes listed in [Table 1]. One batch of students (n = 120) who were pursuing clinical training in our medical school were selected for the study. Students were requested to denote their responses on a Likert scale (5-Strongly agree, 4-Agree, 3-Uncertain, 2-Disagree, 1-Strongly disagree) in a questionnaire which had 12 items focusing on the 12 short-term learning outcomes. Data was summarized using median and interquartile range. Additionally, a retrospective analysis of the graduation and attrition rates of seven batches of first year students (March 2003, September 2003, March 2004, September 2004, March 2005, September 2005, March 2006) who enrolled in the MBBS program before the implementation of PBL who followed the traditional curriculum and after the implementation of PBL (September 2006, March 2007, September 2007, March 2008, September 2008, March 2009, September 2009) was done. Likewise, the attrition and graduation rates of the same batch of students (except March 2009 and September 2009 batches) in second year were determined.
The graduation rate  was calculated by dividing number of students graduated by number of students who wrote the final summative examination multiplied by 100. Attrition rate was calculated by dividing number of failed students by number of students who wrote the final summative examination multiplied by 100. Data was summarized as proportions. Comparisons of the graduation and attrition rates between the PBL and non-PBL groups were carried out using the chi-square test. A P value of 0.05 was considered to be statistically significant. For all statistical analyses, SPSS version 16 was used.
| Results|| |
Seventy-three students responded to the questionnaire (60.83%). Out of the 12 learning outcomes [Table 1], all except sixth (time management; median 3), ninth (motivation for lifelong learning; 3), and twelfth (interest in pursuing medical profession; median 3) outcomes were found to have a median score of 4. More than 75% of students strongly felt that communication skills (item 5) and self-confidence (item 8) have improved due to their involvement in PBL. The graduation and attrition rates were found to be significantly high and low respectively for the PBL students (88.7%; 11.3%) compared to non-PBL students (78.8%; 21.2%) in first year [Table 2], [Table 3]. In the second year also, a similar trend was observed [Table 4], [Table 5]. PBL students outnumbered non-PBL students in terms of graduation rate (PBL 92.7%; non-PBL, 87.7%) The attrition rate was found to be low for PBL students (7.3%) compared to non-PBL students (12.3%) in second year.
|Table 2: Summary of first-year graduation and attrition rates of seven batches of students in the non-PBL and PBL curriculum|
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|Table 3: Distribution of graduation and attrition rates for the non-PBL and PBL batches of first-year students|
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|Table 4: Summary of second-year graduation and attrition rates of six batches of students in the non-PBL curriculum and PBL curriculum|
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|Table 5: Distribution of graduation and attrition rates for the non-PBL and PBL batches of second-year students|
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| Discussion|| |
In Indian medical schools, PBL is yet to find a secure place in the curriculum. Faculty development workshops are being conducted to sensitize faculty regarding the pivotal role of PBL in helping students to become self-directed learners.  Previous studies have reported the effects of PBL during medical school and postgraduate training. ,,,,,, Results of the present study are supported by previous studies which also reported an increase in graduation rate of students in PBL curricula. , Hoffman et al. reported higher performance of PBL graduates in United States Medical Licensing Examinations (USMLE ). Finch  reported that chiropody students at the Michener Institute for Applied Health Sciences who had experienced PBL performed significantly better in tests of deeper understanding and the cognitive skills related to patient management, compared to the traditional cohort of students. In a study conducted among students studying special care in dentistry, a comparison of academic results showed that PBL students scored better than those receiving conventional lectures.  There is a growing body of research concerned with improved academic performance of PBL cohort of students compared to the non-PBL cohort in National Licensing Examinations. ,,
Dolmans and Schmidt  reported that in a PBL curriculum as a major part of the curriculum is delivered in PBL mode, students become more experienced and become better self-directed learners. In the present study, the perceived improvement in outcomes could be due to the fact that students are required to make a conscious effort to assume responsibility in their own learning through these active learning strategies. More student centered opportunities led to more student involvement which was reflected in their perceptions. Our medical school, prior to the introduction of PBL (before September 2006), had self-directed learning sessions as the main active learning strategy in the curriculum along with a minimum of five to six lecture classes per subject per week. In the non-PBL as well as PBL curriculum, students enrolled in the MBBS program had a GPA score of 3.5 and above. Academic background of the students was reasonably homogenous in that 98-100% of the students in all the batches had finished academic levels equivalent to pre-university course in India. Therefore, no difference existed in terms of the ability as well as the age of students enrolled in the program before and after the implementation of PBL. There was not much difference in the assessment practices for the batches included in the analyses. However, with the introduction of PBL in September 2006, there has been a reduction in the number of lecture classes to four per subject per week. Students had considerable scope for improving information gathering, communication, team work, collaborative learning, and presentation skills as they are required to participate in three PBL sessions per block (4 blocks) in first year and three PBL sessions in the first three blocks in second year along with other active learning strategies mentioned above. The significant but small difference (9% difference in the graduation rate between PBL and non-PBL batches in first year and 5% difference in the graduation rate between PBL and non-PBL batches in second year) could be due to the fact that before the introduction of PBL, students were already exposed to SDL sessions and introduction of PBL would have led to further improvement in the outcomes as well as academic performance. We fully agree with Schimdt et al. that active learning strategies lead more students toward better learning leading to better academic performance and thereby higher graduation rates. In one of our earlier studies, we had reported the adoption of deep approach to learning in PBL students compared to non-PBL students in the same medical school. 
At MMMC, PBL was not introduced as a complete curricular reform, instead it was implemented as an adjunct along with lectures, SDL and laboratory sessions similar to the strategy reported by Steele.  Almost all students entering into the MBBS program were school leavers. Also, due to limited self-directed learning skills for these students as explained by Schmidt and Moust  and additionally due to the lack of experience in assuming responsibility for one's own learning  we felt that in the initial phase of the pre-clinical training, a total curricular shift to PBL as proposed by Barrows, , was inappropriate in our setting. As Barrows intended, we felt exposure to PBL in the preclinical years will help students to become better prepared for the subsequent clinical term. 
| Conclusions|| |
PBL along with other active learning strategies employed in the curriculum right from first year culminated in the improvement of almost all the short-term outcomes. Further, the adoption of PBL demanded students to make a conscious effort to assume responsibility in their own learning, thereby resulting in better learning leading to better performance in the examinations.
Our study was not successful enough to confirm the exact role of PBL in describing the changes in graduation and attrition rates. Additionally, it was only the perceived and not the actual impact of PBL on the short-term outcomes that could be determined on a small sample of students.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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