Result: Problem-based learning improves the academic performance of medical students in South Africa / L'apprentissage par résolution de problèmes améliore les performances académiques des étudiants en médecine en Afrique du Sud
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OBJECTIVES: To compare the academic performance of students on the previous, classical, discipline- and lecture-based, traditional curriculum with that of subsequent students who followed an innovative, problem- and community-based curriculum. METHODS: This was a retrospective study that analysed the records of students who enrolled on the doctor training programme between 1985 and 1995, and the records of students who graduated from the programme between 1989 and 2002. OUTCOMES: The educational outcomes assessed were the attrition and graduation rates on the traditional curriculum and those on the innovative curriculum. RESULTS: A total of 149 students on the traditional curriculum and 145 students on the innovative curriculum were studied. Overall, 23% of the traditional cohort as opposed to 10.3% of the innovative cohort dropped out of the course (P = 0.0041) and 55% of the traditional cohort as opposed to 67% of the innovative cohort graduated within the minimum period of 6 years (P < 0.001). The mean throughput period was 6.71 (0.09) years in the traditional cohort and 6.44 (0.07) years in the innovative cohort (P= 0.014) CONCLUSION: The introduction of the problem-based learning/community-based education (PBL/CBE) curriculum coincided with improved academic performance. The PBL/CBE approach to medical education may have contributed to this improvement.
AN0016510285;esf01apr.05;2019Jun04.08:18;v2.2.500
Problem-based learning improves the academic performance of medical students in South Africa.
Objectives To compare the academic performance of students on the previous, classical, discipline‐ and lecture‐based, traditional curriculum with that of subsequent students who followed an innovative, problem‐ and community‐based curriculum. Methods This was a retrospective study that analysed the records of students who enrolled on the doctor training programme between 1985 and 1995, and the records of students who graduated from the programme between 1989 and 2002. Outcomes The educational outcomes assessed were the attrition and graduation rates on the traditional curriculum and those on the innovative curriculum. Results A total of 149 students on the traditional curriculum and 145 students on the innovative curriculum were studied. Overall, 23% of the traditional cohort as opposed to 10.3% of the innovative cohort dropped out of the course (P = 0.0041) and 55% of the traditional cohort as opposed to 67% of the innovative cohort graduated within the minimum period of 6 years (P < 0.001). The mean throughput period was 6.71 (0.09) years in the traditional cohort and 6.44 (0.07) years in the innovative cohort (P = 0.014) Conclusion The introduction of the problem‐based learning/community‐based education (PBL/CBE) curriculum coincided with improved academic performance. The PBL/CBE approach to medical education may have contributed to this improvement.
Keywords: medical; undergraduate/*methods; problem‐based learning/*methods; educational measurement; curriculum; retrospective study; students; education
The Faculty of Medicine at the University of Transkei (UNITRA) was established in 1985 to address the shortage of doctors in the rural and underprivileged areas of the then homeland of Transkei. The main objective of the new institution was to produce doctors with the requisite knowledge, clinical skills and professional attitudes that would enable them to offer quality health care to these communities. At its inception, the new institution adopted the traditional, classical curriculum for training doctors. This move generated a lively debate among doctors, policy makers and medical educators, both within and outside the institution, about whether the tertiary, hospital‐based, technology‐driven, western‐style traditional curriculum adopted would result in doctors who were effective communicators, loyal team members, prudent managers of scarce resources and providers of comprehensive primary care. These attributes were deemed to be basic essentials for doctors working in the rural and impoverished environment of the Transkei. The consensus then was that in order for UNITRA to realise its ambition, it had to adopt an innovative programme of community‐based education (CBE), and that the pedagogical approach to be used would be one of problem‐based learning (PBL) in small tutorial groups.[[1]] This innovative curriculum was adopted with effect from 1992.
Another problem to confront the UNITRA doctor‐training programme was the scarcity of black applicants with the prerequisite higher grade matriculation passes (equivalent to the A‐level [advanced level] General Certificate of School Education [GCSE]) in mathematics and physical science. Most secondary schools within the black population have limited capacities for teaching mathematics and science and offer these subjects at standard grade (equivalent to the O‐level [ordinary level] GCSE). The few black students who obtained higher grades in the subjects chose to enrol in the old, established institutions rather than in the relatively new institution of the former homeland. To address the racial inequality in health care delivery personnel, it was imperative that the intake of black students should increase. It was then decided that students who obtained good passes in mathematics and physical science at standard grade would be considered for admission to the doctor‐training programme. This policy was implemented in 1992, at the same time as the innovative PBL/CBE curriculum was implemented.
From 1989 to 1998, the UNITRA medical school graduated doctors trained in the traditional curriculum. Since 1997 UNITRA has graduated students trained in the innovative PBL/CBE curriculum. There was no overlap between the old and new curricula for any students. Students who were enrolled into the old curriculum continued to be trained in that curriculum until they graduated, even after the new curriculum had been introduced. For some time, therefore, UNITRA ran 2 parallel medical curricula.
