Problem-based learning in ophthalmology: A brief review.

Problem-based learning in ophthalmology

Problem-based learning (PBL) in medical education involves students working on “real-life” scenarios, the process being facilitated by a tutor. The concept of PBL was developed at McMaster University, Canada. PBL curricula are being adopted by a number of universities all over the world with the main premise being that students needed to be directed to active self-learning tendencies. PBL is also known to promote life-long learning by mirroring “real-life” scenarios.[123]

There are many studies which deal with the implementation of PBL in the undergraduate curriculum as a whole. However, the use of PBL in ophthalmology can be an effective method of teaching after proper modification of its present form that needs to be sufficiently analyzed and applied to ophthalmology teaching.

The process of classical PBL begins with the discussion of a case or scenario directed by the content of the curriculum. The following discussion by students attempts to generate a hypothesis that motivates further learning. After a period of independent, self-directed study, the students meet to share and discuss the issues about which they are learning, under the supervision of the facilitator.[4]

The elements of the case serve as triggers for student-developed learning issues. The nature of student learning in PBL depends on the quality of the case presented to the student. Good cases are ideally based on real-life scenarios and should be relatively ill-structured and open-ended. The case should be regarded by the students as being relevant to their profession and to real-world clinical situations: these qualities engage student interest.[56]

The principles of active, self-directed and life-long learning, which are enhanced by PBL, apply as much to ophthalmology as any other medical specialty. Most undergraduate ophthalmology programs are of a short duration and because of this it is difficult to expose the students to the whole gamut of important cases in ophthalmology.[7] Collaborative learning on web-based modules has been shown to be effective in improving ophthalmology teaching.[8] PBL would be an ideal solution to give the students an in-depth understanding of the common ophthalmic conditions. The few studies conducted in the context of PBL in ophthalmology have also suggested that PBL has a definite positive influence in the ophthalmology teaching-learning process.[910111213]

A thorough literature search has found only four studies specifically dealing with the application of PBL in ophthalmology. A study by Kong et al.,[9] compared three types of learning process—normal didactic teaching, PBL based on digital cases and conventional PBL. The total sample size was 90 students and they were divided into three groups of 30 each. The first class studied under a didactic model. The other two classes were divided into six groups (10 students per group) and received PBL teaching; with three groups studying via cases presented in digital form and the others studied via paper-form cases. The PBL group had significantly higher mean results of theoretical and case analysis examinations (knowledge evaluation), but there was no significant difference between the two PBL classes. Stimulation of interest was more in the digital PBL group compared to the conventional PBL group.

The second study by Farrell et al.,[10] involved a sample size of 75 students. This involved 16 cases of conventional PBL based on four ophthalmic problems. The main outcome measures were student satisfaction and knowledge acquisition (based on a pre and post test). The results showed knowledge scores showed statistically significant gains with a mean of 1.7 points. Student satisfaction was also positive—85% stated that they learned more than they would have in the traditional format and 93% agreed that they enjoyed the PBL format.

The third study was by Sahoo et al.,[11] with a sample size of 120 undergraduate students. The study also was based on a conventional PBL model with eight case scenarios covering four common ophthalmic problems. The main outcome measure studied was change in attitude of the students. The majority of the students felt comfortable with the module (88%), felt that PBL was advantageous as a learning method (92%), and that overall the process was enjoyable (91%).

Ayaki et al.,[12] used a modified PBL tutorial where the trigger was a simulated patient (simulated by the students themselves). The sample size was more than 400. The main outcome measure was again mainly change in attitudes and the results showed that 75% said it was an impressive module. The major advantages they indicated were experience of diagnostic process (79%), role play (38%), and watching others’ interview (34%). Of the total 68% actually felt that the course was a bit confusing, but 82% felt that it was fun all the same.

The review of literature shows that there aren’t enough well-designed studies to conclusively say that PBL is an effective teaching-learning modality in the specific context of ophthalmology. The study by Wong et al.,[9] seems to be the best designed, but the number of students in each arm of the study are probably to less to make a conclusive statement on the advantages of PBL per se or of digital cases versus PBL cases. The study by Farrell et al.,[10] was also well designed, but did not compare PBL with the traditional/conventional method of teaching. In the other two studies by Ayaki et al.,[12] and Sahoo et al.,[11] the main outcome measure was related to attitude change and knowledge acquisition was not really evaluated. The study by Ayaki et al.,[12] was significant in terms of the large sample size and longer duration of the study. PBL would be a very useful adjunct in improving the quality of undergraduate ophthalmology teaching. An integrated PBL system combing digital technology and conventional triggers would probably be the best method of implementation. However, at present the evidence for PBL specifically in ophthalmology is not much. Therefore, more studies which are well designed and evaluate knowledge, attitude and behavior ideally over a longer term are need to really say conclusively that PBL is an effective teaching-learning tool in ophthalmology.