Conducting Problem-Stimulated Learning In A Nepalese Medical SchoolCorrespondence Address :
Dr. P. Ravi Shankar,
KIST Medical College,
P.O. Box 14142 Kathmandu,Nepal.
Ph: 977-1-5201680 Fax: 977-1-5201496
The problem-based learning of Pharmacology and Therapeutics has been recommended as a key intervention towards promoting the more rational use of medicines (1). Problem stimulated learning (PSL) sessions in Pharmacology had been conducted at the Manipal College of Medical Sciences, Pokhara, Nepal (2). In this manuscript, the authors describe the initial experiences with problem-stimulated learning in Pharmacology in a new Nepalese medical school.
KIST Medical College
KIST Medical College is a new medical school in Lalitpur, Nepal, which is committed to excellence in holistic healthcare, education and research. The college admits 75 students to the MBBS course every year on the first of the Nepalese month of Magh (around mid-November). The department of Clinical Pharmacology and Therapeutics has the vision of creating doctors who can use essential medicines rationally and to inculcate in them the capacity to keep up to date with new developments in medicine and therapeutics. This department collaborates with the department of Medicine for achieving these objectives. PSL sessions were started right from the beginning and their aim is to develop in students, the capacity for self-directed learning, problem solving and working together in small groups.
In Nepal, Pharmacology is taught during the first two years of the undergraduate medical (MBBS) course in an integrated, organized, system based manner with other basic science subjects.
Comfortable Working Environment
Creating a comfortable â€˜workingâ€™ environment for the students was vital. Students were divided into two batches (each of around 37 students) for the Pharmacology PSL sessions. Each batch was further divided into five groups, each containing 7 or 8 students. The groups worked around an oval table (6 feet by 2 feet). Seating was provided in the form of plastic armless chairs which could be rotated and moved around freely. Chairs with arms were not used as these would occupy too much space and the arms could create a barrier between the group members. The sessions are usually held on Thursday and Friday afternoon for the two batches from 2 pm to 4 pm.
We decided to keep the groups constant for a year in order to facilitate group dynamics. Each group had been named after an eminent scientist or personality in Medicine/Pharmacology. The group names are Oslers (after Sir William Osler, the famous Canadian physician), Lasagnas (after Louis Lasagna, the American Clinical pharmacologist), Paracelsians (after Paracelsus), Abels (after John Abel, the father of American pharmacology) and Ehrlich (after Paul Ehrlich, the father of chemotherapy). The group name was prominently displayed on the work table along with the names of the group members. At the beginning of the year, each group had to prepare a biographical sketch of their â€˜group scientistâ€™. These write ups were prominently displayed in the lab. We believe that this helped to create a sense of identification and belonging among the group members. They also felt pride in their group being named after a prominent scientist.
Introduction of the student participants and the facilitators was done during the inaugural session after dividing them into pairs. Each member introduced his/her partner under certain predefined headings. The introduction statements along with a photograph of all students and facilitators were grouped together according to their interests and hobbies and were displayed as a collection titled â€˜Meet our gallery of expertsâ€™.
The arrangement of the laboratory (where the sessions were conducted) was also crucial. We concentrated on not having bare walls and on affixing posters, drug information sheets and other interesting and informative material. The National Prescribing Service of Australia, Health Action International and the World Health Organization (WHO) helped us with the necessary materials. The department also provided pharmaceutical (medicine) care services in the hospital and the various forms, counseling aids and promotional materials were also displayed in the laboratory.
Designing The Sessions
The team members spent considerable time thinking and discussing about what should be the key learning objectives and how these could be achieved. The member from the department of Medicine contributed a clinical perspective to the deliberations. Training sessions for facilitators were conducted by the first author who had experience of facilitating PSL sessions. Role-plays, case scenarios, problems, activities, discussions, plenary sessions, simulations and videos are used as learning modalities to make the sessions interesting and informative.
A â€˜Safeâ€™ Environment
The students had to be motivated to take greater ownership and responsibility for the learning process. An environment where they could take risks, make mistakes and not be criticized for these had to be created. We decided not to create an artificial â€˜divideâ€™ between the facilitators and the students and decided on the same seating arrangement (plastic chairs) for everyone. The group decided not to have a designated teaching area or â€˜facilitator spaceâ€™ towards which the students would look for answers/solutions. We had a white board at one end of the room which was also occasionally used as a projection screen and two flip boards distributed at different locations which could double up as whiteboards. There was also an alternate projection area (a blank white wall) for simulations and movies. There was a small central table with chairs for role-plays and a bench which could be used for scenarios requiring a supine patient. Two other small tables were distributed at different corners of the room for use by the facilitators.
The Group Process
Instructions on group work prepared by the facilitators were pasted on each table. Each group has to select a team leader, a recorder, a presenter and a time keeper and the roles were rotated during different sessions. For keeping the sessions on time, a big wall clock was prominently displayed in the laboratory. The students generally prepared and presented their group work using flip charts.
Topics And Lesson Plans
(Table/Fig 1) shows the topics covered during different first year Pharmacology practical sessions. The final lesson plans for each session were prepared around a week in advance. The learning objectives and the time line for various activities are finalized after discussions and deliberations. The activities, problems and the scenario were the result of intense intellectual efforts and were crucial in facilitating student learning.
The department had a good collection of videos and documentaries which are shown to the students. The laboratory also had a computer on which various computer-aided learning (CAL) packages were installed. Students could conduct simulated experiments on the computer, which could be hooked up to a projector for demonstrating the experiments to the entire batch. The departmental library had a collection of books and booklets related to rational prescribing. The â€˜Guide to good prescribingâ€™ and the â€˜WHO ethical criteria for medicinal drug promotionâ€™ were used as â€˜textbooksâ€™ during the sessions.
Assessment And Feedback
Formative assessment of the groups was done periodically by the facilitators using a checklist shown in (Table/Fig 2). The assessments were shared with the groups and the strengths and weaknesses discussed. The students also assessed the facilitators periodically. Session feedback was obtained periodically. The students wrote their group work on A4 sheets and after correction, put them in a ring binder. The binder contained basic information for the students about the rational use of medicines and helped them to collate and organize the material. The binder allowed greater flexibility and creativity as compared to a bound practical manual.
Each group by rotation provided a brief summary of the session activities at the end of the session. Student feedback was collected periodically and their suggestions were incorporated if feasible.
Preparing For Sessions
There were training sessions on small group dynamics for the facilitators before the students joined for the MBBS course. The facilitators would meet together at the end of each weekâ€™s session to analyze what went well and assess the areas which could be improved. Before the session, they also would check the preparations using a checklist. The facilitators would usually meet on Wednesdays to finalize the methodology for the next dayâ€™s session. Initially, the Thursday session would be carried out by the first author as chief facilitator, while the others acted as cofacilitators. On Fridays, one of the other authors would act as the chief facilitator and learn by doing under the guidance and support of the first author. These days, the other team members also act as facilitators. The student feedback obtained by using a written form and during informal discussions has been positive. We plan to further develop and strengthen these sessions in future.
The authors acknowledge the help of Ms. Anjali Tuladhar and Ms. Ashmita Parajuli in the general preparation for the practical sessions and of Mr. Ram B Kunwar, Department of Anatomy with the photography of the sessions. The continued support and encouragement of the management of KIST Medical College is gratefully acknowledged.
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