Iputo, Jehu E

South African Medical Journal (SAMJ)

ORIGINAL ARTICLES959December 2005, Vol. 95, No. 12  SAMJThe Unitra (now Walter Sisulu University) medical schooladopted the problem-based, community-based model oftraining doctors in 1993. The formal teacher-centred, discipline-and lecture-based model of teaching was replaced withstudent-based, small-group integrated learning, in which theteacher is a facilitator of the learning process rather than aresource expert.1 The core of the student activity is a group of 8 - 10 students plus one or two members of the teaching staffwho act as facilitators (tutors). Groups meet 3 times a week for2-hour periods. Each group exists for 10 weeks, after whichstudents are re-shuffled into new groups and new facilitatorsarrive.In the first 3 years of the curriculum (the pre-clerkshipphases) the tutorial process is based on set-piece clinicalscenarios developed from real cases. The cases are formatted ina manner similar to the practice-based learning described byBarrows and Tamblyn.2 The first session begins with a briefstatement regarding the patient’s chief complaint. The studentsthen discuss their hypotheses regarding the possibledifferential diagnosis or disease mechanisms, and also discussother questions that they would like to ask the patient. Moreinformation is then provided based on the actual informationavailable (i.e. the progressive disclosure method).  The sameprocess is then applied to physical examination. The informa-tion gathered from the history and physical examination isthen used to determine which laboratory investigation shouldbe performed, and the interpretation of the laboratory studiesemerges from the discussion. Because the Unitra curriculum isbased on the bio-psychosocial model, each case is analysed bythe students from the clinical angle, the biomedical angle, andthe psychosocial angle. Issues pertaining to the above threebroad domains of knowledge are identified by the studentsFacilitating the integrated small-group tutorial in a medicalprogramme – the University of Transkei (Unitra) experienceJehu E IputoQuality Assurance Unit, Faculty of Health Sciences, Walter Sisulu University,Mthatha, E CapeJehu E Iputo, MB ChB, PhDCorresponding author: J E Iputo (iputo@getafix.utr.ac.za)Context. The Unitra (now Walter Sisulu University) medicalprogramme is problem- and community-based, offered in asmall-group tutorial setting under a tutor. The first 3 years ofthe programme are integrated horizontally and vertically. Thehypothetico-deductive format, with progressive disclosure, isutilised in the tutorial process. Regular training of tutors iscarried out to assist faculty in adapting to the new methods oftraining. Performance of tutors is regularly assessed bystudents.Objectives. To describe the students’ perceptions of the facultyperformance as tutors over the past 10 years of the problem-based learning/community-based education programme andto construct a profile of a Unitra tutor.Design. A prospective longitudinal study.Setting. The first 3 years of the medical programme is dividedinto 10 blocks lasting 10 weeks each. At the end of each block,students evaluate their tutors using a pre-designed form withitems pertaining to both process and content facilitation. Foreach item, the tutor is assigned a score on a scale that rangesfrom ‘unacceptable’ to ‘superlative’. Students’ evaluations overthe years were reviewed and the findings were analysed fortrends and similarities.Main outcomes. Process facilitation and content facilitation.Results. Evaluations from 460 individual tutorial groups, and of83 tutors, were analysed. Process facilitation. Tutors were regular in attendance, werepunctual and showed enthusiasm for the tutorial process. Theywere proficient in keeping the group on track, in givingfeedback to the group, and in helping the group to function.They were less proficient in managing group time and ingiving feedback to individuals within the group. They did notgive students adequate direction in the clinical reasoningprocess.Content facilitation. Tutors were proficient in asking probingquestions, in encouraging students to pursue learning issues,in integrating basic and clinical sciences and in identifyinglearning errors, and they often shared their experiences withstudents. They tended to teach within the tutorial session, anddid not lay strong emphasis on psycho-social issues raised bythe cases. Conclusion. The students are generally happy with the Unitratutors. Content is better facilitated than process. Integratingpsychosocial issues into the tutorial process, minimisingteaching in the tutorial room, giving feedback to individuals,and giving appropriate guidance to students in thehypothetico-deductive clinical reasoning process are the majorchallenges facing the Unitra tutor.S Afr Med J 2005; 95: 959-962.Pg 959-962 Tib  28/11/05  4:35 pm  Page 959ORIGINAL