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Meta-Analysis

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10
1025

Problem based learning - Friend or Foe?

What is Problem Based Learning? During my time at medical school, I enjoyed (at times) a curriculum delivered through the traditional model. As the name suggests, this is an approach experienced by the majority of doctors to date. The traditional model was first implemented by the American Medical College Association and American Academy of Medicine in 1894 (Barr, 2010) and has been used by the majority of medical schools. It traditionally consists of didactic lectures in the initial years covering the basic sciences followed by clinical years, where students learn clinical medicine while attending hospital placements. Is It Better? A few years after my graduation I found myself teaching at a university which had fully adopted the use of problem based learning (PBL) in the delivery of their curriculum. PBL is a philosophy of teaching that has increasingly been used in medical education over the past 40 years. It has rapidly been replaced or supplemented in medical education as opposed to the traditional model. PBL seeks to promote a more integrated and active approach to learning right from the first year with less reliance on didactic lectures. Having been involved in these two different approaches to medical education, I was interested to explore what the evidence was for and against each. For the purposes of this blog, I have looked at four specific areas. These include student attitudes, academic achievement, the academic process of learning and clinical functioning and skills. Student Attitudes Student attitudes to PBL have been highly featured in studies and many show that there is a clear favourability towards this philosophy of teaching. Blumberg and Eckenfel (1988) found that students in a problem based preclinical curriculum rated this three times higher than those in the a traditional group in terms of what they expect to experience, what they would like, and what they actually experienced. Heale et al (1988) found physicians in the problem-solving sessions rated a Continuing Medical Education short course higher compared to others who attended traditional lectures and large-group sessions. Vernon and Black (1993) performed a Meta analysis on 12 studies that looked at attitudes and towards PBL and found PBL was favored in some way by all studies. PBL appears to be preferred by the majority of students at a range of academic levels. However, Trappler (2006) found that converting a conventional curriculum to a problem based learning model for part of a psychopathology course did not show complete favourability. Students preferred the conventional lectures given by experts, rather than PBL groups run by mentors and not experts. They did however show preference towards PBL small group sessions run by experts Academic Achievement Academic achievement is an important factor to assess. Vernon and Blake (1993) compared a number of studies and found that those, which could be compared, showed a significant trend favouring traditional teaching methods. However, it was felt this might not be reliable. When looking at the heterogeneity of the studies there was significant variation that could not be accounted for by chance alone. Interestingly, they found that there was significant geographical variation across the United States such that New Mexico showed consistently negative effects and Michigan State showed consistently positive. Other studies have shown that the traditional method may show a slightly better outcome when assessing academic achievement. Schmidt et al (1987) looked at the same progress test taken among students in six different Universities in the Netherlands and found that those taught by a traditional approach showed slightly better outcomes. Baca et al (1990) compared performances of medical students in two separate tracks, one PBL the other a traditional model. Baca et al found that PBL students scored slightly lower in the National Board of Medical Examiners (NBME) examinations. Dochy et al (2003) conducted a meta analysis comparing 43 studies and found that when considering the effect of PBL on the knowledge of students the combined effect size is slightly negative. The academic process of learning It is important in medical education to enable people to continue life long learning, to overcome problems and fill in knowledge gaps. Coles (1990) and Entwistle (1983) found that PBL students would place more emphasis on understanding and meaning compared to just rote learning, seen more in those taught by a traditional approach. Students on a PBL course also place more focus on using resources such as the library and online sources rather than those taught in a traditional approach (Rankin, 1992). Students taught by a traditional model place more emphasis on the resources supplied by the faculty itself. It has also been shown that students who learn through a process of problem solving, are more likely to use this spontaneously to solve new problems in the future compared with those taught in a traditional way (Bransford et al, 1989). Clinical functioning and skills Clinical competence is an important aspect in medical education and has been measured in studies comparing PBL and traditional methods. The traditional model focuses acquisition of clinical competence in the final years of a program with hospital placements. In a PBL course it may be more integrated early on. There are however, only a few studies that look at clinical competence gained in undergraduate PBL courses. Vernon and Blake (1993) compared some of these studies and found that students obtained better clinical functioning in a PBL setting compared to a traditional approach. This was statistically significant, however there was still significant heterogeneity amongst studies and for conclusive results to be made 110 studies would have to be compared, rather that the 16 samples they were able to use. They also found that in contrast to the NBME I giving better results in the traditional model, PBL students score slightly higher in NBME II and federation licensing examination which related more on clinical functioning than basic sciences. On reflection, this evidence has indicated to me that PBL is a very valuable approach and it has a number of benefits. The traditional model in which I was taught has provided a good level of academic education. However, it may not have supported me as well as a PBL course in other areas of medical education such as academic process, clinical functioning and satisfaction. On reflection and current recommendations are for a hybridisation of the PBL and traditional approach to be used (Albanese, 2010) and I would support this view in light of the evidence. References Baca, E., Mennin, S. P., Kaufman, A., and Moore-West, M. A Comparison between a Problem-Based, Community Orientated track and Traditional track Within One Medical school. In Innovation in Medical Education; An Evaluation of Its Present Status. New York: Springer publishing Barr D. (2010) Revolution or evolution? Putting the Flexner Report in context. Medical Education; 45: 17–22 Blumberg P, Eckenfels E. (1988) A comparison of student satisfaction with their preclinical environment in a traditional and a problem based curriculum. Research in Medical Education: Proceedings of the Twenty-Seventh Annual Conference, pp. 60- 65 Bransford, J. D., Franks, J. J., Vye, N. J., & Sherwood, R. D. (1989). New Approaches to Instruction: Because Wisdom Can't Be Told. In S. Vosiadou & A. Ortony (Eds.), Similarity and Analogical Reasoning (pp. 470 297). New York: Cambridge University Press. Coles CR. (1990) Evaluating the effects curricula have on student learning: toward a more competent theory for medical education. In: Innovation in medical education: an evaluation of its present status. New York: Springer publishing; 1990;76-93. Dochy F., Segersb M., Van den Bosscheb P., Gijbelsb D., (2003) Effects of problem-based learning: a meta-analysis. Learning and Instruction. 13:5, 533-568 Entwistle NJ, Ramsden P. Understanding student learning. London: Croom Helm; 1983 Heale J, Davis D, Norman G, Woodward C, Neufeld V, Dodd P. (1988) A randomized controlled trial assessing the impact of problem-based versus didactic teaching methods in CME. Research in Medical Education.;27:72-7. Trappler B., (2006) Integrated problem-based learning in the neuroscience curriculum - the SUNY Downstate experience. BMC Medical Education 6: 47. Rankin JA. Problem-based medical education: effect on library use. Bull Med Libr Assoc 1992;80:36-43. Schmidt, H G; Dauphinee, W D; Patel, V L (1987) Comparing the effects of problem-based and conventional curricula in an international sample Journal of Medical Education. 62(4): 305-15 Vernon D. T., Blake R. L., (1993) Does Problem-based learning work? A meta-analysis of evaluated research. Academic Medicine.  
Dr Alastair Buick
almost 8 years ago
Podcast 5
8
46

