How to help students to improve their learning?

The facilitation of learning in the different steps.

If small groups are to function well, both students and tutors should understand the significance of the different steps. Tutors need special training to learn to facilitate in an effective way. But tutors do not have sole responsibility for the quality of the education. The learning programme has goals and it must be organised in such a way that its goals are reached. Thus, those who prepare problems will prepare relevant problems, and all that take part, as tutors should strive to find ways in which student's learning can be made easier (facilitated).

Lets start with the very beginning of the learning-session, the presented problems. What can be said about the presentation and the construction of the cases? And what can be done to stimulate the students to work effectively on these patient problems? And how can we help them not only with the formulation of the learning questions, but help them to study themselves effectively as well? How can we ensure that they make the most of their studies in the libraries? And how can they present the results of their self-directed learning so that the other students and the tutor will understand what they have grasped from their reading.

In this chapter we will deal with the following subjects:

1. How to use problems as a good trigger for starting learning in the small group? (Step1).
2. How to construct problems in harmony with the (changing) prior knowledge of the students and with the course objectives? (Step1).
3. How to use brainstorm sessions to improve the analysis of the problem into the problem list, the explanations/hypotheses and the formulation of learning issues? (Step 2,3 and 4).
4. How to help students to develop adequate study skills in their self guided learning? (step5)
5. What are the possible resources and their use for self-study? (Step5).
6. How to present the learning results as effective as possible to the other students and the tutors? (step 6)
7. What is and how to get adequate feedback on this learning result?

Problems

If problems are constructed well these problems form triggers for the starting of the learning process. In the previous chapter we presented written or narrative patient cases. But other kind of problems will function as a trigger as well. Variation in the format can be a challenge for the students.

Variation in the format of problems

Presented problems can be either

• written
• real patients
• role-play and simulated patients
• specific reports
• graphs, tables, figures
• video's, slides, films and pictures

In many places where the PBL method is used the written or narrative problems - like the problem we used in the first chapter ( Peter)-are used and they are very effective starting point. Thus even in the absence of real patients and electricity these narratives can trigger adequate learning. But written problems are by no means the only method, whether for starting PBL or in an established programme.

In hospitals in Africa and Asia many real patients are available so a tutor group can also start with a patient. Students can collect data from a patient and use these data to identify problems that must be analysed further, so that the patient is used as the basis for student's learning. An encounter early in the training course with either a TB or a leprosy patient may be a strong motivating factor to start learning about the many aspects of the disease and its control.

However we must emphasise in this context that the purpose is not to solve the problem of the patient, but rather to use this first contact to give the students an opportunity to use previous knowledge and to analyse the different subsidiary problems that arise, in order to understand the problem more thoroughly.

Another method is role-play, which can be helpful, enjoyable and amusing. It is surprising how it get students thinking. For example somebody in the group can play the role of a leprosy patient who visited a herbalist and another student will play the role of a leprosy worker. Students in Africa have often had experience with herbalists so that they can present this kind of problems in a very realistic way, which help their colleques to analyse it, so that they can use it for further study. (Self study).

Sometimes it is helpful to ask somebody outside of the group to play the role of the patient. These people are asked to play this role with specific instructions about the disease. That is why these people are called simulated or programmed patients.

In order to give variety sometimes very specific reports will be helpful, especially for community problems or management problems, well selected articles facilitate good discussion and produce a lot of questions which can be an excellent stimulus for self directed learning. The reports maybe about any subject, an outbreak of diarrhoea, or the failure of a harvest. Journals, magazines or newspapers can be used for this purpose. In Kenya at a medical school a group of boys were invading the dormitories of the girls. They panicked and tried to get out of the rooms with devastating consequences.

Another example was a report a large group of disabled persons affected by leprosy. They took the main streets of the capital for begging, when the social welfare services had been seriously deteriorated. They blocked the streets and thus created traffic jams, which caused the authorities finally to take action. This incident reached TV, radio, and all the national newspapers.

When this kind of actual events are discussed in the community, these cases form an excellent start for PBL in a medical school and in training centre for leprosy. A tremendous involvement of the students is guaranteed.

