Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the threedecade lag between initiation of the movement and widespread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians. Acad. Med. 2002;77:361‐367.

Shifting Paradigms: From Flexner to Competencies

Background Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory.

Purpose  This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill − the ‘clinical reasoning' process; (b) research based on probes of memory − reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations − semantic qualifiers, scripts, schemas and exemplars.

Results and Conclusions  Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy.

Implications  It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.

/pdf/research-in-clinical-reasoning-past-history-and-current-n8pgre7mvk.pdf

Research in clinical reasoning: past history and current trends.

In a recent review article, Colliver concluded that there was no convincing evidence that problem-based learning was more effective than conventional methods. He then went on to lay part of the blame on cognitive psychology, claiming that 'the theory is weak, its theoretical concepts are imprecise. the basic research is contrived and ad hoc'. This paper challenges these claims and presents evidence that (a) cognitive research is not contrived and irrelevant, (b) curriculum level interventions are doomed to fail and (c) education needs more theory-based research.

/pdf/effectiveness-of-problem-based-learning-curricula-theory-2il22s1k5t.pdf

Effectiveness of problem-based learning curricula: theory, practice and paper darts.

Medical Education 2011: 45: 792–806

Objectives  In this review, we portray the process of problem-based learning (PBL) as a cognitive endeavour whereby the learner constructs mental models relevant to problems. Two hypotheses are proposed to explain how learning is driven in PBL; an activation–elaboration hypothesis and a situational interest hypothesis.

Methods  Research relevant to these hypotheses is discussed. In addition, research studying the effects of various support strategies used in PBL is reviewed. Finally, we summarise a number of recent studies in which a new ‘micro-analytical’ methodology was used to trace the process of PBL in the natural classroom setting.

Conclusions  We conclude that there is considerable support for the idea that PBL works because it encourages the activation of prior knowledge in the small-group setting and provides opportunities for elaboration on that knowledge. These activities facilitate the comprehension of new information related to the problem and enhance its long-term memorability. In addition, there is evidence that problems arouse situational interest that drives learning. Flexible scaffolding provided by cognitively and socially congruent tutors also seems to be reasonably effective, as opposed to ‘hard’ scaffolding represented by, for instance, worksheets or questions added to problems. Small-group work protects against dropout and encourages students to study regularly. Initially, students do not study much beyond the learning issues generated; the development of personal agency in self-study needs time to develop. The extent of learning in PBL results from neither group collaboration only (the social constructivist point of view) nor individual knowledge acquisition only; both activities contribute equally to learning in PBL.

The process of problem‐based learning: What works and why.

Purpose Cognitive psychology research supports the notion that experts use mental frameworks or ‘schemes’, both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem-solving strategies and the likelihood of diagnostic success.

Methods Think-aloud protocols were collected to determine the diagnostic reasoning used by experts and non-experts when attempting to diagnose clinical presentations in gastroenterology.

Results Using logistic regression analysis, the study found that there is a relationship between diagnostic reasoning strategy and the likelihood of diagnostic success. Compared to hypothetico-deductive reasoning, the odds of diagnostic success were significantly greater when subjects used the diagnostic strategies of pattern recognition and scheme-inductive reasoning. Two other factors emerged as independent determinants of diagnostic success: expertise and clinical presentation. Not surprisingly, experts outperformed novices, while the content area of the clinical cases in each of the four clinical presentations demonstrated varying degrees of difficulty and thus diagnostic success.

Conclusions These findings have significant implications for medical educators. It supports the introduction of ‘schemes’ as a means of enhancing memory organization and improving diagnostic success.

Diagnostic reasoning strategies and diagnostic success.

Currently, medical curricula are structured according to disciplines, body systems, or clinical problems. Beginning in 1988, the faculty of the University of Calgary Faculty of Medicine (U of C) carefully evaluated the advantages and disadvantages of each of these models in seeking to revise their school's curriculum. However, all three models fell short of a curricular structure based on current knowledge and principles of adult learning, clinical problem solving, community demands, and curriculum management. By 1991, the U of C had formulated a strategic plan for a revised curriculum structure based on the way patients present to physicians, and implementation of this plan has begun. In creating the new curriculum, 120 clinical presentations (e.g., "loss of consciousness/syncope") were defined and each was assigned to an individual or small group of faculty for development based on faculty expertise and interest. Terminal objectives (i.e., "what to do") were defined for each presentation to describe the appropriate clinical behaviors of a graduating physician. Experts developed schemes that outlined how they differentiated one cause (i.e., disease category) from another. The underlying enabling objectives (i.e., knowledge, skills, and attitudes) for reaching the terminal objectives for each clinical presentation were assigned as departmental responsibilities. A new administrative structure evolved in which there is a partnership between a centralized multidisciplinary curriculum committee and the departments. This new competency-based, clinical presentation curriculum is expected to significantly enhance students' development of clinical problem-solving skills and affirms the premise that prudent, continuous updating is essential for improving the quality of medical education.

Developing a "clinical presentation" curriculum at the University of Calgary.

At the University of Calgary Faculty of Medicine in 1991, the authors sought to determine the effects of tutors' levels of content expertise on learning issues generated within problem-based learning (PBL) tutorials For an integrative course taken prior to clinical clerkships, the 70 students in the class of 1992 divided into ten small groups, which were facilitated alternately by content experts and non-experts The authors found that--across 35 simulated-patient case encounters (24 with non-experts and 11 with experts)--when the groups had tutors with expertise in the clinical cases studied, the groups generated approximately twice as many learning issues per case, and these issues were approximately three times more congruent with the case objectives In addition, when the groups had expert tutors they spent approximately twice as much time per case in overcoming identified learning deficiencies The authors conclude that it is important for tutors (1) to be well informed about cases and case objectives and (2) to be well versed in the PBL tutoring process

Effects of Tutors with Case Expertise on Problem-Based Learning Issues.

Teaching medicolegal issues using a standardized patient and mock trial.

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Developing a "clinical presentation" curriculum at the University of Calgary.

Effects of Tutors with Case Expertise on Problem-Based Learning Issues.

Teaching medicolegal issues using a standardized patient and mock trial.