| Abstract|| |
To assess teaching in the Renal System Block of an integrated problem-based learning (PBL) undergraduate medical curriculum by the students' and tutors' according to their perceptions of relevance, stimulation and amount learned from the problems, a 16-item questionnaire focusing on these issues was distributed to a group of 1st year medical students in Riyadh, Saudi Arabia (n = 17) and their tutors (n = 3). Group ratings on Likert-type rating scales and open-ended comments were analyzed to determine median and qualitative differences. Students' and tutors had favorable, congruent perceptions of amount learned, stimulation and relevance of renal medicine problems to the Saudi Arabian healthcare context. Open-ended comments of both groups were highly supportive of the Block objectives, content and integrated teaching. It is concluded that exploring the congruence of students' and tutors' perspectives has been helpful in determining the necessity for renal medicine block modifications; emulating a PBL collaborative knowledgebuilding approach in curriculum development.
|How to cite this article:|
Elzubeir MA. Teaching of the renal system in an integrated, problem-based curriculum. Saudi J Kidney Dis Transpl 2012;23:93-8
|How to cite this URL:|
Elzubeir MA. Teaching of the renal system in an integrated, problem-based curriculum. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Jun 3];23:93-8. Available from: http://www.sjkdt.org/text.asp?2012/23/1/93/91309
| Introduction|| |
Traditional undergraduate medical school curricula are often divided into pre-clinical and clinical years, and are dominated by a teacher-centered, reductionist approach, with renal medicine taught in a didactic, fragmentary manner usually in large lecture theaters by teachers with expertise in the areas of their research interests.
This makes it difficult for undergraduates to integrate knowledge of renal anatomy and physiology with interpretation of clinical renal problems.
Teaching may also emphasize complex and specialist topics, which are rarely seen by most doctors in their future clinical practice. 
Problem-based learning (PBL), however, provides opportunities for authentic, integrated problems to drive the learning of undergraduate students and to reduce the burden of factual information. Underpinned by constructivist, experiential, adult learning principles  PBL is increasingly considered to be among the best educational practices that medical schools internationally are adopting as they revitalize their curricula and shift to a learner-centered focus.
PBL embraces a pedagogic theory intended for enhancing self-motivation, active, life-long learning, critical thinking, professional behaviors, effective communication and collaborative team-work approaches of students. 
However, for PBL to be effective, construction of well-designed cases/problems that drive meaningful learning is crucial as these are the starting point for students' learning activities that largely impact on the quality of student learning. 
Designing problems that stimulate students toward meaningful learning require realistic, open-ended, ill-structured problems that build on students' prior knowledge and are in contrast with other problems that help students appreciate and evaluate new information whilst developing their knowledge, skills and attitudes. ,
Dolmans et al  outline seven principles of effective case design, which include: relevance to the context of future professional practice, integration of basic and clinical concepts, stimulation of self-directed learning by encouraging students to generate learning issues and conduct literature searches and matching one or more of faculty learning objectives.
Following their experiences with cases/problems, ideally, students and PBL tutors should evaluate the case and its suitability for PBL. 
Eliciting students' and faculty perspectives regarding the process of learning and teaching have long been a necessary activity in any educational process, and the most often used data collection methods are evaluation questionnaires inviting ratings on different dimensions of the instructional process.
We aimed, in this study, to determine the effectiveness of PBL as an approach to teaching renal medicine from the perspectives of students and tutors in a new medical school in Riyadh, Saudi Arabia, and to consider implications for case development.
| Materials and Methods|| |
Context: Description of the renal system block
Five medical schools in Saudi Arabia are known to be implementing PBL curricula. The College of Medicine, King Saud bin Abdul Aziz University for Health Sciences is one such medical school where the traditional discipline-based boundaries dividing the teaching and learning of basic medical sciences, such as physiology and anatomy, do not exist. For the past seven years, student-centered, self-directed PBL has been the main form of instruction for students learning in all system-based blocks. Our PBL curriculum pedagogy emphasizes the process of learning via constructive, collaborative inquiry and integration rather than acquisition of factual knowledge. Interactive and integrative lectures and other small group learning modalities are also applied, which support learning in PBL.
The 8-week block covers the renal and reproductive systems. In the first part of the block, renal medicine is studied and emphasis is placed on the basic anatomy, physiology and homeostatic role of this system while integrating commonly encountered pathological and clinical conditions. The second part of the block addresses the reproductive system from basic sciences and practical perspectives that include exposure to important clinical problems and their pathophysiological mechanisms.