An imaginative tutor or facilitator can use many methods, anything which can be the basis for discussion and which will demand discussion of the students, so that they can analyse the problem and identify what additional information they want to have.

Also figures and tables can form an interesting starting point for he group session.

Exapmle of figures:

Click on the figure to enlarge

or

A supervisor asks a patient to take off his shirt. When the patient is undressed you see this.

Click on the figure to enlarge

Example of a table

Characteristics of problems

The selection of the different kind of problems must be of course in harmony with the general aims of the course. So the kind of problems may vary considerably depending on the kind of courses. introductory courses in leprosy or TB and refresher courses demand a very different approach.

To give another example; when a course objective is that the students must be able to distinguish between the different kinds of leprosy the problems must be presented in such a way that the students are challenged by the range of disease in leprosy patients and how they might be classified.

But in addition, a patient with leprosy is not an isolated case so that the problem must address problems in the community in order to confront students with the context in which they have to perform as a health worker.

The selection and presentation of the problems (patients, role-play reports etc) must be such that the students are invited to study at least the main subject to be covered during a particular session, according to the course objective.

In general the problems must have the following characteristics.

1. Related to the general objectives. The general course objectives must always kept in mind. In a leprosy course it is necessary to construct problems for reaching the clinical, community, management, laboratory and other objectives. But these objectives themselves can be further divided: thus a clinical problem may relate to different levels of structure: cells, tissues, organ and system levels. In the community one can construct problems dealing with the individual, the family and the community itself, and problems which deal with the stigma of leprosy and its epidemiological problems. Sometimes it is important to present cases that allow ethical discussions.
2. As realistic as possible. Patients do not give medical data to the doctor but they do have complaints. Unfortunately from the point of view of the doctor, they do not always complain about the most relevant matters. The learning issues must be deduced in a reasonable way from the patient problem, but if there is too much irrelevant information it can distract students so that they are diverted from the core problems.
3. Simple without jargon. The problem must not contain too much medical jargon, Of course when students already understand specific data these data can be used but, in general, the case must not contain so much jargon that it becomes confusing for the students. Write the problems as simply as possible at the beginning of the course and when possible, include visual material that shows the phenomena that have to be studied and explained.
4. Related to prior knowledge. The students always have prior knowledge, which will increase during the learning sessions. The course should be organised in a way, which will enable students to use and build on this in the problems. This will be a real encouragement to them and they will be motivated to learn more and will not be bewildered by the complexity of a problem. Learning processes are stimulated in the best way when students can learn from the known to the unknown.
5. Skills. The faculty has to consider with each case what kind of skills apart from knowledge is intended to learn. And what kind of learning resources are requested to master these skills. For example, the results of microscopy investigations are presented to the students in a patient case. Than students must also visit the laboratory and preferable stain and examine smears themselves. Another example. If a case is dealing with a severe reaction in leprosy than students must learn somewhere in the programme to examine a patient with this kind of reaction by palpation of the nerves, the muscle function test (VMT/ST), observe and describe the swollen lesions.
6. Interesting and attractive. Problems must have a title and some trigger material. Material that demands the attention of the students, comparable with a good article in the newspaper, or a good story. All kind of materials can be provided to the student, a photograph of the patients of materials that show the lesions, and so on.
7. Revision of the problems. Those responsible for a course have to plan from the onset how to revise the problems to keep them congruent with the learning goals and closely related to health priorities.

Group Discussion

When new tutor groups start, it is sometimes very difficult to get the most of the discussions. Brainstorming is very helpful to allow every student to contribute in a creative way. A critical analysis of all these contributions at the end of discussion may result in a very effective and adequate list of problems, explanations and learning issues.

Brainstorming

Students work in small groups. We will discuss the importance of a tutorial group later and in more detail, but students have to start discussions about problems and specific skills are necessary if discussions are to be useful.

When the members of a group begin to analyse the presented problem, they have to generate ideas and opinions built on their prior knowledge, and to develop their reasoning in order to try to understand the problem and its underlying mechanisms. In order that every member of the group should learn effectively each must be given the opportunity to raise his or her ideas and to contribute. This must be done before decisions are made about the learning questions. It is called brainstorming and principally involves the student(s) in writing down as many ideas as they can in quick succession. The idea is to encourage the students to explore a topic by giving free range to their thoughts. During this process all ideas are accepted and no questions and discussions are allowed. These ideas are then used for subsequent discussion. All students are encouraged to participate, and the slower students are not at a disadvantage because they have time to prepare their ideas before contributing to the group.