ARTICLES960with the help of their tutors. These then become the learningissues for students to study and report on during thesubsequent sessions. It is the duty of the tutor to ensure thatthe agreed list of learning issues is relevant to the case. In theUnitra curriculum, the direction of learning is a sharedresponsibility between students and tutor. When the groupreassembles, the learning issues are the first item of business.One of the features of the tutorial process is the adherence tothe principle of student ownership of the process and activitiesof the group. Tutors are facilitators of the process rather thanresource experts in any area under discussion. They areactively discouraged from answering questions of substance.They serve to monitor and counsel on process matters andcritical thinking. Because of the relative newness of the problem-based andcommunity-based learning medical programme in ourenvironment, and its innovative focus on active learning, staffdevelopment was identified as a top priority by our institution.Regular training workshops are held to help the traditionallytrained faculty to adapt to their new role. The faculty has beenencouraged to believe that students can and will identifyrelevant material for study on their own. They should knowwhen and how to offer help when the group is struggling andwhen to back off. The faculty has been urged to consciouslyexercise restraint and desist from turning the integrated small-group, problem-based tutorial into a traditional one.  Newtutors are teamed up with experienced tutors who act as theirmentors. Frequent use is made of personnel from outside theinstitution to assess and endorse the programme, which bringsobjective judgements, high-quality expertise and new ideas tothe programme. We make frequent use of instruments andprocedures to assess the quality of student learningexperiences. The performance of tutors, for example, isregularly monitored through both peer and student evaluation.In this article we describe students’ evaluation of tutors’performance as facilitators of integrated small-group learningover the first 10 years of the problem-based, community-basedlearning programme at University of Transkei. We alsoconstruct the profile of a ‘Unitra tutor’ from the point of viewof our students. MethodsThe first 3 years of the medical curriculum is based onintegrated small-group tutorial learning. It is divided into 10blocks lasting on average 10 weeks each. In each block,students are randomly allocated to small groups of 8 - 10students under one or two tutors. At the end of each block,students (as individuals) evaluate their tutors with regard toregularity of attendance, punctuality, and their abilities atprocess and content facilitation. The performance is graded as‘unacceptable’, ‘cause for concern’, ‘competent’, ‘better thancompetent’, or ‘superlative’. The students’ evaluations over thefirst 10 years of the curriculum have been reviewed, and thefindings analysed for trends and similarities. The focus hasbeen on the grades ‘unacceptable’ and ‘cause for concern’,which are deemed to be unsatisfactory.Main outcomesIntake into the medical programme rose from 30 students in1993 to 110 in 2002. The total number of tutorial groups in thepre-clinical phases rose from 15 in 1993 to 80 in 2002. A total of460 tutorial groups were analysed over the 10-year studyperiod. Eighty-three different faculty staff members participated astutors over the 10-year study period. Faculty from the Republicof Cuba was introduced into the programme (a small group in1997, and a much larger group in 2001) and contributed toabout 40% of faculty staff that participated in the tutorialprocess during the study period. Of the 83 tutors, 65 (78%) hadbasic medical qualification and the rest were science graduates.There was no tutor with a behavioural sciences background.The tutor pool for the pre-clerkship phases rose from 15 in 1993to 49 in 2002. Of the 49 members of the tutor pool in 2002, 21(43%) had been with the programme throughout the 10-yearperiod under review. The average period of activity within theprogramme by faculty staff was 3 years. It took an average of 2years of tutoring for individual faculty members to attain theirbest level of performance. Throughout the 10 years of the programme, more than 95%of the students were satisfied with the regularity of tutors’attendance, with their punctuality, and with the enthusiasmthey showed for the tutorial process. The majority of the tutorsaccepted feedback from the group non-defensively. They oftenshared their experiences with students, and they did nothesitate to identify useful resources for students.Process facilitationFig. 