SHORT COMMUNICATION Introduction of Vertical Integration and Case-Based Learning in Anatomy for Undergraduate Physical Therapy and Occupational Therapy Students Suresh K. Parmar, Bertha A.D. Rathinam* Department of Anatomy, Christian Medical College, Vellore, Tamil Nadu, India The purpose of the present pilot study was to evaluate the benefits of innovative teaching methodologies introduced to final year occupational and physical therapy students in Christian Medical College in India. Students’ satisfactions along the long-term retention of knowledge and clinical application of the respiratory anatomy have been assessed. The final year undergraduate physical therapy and occupational therapy students had respiratory anatomy teaching over two sessions. The teaching involved case-based learning and integrated anatomy lectures (vertical integration) with the Anatomy department. Pretest and immediate and follow-up post-tests were conducted to assess the effectiveness of the innovative methods. A feedback questionnaire was marked to grade case-based learning. The method of integrated and case-based teaching was appreciated and found to be useful in imparting knowledge to the students. Students retained the gained knowledge adequately and the same was inferred by statistically significant improvement in both post-test scores. Vertical integration of anatomy in the final year reinforces their existing knowledge of anatomy. Case-based learning may facilitate the development of effective and clinically sound therapists. Anat Sci Educ 4:170–173. © 2011 American Association of Anatomists. Key words: anatomy teaching; vertical integration; gross anatomy education; case-based learning; physical therapy education; occupational therapy education; India INTRODUCTION Learning and retention of basic science information has long been a central concern in undergraduate medical education. During the 1980s and early 1990s, basic science instruction was commonly criticized for an emphasis on rote learning of an unrealistically large volume of factual material, a lack of clinical relevance for portions of the material covered, inattention to the practical application of basic science knowledge to clinical situations, and use of passive, lecture-based teaching methods (Barrows and Peters, 1984; Neame, 1984; *Correspondence to: Dr. Bertha A.D. Rathinam, Department of Anatomy, Christian Medical College, Bagayam, Vellore 632002, Tamil Nadu, India. E-mail: [email protected] Received 7 February 2011; Revised 5 March 2011; Accepted 9 April 2011. Published online 9 May 2011 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.225 © 2011 American Association of Anatomists Anat Sci Educ 4:170–173 (2011) Online Library Tosteson, 1990). Therefore, medical education has been transformed in the recent decade to meet the challenges of future professionals in various ways including horizontal and vertical integration, student-centered, community-oriented, and problem-based learning (Dornan and Bundy, 2004; Kamalski et al., 2007). Many institutions universally have ongoing research to improvize their curricula, not only to develop attitudes and affective behaviors of the future professionals but also to build professional competence and confidence (Lie, 1995; Ten Cate, 2007). Several studies indicate that the majority of clinicians feel current anatomical education of medical students is inadequate, and below the minimum necessary for safe medical practice (Fitzgerald et al., 2008; Ahmed et al., 2010; Smith and Mathias, 2011). There is widespread support among clinicians for more vertical integration of anatomy teaching throughout the undergraduate curriculum (Waterston and Stewart, 2005; Sugand et al., 2010). Case-based learning has been demonstrated to be successful in fostering independent reasoning and problem-solving skills that are vital for future practitioners (Banda, 2009; Bowe et al., 2009; DiLullo et al., 2009; Layne et al., 2010). Although widely adapted in many MAY/JUNE 2011 Anatomical Sciences Education nations, innovations in teaching for occupational therapy (OT) and physical therapy (PT) students have not risen in India to address this need. (Solomon 2005; Foord-May, 2006; Youdas et al., 2008; Van Peppen et al., 2009; Wait et al., 2009). The purpose of this study was to introduce vertically integrated and case-based learning (CBL) of respiratory anatomy for final year OT and PT students to nurture their ability to assimilate knowledge and transfer such information to solve problems analytically. students, because one was absent in the post-test. The