Brainstorming can be used as a warming up exercise to get the discussion started, but it is chiefly used as a means to produce ideas, which can be clarified later on. Sometimes it can be used as a mean for producing a list of alternatives, rather than accepting the obvious or most vocal argument.

This kind of freedom for every participant is essential if the groups are to function well. In every small learning group, some students can be dominant in their attempt to solve the problem as quickly as possible. They may jump to conclusions, so that they forget that others too may wish to contribute, or, even worse, they simply ignore essential information from the other students who raise most important questions. In a case problem, some students select a diagnosis very soon by association because his diagnosis fits with a symptom, but they ignore information or do not try to explain other symptoms and signs in harmony with the selected possibility.

Everybody must have an opportunity to contribute: no one should plead for their own ideas and suggestions related to their own pet concerns or philosophies: Sometimes members of the group compete or vie with others to produce the best ideas, or conversely, they may try to get favour with others .The leader of the group must prevent this sort of behaviour and allow brainstorming to function properly.

It is necessary to make a very strict distinction between the production of ideas and suggestions and other creative contributions, and a critical review of them. In its most strict format brainstorming has four distinct stages. Of course when a tutorial group becomes more experienced the technique can be used in a flexible way, but is nevertheless essential that the creative part, when ideas are produced is separated from the critical review. The first part is really a kind of " blow up"; the second part is "shrink". Let us go back to the case of Peter summerized in Table 2.

When we look at the column on explanations/hypotheses in a brainstorm session also other possibilities were suggested in the brainstorm session in addition to birthmark, a scarf, fungal infection etc. (Blow up)

Mentioned but not selected for study were;

..Exposure to chemicals

..Traditional medicine application

..Too much consumption of cassava

..Wrong examination procedure by health worker

..anthrax

..psoriasis

..erythema multiforme

But as we saw, the group decided to take these possible explanations not into account for further study. They shrunk their list of possible hypotheses.

When all the important problems are listed after the critical review, the tutorial group is now ready to undertake the next step, the formulation of the learning questions. What answers are needed to understand the problem in a better way?. What objectives for study have to be defined?

Self Guided Learning Objectives

Objectives. Responsibility of teachers and students in PBL.

Let's spend a few words to one of the core definitions in education: objectives.

The formulation of good, well-understood objectives are very important; in fact they act as the pilots for the learning process. "If you are nor certain of where you are going you may very well end up somewhere else ( and not even know it)".

In education objectives are formulated at 3 different levels. First on the general level of the institution, school or training centre. At this level the goals of the leprosy worker in a country or community are considered so general or institutional objectives correspond to the functions and tasks of the health personnel trained in and established in the community, At this level activities are described to meet the health needs of the population. Thus an objective of a training school could be to train TB/leprosy supervisors for district or regional level.

On the second level the objectives of specific courses are defined.

An example is to train laboratory technologists in AFB microscopy or to train general health workers to identify suspected individuals to have TB or leprosy.

On the last and third level are learning or educational objectives. These describe what students should be able to do at the end of the course that they could not do at the beginning. These objectives can therefore be used as the basis of any examination because students know what is expected from them.

In most traditional school responsible teachers do the formulation of objectives, how they are to be achieved and how their outcome is measured on all 3 levels. That is why most traditional education is called teacher centred. The learners just have to do what the teachers prescribe. In good traditional educational good and concrete objectives, in less good educational settings just by summing up the books and articles that must be read.

In PBL a considerable part of the formulation of objectives is done by the students themselves(student centred). The teachers still formulate as concrete as possible the general and course objectives, but the student s formulate their own learning objectives , concrete questions they will research in the library or with the help of other resources.

Instead of listening passively to a lecture, as in a traditional programme, the student now actively seek out what they want to learn. What mostly is presented in lectures in traditional education is now researched by the students themselves.

