The Medical Curriculum: Need for Change

“...the NUS Faculty of Medicine needs to respond decisively and appropriately to the rapid changes in medicine and medical education, to ensure that its graduates are well equipped to meet the challenges of medical practice in the years ahead.”

(Dean’s Message, Curriculum Bulletin, No. 1, March 1999)

Many leading medical schools in the world have extensively revised their respective course curriculum to prepare ‘Today’s Medical Students’ to become ‘Tomorrow’s Doctors’. Our Faculty of Medicine has recognised that there are clearly “a number of potential shortcomings” with the existing traditional undergraduate curriculum. First, students lack a clear perspective of the context and the clinical significance of their learning in the early years of medical school, due primarily to a lack of integration in the teaching of the basic science disciplines, as well as between the basic sciences and the clinical disciplines. Moreover, the traditional lecture, the main instructional mode used, provides a mainly passive learning environment that promotes the memorisation and regurgitation of facts in examinations.

The need to revise the medical curriculum was therefore inevitable. In the academic year 1999/2000, the new undergraduate medical curriculum will be implemented for Year I students. The “direction and substance of the curriculum reform—was guided by the vision of the type of graduate which it aspired to train”, as stipulated in the overall educational objectives of the medical course. In essence, our Faculty has adopted “an integrated systems-based approach supplemented by problem-based learning methodologies” so as to “encourage active learning processes while ensuring that the medical graduates retain a strong basic science foundation which would underpin their clinical practice” (Dean’s Message, op. cit.).

Problem-based Learning (PBL) and Its Expected Educational Outcomes

“Problem-based learning (PBL) is grounded in the belief that learning is most effective when students are actively involved and learn in the context in which knowledge is to be used.”

(The Challenge of Problem-based Learning, 2nd edition, edited by D. Boud and
G. Feletti, London/Stirling (USA): Kogan Page Ltd, 1997)

Problem-based learning (PBL) is an innovative educational approach with the potential to enhance the educational process and its outcomes. The main instructional strategy used in PBL is the small group tutorial in which students are actively involved in and take greater responsibility for their own learning and the teacher/tutor facilitates the learning process that is therefore highly student-centred. In PBL, content learning occurs in the context in which knowledge acquired is applied to understanding or solving problems commonly encountered in medical practice.

Essentially, PBL is problem-first learning (i.e. before the acquisition of new knowledge). The problem presented in the first tutorial (Session I) serves as the stimulus and focus of learning. It then leads progressively to student-directed problem analysis, generation of ideas and hypotheses, identification of learning needs and issues (goals, objectives), assigning learning tasks to group members and search for information through independent self-directed study, including the use and evaluation of appropriate resources (including staff expertise) available. In the second tutorial (Session II), students share and integrate their newly acquired knowledge to re-analyse the problem, critique and refine their initial hypotheses and then attempt to resolve the problem. Students also perform self- and peer-evaluation (including the tutor) regarding individual and group progress in and contributions to the learning process and the learning achieved.

The expected educational outcomes of PBL include knowledge acquisition with sound comprehension, enhanced knowledge retention and recall, and motivation of student learning through the joy of learning in a PBL environment. Students also have better opportunities to develop critical thinking and reasoning, and problem solving skills with enhanced ability to apply, analyse, synthesise and evaluate information and knowledge. Through group work, students also learn and develop important process skills (including communication, interpersonal and social skills), peer instruction and interaction, and self- and peer-evaluation, independent self-study, teamwork, cooperation and the efficient and critical use of resources. More importantly, achieving the overall educational outcomes will foster the development of independent, self-directed and lifelong learning.

Implementing PBL in the Faculty of Medicine

In the academic year 1999-2000, 20% of the curriculum time for Year I will be allocated to PBL which, together with our revised conventional curriculum, will form a hybrid system similar to that implemented in the Harvard Medical School. Each small group will have 10-12 students with a total of 17 tutorial sessions running simultaneously during each study period. A pool of 50 tutors (comprising mainly Year I teachers with some clinical teachers) will serve as facilitators for the PBL sessions.

Getting Teachers and Students Ready for Change

As our medical curriculum is deeply entrenched in traditional methods of teaching, the need to change the mindsets of teachers from teacher-centred lecturer to student-centred tutor (facilitator) and those of students from highly teacher-dependent students to skilled independent learners is of utmost importance. Strong conviction to the cause, commitment, dedication and much enthusiasm are required to ensure the successful implementation of PBL. The Dean’s unstinting support and clear vision has played a pivotal role in this respect. Conducting training for staff and students in-house, instead of using external expertise, greatly reduced implementation costs.

