Evidence-based medicine and problem based learning a critical re-evaluation.

Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s. The EBM educational prescription is revealed to be aligned with the information processing psychology (IPP) model of learning through acquisition of general problem solving skills that characterized the early McMaster version of PBL. The IPP model has been identified in the literature as discordant with an alternative, constructivist, model that emerged at Maastricht University in the Netherlands over the subsequent period. Strengths and weaknesses of EBM are identified from the standpoint of the underlying cognitive theories. Principles are proposed with which to guide an educationally viable approach to learning and teaching the valuable skills included within the original EBM formula.

McMaster at 50: lessons learned from five decades of PBL.

Although educators frequently act as if curricula are as standardized as drug doses (300 mg of PBL t.i.d.), such is not the case. As a case in point, at its inception, Problem Based Learning was hailed as a major curriculum innovation, with the promise of enormous gains in learning outcomes. Very quickly, ecclesiastical debates arose as what was true PBL and what was "modified PBL". Ironically, systematic reviews conducted fairly early in its evolution showed that the gains in learning outcome from PBL were neither large nor uniform (Vernon and Blake in Acad Med 68:550-563, 1993), and the most consistent finding was greater student satisfaction. In this paper, we review five decades of experience with the first PBL curriculum at McMaster. We point out how the curriculum has evolved, both theoretically and practically, in response to external influences, based both on empirical evidence and practical demands. We describe these changes in four broad domains-theoretical rationale, the curriculum, assessment and admissions.

Problem solving skills versus knowledge acquisition: the historical dispute that split problem-based learning into two camps.

This paper sheds light on an intellectual dispute on the purpose of problem-based learning that took place in the 1970s between two major figures in the history of PBL: Howard S Barrows from McMaster University and Henk Schmidt from Maastricht University. Using historical evidence from archive materials, oral history accounts and contemporary publications, the paper shows that at the core of the dispute was their divergent understanding of cognitive psychology. On the one hand, Barrows espoused hypothetico-deduction, and on the other, Henk Schmidt was a proponent of constructivism. The paper shows how the dispute played out both in the scientific literature and in the divergent practice of PBL at McMaster and Maastricht and continues to affect the way PBL is done today.

Enseñando a Pensar a los Estudiantes de Medicina: El Pensamiento Narrativo, Mecanístico y Matemático / Teaching Medical Students How To Think: Narrative, Mechanistic and Mathematical Thinking

Los ordenadores están empezando a ser mejores que los médicos para algunas actividades médicas. Para poder sobrevivir estos avances los médicos del siglo XXI necesitan aprender a ser mejores pensadores. La habilidad cognitiva más propiamente única de los humanos es la habilidad para entender otras mentes humanas creando historias sobre uno mismo y sobre los otros (el pensamiento narrativo). El pensamiento narrativo es el núcleo central del arte de la medicina y dominó la medicina hasta el siglo XIX en el que empezaron a tener peso dos tipos de pensamiento científico: el pensamiento mecanístico y el pensamiento matemático. El pensamiento mecanístico se basa en mecanismos (conceptos abstractos que no se pueden demostrar en experimentos, pero se necesitan para formular hipótesis e interpretar las observaciones de los experimentos). En los siglos XIX y XX, los médicos agruparon los síntomas y los signos en síndromes con la esperanza de separar los síndromes en enfermedades gracias a los mecanismos etiopatogénicos y/o los mecanismos fisiopatológicos. El siglo XXI ha traído los mecanismos basados en la genética molecular. El pensamiento médico matemático se desarrolló en el siglo XX gracias a las herramientas desarrolladas por los estadísticos. El desarrollo de la minería de datos y el aprendizaje de máquinas está empezando a amenazar a los estadísticos. El aprendizaje tradicional en medicina en los que los estudiantes aprenden de unos tutores que son clínicos experimentados, pero no son capaces de desarrollar un pensamiento auto-reflexivo, quizá ya no sea suficiente. Los tres tipos de pensamiento (el narrativo, el mecanístico y el matemático) deben ser asimilados por el médico del siglo XXI e incorporados en un modelo biopsicosocial en el que el paciente es el centro. Las computadoras nunca podrán sustituir a expertos médicos auto-reflexivos que son conscientes de: 1) las limitaciones de los seres humanos y 2) una realidad caracterizada por la sobrecarga de la información