But this kind of individual work must not seen as a rigid procedure as was already mentioned in the introduction. The students have a lot of autonomy but also on this level other teaching methods will fit in the PBL method. One of the errors too readily made by those initiating a change to PBL is to discard other methods of teaching which for certain objectives to be attained are more appropriate. As an example, learning to measure the nerve function and the degree of sensory loss can be best learned by practice, though PBL may be the appropriate method for understanding many aspects of the problem.

Key issues in the process of formulation of self guided learning objectives

Self-guided learning objectives can be characterised as follows:

• it is a method to find out what you would like to learn.
• it is a choice about the way you like to present your knowledge to the small group
• it is a way of getting feedback as effective as possible.

Students in PBL programmes have a lot of autonomy in defining their own learning objectives as was explained in the previous paragraph . In practice most of students in small groups will define just learning questions (issues) which will guide the self-study. The result of their studies will be notes, copies of the most important pages of articles, books , maybe the information is marked by colouring pencils. But sometimes it is very helpful for the understanding of what you like to learn to think about the product of your learning process. There are more possibilities than making notes and colouring important sentences. We will introduce a systematic approach that helps the student to find his way through questions to learning resources and to make decisions about the end result of this study. We take a new case from TB, the case of the clerical worker, and the case of Olumide, which was described in the "Do it yourself excercise"

Clerical worker

A male clerical worker, aged 28 years, from a large town in Nigeria had been feeling tired for four weeks. He had a cough for the same time, which produced sputum, which was white. He also had episodes of diarrhoea. He said to the supervisor that his clothes did not fit properly any more, he thought that he had lost a lot of weight. He was afraid to go to see a medical officer and so had been to a traditional healer who gave him medicine, which made his diarrhoea worse.

Small groups suggested the following additional problems, and suggested a number of possible explanations and causes, using previous knowledge. See Table 4

The discussion about learning questions resulted in the following list:

The application of a method to formulate the learning objectives.

The student must take these (or some of these) questions as a starting point. He can write his questions in column 1 of Table 6. "Process of the formulation of self guided learning objectives".

With the help of this table he may be able to formulate the outcome of his self directed learning as concretely as possible in advance. When learning questions are rather difficult this could be of great support. It will help him not to get lost and to end up somewhere else or to drown in to many irrelevant details.

But before we take the first question, we like to explain the table "Self guided learning objectives" more in detail.

• In column 1 the student writes the questions he likes to study. Maybe it is one question ore more. This is the result of the decisions during the group discussions. For our explanation now we consider all the questions of "Olumide" and the "male clerical worker."
• Column 2 consists of two parts. The student has to consider what sort of questions he has to study (a). Some questions are just factual which means that the relevant facts have to be found. But sometimes the questions refer to, to take another example to compare TL with LL in leprosy. This means that if a student is able to decide what kind of questions he has to study, the sort of study activity is also indicated.(b). List the facts and compare and contrast the two kinds of leprosy.
• Column 3 will help the student to consider the different resources he can use to find answers. This list of possibilities will vary from training institute to training institute. But it will help the student tremendously when the relevant resources for the problems are indicated.
• Column 4 list the sort of end products the student can choose to present his findings to the other students. This choice is highly dependent on the sort of question and the way the question is studied by the student.
  • Column 5 list the different possibilities for the small group to evaluate the quality of study and learning. During the group sessions the student will get some feedback of other students, maybe of the tutor. This kind of information will help him to decide whether he is doing well or not during his individual studies.

Now we will work out this method with the help of the learning objectives concerning Olumide and the male clerical worker.

The first question; " What is the mechanism of cough? (question 1) Now we are talking about a mechanism. Mechanism is a process. (column 2a). If you like to study a process you have to analyse the most important features of the process and describe these step by step in a logical sequence. (column 2b) . For example; if a patient has a respiratory disorder, it may be due to pneumonia. Pneumonia subsequently obstructs the airway, then the cough reflex is activated.

In the same way question number 3 can be studied because. Sputum increase is a process, which must be analysed and described.

What is the significance of white sputum.(question 3). Is this normal or abnormal? If it is abnormal, how abnormal is this. So students must consider the importance of this and discuss their reasons or arguments for the significance.