1 summarises the findings on process facilitation. Thestudents’ level of dissatisfaction with various aspects of processfacilitation ranged from 10% to 55% over the 10-year studyperiod. In general, the tutors were proficient in guiding thegroup. They encouraged group processing, and helped thegroups to function. They were proficient in keeping the groupson track. However, they were less proficient inmanaging time (where the level of dissatisfaction wasconsistently higher than 25% over the study period), and werereluctant to give feedback to individual students within thegroup (the level of dissatisfaction was consistently more than25% over the study period). Content facilitationFig. 2 summarises the findings on content facilitation. Thestudents’ level of dissatisfaction with the various aspects ofcontent facilitation ranged from 5% to 52% over the 10-yearDecember 2005, Vol. 95, No. 12  SAMJFPg 959-962 Tib  28/11/05  4:35 pm  Page 960ORIGINAL ARTICLESDecember 2005, Vol. 95, No. 12  SAMJstudy period. In general, the tutors were proficient in contentfacilitation. They asked probing questions, encouraged thepursuit of learning issues, and helped students identifylearning errors. Students were satisfied with the tutors’ help inintegrating basic and clinical science issues.  However, thestudents felt that the tutors did not offer sufficient help duringthe clinical reasoning process (i.e. they could have been moredirective). This was more evident in the earlier blocks, wherethe level of dissatisfaction was as high as 46% in someinstances. Students felt that psycho-social issues (especially inthe later blocks) were often not adequately discussed (the levelof dissatisfaction was consistently higher than 30% throughoutthe study period). The tendency for the tutors to lecture duringthe tutorial was unacceptably high (the level of dissatisfactionwas more than 25% throughout the study period).2001 was a particularly bad year, in which the level ofdissatisfaction with most aspects of process and contentfacilitation rose sharply. This was due to the influx of newtutors from Cuba. However, by the year 2002 the new tutorshad settled in and student satisfaction had improved to theprevious levels.DiscussionThis study presents the evaluation of the performance ofUnitra faculty as facilitators of integrated small-group tutorialsessions by students in the medical training programme.Students are a reliable and valid source of information abouttutor performance in the tutorial room and have often beenused to evaluate tutors.3,4This study shows that Unitra students in the problem-basedlearning/community-based education integrated small-grouptutorial system are generally happy with the performance oftheir tutors. The level of enthusiasm about the programmeamong the tutors is still high 10 years into the programmedespite the high workload necessitated by the increasingstudent numbers and a relatively small tutor pool. In general,content facilitation has been achieved better than processfacilitation.  The are four major challenges facing the Unitratutors: how to give feedback to individuals within the group;how to minimise teaching in the tutorial room; determininghow much direction to give to the students in the hypothetico-deductive clinical reasoning process; and how to integratepsychosocial issues into the tutorial process.Our tutor training programme emphasises the importance ofgiving immediate feedback to students, offering tips on how togive feedback in a non-judgemental and non-threateningmanner.  Research has shown that students benefit fromimmediate feedback from tutors so that misconceptions can becleared promptly,5 and yet giving feedback to individualswithin the group, especially if the feedback is negative, remainsa challenge to a sizeable portion of our tutor pool.The transition from ‘sage-on-the-stage’ to ‘guide-by-the-side’has not been easy for the Unitra tutors. A proportion of ourtutor pool has had difficulty in adapting to the role of PBLtutor, even after training and staff development sessions. Theyare more familiar with directing students in lectures and arestill directive even in the PBL setting.  They refuse to surrenderthe seat of authority to the students. Ideally we should not beusing these people as tutors, but the very real staffing problemswe face give us no choice. We often pair them with good tutorsto try to limit their influence on the tutorial process.One of the features of the Unitra curriculum is early clinicalexposure. From the second semester of the first year of theprogramme, students are introduced to the hypothetico-deductive clinical reasoning process using the progressivedisclosure method. It is not often appreciated that clinicalreasoning is a skill that students need to acquire. Somestudents find it difficult to cope when asked to transform intoactive and critical thinkers. The tutor should offer scaffoldingto the students, preparing them to think critically and to makeinformed decisions.6 Students should be ‘coached’ to the extentthat they perform intellectual tasks, like the clinical