Student-directed Learning: A Change from Faculty Objectives to Student Generated Learning Goals

In the recent past, almost all of the modules in our curriculum were written with defined objectives set by the faculty. Unfortunately, this approach is felt to have has somewhat undermined the ability of the students to generate their own learning objectives and at worst limited their students interest in exploring the problem and defining their own learning needs. Defined objectives were therefore seen as “the curriculum” and perceived as the faculty’s expectation for student assessments. Consequently, students simply tried to answer and cover the breath of the objectives but not the depth in knowledge content, effecting therefore a subtle but gradual shift from “critical reasoning” to simply covering grounds with uncertain depth of knowledge.

Currently, there is a growing call for encouraging the students to identify their own learning goals while the faculty simply identifies key learning goals during tutorials or provide a brief overview. This approach is claimed to enhance critical reasoning while fostering self directed learning SDL among students.

The following module therefore is aimed towards this goal. Course objectives are not provided and the progress of students will depend on the students working as a group, defining their own learning objectives. Expectedly, a brief clinical trigger will be given, while further clinical information is only provided when the “need to know” is recognized by the students. Emphasis of the discussion is on the mechanism , principles and connecting links between known and new knowledge.

FOR TUTOR’S COPY

The columns of “reasoning and discussion” and “learning goals and learning issues” sample items are given to s serve as guide. Students’ copy however will simply contain empty boxes . They must identify their own learning goals which has to be listed in the columns provided for. At the end of the session, the learning goals listed by the students will have to be submitted to the Evaluations Committee to serve as guidelines in the preparation of the students summative evaluations. Likewise, the students must agree to assign these learning goals among themselves and to share this in the next session.

INTRODUCTION

Traditionally, students in medicine have been taught in a structured approach. They are to gather complete clinical information and solve clinical problems in separate but sequential blocks. First, they are to get a complete history, then do a complete physical examination, then order routine laboratory tests. When these tasks are completed, they are asked to gather important clues from these three sources, then put them together to fit into a clinical diagnostic pattern.

This method is tedious and time consuming, although infrequently necessary for complicated or multi-systemic disorders. But this is not how it is done in real life practice by experienced clinician. Studies have shown that seasoned clinicians first form hypotheses immediately right from the given chief complaint of the patient, tracks a clue, forms a cluster, spots triad or tetrad of symptoms, considers a differential diagnosis, pursues only one subset of data, validate their hypothesis and subsequently focus on a very likely diagnosis. This approach is thought to lead into a focused physical examination while only appropriate laboratory test are requested.

Students, even early in their medical training, can be taught this approach. This type of learning is compatible to the principles of adult psychology where learning is undertaken in the way it will be applied in real life situation.

This case that follows this philosophy. It is presented to demonstrate the prime problem solving methods used by seasoned clinician. Including their Including their pattern of data collection and data analysis five separate decision point will be pursued.

1. Is the bleeding a local problem or generalized?
2. If diffuse, is the defect congenital or acquired?
3. If acquired, is the condition caused by a defect in the capillaries, platelets or coagulation factors?
4. If there is deficiency of platelets, is it due to production problem or excessive destruction?
5. If caused by excessive destruction, what are the various causes? e.g. TTP, DIC or AITP

MODULE FRAMEWORK AND STUDENT EVALUATION

The entire module on MUCOSAL and GUM BLEEDING, like the other modules in our institution, is organized around the three strands that makes up the total framework of the Problem Based Learning-Competency Based-Community Oriented Curriculum. These three strands are:

PROBLEM SOLVING SKILL STRAND
PROFESSIONAL SKILL STRAND
COMMUNITY SKILL STRAND

The module enclosed here will be for the Problem Solving Skill Stand, using a PBL strategy where the knowledge base on coagulation will be taken and the learning objectives generated by the students. The Professional skills strand on the on the other hand, includes a visit to the hospital where a bedside teaching covering the PE and History taking on a patient with gum bleeding will be undertaken. Students are to submit a case discussion of the patient assigned them following our standard format. Patients with other forms of bleeding disorders may be taken depending available patients in the ward. Included likewise is a session in the laboratory, viewing hematologic slides, CBC determination ( microscopic analysis of the peripheral blood smears), including Hemoglobin Reticulocyte counting, Mean Corpuscular Volume, and Hematocrit determination, identification of WBC differentials and PT and PTT determination. A section in the discussion of this module will cover for the Community Skill Strand where issues on population will be discussed. Behavioral Issues are likewise taken e.g. Religious beliefs on blood transfusion. The incidence of gingivitis as a cause for recurrent bleeding and poor dental hygiene among Filipinos will be emphasized. This can be taken in a debate session or simply an issue for discussion. The tutor will decide which course to take ( debate or disucssion)

Enclosed at the end of this module is a short assessment MCQ which should serve as a formative evaluation for students. It, unfortunately simply assess the Problem Based skill Strand of the students. However, the Case discussion to be submitted will serve partly for the student assessment on the Professional skill strand particularly in taking the history and doing the physical examination. These papers should be returned to the student with proper comments by the tutors and for the students to submit the final report with suggestions incorporated. The rest of the professional skills of the students will be assessed during the regular scheduled OSCE .

TIME LENGTH OF MODULE -This module can be taken in two or three days sessions. This will include the group discussion, hospital exposure, laboratory exposure and the debate to cover population perspective.

SUGGESTED SCHEDULE

Day 1 – Problem Based Learning Strand

Session 1 – Setting of agreed schedule for the module
Present the Clinical case
Initial group discussion

Session 2 – Sharing of new information regarding learning goals after SDL ( self directed learning)
Continue group discussion

Day 2 – Professional Skill Strand

Hospital Exposure -bed side
Laboratory Exposure

Day 3 – Community Skill Strand

Debate Issue or discussion issue 
Religious belief in conflict with medical management involving blood transfusion products
Closure of private blood banking
Filipino views on Blood donation
Issues on Direct Blood transfusion for infants and neonates
Is it practical or risky?

CLINICAL PRESENTATION

23 year old woman comes to you for medical consultation complaining of bruises over her body and bleeding gums for the preceding two days.

Trigger Questions for Tutors

After an initial discussion, the students may wish to request for more information. It can be provided accordingly by the tutor. Usually it is best to go through the usual stages like
Eliciting further history before proceeding to the P.E. findings and
subsequently the paraclinical studies results.

As the students ask for information : try to probe them further with the following question. It will surprise you what is in their mind.

Why do you wish to know that?
How will this information help us in the analysis of this case?
What is in your mind. Why to do want to know that?
Do you agree with his/her explanation?

If the students are unable to go further discussing over an issue, do not provide the answer. Have the issue listed in the board as a learning gap that must be pursued later. After listing, simply move on to discuss there other issues. 

HISTORICAL INFORMATION

Note, not all information the students may ask will be available here. The tutor is given the liberty to ad-lib information to suite the situation. What is listed here are simply the relevant information that will help build the case.

At this point, challenge the students to make hypotheses even based on the limited information they have. These hypotheses will eventually guide them to ask for more specific and directed questions of focused PE information or laboratory studies.

Preferably, an algorithm can be drawn in the board on the mechanism of blood clotting with a listed possible causes of bleeding resulting from a faulty clotting mechanism. This algorithm should be “student directed”. This student led algorithm can serve as the knowledge scaffolding by which subsequent medical information can be stored and organized for better retention, and recall.

Although the tutors are given a framework and additional “tutor notes”, this is meant mainly for the tutors to have a handle on the case… especially for those tutors who may not be hematologist. 

PHYSICAL EXAMINATION DATA

LABORATORY TESTS

FOR TUTOR’S GUIDE

FOR STUDENTS