Our faculty formed a PBL Committee in January 1999 with the following as members: Matthew Gwee (Chairman), P. Balasubramaniam, Rethy Chhem, Khoo Hoon Eng and Kuldip Singh. The Committee organised the first full day PBL Workshop on 27 February 1999 with the theme: Let’s Work Together. A pre-workshop meeting was held for pre-assigned tutors to view a videotape illustrating a PBL session in action. At this workshop mainly for Year I teachers, some members of the Committee spoke on Promoting Active Learning, The PBL Process, The Role of the Tutor and The Use of Resources for PBL. A practice session followed with some teachers taking on the role of tutors and others as learners working through a non-medical problem (‘How to design a poets’ corner in NUS?’) in a typical PBL small group tutorial session.

At the end of the practice session, group ‘scribes’ presented the learning issues/goals identified by the respective groups and also responded to the following questions: ‘Was peer instruction and interaction good? Was discussion focused? Did you need a ‘content expert’ to facilitate the discussion? Was there any ‘silent introvert’ in the group? Was the session enjoyable? Was the facilitator more dominant than group members? Can you apply the process to a student group?’ The overall consensus to all the questions posed was highly positive, clearly indicating that group functioning proceeded well during the learning period. A more formal feedback was carried out with encouraging responses from participants: 21 rated the workshop from ‘good’ to ‘very good’; 4 considered it ‘fun’ while 23 considered it ‘useful’ to ‘useful and enjoyable’.

A second half-day workshop for Year I teachers was held on 12 April 1999. A different group of teachers was selected as ‘tutors’. An important feature of this workshop was that thirty Year II students were invited to participate as three groups of ‘learners’ together with six groups of teachers. The problem (‘The Claw Hand’) selected dealt with a medical case written by Professor Balasubramaniam. A pre-workshop briefing was again arranged for the selected tutors. The feedback from teachers (28) was again very positive: the practice session was considered by the respondents as ‘useful’ (14), ‘useful and enjoyable’ (9), ‘great fun’ (1) and ‘blur’ (1); the overall evaluation for the workshop was ‘satisfactory’ (6) and ‘good’ (18). Student responses (19) to the same items were 5, 11, 1 and 2, respectively, and 4 and 8 for the overall evaluation. Students also responded to the following items:

* 1 student mentioned that he thinks better during the PBL session, but he’s not sure about learning.

Moving On Together

Several more PBL workshops for staff and students have been planned, so that learners and teachers can optimise their respective roles and reap the maximum educational benefits from the change in educational strategy. In mid-July, a staff workshop will be held to focus on ‘Session II’ of the PBL process, so that participants would have to complete their ‘homework’ (Session 1) before attending the workshop. Four medical problems, representing different modular teaching themes, will be used for this practice session.
Three practice workshops for students have also been scheduled in July before the official PBL classes begin. The main emphasis in these workshops is to explain to students the expectations of their active role and their responsibility to one another in PBL. A PBL Users’ Guide for students is under preparation and will be given to students before the workshops are held.

Selecting, Designing and Writing Medical Problems and Tutor Guides

Medical problems used for PBL must reflect the appropriate level of learning expected (as specified in the educational objectives), ensure integration of basic science knowledge relevant to the understanding of the problem and represent commonly encountered problems in medical practice. Different teams of ‘experts’, each with its own team leader, and consisting of clinical and non-clinical teachers, have been appointed for this task. The written problems will be reviewed by the Curriculum and PBL Committees, field-tested (at the staff workshops), and then used by students in the PBL sessions. Problem (case) writers must also prepare ‘Tutor Guides’ for use with the associated problems by tutors to guide students to achieve their learning goals.

Concluding Remarks

Our Faculty has accepted the challenge to enhance the educational environment for our students. Steadfast in purpose, we have started on a long and difficult journey aimed at reaching our goal in implementing PBL as an innovative educational pathway to promote independent and self-directed learning skills in our students. We teachers need to ensure that the quality of medical education we provide in the new millennium will guarantee that our students will graduate as doctors with sound knowledge, comprehension, and the ability to critically apply, analyse, synthesise and evaluate knowledge and information for the ultimate benefit of their patients.