"What are the causes of diarrhoea?(question 4) Causes means causation, which means that there is cause and an effect. So the task for the student is to make a distinction between possible causes for diarrhoea and then to list them.( Column 2 part b). If these causes have more effects than only diarrhoea, these effects should also be listed and described. In the table above three causes were hypothesised, Aids and traditional medicine and drug treatment. Maybe more causes will be found when the student studies diarrhoea.

Table 6. Process of the formulation of self guided learning objectives

What is the relationship between diarrhoea and TB?. ( Question 5). Maybe we found that TB causes Diarrhoea. (Question 4).But when TB is not always causing this, can we than explain under what circumstances this will happen? Is it possible to draw this relationship?

"Why is the clerical worker afraid to go to a medical officer?". (Question 6). Maybe there is one reason or there are more reasons. In any case when there are more possible reasons , the student has to distinguish between the possible reasons and list them. Maybe he has to cluster the different kind of reasons in categories. Very local reasons, personal reasons for example.

How are the nerve supply and the structure of the bronchi? (question 7). A structure must be analysed like a map. What are the most important components? (roads).

"What is the significance of the lost of weight in a man of 28?" (question 8). Significance has to be estimated, what is the importance: very important, lethal, or not very important. These different estimations have to be discussed with arguments.

Now we continue with the example of Olumide.

Question 1: "What are reactive skin lesions?." These are facts to be studied. The student has to make a list of features of reactions, like swelling, tenderness, redness etc.

Question 2: "What is the change in nerves exactly?" A change is a process. This process must be analysed and a step by step description must be presented what the changes are in the nerves. For example the invasion by leprosy bacilli, then the inflammatory response which causes oedema and swelling of the nerves. And subsequently more steps to the end, the loss of structure by scar formation.

Question 3."What causes the fear for the disease?" We can call this causation. The student can list now the different causes. For example: He sees disabled old people and the effect of this is that Olumide may think that he will end up as a disabled person as well.

Question 4: "Is the fear for permanent disabilities justified?" What are the reasons that support justification, and what are the reasons that are not supporting this justification. So the student has to distinguish different kinds of reasons for fear. For example "Yes" when the reactive phenomena have occurred for more than half a year. The reasons for "No" because treatment can cure leprosy and reverse disabilities and thus prevents ending up deformed. During their studies the students may try to find the facts that support these different justifications.

Question 5 and 6: "Can reactive skin lesions occurred by chemicals and drugs?" The different reactions of both must be compared and contrasted.

Question 7: "How does the normal skin look like?" If the student likes to know this he can describe this succincly, or when necessary more extensively.

Question 8: "Is there a relationship between stroke and clawing of the fingers?" The student must explain if there is a relation and how this relation exists. For example, if the stroke is the end result of a bleeding of the brain, this results in the damage of the brain cells. But only if the affected part of the brain controls the function of the forearm, the nerves will not send signals to certain muscles and subsequently other muscles may cause bending of the muscles. Thus there is a relation between stroke and clawing of fingers but only under specific circumstances.

Resources

The most important resources are

• The library
• Experienced people
• Subject experts
• Fieldwork

In the library, books and articles from journals are the most appropriate for self-directed learning.

Many students, in traditional teaching programmes read textbooks from the first chapter to the end, but this is wholly inappropriate in PBL. Books and articles are still the most significant resource for students' self-directed learning, but they have to be used appropriately. Because students like to find an answer on a question, or a very specific subject, the use of keywords helps them to find their way through the books and articles. If students want to study the case of Olumide, important keywords are, clawing of hands, foot drop, and skin lesions. To find information on these subjects the student must use the index of the book to search for the subjects. For example " Leprosy" edited by Robert.C. Hastings. Under claw(ed) the student will find several pages dealing with this subject. Pages will also be found on foot drop. If the student searches for skin lesions he will find a lot of information about skin, not about lesions. But with the keyword lesions more specific information will be found in this book concerning the problem of Olumide. In this way the student can go through the different books and articles to collect enough and valid information to help them to give an answer on his question.

But other resources like books and articles are important in the library as well. Self-instructional units, audiovisual materials and all kind of specific documents will help the student to benefit from these learning materials. The students must become familiar with all these resources in order to get the best answers to their questions, and thus the best of their hard work.