reasoningprocess, on their own. The tutor must go beyond just being aFig. 1. Process facilitation in the integrated small-group tutorial.Fig. 2. Content facilitation in the integrated small-group tutorial.0102030405060Dissatisfaction (%)Helping group functionFeedback to groupFeedback to indivisualskeeping group on trackkeeping timeallowing group to flaunderAsking probing questionspursuing learning issuesintegrating basic and clinical sciencespursuing psychosocial  issuessharing experienceidentifying learning errorteaching in the tutorial room01020304050601 32 54 76 98 10Dissatisfaction (%)YearsYears1 32 54 76 98 10961Pg 959-962 Tib  30/11/05  12:12 pm  Page 961ORIGINAL ARTICLES962‘facilitator’ of the tutorial process to being an ‘activator’ oflearning by motivating students, and challenging them withnon-directive questions at the meta-cognitive level.7 Tutorswithout a medical background might have difficulty in offeringthis type of support, and students facilitated by such tutorsoften complain of being left to flounder. In the early stages ofthe programme, when the hypothetico-deductive clinicalreasoning skills are still rudimentary, students should probablyhave a medically qualified person as one of the tutors.The Unitra medical curriculum is based on the bio-psychosocial model of medical training and delivery whichputs emphasis on the social, psychological, and behaviouraldimension of illness at par with the biomedical dimension.8Every problem that is developed for the PBL programme isplaced in its proper social context. In the tutor training anddevelopment programmes, tutors are urged to encouragestudents to approach the patient in his or her social context andto treat a person as a whole. The reality on the ground,however, is that a sizeable portion of our tutor pool pays scantattention to psychosocial issues in the tutorial process. It isdifficult to change attitudes and practices of people trained inthe traditional biomedical model and working in atechnologically driven health care system. This has been theexperience in developed countries and is certainly true forUnitra as well.9 The absence of tutors with a behavioralsciences background compounds the problem. Steps are beingtaken to create a fully fledged department of humanbehavioural sciences within the faculty of health sciences tospearhead the integration of behavioural sciences into themedical training programme.ConclusionsStudents are generally happy with the Unitra tutors. Contentfacilitation is better done than process facilitation. How tointegrate psychosocial issues into the tutorial process, how tominimise teaching in the tutorial room, and determining howmuch direction to give the students in the hypothetico-deductive clinical reasoning process are the major challengesfacing the Unitra tutor.References1. Iputo JE, Nganwa-Bagumah AB. The innovative medical curriculum of the University ofTranskei Medical School. Part I. Problem-based learning. S Afr Med J 1996; 86: 649-651.2. Barrows HS, Tamblyn RN. Problem-Based Learning: An Approach to Medical Education. NewYork: Springer, 1980.3. Morrison J. ABC of learning and teaching in medicine: Evaluation. Br Med J 2003; 326: 385-387.4. Zanolli MB, Boshuizen HP, De Grave WS. Students’ and tutors’ perceptions of problems inPBL tutorial groups at a Brazilian medical school. Education for Health (Abingdon) 2002; 15(2):189-201.5. Norman GR, Schmidt HG. The psychological basis of problem- based learning. A review ofevidence. Acad Med 1992; 67: 557-565.6. Boud D, Feletti, G, eds. The Challenge of Problem-Based Learning. 2nd ed. London: Kogan, 1997.7. Mayo WP, Donnelly MB. The characteristics of the ideal problem-based learning tutor inclinical medicine. Evaluation and the Health Professions 1995; 18(2): 124-136.8. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.9. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later:Principles, practice, and scientific inquiry. Ann Fam Med 2004; 2(6): 576-582.December 2005, Vol. 95, No. 12  SAMJThe MRC Unit on Anxiety Disorders invites you to attend theINTERNATIONAL ANXIETY DISORDERS CONFERENCE24 - 26 FEBRUARY 2006SPIER ESTATE, STELLENBOSCHPlease refer to the website below for all details or contact Nelda Rousseau (neldar@sun.ac.za, Tel: 021 938 9651, Fax: 021 933 2649)http://www.mentalhealthsa.co.za/anxietyconference.htmlPlease note:9 December 2005Closing date for early congress registrations& accommodation at special rates8 February 2006Closing date for congress registrationsPg 959-962  22/11/05  8:04 pm  Page 962

Facilitating the integrated small-group tutorial in a medical programme - the University of Transkei (UNITRA) experience

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Facilitating the integrated small-group tutorial in a medical programme - the University of Transkei (UNITRA) experience

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