Computers are becoming better than physicians in some activities. To survive, 21st century physicians need to become better thinkers. The most unique human cognitive skill is the ability to understand other human minds by creating stories about oneself and others (narrative thinking). Narrative thinking is at the core of the art of medicine, and dominated medicine until the 19th century when two types of scientific thinking (mechanistic and mathematical thinking) started to become influential. Mechanistic thinking uses mechanisms (abstract concepts which cannot be demonstrated in experiments but are needed for making hypotheses and interpreting observations from the experiments). In the 19th and 20th centuries, physicians grouped symptoms and signs into syndromes with the hope of separating each syndrome into various diseases based on etiopathological and/or physiopathological mechanisms. The 21st century brought mechanisms based on molecular genetics. Mathematical medical thinking expanded in the 20th century with the tools developed by statisticians. Now data mining and/or machine learning is threatening statisticians. The traditional teaching of medical students based on the example of a clinician mentor who does not engage in reflective thought may no longer be enough. The three types of medical thinking, narrative, mechanistic and mathematical, need to be incorporated by the 21st century physician, whose thought process should also consider the biopsycho social model of disease and its center, which is the patient. Computers will never substitute for a self-reflective medical expert who is aware of the strengths and limitations of human beings and of an environment characterized by information overload

A historical account of the governance of midwifery education in Australia and the evolution of the Continuity of Care Experience.

BACKGROUND: Midwifery programs leading to registration as a midwife in Australia have undergone significant change over the last 20 years. During this time accreditation and governance around midwifery education has been reviewed and refined, moving from state to national jurisdiction. A major change has been the mandated inclusion of Continuity of Care Experiences as a clinical practice-based learning component. AIM: The purpose of this discussion is to present the history of the governance and accreditation of Australian midwifery programs. With a particular focus on the evolution of the Continuity of Care Experience as a now mandated clinical practice based experience. METHODS: Historical and contemporary documents, research and grey literature, are drawn together to provide a historical account of midwifery programs in Australia. This will form the background to the inclusion of the Continuity of Care Experience and discuss research requirements to enhance the model to ensure it is educationally sound. DISCUSSION: The structure and processes for the Continuity of Care Experience vary between universities and there is currently no standard format across Australia. As such, how it is interpreted and conducted varies amongst students, childbearing women, academics and midwives. The Continuity of Care Experience has always been strongly advocated for; however there is scant evidence available in terms of its educational theory underpinnings. CONCLUSION: Research concerned with the intended learning objectives and outcomes for the Continuity of Care Experience will support the learning model and ensure it continues into the future as an educationally sound learning experience for midwifery students.

Teaching clinical reasoning: case-based and coached.

Optimal medical care is critically dependent on clinicians' skills to make the right diagnosis and to recommend the most appropriate therapy, and acquiring such reasoning skills is a key requirement at every level of medical education. Teaching clinical reasoning is grounded in several fundamental principles of educational theory. Adult learning theory posits that learning is best accomplished by repeated, deliberate exposure to real cases, that case examples should be selected for their reflection of multiple aspects of clinical reasoning, and that the participation of a coach augments the value of an educational experience. The theory proposes that memory of clinical medicine and clinical reasoning strategies is enhanced when errors in information, judgment, and reasoning are immediately pointed out and discussed. Rather than using cases artificially constructed from memory, real cases are greatly preferred because they often reflect the false leads, the polymorphisms of actual clinical material, and the misleading test results encountered in everyday practice. These concepts foster the teaching and learning of the diagnostic process, the complex trade-offs between the benefits and risks of diagnostic tests and treatments, and cognitive errors in clinical reasoning. The teaching of clinical reasoning need not and should not be delayed until students gain a full understanding of anatomy and pathophysiology. Concepts such as hypothesis generation, pattern recognition, context formulation, diagnostic test interpretation, differential diagnosis, and diagnostic verification provide both the language and the methods of clinical problem solving. Expertise is attainable even though the precise mechanisms of achieving it are not known.