It is important to give every new student an introduction in the use of the library and its facilities. And the study result will become very promising. Investigations show that students use these facilities in a PBL environment more than 5 times more than in traditional learning environments. These investments will pay back during PBL courses.

Information gathered from experienced people. Other sources than the library are important as well. Let us take the learning question "Why is the male clerical worker afraid of going to a medical officer". Maybe the student will find some literature on this subject in the library. But in a specific community, the consultation of somebody who has experiencewith these phenomena is quite helpful. Students can go to see such persons and interview them on their experiences with people who are afraid to see medical officers and prefer to go to local healers when they don't feel well.

Other specific questions may come up during the tutorial sessions. After elaborate studies and discussions it is possible that the group can't find a valid answer to some questions. Tutors are not always able to help them, since they are not always the experts in specific areas (see Tutor Expert versus Non-expert tutor) . For such reasons the consultation of an expert will be fruitful. Such an expert can be invited for one of the group meetings, or a small delegation of students discusses the issue with the teachers and reports back to the group. The teacher can also be invited to present a small lecture on that subject. For such a presentation also other interested people can be invited.

But students also can get outside the training institute themselves. They can observe what happens in dispensaries, they can interview patients and health workers or do some other small investigations.( Fieldwork).

The product or results of self directed learning

results of self-study can be:

• Individual notes
• presentation
• literature review
• essay
• tables, figures and diagrams
• knowledge box

Mostly the products will be individual notes the students make, or copy of the most important pages from books, articles etc, which are used to explain to the other members of the group.

But other products can also be sometimes very useful. Maybe a student will make a small presentation to the others. After the self-study the trainee will collect the important information from the different sources and present this in a systematic way to the other trainees. For example question 1 an 2 from the case of Olumide, reactive skin lesions and changes in the nerves can be explained to the other students in a presentation of important facts and the process of change. When necessary the student can use black or white boards, overhead transparencies etc.. Other members can make notes and discuss the value of the information for answering the question.

In some cases one or more students are invited to make a small literature review. A literature review is a summary of the most important articles on a specific subject: it governs the most important questions and what is found in the different studies in order to get an overview of this subject. For example ""Fear for leprosy". Maybe some students can make a small literature review of the most important articles on this subject, to present to the other students.

An essay refers to any piece of writing that analyses or interprets something in a personal way. Especially when values are involved writing a small essay would be a marvellous product to convince other trainees of a point of view. An example for an small essay is "stigma in leprosy"", written by a student see below

A small essay on stigma.

(Written at a training course by a leprosy supervisor from China.)

Even though leprosy has been well recognised as a chronic, infected skin disease caused by M.leprea and can be cured by MDT at present, it still has a lot of social problems, of which stigma id the most important.

Leprosy is unique in its psychosocial aspects.

Its mortality is low. It is not a disease that causes much pain. It allows its suffers a considerable degree of normal activity, and often apparently normal health. But why is the disease so apart? Why has it been more feared than the killing diseases like tuberculosis and hepatitis? We are convinced that the horror and the dread of leprosy are rooted in its deformity. It is thought as a loathsome disease, an unclear disease. Perhaps for this reason leprosy has commonly been considered to be a punishment from God. To the average person the mention of the word "leprosy" conjures up the thought of missing fingers and toes, of open soles and of a deformed face. Even a patient without disability, by the time he has become bacteriologically negative, and is carrying a certificate to say that he is not infectious, he or she still is not accepted to live a normal life by the community in a number of areas in the world. There is no other disease so associated with stigma and fear.

The attitude of the society towards those suffering from leprosy has given rise to many unfortunate incidents of insult, rejection and even murder of patients ,and in some societies these still continue. As for the patients themselves, these respond in various ways to the attitude society takes towards them. Many of them submit and accept while others take an attitude of unjust persecution, but those who have not yet suffered from this disease do not want to be treated as they had been. They are afraid of being diagnosed as leprosy when they have any early suspected signs. Probably for this reason, many cases are detected very late and with disabilities, and thus increase the stigma of leprosy further.

The best solution of stigma in leprosy is to intensify health education tot he patient and public by demonstrating examples of those patients who were detected early without any disability and were cured successfully. They can be presented as normal people, even in their appearance on the one hand, and to promote technical training of medical workers, making them aware of early signs of the disease on the other.