Capnography for Diagnosis of Pulmonary Embolism; a Useful Tool or a Load of Hot Air?

What benefit does a recent meta-analysis show for the use of ETCO2 in the diagnosis of PE? A review of the results and a refresher on the use of likelihood ratios in clinical practice.  
heftemcast.co.uk
over 6 years ago
Preview
2
36

Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis

Objective To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma.  
bmj.com
over 6 years ago
Www.bmj
2
50

Methotrexate use and risk of lung disease in psoriasis, psoriatic arthritis, and inflammatory bowel disease: systematic literature review and meta-analysis of randomised controlled trials

Objective To evaluate the relative risk of pulmonary disease among patients with psoriasis, psoriatic arthritis, and inflammatory bowel disease treated with methotrexate.  
bmj.com
over 5 years ago
8
1
32

Meta-analysis of Glucose Control

Tight glucose control has been widely introduced into critical care This meta-analysis, recently published in JAMA, critically evaluate the effects of these trials in reduction of sepsis as well a mortality. The results might surprise you.  
Jeffrey S. Guy, MD, FACS
about 10 years ago
7
1
40

Hemoglobin Based Blood Substitutes: Increased Morbidity and Mortality

In this week's <em>Journal of the American Medical Association</em> a meta-analysis was published that concluded that use of hemoglobin based blood substitutes result in an increased morbidity and mortality.&nbsp; Included in the same journal is an editorial critical of the method the research has been regulated by the US FDA.&nbsp;&nbsp;  
Jeffrey S. Guy, MD, FACS
about 10 years ago
Www.bmj
1
29

Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis

Objective To provide an accurate assessment of complications of pregnancy in women with chronic hypertension, including comparison with population pregnancy data (US) to inform pre-pregnancy and antenatal management strategies.  
bmj.com
over 6 years ago
Www.bmj
1
29

Incretin treatment and risk of pancreatitis in patients with type 2 diabetes mellitus: systematic review and meta-analysis of randomised and non-randomised studies

Objective To investigate the risk of pancreatitis associated with the use of incretin-based treatments in patients with type 2 diabetes mellitus.  
bmj.com
over 6 years ago
Preview
1
17

Statins may have fewer side effects than is claimed, meta-analysis finds

Only a few types of side effect reported from use of statins are genuinely due to the drug itself, as almost all side effects were reported just as often with a placebo, a systematic review of randomised controlled trials has concluded.1  
bmj.com
over 6 years ago
Www.bmj
1
29

Incretin treatment and risk of pancreatitis in patients with type 2 diabetes mellitus: systematic review and meta-analysis of randomised and non-randomised studies

Objective To investigate the risk of pancreatitis associated with the use of incretin-based treatments in patients with type 2 diabetes mellitus.  
www.bmj.com
over 6 years ago
Www.bmj
1
17

Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies

Objectives To review, summarise, and compare the evidence for effectiveness of screening sigmoidoscopy and screening colonoscopy in the prevention of colorectal cancer occurrence and deaths.  
bmj.com
over 6 years ago
Www.bmj
1
15

Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies

Objectives To review, summarise, and compare the evidence for effectiveness of screening sigmoidoscopy and screening colonoscopy in the prevention of colorectal cancer occurrence and deaths.  
bmj.com
over 6 years ago
Www.bmj
1
14

Smoking bans are linked to reduction in preterm births and childhood asthma, says study

Rates of preterm births and paediatric hospital admissions for asthma fell by 10% within a year of smoke-free legislation taking effect, says a systematic review and meta-analysis on the issue.1  
bmj.com
over 6 years ago
Www.bmj
1
18

Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies

Objectives To review, summarise, and compare the evidence for effectiveness of screening sigmoidoscopy and screening colonoscopy in the prevention of colorectal cancer occurrence and deaths.  
bmj.com
over 6 years ago
Www.bmj
1
28

Discrepancies in autologous bone marrow stem cell trials and enhancement of ejection fraction (DAMASCENE): weighted regression and meta-analysis

Objective To investigate whether discrepancies in trials of use of bone marrow stem cells in patients with heart disease account for the variation in reported effect size in improvement of left ventricular function.  
www.bmj.com
over 6 years ago
Www.bmj
1
25

Maintenance treatment for adults with chronic asthma

Which treatment for asthma is most likely to reduce the risk of exacerbations in adults? In a linked paper, Loymans and colleagues (doi:10.1136/bmj.g3009) seek to address this question using network meta-analysis.1 The authors identified and compared 16 different treatment approaches, using evidence from randomised trials of at least 24 weeks’ duration. The primary outcome was severe exacerbations (leading to admission to hospital, a visit to the emergency department, or a course of oral steroids).  
bmj.com
over 6 years ago
Preview
1
21

Helicobacter pylori eradication therapy to prevent gastric cancer in healthy asymptomatic infected individuals: systematic review and meta-analysis of randomised controlled trials

Objectives To determine whether searching for Helicobacter pylori and treating with eradication therapy leads to a reduction in incidence of gastric cancer among healthy asymptomatic infected individuals.  
bmj.com
over 6 years ago
Www.bmj
1
20

Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

Data sources PubMed, ISI Web of Science (Science Citation Index Expanded), Embase, Pascal, Cochrane Library, LILACS, and MedCarib, along with published surveys reporting prevalence of sunbed use at national level in Europe.  
bmj.com
almost 6 years ago
Preview
1
16

Blood pressure targets for type 2 diabetes should be lower, say researchers

Recent changes to guidelines on lowering blood pressure in patients with type 2 diabetes should be reconsidered to reinstate the lower target level, researchers have said in JAMA after carrying out a meta-analysis of randomised controlled trials.1  
bmj.com
over 5 years ago
Static.www.bmj
1
18

The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta-analysis in the acute care setting

Objectives To determine and compare the diagnostic accuracy of serum natriuretic peptide levels (B type natriuretic peptide, N terminal probrain natriuretic peptide (NTproBNP), and mid-regional proatrial natriuretic peptide (MRproANP)) in people presenting with acute heart failure to acute care settings using thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure.  
bmj.com
over 5 years ago