The Crazy, Intense, Kind of Beautiful World of Problem-Based Learning

 

You can’t talk for very long about Chatham’s Master of Physician Assistant Studies (MPAS) or Doctor of Physical Therapy (DPT) programs without someone mentioning problem-based learning (PBL). If you tell them you’re not familiar, they might say something like students are responsible for teaching themselves or they work on simulated patient cases, or, if you press, it’s definitely not for everyone, or it was the number one thing that attracted me to the program.

stethescope.png

I sat in on a number of sessions of a PBL course (called Essentials for the Physician Assistant II) for the MPAS program to learn what all the fuss was about, and let me say: This might be the best way anyone has taught anyone anything, ever.


PBL is the cornerstone of MPAS students’ first year. Here’s how it works:  

1. The incoming class is divided into groups of eight or nine students each.  
2. Groups (and their faculty instructor/facilitator) work together for five weeks. Class meets for 3.5 hours, three times each week. (Groups meet together outside of class, too.)
3. They try to “solve” (diagnose, and provide patient education and treatment recommendations) 5-8 simulated patient cases that are presented by a robust software program called DxR Clinician.
4. At the end, they take two exams that covers what they might be expected to have covered during those weeks, one of which requires that they work through a clinical reasoning problem similar to a PBL case.
5. Steps 1-4 repeat five more times. Students might work together in more than one group, but they encounter each instructor only once.

And look at that: starting over every five weeks, working with ever-changing groups of people, having to show up at different times? The very structure of PBL prepares students for their clinical rotations before they’ve cracked a single book.  


Wednesday, 8:30am.

Eight students and Associate Professor of Physician Assistant Studies and PBL Coordinator Susan Hawkins (see sidebar) are seated around a hexagonal table, dotted with water bottles, that leaves little room for anything else. Lists bloom on butcher paper hung on the walls. Students wear hoodies, leggings, running shoes. No laptops are allowed in the classroom.

The class is eager to start a new case, and today, roles are assigned by picking slips of paper from a hat:

THE PATIENT is Maddie Bell.

She serves as the interface between the class and the DxR Clinician program, typing questions and reading out the answers.

THE TYPING SCRIBE is Brooke Scheider.

She takes notes on what the group learns on the Google Doc projected on a screen at the front of the room. 

THE WRITING SCRIBE is Loren Tetzlaff.

He darts around the room, writing the lists that allow the class to keep track of, well, everything – information, ideas, “learning issues” (gaps in their knowledge to research later), problems the patient is having, tests and procedures they want to do.

 

The role of physician assistant is shared among the other members of the group—Arsh Kaur, Margaret Kasper, Mia Ryckman, Chelsea DiVella, and Sarah Huber. Everyone can ask the patient questions. 

Hawkins pulls the new case up on her laptop, which is projected at the front of the room. There’s a photo of an elderly man, and a description, which Arsh reads aloud:

“Patrick Benedetti is a 70-year-old white male. He was brought in by his neighbor, who found him unconscious on the floor of his hallway, where he had been incontinent and appeared to have been lying for some time. By the time he arrived at the Emergency Department, Mr. Benedetti was awake, and able to answer questions coherently.”

“What would you like to do next,” asks Arsh. The options appear on the screen, but having gone through this process many times, she recites rather than reads them.  “Ask questions, physical exam, order lab tests?”

But what they do next, every time, is brainstorm everything that it could possibly be. Loren writes all suggestions on a piece of paper, titled IDEAS, on the wall—everything from dehydration to elder abuse, seizure to medication imbalance. Then the group decides to ask the patient some questions, including: “Mr. Benedetti, do you have any long-standing illnesses or chronic conditions?”  

Maddie reads the answer. It’s a lot of disconnected information, including “all the usual childhood illnesses” and and “arthritis in right knee following a fall”. Brooke types information into a patient chart Google Doc – projected onto a screen at the front of the room. The benefit of having the “patient” read the answer aloud, instead of displaying it on screen, is that it trains the student to pay close attention to what a patient says.

“Part of being a PA is documenting things, so it’s definitely great practice to take what the patient says and write it down in medical terms on a document,” says Maddie. “You also get the benefit of having everyone in the class look at what you’re writing, so they can help you phrase things better, or find things you’ve missed,” adds Mia Ryckman.

The group decides to ask for the patient’s vitals—weight, blood pressure, and temperature. Maddie types and reads out the numbers. “What are the words we can take away from these vitals?” asks Arsh. Someone says “severely underweight.” Temperature seems to be low. Someone wonders if temperatures tend to be low in geriatric populations. Up the question goes on the Learning Issues list. 

While students talk over the implications of what they’re learning about Mr. Benedetti, here’s what else is happening: Loren is not only adding to the list of potential diagnoses, but also “up-” or “down-arrowing” some of the entries, indicating increased or decreased likelihood based on new information.


 “PBL starts off as unsettling, honestly”, says Arsh, “because it’s very different from what undergraduates are used to. We’re all used to being the smart ones in the room, but now the room is filled with people like that, and we’re asked all these questions that bring us to the bottom of our knowledge base, rather quickly.” Everyone laughs. “And there are times when we’re just silent, because no one has an answer. And it’s important to not be discouraged by moments like that, because they will happen, a lot.”