mean pretest score was 10.50 (50.3%), the immediate post-test score was 15.88 (79.4%), and the follow-up post-test score was 14.82 (74.1%). The increase was found to be statistically significant in both immediate and follow-up post-test scores (P < 0.001). All the students felt that the integration with anatomy was effective and useful; the topics were relevant and clinically applicable. MATERIALS AND METHODS Case-Based Learning The entire cohort of undergraduate OT and PT students was introduced to CBL and integrated anatomy lectures in their final year. This pilot intervention focused on the respiratory anatomy module. The OT and PT curriculum of the Tamilnadu Dr. M.G.R. Medical University in Tamilnadu, India spans over four years followed by six months compulsory revolving internship. In the first year, 200 hours of gross anatomy is taught. The rest of the three years include clinical and paraclinical specialties and relevant OT and PT subjects. The present curriculum does not include any integrated or problem-based teaching learning methods. The OT and PT students do not have any revisits to the Department of Anatomy after the first year, according to the existing regulations. The entire cohort of students’ mean score was found to be unsatisfactory (56.7%) after traditional teaching of clinical respiratory module, in formative assessment. This formative assessment included essay, short answers, and brief questions. Therefore, a pilot intervention was designed to assess if CBL and integrated anatomy lectures would facilitate the students in assimilating knowledge and transfer the information learned to solve problems analytically. Ten students from OT and ten students from PT programs (n 5 20) were included for the pilot study after obtaining ethical clearance from the Institutional Review Board. They were assessed for existing knowledge of anatomy by a pretest which included multiple choice and reason–assertion questions (Appendix A). Of the topics in respiratory anatomy, some like respiratory movements, biomechanics of thoracic cage were taught as didactic lectures and demonstration with prosected specimens. For CBL, the students were divided into two mixed groups of ten students each and given a clinically oriented case at the end of the first session (Appendix B). The relevant anatomy learning was facilitated through discussion of the case and its clinical application by faculty. Post-tests of similar format and difficulty, covering similar content as pretest were conducted at the end of the second session and four weeks later. A standardized questionnaire was provided to the students at the end of the sessions, and they were asked to rate the effectiveness of integration and CBL using a five-point psychometric Likert scale with open ended questions for their comments and suggestions. Content analysis of open ended questions was done. Statistical analysis of the results of tests and the rating of the questionnaire was done using SPSS statistical package, version 16.0 (SPSS Inc., Chicago, IL). RESULTS Integrated Anatomy Lectures Of the twenty students, 18 took the pretest and only 17 answered both the post-tests. Paired t test was done for 17 Anatomical Sciences Education MAY/JUNE 2011 All the students felt that the topics chosen for case-based learning were relevant, and 87.5% thought that it is clinically applicable. 68.8% opined that the time allotted for CBL was not sufficient. 93.8% felt that the entire program enhanced their learning of anatomy. 68.8% strongly suggested similar integrated and CBL to be introduced in the first year of college. None of them had been exposed to integrated or casebased learning before. There was no difference in the performance between the two student groups (OT and PT) and both student groups benefitted equally from the intervention (P 5 0.1068). Content analysis of the open ended questions revealed the following themes: ‘‘CBL makes learning very interesting (100%),’’ ‘‘effective (60%),’’ and ‘‘very much appreciated (72%),’’ and they also suggested similar methods to be followed for other subjects (10%). DISCUSSION Vertical integration by definition incorporates preclinical sciences with paraclinical and clinical subjects. It is the mantra of contemporary medical education. Integrated education is proven to be effective in enabling the students to comprehend basic sciences and promote lifelong learning (Dahle et al., 2002). A study inferred that a rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualize, and integrate medical education (Dornan and Bundy, 2004). Another