The trainees in both programmes came from basically similar social and educational backgrounds. The faculty involved in training and evaluation in both programmes has been virtually the same. The changes observed in the academic educational outcomes in the 2 programmes most probably reflect the attributes of the different curricula. This has offered UNITRA a unique opportunity to document the effects of the PBL/CBE curriculum on doctor education in the South African context. Negative literature on the effectiveness of PBL curricula makes such studies essential.[[3]] We have previously reported on the positive impact that the PBL/CBE curriculum has had on the learning styles and strategies of this same cohort of students.[6] The purpose of this study was to investigate the impact of the PBL/CBE curriculum on the acquisition of knowledge and clinical skills by students from relatively disadvantaged educational backgrounds in a doctor‐training programme.
Methods and Materials
Study groups
This was a retrospective study that analysed the records of students who enrolled on the doctor‐training programme between 1985 and 1995, and the records of students who graduated from the programme between 1989 and 2000. The students were divided into 2 groups.
Traditional curriculum group
This group comprised the students who enrolled between 1985 and 1991 and graduated between 1989 and 1998. They were trained in the traditional, classical, western‐style, hospital‐based curriculum. Students who enrolled on this curriculum continued to be trained in this curriculum even after the implementation of the PBL/CBE curriculum.
PBL/CBE curriculum group
This group comprised the students who enrolled between 1992 and 1995, and graduated between 1997 and 2002. All students who were admitted to the medical programme followed the PBL/CBE curriculum. There was no self‐selection into the PBL/CBE curriculum.
Educational outcomes
Educational outcomes were defined as follows:
• 1
• 2
Statistical analysis
Comparison of the attrition and throughput rates between the traditional and PBL/CBE programmes was made using the chi‐squared test.
Results
Study groups
Table 1 summarises the characteristics of the traditional and PBL/CBE curriculum groups. The PBL/CBE group had a significantly higher proportion of female students and a lower percentage of graduate students. The teacher : student ratio was lower in the PBL/CBE curriculum than in the traditional curriculum, but the actual contact time between staff members and students was higher in the PBL/CBE group (maximum 13 hours/week/staff member) than in the traditional curriculum group (maximum 7 hours/week/staff member). There were no students with standard grade entry on the traditional curriculum. In all other aspects the 2 groups were similar.
1 Summary of student profiles on the traditional and PBL/CBE curricula
Attrition rates
Table 2 summarises the attrition patterns in the 2 curricula. Dropout rates were significantly higher in the traditional curriculum than in the PBL/CBE curriculum.
2 Summary of attrition rates of medical students on the traditional and PBL/CBE curricula
In the traditional curriculum, 34 of 149 (23%) entrants did not complete the course. Ten students were discontinued on academic grounds, 2 students died before completing the course and 12 students dropped out after being asked to repeat a year of the course. The dropout rate among non‐black students was significantly lower than that among black students. There was no significant gender difference in dropout rates. Graduate students had a dropout rate similar to that of the rest of the students.
In the PBL/CBE curriculum, 15 of 145 (10.3%) entrants did not complete the course. Two students dropped out after being asked to repeat a year of the course, 3 requested a transfer to other institutions, 1 was dismissed on disciplinary grounds and 9 students (60% of the dropouts) absconded for no apparent reason. The dropout rate of black students was similar to that of non‐black students. The graduate students had a significantly lower dropout rate than that of the rest of the students. The dropout rate of lower grade entrants was significantly lower than that of higher grade entrants.
Throughput rates
Table 3 summarises the throughput patterns in both curricula. The throughput rates were much better in the PBL/CBE curriculum than in the traditional curriculum. A higher percentage of the students completed the programme within the prescribed 6‐year period in the PBL/CBE curriculum than in the traditional curriculum. The average number of years that it took to complete the programme was significantly shorter in the PBL/CBE curriculum than in the traditional curriculum.
3 Summary of throughput rates of medical students on the traditional and PBL/CBE curricula
1 * ,
2 †
In both curricula, there was no gender difference in throughput rates. Non‐black students had better throughput rates than black students in both curricula. Graduate students had the best throughput rates in both curricula. Lower grade entrants had the lowest throughput rate in the PBL/CBE curriculum. Their rate was significantly lower than that of higher grade students.
Discussion
There are very limited published data on student attrition and throughput rates in South African medical schools.[[7]] The high attrition rate observed in black students in the UNITRA traditional curriculum is probably similar to that pertaining at the historically white medical schools.[[7]] The adoption of the PBL/CBE curriculum coincided with a reduction in student attrition and an improvement in throughput rates. This has been more marked among black students than among non‐black students.