In conclusion, the whole society, including the medical profession, should be fully aware that leprosy is not only a curable disease, but its disability is also preventable if patients have been early detected and treated timely and appropriately.

Tables and figures. When a learning question is "What kind of drugs are available in leprosy and what the dosages are a small table will show the possibilities in a very effective way. See table below.

When a learning question is, "What is the relationship between age and incidence rates?", a student can present his study result in a figure. See figure below

Click on the figure to enlarge

Sometimes a diagram illustrates relationships very clearly. In such a presentation one can draw with lines the different relationships or mechanisms. If we take the case "The clerical worker with a cough" again in our mind (Clerical worker), the student can make a diagram of this problem. He must take the following into account, during the self-study.

• What are the most important concepts?
• What are the relations between these?
• Start with the concepts on a piece of paper and try to indicate the relations with lines and arrows
• Try to confine yourself to the core issues

Let's take the example of cough and the hypothesised cause pneumonia. See Diagram below.

In a Knowledge box all the information of a very specific subject is gathered. This is new term but we think that it is useful because students wish to use it to help their studies. For example it could contain a summary of chief properties of a drug or of major points in a disease. For example:" What is known of about the drug rifampicin. A small knowledge box is an elegant format for all kind of "short memo's" somebody can write in his diary to read when this is necessary.

See an example of a knowledge box on the drug rifampicin below.

Knowledge box

Rifampicin

• The most effective anti-leprosy drug
• antibiotic, bactericidal
• dosage 600 mg adults, 10 mg/kg children, once monthly
• available in capsules of 150mg and 300 mg
• should be taken on an empty stomach
• has to be administered under supervision and under tight schedule
• should be used in combination drug regimes: not recommended in the first trimester of pregnancy

Side effects

it rarely gives side effects if given monthly, but it may cause

• "flu-like" syndrome (intermittently, chills, fever, headache, muscle and bone pain)
• hepatotoxicity (note: anorexia, nausea, vomiting, jaundice)
• effects on the metabolism of other drugs
• reddish-orange to reddish brown discoloration of urine, faeces, salvia, sputum, sweat and tears.

If serious complications occur, such as thrombocytopenia, purpura, renal failure, or haemolytic anaemia, treatment should be stopped at once and not reinstituted at a later date.

Sources

Leprosy, edited by Robert c. Hastings, Churchill Livingstone 1985

Leprosy, Anthony Bryceson and Roy E. Pfaltzgraff. Churchill Livingstone 1990

Leprosy for medical practitioners and para-medical workers, R.H. Thangaraj, and S.J. Yawalkar (1987)

Guidelines for writing a Health Workers Manual for Leprosy Control Volume 1

ILEP medical commission Leprosy Control Discipline 1994

Evaluation of the "self directed learning"

In the last column (5), evaluation, of the table 'Process of the formulation of self guided learning objectives', the tutors/facilitators and the group itself have to raise the question," What is the quality of these self directed studies? Of course the first question is whether the gathered information makes it possible to answer the different learning questions. Does the tutorial group have a better understanding of the problem that was presented to them at the beginning? Or can they solve the problem?

But other aspects of the study must be considered as well. In tutorial groups one can expect that the contributions of the group members will differ. Some students are better able to guide their own study then others do. Students will react to the contributions of their fellow students (peer review), but important for the facilitators is to evaluate the different contributions from time to time. The students must become familiar with the skills and resources needed to keep up, so that when they see that students have problems in keeping up, they need to be able to help those who are in difficulty.

This process of looking back to the activities of the learning group is called evaluation. Is the group reaching its goals? Is every student making an adequate contribution? What are the hindrances in the ongoing process?

From time to time it is necessary to make these "stops", to see how things are going in the group before deciding how to proceed.

Sometimes the group itself, with the help of the facilitator can perform these evaluations. The group can decide itself in the last step of the 6 steps in PBL (synthesis), whether they can answer the learning questions, and have a better understanding of the presented problem. The contributions of the different members of the group can be judged in this context. But sometimes it is necessary that the facilitator takes initiative to evaluate an individual student and than tries to help him to improve his learning. Specific study assignments are used to focus the learning on core activities in PBL. For example how to find important literature, and how to study the most relevant issues in order to understand the patient problem better.