Block teaching and learning activities consists of seven PBL problem presentations, of which three are specifically related to the renal system. An introduction to the block is provided on the first day followed by PBL session 1. Throughout the block lectures, clinical diagnostic skills, communication skills, patient-doctor generic skills, basic and clinical sciences sessions, personal and professional development, evidence-based medicine and community doctor themes are also provided to support learning in the block. The PBL, integrated, community-oriented curriculum was developed in collaboration with the University of Sydney, Australia, and therefore PBL cases/problems were initially developed in this socio-cultural context.
Students work in three 90-minute small group PBL tutorials per week. They work in groups of eight to ten students with a student chairperson and a scribe. They are supervised by a PBL tutor who facilitates the process. These PBL tutorials are supported by resource sessions including lectures, theme sessions, practical classes, web-based learning packages and clinical sessions in the main teaching hospital. Formative and summative assessments are integrated in relation to each block. An online curriculum facilitates PBL by providing an interface for the delivery of the curriculum.
Learning is facilitated by trained tutors who need not be renal medicine experts by background. All students are expected to participate in PBL tutorial sessions and tutors are expected to evaluate the extent to which they demonstrate study and preparation between sessions and actively contribute during group discussions. Problems are carefully designed to provide students with clinical relevance and diagnostic significance of what they learn.
To illustrate the importance of renal medicine in a health care problem, a trigger problem is given as a typical example (see [Table 1]).
At the end of the block, students and tutors are expected to evaluate the block using an in-house designed instrument, which includes ratings of the problems on a five-point Likert-type scale for relevance, stimulation and amount learned. Rating of the PBL sessions is also solicited in terms of group rapport/cooperation, depth of analysis/critical thinking, balance of participation, division of work, function of the chairmen and function of scribes. Perspectives regarding block duration, appropriate length of problems and work time estimate on the PBL problems before and after sessions were also provided by students.
All 1 st year medical students in the 2006/7 academic year at the College of Medicine, King Abdul Aziz University for Health Sciences were invited to complete an end of block evaluation form. All cohorts were exposed to the same renal block teaching modalities, materials and evaluation tools, had limited prior knowledge of renal medicine and had been used to a traditional, didactic approach to teaching and learning medicine. Tutor evaluations of the block and the problems were also analyzed. Because of the small size of the groups, only three PBL tutors' ratings of problems were available.
Students attended a variety of teaching and learning activities in the renal, reproductive and sexual health block. These included the same PBL tutorial format, sequence of learning sessions, tutorial structure, materials, slides and evaluation tools used. Significant student participation was expected and encouraged. PBL sessions were based on real cases that demonstrated core learning objectives in each case. At the end of the block, a reproduced self-administered questionnaire was utilized to gain student feedback on instructional effectiveness, stimulation, relevance and amount learned from the cases. Students and tutors anonymously rated items on a five-point Likert-type scale, where 1 = poor and 5 = excellent. Space was also provided for open-ended comments to the questions "what did you like most about this Block?" and "what would you like changed in this Block?"
| Data Analysis|| |
Students' and PBL tutors' feedback data were entered into an Excel spreadsheet. Mean responses were calculated for all evaluation questions. Open-ended comments were analyzed qualitatively to explore the content of commentaries, compare and contrast students' and tutors' perceived strengths and weaknesses of the block and PBL cases in terms of relevance, stimulation and amount learned.
| Results|| |
A total of 17 questionnaires were returned (50% response) by students and three by tutors (75%). [Table 2] shows the students' and tutors' ratings of the problem on a five-point Likert-type scale, where 1 = poor and 5 = excellent. Students' and tutors' ratings of perception of the learned amount, stimulation of the problem and relevance of the problem for the Saudi Arabian healthcare context were very similar. Critical thinking and depth of analysis of the problems were rated as "very good" (4.0) by the tutors. Three to five students offered open-ended comments, which were supportive of the block organization and content. Things they liked most about the block included renal lectures, content and learning objectives, interesting topics, self-study opportunities and organization of the nephrology teaching. Tutors comments were also very supportive. Typical comments are presented in [Table 3], from which slight differences in length and fluency of comments are discernible.
|Table 3: Students' and tutors' comments on things liked best and things they would like to see changed in the renal block.|
Click here to view
| Discussion|| |
Since our PBL curriculum was developed in collaboration with the University of Sydney, Australia, it has been particularly important to determine the relevance of cases for the Saudi health care context. Students' and tutors' ratings on this dimension of case evaluation indicated that they perceived the three cases as very relevant. This implies that the three cases exposed students to professionally meaningful problems that have a strong similarity to problems they will encounter in their future professional careers. In PBL, our students were confronted with the integration of basic science and clinical knowledge in the context of a common clinical renal problem. Some studies have indicated that this integration results in better student diagnostic performance. , The depth of analysis and critical thinking engendered by the problems as determined by the tutors' ratings was also supportive and suggested that students were intrinsically interested in the subject matter and motivated to spend time on exploring the issues both within and outside the PBL process. It is well known that motivation plays an important role in sustaining self-directed learning. 