study concluded that vertical integration of anatomy teaching throughout the full medical course may be useful (Bhangu et al., 2010). Knowledge of anatomy is perceived to be important for safe clinical practice. Anatomy should be taught with other relevant system or clinical modules (Ahmed et al., 2010). Our study showed improved performance of the students by an increase of 5.38 points in mean post-test scores at the end of the session (P < 0.001) and an increase of 4.32 (P < 0.001) in the four weeks follow-up post-test scores. It is unlikely that the significant increase in the immediate post-test performance can be attributed to mere memory recall, because the students’ demonstrated sustained, similar improvement in the follow-up posttest. This shows that there is better assimilation of knowledge and comprehension leading to long-term retention of facts necessary for clinical practice. CBL is an educational method in which small groups of students are given case scenarios (Bowe et al., 2009). A study, among second year medical students, confirms that students have recognized that the case-based projects were about obtaining a deeper understanding of the anatomy (Peplow, 1990). In another CBL study introduced to second year medical students, they were able to identify their own deficiencies, develop strategies for thinking and learning, resulting in the 171 acquisition of expertise in problem solving, and extend their communication skills by working with colleagues (Scott, 1994). The goals of working out the clinical case are to provide a clinical context for learning, activate prior knowledge, motivate students, and stimulate discussion (Aziz et al., 2002; Banda, 2009). Self-directed learning which is student-centered is the major strength of this program (Peplow, 1990; Saarinen-Rahiika and Binkley, 1998). This study suggests that introduction of CBL improves comprehension of the students, enabling them to be better health care providers. CONCLUSIONS Although this pilot study was of short duration and with a small sample size, it is evident that vertical integration of basic sciences and CBL during students’ clinical postings are very much welcomed and appreciated by students. It not only improves their academic performance, as shown by their post-test scores, but also prepares them for better clinical practice. We recommend that CBL become an integral part of curriculum of the paramedical courses as this would ensure better health care delivery and professional competence in the students when they become practitioners. NOTES ON CONTRIBUTORS SURESH K. PARMAR, M.Sc. (Anatomy), B.P.T., is a senior demonstrator in the Department of Anatomy at the Christian Medical College, Vellore, Tamil Nadu, India. He teaches gross anatomy to medical, nursing, and paramedical undergraduate students. BERTHA A. D. RATHINAM, M.S. (Anatomy), M.B.B.S., is an assistant professor of anatomy at the Christian Medical College, Bagayam, Vellore, Tamil Nadu, India. She teaches gross anatomy to postgraduate and undergraduate medical, nursing, and paramedical students. Banda SS. 2009. The Case Anatomical Knowledge Index (CAKI): A novel method used to assess anatomy content in clinical cases. Anat Sci Educ 2:9–18. Barrows HS, Peters MJ (Editors). 1984. How to Begin Reforming the Medical Curriculum. 1st Ed. Springfield, IL: Southern Illinois University School of Medicine. 204 p. Bhangu A, Boutefnouchet T, Yong X, Abrahams P, Joplin R. 2010. A three-year prospective longitudinal cohort study of medical students’ attitudes toward anatomy teaching and their career aspirations. Anat Sci Educ 3:84–190. Bowe CM, Voss J, Aretz TH. 2009. Case method teaching: An effective approach to integrate the basic and clinical sciences in the preclinical medical curriculum. Med Teach 31:834–841. Dahle LO, Brynhildsen J, Behrbohm Fallsberg M, Rundquist I, Hammar M. 2002. Pros and cons of vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum: Examples and experiences from Linkoping, Sweden. Med Teach 24:280–285. DiLullo C, Morris HJ, Kriebel RM. 2009. Clinical competencies and the basic sciences: An online case tutorial paradigm for delivery of integrated clinical and basic science content. Anat Sci Educ 2:238–243. Dornan T, Bundy C. 2004. Learning in practice: What can experience add to early medical education? Consensus survey. BMJ 329:834–837. Fitzgerald JE, White MJ, Tang SW, Maxwell-Armstrong CA, James DK. 2008. Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors. Clin Anat 21:718–724. Foord-May L. 2006. A faculty’s experience in changing instructional methods in a professional physical therapist education program. Phys Ther 86:223–235. Kamalski DMA, Ter Braak EWMT, Ten Cate ThJ, Borleffs JCC. 2007. Early clerkships. Med Teach 29:915–920. Layne K, Nabeebaccus A, Fok H, Lams B, Thomas S, Kinirons M. 2010. Modernising morning report: Innovation in teaching and learning. Clin Teach 7:77– 82. Lie N. 1995. Traditional and non-traditional curricula. Definitions and terminology. Tidsk Nor Laegeforen 115:1067–1071. Neame R. 1984. The preclinical course of study: Help or hindrance. J Med Educ 59:699–707. Peplow PV. 1990. Self-directed learning in anatomy: Incorporation of case-based studies into a conventional medical curriculum. Med Educ 24: 426–432. Saarinen-Rahiika H, Binkley JM. 1998. Problem-based learning in physical therapy: A review of the literature and overview of the McMaster University experience. Phys Ther 78:195–207. Scott TM. 1994. A case-based anatomy course. Med Educ 28:68–73. Smith CF, Mathias HS. 2011. What impact does anatomy education have on clinical practice? Clin Anat 24:113–119. ACKNOWLEDGMENTS Authors acknowledge Dr. Vyas Rashmi, core educator in the Medical Education Cell and professor of physiology at Christian Medical College, Vellore, for her valuable input toward the planning of the educational intervention and help in revision of the manuscript and Mrs. Rebekah Grace, a statistician at Christian Medical College, Vellore, for her statistical help. LITERATURE CITED Ahmed K, Rowland S, Patel V, Khan RS, Ashrafian H, Davies DC, Darzi A, Athanasiou T, Paraskeva PA. 2010. Is the structure of anatomy curriculum adequate for safe medical practice? Surgeon 8:318–324. Aziz MA, McKenzie JC, Wilson JS, Cowie RJ, Ayeni SA, Dunn BK. 2002. The human cadaver in the age of biomedical informatics. Anat Rec 269:20–32. 172 Solomon P. 2005. Problem-based learning: A review of current issues relevant to physiotherapy education. Physiother Theory Pract 21:37–49. Sugand K, Abrahams P, Khurana A. 2010. The anatomy of anatomy: A review for its modernization. Anat Sci Educ 3:83–93. Ten Cate O. 2007. Medical education in the Netherlands. Med Teach 28:752–757. Tosteson DC. 1990. New pathways in general medical education. New Engl J Med 322:234–238. Van Peppen RP, Schuurmans MJ, Stutterheim EC, Lindeman E, Van Meeteren NL. 2009. Promoting the use of outcome measures by an educational programme for physiotherapists in stroke rehabilitation: A pilot randomized controlled trial. Clin Rehabil 23:1005–1017. Wait KR, Cloud BA, Forster LA, Jones TM, Nokleby JJ, Wolfe CR, Youdas JW. 2009. Use of an audience response system during peer teaching among physical therapy students in human gross anatomy: Perceptions of peer teachers and students. Anat Sci Educ 2:286–293. Waterston SW, Stewart IJ. 2005. Survey of clinicians’ attitudes to the anatomical teaching and knowledge of medical students. Clin Anat 18:380–384. Youdas JW, Hoffarth BL, Kohlwey SR, Kramer CM, Petro JL. 2008. Peer teaching among physical therapy students during human gross anatomy: Perceptions of peer teachers and students. Anat Sci Educ 1:199–206. Parmar and Rathinam Appendix A Appendix B Example of a multiple choice question and reason-assertion question: Example of a clinical case for group discussion. The integrated respiratory anatomy module for OT/PT final year examination: 1. A 60 year-old female who has copious amounts of fluid in the left pleural cavity due to acute pleurisy, was admitted under your care. When you examine her as she sits up in the bed (trunk upright), where would the fluid tend to accumulate? (a) Left costodiaphragmatic recess (b) Left costomediastinal recess (c) Cupola pleurae (d) Hilar region 1. A 28 year-old female was brought to the hospital with high fever, difficulty in breathing and severe pain in the right side of the chest. The pain radiated to the right anterior abdominal wall. Auscultation of the chest showed absent breath sounds over the inferior lobe of the right lung and chest X-ray confirmed the presence of fluid in the pleural cavity in the right side. (1) Name the condition in which there is accumulation of fluid in the pleural cavity. (2) Name the different regions of the parietal pleura and give its innervation. (3) Give explanation for radiation of pain to anterior abdominal wall in this case. (4) Describe the pleural recesses. 2. Reason: The right main bronchus is shorter, wider and more vertical compared to the left side. (True / False) Assertion: Aspiration of foreign bodies is more common to the left lung. (True / False) Anatomical Sciences Education MAY/JUNE 2011 173
1/--страниц