Lets us give some examples of how the group itself will do some evaluations, and how a tutor will evaluate the contributions of different students. (tutor evaluation)

In peer group evaluations it is sometimes desirable that members of the group must say something about the way they observe other student's work and behaviour. This kind of feedback is not always easy to give or to receive.

First of all, acceptable feedback is highly depended on the climate in the group. If the communications are open, it is more easily to convey personal impressions and observations to the fellow students, than in groups were the climate is less comfortable. But students must always beware of putting things in a straightforward manner. Like: "I think you always talk to much!", or, "You don't understand the question!" It is quite possible that a student feels accused and will become defensive. Besides there are cultural differences in the different countries. What is acceptable in one country is not acceptable in another country. Maybe one advice is dedicate. Avoid judgement on the work of others, don't be didactic, or make moral observations. Feedback is most effective if you just describe what you observe or feel. Or just tell other students what kind of effect their behaviour has on you. These are very subtle but important processes in a learning group.

Tutors also have opportunities to help the students, if they show weaknesses in the self-study. If some students have difficulty in their learning specific study assignments will help them to get more experience in using the library and other resources.

The tutor can select a specific topic, for example "the treatment with prednisolone in leprosy". The student is invited to go to the library and find references on this subject. The tutor may also add some questions the student must answer. For example: "When do you prescribe it?", "What are the guidelines for a leprosy programme?", and "What are the advantages and disadvantages of prescription in the hospital and in the field?" The product of study could be a small literature review, or a tutor may invite the student to make a knowledge box on subjects like footdrop, lamprene etc.

An effective way of assessing students' competence at self directed learning in a more complete way is the "McMaster's Triple Jump" test. A special patient case is presented to a student

• Step 1: The student reads the problem and discusses his first impressions with the tutor/facilitator. He then selects issues for further learning and decides what additional information is needed.
• Step2:The student uses any relevant sources of information to tackle the problem during private study.
• Step3: The student reports back his findings. The tutor provides feedback on the way in which the student has used the resources and tackled the problem.

Closing Remarks

This chapter on the facilitation learning seems to be rather complicated for tutors and students. But we believe it addresses to core of learning. Students may learn to be very analytical when they study real problems. What are the different sub problems, and what are the important issues inherent to these patient cases. The students are invited to be very active. They can generate possible explanations and define the most important learning issues. But this is not always as easy as it looks like. Students need good challenges, thus the tutor must present valuable patient problems, which allow student to study the real matters. And they need a lot of support to become independent learners. They learn from each other but sometimes they need some extra guidance perform well in the self-guided learning. We believe the process of formulation of good learning objectives will help the students to hit the bull eyes in their learning issues. It seems complicated but after some exercise and guidance of good tutors it will help the student to become critical and creative students.

Of course it is not necessary to follow all the steps in a rigid sequence. But sometimes it can be very helpful to follow this analytical process step by step, so that the gathered information can be brought together in the best possible way. It helps the student to tackle the study problems in a logical and effective way, to make sure that he really gets really answers to his questions. Study skills are the backbone of effective PBL. It is the responsibility of good facilitators to help the student to master these skills. Study assignments and the evaluation of these helps to diagnose the problems students have in studying patient problems. This makes it possible to advise them how to improve these study skills.

Do it yourself exercise 2

The increase of TB

The medical officer in charge of a hospital was whiting the 1998 annual report. She compared the data of 1998 with previous years and saw that the total number of patients admitted and treated ant the OPD for TB had clearly increased in the last few years.

How had the hospital coped with the increase? She was interested in finding out how many of the TB patients who had started their treatment at the hospital, were cured. She wondered how to go about it.

Make your own problem list, formulate possible explanations for these problems, and make your list of learning questions. Put your learning questions in Table 6. "Process of the formulation of self guided learning objectives". and use this to find out the sort of questions you have to deal with. When you have finished this, decide what kind of resources you need to study, and how you like to present the result of your self guided study to the group.

You may compare your work with the work of others. See Model answers 1.