There are, admittedly, many factors that contribute to students dropping out of academic programmes, some of which are academic while others are not (e.g. inability to pay tuition fees or poor motivation as some students discover that medicine may not be their ideal career choice), and it may be simplistic to attribute the improvement in the UNITRA figures to the introduction of the new curriculum. It could be argued, for example, that the new curriculum was introduced at the same time that new political dispensation was being introduced in South Africa. Black students, who are in a majority at UNITRA, may have been caught up in the euphoria that engulfed the black population at that time and this euphoria manifested itself in increased motivation to study and be successful and hence in lower attrition rates and higher throughput rates. However, the attrition rates of black medical students in the traditional universities, in contrast to the UNITRA experience, remained static at about 22% even during the post‐apartheid period.
We believe that the improvement in student wastage can partly be attributed to the nature of the UNITRA curriculum. It places special emphasis on the process of learning. How students learn has become as important as what they learn. The level of preparedness for university education among black students is very low. They often have problems coping with the demands of university education. Teaching them the process of learning becomes as essential as the content to be learnt. This is in contrast to American and European students, where the level of preparedness is so high that the method of teaching has only a marginal effect on acquisition of knowledge and skills. This may in part explain why the PBL/CBE curriculum has had a significant impact on the academic performance of the UNITRA students, contrary to experiences in America and Europe.
There are aspects of the curriculum that deserve mention. One is the close interaction between faculty and students that occurs in the small group tutorial setting. Although the staff : student ratio was higher in the traditional group, there was closer interaction between students and staff in the PBL/CBE curriculum, as indicated by the actual contact times. It allows for closer monitoring of the learning process and for quicker feedback to the student, hence facilitating academic development. The other involves the placing of academically weak students with stronger students in the same tutorial group. We have noted significant improvement in the performance of weak students over time. We attribute this to the co‐operative learning strategies encouraged in the tutorial groups. The students are encouraged to help each other, share information and counsel each other. Lastly, the PBL/CBE curriculum has a very strong mentoring programme that is predominantly student‐based. Senior students mentor their junior colleagues (big brother/sister concept) and guide them, both socially and academically, through the rigorous demands of the curriculum. Students appreciate the guidance offered by their own colleagues, especially during first 3 years of the course. We believe that this may have contributed to the observed decrease in the dropout rate.
As previously reported,[6] we noted significant changes in the learning styles and strategies of this particular cohort of PBL/CBE students as they progressed through the course. The short version of the Lancaster Inventory of Learning Styles[9] was administered to the students on admission and thereafter on a yearly basis throughout the duration of the medical course. At the time of admission, the students showed no dominant learning style. Both the comprehensive learning style (the holist approach) and the operational learning style (the serialist approach) showed moderate scores. As the years progressed, the students showed increased usage of the operational learning style. This increased usage of the operational learning style was in addition to, rather than at the expense of, the comprehension learning style. In other words, the students became more versatile learners. Versatile learners can vary their strategy from holist to serialist and vice versa according to the characteristics of the task, and should, therefore, be able to withstand diversity and inconsistency. Further evidence of this trend was provided by the decline in the scores for globetrotting (overemphasis on comprehension learning) and the scores for improvidence (overemphasis on operation learning) as the course progressed. It was also noted that levels of anxiety and fear of failure subsided over the years, and the students became more confident and syllabus‐bound as the years progressed. We believe that this may be partly responsible for the decrease in attrition rates and the improvement in throughput rates.
Conclusion
Our study has several limitations that need to be considered. It was limited to a single medical school in South Africa and the sample size was relatively small. The demographics of the 2 groups had key differences in gender composition and entry qualifications that might, in various ways, have impacted on the outcomes. Despite these limitations, there are some important conclusions that can be drawn from our study. The adoption of the PBL/CBE curriculum in UNITRA has had a positive impact on 2 important global outcome measures in medical education − the dropout and throughput rates − especially for black students from poor educational backgrounds and with low levels of preparedness for university education.
<bold>Contributors: </bold> JEI acted as principal author, mined the database, analysed the data and wrote the manuscript. EK was responsible for maintaining the student records database.
<bold>Acknowledgements: </bold> none.
<bold>Funding: </bold> none.
<bold>Conflicts of interest: </bold> none.
<bold>Ethical approval: </bold> ethical approval was obtained from the Ethical Committee of the University of Transkei.
Overview
What is already known on this subject
Problem‐based learning methodology has not been shown to offer any special advantages in knowledge and skills acquisition in American and European studies.
What this study adds
This study shows that PBL methodology has a positive impact on students from disadvantaged educational backgrounds, reducing attrition rates and improving throughput rates.
Suggestions for further research
More research should be carried out to ascertain the possible role of PBL in remedial education of medical students with low levels of preparedness for university education.
References
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By Jehu E Iputo and Enoch Kwizera
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