Considerações sobre aprendizagem baseada em problemas na educação em saúde / Considerations about problem-based learning in the process of health education

A aprendizagem baseada em problemas (Problem-Based Learning – PBL) tem sido reconhecida mundialmente como uma abordagem capaz de promover a aquisição de conhecimentos pelos alunos ao mesmo tempo em que os ajuda a desenvolver habilidades e atitudes profissionais desejáveis. Diferentemente dos métodos convencionais de ensino, que utilizam problemas de aplicação após a apresentação da teoria, o PBL utiliza um problema para iniciar, enfocar e motivar a aprendizagem de novos conceitos. Nessa abordagem, o aluno utiliza diferentes processos mentais, como capacidade de levantar hipóteses, comparar, analisar, interpretar e avaliar, desenvolvendo a habilidade de assumir responsabilidade por sua formação. A metodologia PBL tem se mostrado um instrumento valioso na formação do profissional de saúde, com vantagens sobre o método de ensino tradicional. No entanto, para a sua implantação, há necessidade de um considerável esforço institucional. São necessárias adaptações, tais como mudanças na forma de avaliação, mudanças na forma de ver o papel do docente no processo ensino/aprendizagem, investimentos em infraestrutura, adaptações do ambiente, melhoria das bibliotecas, entre outros. O processo de mudança da educação traz inúmeros desafios como, por exemplo, romper com modelos de ensino tradicional e formar profissionais de saúde com competências que lhes permitam recuperar a dimensão essencial do cuidado: a relação entre humanos.

Problem-Based Learning (PBL) has been recognized worldwide as an approach that promotes the acquisition of knowledge by students at the same time that it helps them develop desirable skills and professional attitudes. Unlike the conventional teaching methods, which use problem-solving after the theory has been presented, PBL uses a problem to start, focus and motivate the learning of new concepts. According to this approach, students use different mental processes, such as ability to suggest hypotheses, compare, analyze, interpret, and evaluate, to develop the ability to take responsibility for their education. PBL methodology has been a valuable tool in the education of health professionals, with advantages over the traditional teaching method. However, in order to implement such methodology, considerable institutional effort is necessary. Adjustments must be made, including changes in the methods of evaluation, changes in mind-set on the role of teachers in the teaching/learning process, investments in infrastructure, adaptations of the environment, improvement of libraries, among others. The process of change in education brings many challenges, such as breaking with traditional models of education and training health professionals so that they acquire skills to recover the essential dimension of care: the relationship between people.

Possibilidades para o ensino orientado na problematização: para a realização da concepçãode "aulas abertas às experiências" / Posibilidades de la educación dirigidas en la investigación: para la realización del concepto de "abrir las lecciones en las experiencias" / Possibilities for problem-based learning: for realization of the concept of \"classes open to experiences\"

A Concepção “Aberta” no Ensino da Educação Física escolar brasileira tem apontado para que se oriente as aulas na problematização (Grupo de Trabalho Pedagógico UFPe-UFSM, 1991). Esta pesquisa teve como objetivo apreender, em uma experiência de ensino na Educação Física Infantil, possibilidades pedagógicas para a realização desta orientação. Utilizou-se como metodologia a pesquisa exploratória-descritiva. Para a interpretação das aulas utilizou-se como método a hermenêutica, a arte de compreender. Do trabalho realizado, foram abertas três possibilidades para a realização do ensino orientado na problematização: o desafio, o questionamento e a tarefa.