Our results also suggest that the three cases were good drivers of learning and would require no or very little future modification. Change of patient names, reflecting typical Saudi names, is already in progress. Student comments included "huge amount to be learned and lots of self-directed learning" as well as the suggestion to "separate renal and reproductive into two Blocks," suggesting that students felt some time pressure and needed to develop some control over their learning. The tutors' role in helping students to manage time and their learning is important in this regard. 
Students' comments on provision of learning objectives in the block were also encouraging. College of Medicine lecturers were encouraged to state clear educational objectives at the beginning of each session, and PBL cases were designed to lead students to formulation of group learning objectives that were similar to those intended by case developers. Indeed, we have discerned that learning objectives formulated by students not only covered but often went beyond those intended by case developers.
The challenge in any PBL curriculum is ensuring that the pathway students take through the problems lead to their meeting the intended learning objectives, and that all student groups achieve the objectives of the cases.  Various authors have analyzed learning issues identified by students in PBL groups and compared them with core learning objectives intended by the faculty, , and found that at least 60% of essential learning objectives was identified by all groups. A similar process of learning objectives evaluation is recommended at the College of Medicine. Furthermore, some authors have warned of biases in PBL problems toward more acute problems in younger age groups, urban healthcare and dominant culture issues,  arguing that dominant culture stereotypes can work at cross-purposes to the desired objectives from which they were drawn.
It is concluded that integration of various disciplines in a renal system block using the PBL approach is illustrative of authenticity in this field. Exploring the congruence of students' and tutors' perspectives has been helpful when determining necessity for renal medicine block modifications, emulating a PBL collaborative knowledge-building approach in curriculum development.
| References|| |
|1.||Rayner HC. A model undergraduate core curriculum in adult renal medicine. Med Teacher 1995; 17(4):409-11. |
|2.||Steinert Y. Student perceptions of effective small group teaching. Med Educ 2004;38:286-93. |
|3.||Hmelo-Silver CE. Problem-based learning: what and how students learn. Educ Psychol Rev 2004;16(3):235-66. |
|4.||Dolmans DH, Snell-Balendong H, Wolfhagen IHAP, van der Vleuten CP. Seven principles of effective case design for a problem-based curriculum. Med Teacher 1997;19(3):185-9. |
|5.||Dolmans DH, De Grave W, Wolfhagen IH, Van der Vleuten CP. Problem-based learning: Future challenges for educational practice and research. Med Educ 2005;39:732-41. |
|6.||Schmidt HG, Dolmans D, Gijselaers WJ, Des Marchais JE. Theory- guided design of a rating scale for course evaluation in problem-based curricula. Teaching Learning Med 1995;7:82-91. |
|7.||Schmidt HG. Problem-based learning: rationale and description. Med Educ 1983;17:11-6. |
|8.||Schmidt HG, Machiels-Bongaerts M, Hermans H, ten Cate TJ, Venekamp R, Boshuizen HP. The development of diagnostic competence: A comparison between a problem-based, an integrated, and a conventional medical curriculum. Acad Med 1996;71(6):658-64. |
|9.||Pintrich PA. The role of motivation in promoting and sustaining self-regulated learning. Internat. J Educ Res 1999;31:459-70. |
|10.||Dolmans DH, Ginns P. A short questionnaire to evaluate the effectiveness of tutors in PBL: validity and reliability. Med Teacher 2005;27 (6):534-8. |
|11.||Albanese A. Problem-based learning. Association for the Study of Medical Education Series on Understanding Medical Education, 2007; ASME, Edinburgh. |
|12.||Dolmans DH, Gijselaers WH, Schmidt HG. Do students learn what their teachers in-tend they learn? Guiding processes in problem-based learning. Paper presented at the Annual Meeting of the American Educational Research Association, San Francisco, California, April, 1992. |
|13.||Coulson RL, Osborne CE. Insuring curricular content in a student-directed problem-based learning program. In: Schmidt HG, de Volder ML (eds). Tutorials in Problem-based learning, 1984;225-9. Maastricht. |
|14.||Hays R. Problems with problems in problem-based curricula. Med Educ 2002;36:790. |
Margaret A Elzubeir
College of Medicine (Mail Code 3118), King Abdul Aziz University for Health Sciences, P. O. Box 22490, Riyadh 11426
[Table 1], [Table 2], [Table 3]