 

The extent to which students “teach themselves” is a bit of a sticky point. Understandably, prospective students may not want to pay graduate school prices to teach themselves, so admissions materials tend to talk about “active learning”. But students have their own perspective. “What surprised me was really how on our own we are,” says Maggie. “Our facilitator won’t say whether we’re right or wrong—we’re teaching ourselves, we truly are.”

But it would be a grave mistake to imagine that facilitators sit back and relax. From the week I spent in class, Hawkins’ contributions seemed to be of two primary types:

1. Encouraging/supportive. “She does an excellent job of asking us a ton of questions, and she’ll let us know that she trusts us to figure something out before we put it up as a learning issue,” says Arsh. “She’ll say I think you guys can talk about this and figure it out.” Both her confidence in the PBL process, and the sheer joy she takes in her students, are palpable. And the esteem is mutual. “Susan is the Queen of PBL,” says Loren. “She travels the country teaching other people how to do it. She implemented it into Chatham’s PA program when it started 22 or 23 years ago.”

2. Something I’m trying not to call pearls of wisdom. This is hard-earned, practical advice that it’s easy to imagine differentiates the early-career practitioners who heard it from those who did not. For example, she says, There might be times when you know things that your preceptor doesn’t, so you’ll want to be careful in how you phrase things, and Sometimes people get too dead-set on a diagnosis. When a treatment doesn’t work, they’ll try another treatment, rather than ask what else it could be and What’s next? Think! You’re in the emergency department; you won’t be able to think for 30 or 60 seconds between things.”


 

To not know what will be on a test is literally the stuff of nightmares, yet here it’s par for the course, as it were. “We never know how much we need to know,” says Chelsea DiVella. “So we study until we can’t study anymore.” Luckily, students only need to get a 65% on the test, a number that initially struck some as preposterous.

“When I first heard that, I thought I’ve never gotten a 65 before in my life,” says Loren. Then I got my first 75 and almost cried from joy.” Everyone laughs.  

What makes the exam system works is what’s known as remediation. For every answer that students miss, they write 1-2 pages about why the right answer is right, and why their answer is wrong. “They take about an hour to write each,” says Loren, “and when you’ve got 30 of them that you have to write, on top of all your other work, and you just have a couple days to do it—”

“— you really know that information, because you’ve suffered for it!” Mia finishes.

 

“It prepares us for how we’re going to teach ourselves for the rest of forever,” says Chelsea. “And we’ll remember things forever,” adds Mia, “because we’ll be like oh, a PBL patient had that! We’ll be remembering narratives, not just facts.”


It’s a new day, and the room is evaluating Arsh on how she explained a rash diagnosis to a 14-year-old boy, portrayed by Maddie (at any time, students are working on multiple patient cases at once, and have to decide together how to allocate the time). “You said that he had a genetic predisposition, and then you explained what that meant. I think you could have just explained what it means,” says Brooke.

“I liked how you asked him questions that you knew that he knew the answer to, like ‘your mom had this too, right?’ That kind of checking in pulls him into the conversation, said Loren.


A big part of this program is evaluation and feedback—from peers, the facilitator, the self. There are two rules: When giving feedback, never commiserate (“The biggest no-go is ‘I would have probably done that too’, says Arsh. “It doesn’t matter. The point is, they shouldn’t have.”). And when receiving feedback, never justify your action. “This is supposed to really help on rotations,” says Mia. “Unlike someone from a different program who may have never been given feedback so bluntly before, we’re just like, okay, thank you, and then we fix it.”  

During each unit, the class spends two sessions evaluating every aspect of each other’s performances, including participation, teamwork, knowledge integration, communication, clinical reasoning, and the quality of the evaluations they themselves give. On top of that, feedback is given in almost-real time, with the upshot that you’re not just learning clinical reasoning, you’re getting a very full picture of how you are likely to function (and can continue to improve) in a clinical setting.


This consistent role-playing communication (with students playing clinical supervisors as well as patients) means that students enter rotations with not only experience under their belts, but experience that has been vetted by each other and by the faculty facilitator. When Hawkins tells you “You got a little folksy there, and we really don’t get folksy in the ER,” you remember it.

 The class is discussing a patient with a suspected condition that has incontinence as a symptom. “How would you ask about incontinence?” asks Hawkins. Someone suggests do you have trouble controlling your urine? Someone else suggests do you ever wet yourself?

“Well, what would be the most common type of incontinence for this patient?” asks Hawkins.

“Stress induced,” says Arsh. “So when you cough or laugh.”

Finally, a question is formulated, agreed upon, and Loren types it into the laptop: Do you ever pee a little when you cough or laugh? The answer comes back. “No,” he reads, after all that, to the laughter of his classmates and faculty facilitator.

pbl-boxes-right.png

Watching the class, I am reminded of “reflective practice”—the ability to reflect on your own actions to engage in a process of continuous learning. It promotes mindfulness that both distances the “dancer from the dance” in terms of ego while also encourages of a deep, ever-expanding mastery. I’d be in excellent hands if any one of the men and women I met were my PA—there’s not a doubt in my mind. You would be, too.