The conception “Opened” in Teaching of the Physical Education pertaining to school Brazilian has pointed so that if it has guided the lessons in the inquiry (Pedagogical Work group UFPe-UFSM, 1991). This research had as objective to apprehend, in an experience of education in the Infantile Physical Education, pedagogical possibilities for the accomplishment of this orientation. The explorer descriptive research was used as methodology. For the interpretation of the lessons the hermeneutics, the art to understand was used as method. Of the carried through work, three possibilities for the accomplishment of the education guided in the inquiry had been opened: the challenge, the questioning and the task.

El concepto “abierto” en la enseñanza de la Educación Física referente a brasileno de la escuela ha señalado de modo que si ha dirigido las lecciones en la investigación (Grupo de Trabajo Pedagógico UFPe-UFSM, 1991). Esta investigación tenía como objetivo prende, en una experiencia de la educación en la Educación Física Infantil, posibilidades pedagógicas de la realización de esta orientación. La investigación explorador-descriptiva fue utilizada como metodología. Para la interpretación de las lecciones el hermeneutics, el arte a entender fue utilizado como método. Del llevado a través del trabajo, tres posibilidades de la realización de la educación dirigido en la investigación habían sido abiertas: el desafío, el preguntar y la tarea.

Back to the future? Active learning of medical physiology in the 1900s.

In the early 1900s, teachers of medical physiology faced a problem familiar to those teaching the subject in a contemporary setting: too much information, too little time, too many students in crowded rooms, and exams that discouraged real learning. They wanted students to question authority and demand evidence and thus be better prepared for medicine. Their solution was to bring students into laboratories and minimize didactic learning as they felt strongly that useful information could not be obtained merely from books. Thus, they were strong proponents of what we now call active learning.

Teaching and learning in the interactive classroom.

The Claude Bernard Distinguished Lectureship of the Teaching of Physiology Section is presented annually at the Experimental Biology meeting. The lectureship is named for Prof. Claude Bernard, the experimental physiologist who is credited with introducing the concept of homeostasis. The 2006 Claude Bernard Distinguished Lecture was given by Dr. Dee U. Silverthorn from the University of Texas at Austin, TX.

Problem-based learning: description, advantages, disadvantages, scenarios and facilitation.

Problem-based learning arose out of educational initiatives in the 1960s and is often one of the most contentious issues within medical education. McMaster University in Canada was the first to implement problem-based learning on a large scale within medicine and this was soon followed by universities in Europe and Australia. In modern times, few western medical schools do not include at least some aspect of problem-based learning within their instructional itinerary, and many build their entire curriculum and instructional procedures around problem-based learning. This article provides an overview of problem-based learning within medical education, pertinent background, describes the characteristics of problem-based learning, its advantages and disadvantages, problem-based learning scenarios and facilitation.

Éxito y difusión de la literatura de problemas en la Castilla del siglo XVI: la traducción castellana de Il Perché de Girolamo Manfredi (Zaragoza, 1567) / No disponible

Descripción y análisis del Libro llamado el Porqué (1567), versión castellana de Pedro de Ribas del exitoso Liber de homine o Il Perché (1474), a la vez régimen de salud y tratado de fisiognomía, escrito por el médico bolonés Girolamo Manfredi (ca 1430-1493). Se estudia la difusión de esta obra de Manfredi (las numerosas ediciones italianas realizadas en los siglos XV, XVI y XVII, la traducción catalana anónima impresa en 1499 y las cinco reimpresiones de la traducción castellana llevadas a cabo durante el siglo XVI) en el contexto de la proliferación del género de los problemata en la Castilla del siglo XVI

Description and analysis of the Libro llamado el Porqué (1567), the Castilian version by Pedro de Ribas of the successful Liber de homine or Il Perché (1474), a regimen of health and treatise of physiognomy, written by the Bolognese physician Girolamo Manfredi (ca. 1430-1493). The diffusion of Manfredi´s work (the numerous Italian editions made in the 15th, 16th and 17th centuries, the anonymous Catalan translation printed in 1499 and the five reprints of the Castilian translation carried out during the 16th century) is studied in the context of the proliferation of the problemata gender in 16th-century Castile