March 15, 2008, by Teaching at Nottingham

The problem-based learning cycle

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Session 1

Pete Jennings: “PBL starts with session 1 – here at GEM it’s divided into 3 sessions. So session 1, the students come together, they’re presented with a trigger text which gives them enough clues to hopefully identify questions that they might have around certain topics.”

Student group working

“Low energy levels for about 3-4 months…”
“Has it been that long?”
“Ankles were swelling up at the end of the day.”
“And she had a bloated stomach.”
“She had no weight loss but she had been off her food.”

Pete: “So for example a patient comes to their GP complaining of chest pain and the students would look at that and start to dissect, really, the terminology within the text so ‘By chest, what do they mean?’ ‘What’s in the chest?’ And they would start to ask questions about ‘What do we know about the heart?’ or ‘What do we know about the lungs?’ And really start to brainstorm and think very, very broadly about all of the different complications that could be.

Student group working

“So it could be her diet or lack of correct nutrients.”
“But then why wouldn’t she lose weight?”
“It could be nutrients, it could be something essential…so she’s getting enough calories but not getting the right balance for it.”
“Yeah, like vitamin K…”
“Yeah, B12.”
“She’s got a hectic schedule, she probably just snacks, grabs stuff, you know…”
“Yeah, what’s her diet?”
“Oh, that can keep you awake, though, can’t it?”

Pete: “And then what they try to do is get to kind of the edge of what they know about each of these areas, so they’re trying to pull in their previous learning about physiology, anatomy, pharmacology – if they have any – to try and answer some of these questions they have.”

Student group working

“Anaemia…do we want to do a bit of red blood cell…because I don’t think we’ve done a lot of blood. Red blood cell, metabolism, manufacture…”
“Part of the maturation pathway.”
“Because at this point in time we’re going to do platelets next week, so blood, formation and…breakdown in metabolism.”

Pete: “And when they get to a point where they might say ‘Well, I don’t know what’s in the chest’ then that’s a learning issue and they’re able to go away and answer that question in between kind of session 1 and session 2. And when they come back to session 2, hopefully they’ve done research around these learning issues and they’re able to present back to members of the group. In either, you’ll sometimes see groups using a very traditional lecture style format and they’ll give kind of a mini tutorial to the group.”

Session 2

Student presenting to group

Shirley (student): “So you need iron, globin, vitamin B12 and the C code to get these red blood cells to differentiate and spread out. So they then merrily go round in the blood stream for about 120 days, and then that’s them knackered and it is time for them to go to the graveyard. So they carry on to get broken down in the bone, the liver or the spleen.”

Pete: “Other groups will have a very informal discussion, and people will be feeding in what they’ve read and they’ll have a bit of discussion or argument about “Well, I thought it was this” “No, actually it’s this” and they’ll check the learning that they’ve done.”

Student discussion

“How do get…from here?”
“You can’t, you just don’t absorb it.”
“You need some sort of receptor because that’s kind of like, yes, you get all these sorts of things getting absorbed into the blood, so they can makes things well, but there’s specific receptors are something isn’t there?”
“Yeah, because to absorb iron you possibly need vitamin B12 but you also need an acid environment. That’s why it’s done…”
“There’s something else because if you’ve got too much iron then it goes ‘Nope, don’t need any more thank you today’.”
“So how is iron absorbed?”
“The liver makes…”

Pete: “And then about usually halfway through that session they’re presented with some more patient data, so they could start to get a feel about what kind of chest pain is this patient having, where is it exactly located, they get some information about the past medical history of the patient, so ‘Do they smoke, are they overweight, do they exercise?’ If you’re going down a kind of cardiac route.”

Student discussion

“The liver is enlarged and it’s making an irregular outline which features hepatic change…”
“There’s evidence of photo systemic collateral circulation.”

Pete: “And hopefully those questions and that kind of physical exam that they do and history-taking help them to start to bring together their thinking around the anatomy, the physiology, what’s happening in the patient’s life – like, let’s say with their work or their family – and start to integrate all of these different separate subject areas into kind of caring for the patient and identifying what the diagnosis is and thinking about how they would manage that.”

Student discussion

“So she’s basically got high liver cirrhosis and hep C. Girl’s doing well. And she’s an alcoholic. Would you call her an alcoholic?”
“She drinks everyday.”
“Yeah, well, quite a few people do, though, but that doesn’t make them alcoholic.”
“Well, we need to see if she can go without.”
“And if she starts to get better.”
“And also what she drinks…she doesn’t drink wine.”
“The thing is we can sit her down and go “Look, you’ve got a problem with your liver, this is really bad, you really need to stop drinking” …She’s maybe just ignorant, not thinking about it, not worrying about it, maybe just saying to her ‘Look, your liver is shot, you need to stop drinking,’ and she might just respond to that.”
“Well we did, we asked her before ‘would you be willing to stop drinking,’ and she did say yes if she thought it was going to make her feel better.”

Session 3

Pete: “And then in session 3 they would identify and feedback any learning issue they identified at the end of session 2, and start to think then a bit about kind of answering these again, the learning issues with the group members and having a bit of discussion around any outstanding issues.”

Student discussion

Jonathan Ball (facilitator): “I know, but it might be worthwhile revisiting your hepatitis…Yeah, you can be a carrier, but its carriage state in hep B is about 20%. In hep C it’s about 80%. So 20% of people who didn’t have hep B would be carriers.”

Pete: “And then starting to look at how this case would be managed, so what kind of therapies would they be offering to the patient, deciding on what their diagnosis is, and then exploring treatment options kind of longer term.”

Student discussion

“So, treatments…”
“Are you going to give me some help with that?”
“Yes, would you like some help with that?”
“What can we do with hep C?”
“What’s Ribavirin?”
“Ribavirin with peginterferon alpha, apparently.”
“…it’s used in infection, peginterferon alpha may be superior to interferon alpha.”
“But she should be admitted for this, she would wouldn’t she? She’s in a terrible state.”

Pete: “And then finally the group kind of wraps up by looking at ‘How have we worked this week?’, ‘Are there any issues around the group process that we’re kind of interested in tweaking for the next session?'”

Student discussion

Jonathan Ball (Facilitator): “Very, very quickly because it’s still important, very quick, one sentence max, how the case went, whether you contributed to it, whether I was OK, or what I could do that’s better. Very quickly, one sentence max.”
Student: “Yeah, generally thought it was quite good, bit slow on Tuesday though I did enjoy lots of it. I think it could have been a bit quicker, a bit more disciplined.”

Pete: “That’s a very kind of paper, official kind of view about how things go, but I’d like to say that actually, with the groups it’s never quite like that. It follows a kind of familiar feel, but groups work very, very differently and you can get 2 groups working side by side that have a different approach.”

Jonathan Ball (School of Molecular Medical Sciences), 
Pete Jennings (Graduate Entry Medicine & Health).

A description of the PBL process, with extracts from the PBL sessions that are the focus of pre-clinical education on the Graduate Entry Medicine & Health course. This video was originally published as part of PESL’s Teaching at Nottingham collection. Produced March 2008.

Posted in Problem based learning