During problem-based learning, medical students analyze, in teams, a real-life case scenario, step-by-step, as if they were seeing the patient themselves. How does this play out specifically in an international medical school?
At IMS-Milan, this month, we began problem-based learning (PBL). It is a technique that we will be using throughout our six years here. PBL is growing in popularity in medical schools worldwide. Stanford University describes it as “work with classmates to solve complex and authentic problems that help develop content knowledge as well as problem-solving, reasoning, communication, and self-assessment skills.”
I had seen PBL in action for three years while I was working as a researcher in the Emergency Department of Columbia University Medical Center/New York-Presbyterian hospital. Every day at lunch, medical students and residents would gather together to discuss a particular clinical case. One person would present the patient’s signs, symptoms, and context, and the residents and students, as a group, asked questions, trying to determine what the patient had and how to treat it. The atmosphere was not all that different from what you might see in an episode of House, when the doctors sit around the conference room and do a differential diagnosis, guessing whether the patient has sarcoidosis, lupus (they pretty always included one of these), or something else.
Our professors here at IMS-Milan have created a version of PBL, tailored to the international environment, and integrated into our curriculum. This week, we were split up into groups of about 15 students, each with a tutor. My group’s tutor was a researcher in auxology, the study of human growth. We were then given a case study about a patient in her family and cultural context. This case study came from the US National Center for Case Study Teaching in Science at the University of Buffalo, so it has been tested repeatedly to ensure that it is realistic and well thought-through. Our particular case had 5-alpha-reductase deficiency, a genetic condition which usually results in the individual showing, as a child, various varieties of genitalia, with a male gender identity emerging at puberty.
5-alpha-reductase deficiency tends to occur in relatively isolated populations in the Dominican Republic and Papua New Guinea. Like many diseases, it raises important questions about culture. How might a patient, her family, or her community react, when, during puberty, she transitions from a female to male gender identity? How does the clinician respond? The many ways that our group treats these questions is going to depend on the diverse cultural backgrounds of the students.
No medical school is monocultural, but there are degrees of diversity, and on that spectrum, IMS-Milan is about as diverse as just about any school in the world. In a, say, Japanese, Latvian, or Peruvian medical school, you will probably find, respectively, mostly Japanese, Latvian, or Peruvian students. Even at an internationally-ranked English-language institution like Columbia, you will find mostly American students, even though among them a number of different cultural backgrounds may be represented; Columbia, therefore, might stand somewhere in the middle of the spectrum. In all of these institutions, of course, students are able to think creatively, and they turn out to be fine doctors and team-players.
However, IMS-Milan has 23 countries represented among 47 students in our first-year class. The only school that I know of which is as culturally diverse as IMS-Milan is, perhaps, the excellent Medical School for International Health in Beersheba, Israel (to which, by the way, I considered applying). (I ultimately chose Milan for a host of reasons, which I would be happy to explain. if readers like.) Our diversity made for a unique experience of PBL.
My fellow students, in our group, expressed a range of analyses of the socio-cultural context of 5-alpha-reductase deficiency. That range is probably greater than what would come out at even a Columbia PBL session, and this is where IMS-Milan really shines. Someone, like me, who wants to work in international health, is exposed at IMS-Milan immediately to attitudes, about health and disease, from all around the world — and not just from professors and lecturers, but from my fantastic fellow students, who surround me in the classroom every day.
In PBL, after being given a case summary, we drew up a list of questions that it raises. We then spent about a week researching them as a group, trying to gather as much information as possible. We then returned to a new session with our tutor and delivered our findings, as she talked us thröugh them and presented new questions. The whole point of engaging in this discussion is to learn to find the best resolution to the complex social and scientific problems involved in medicine, informing them with different viewpoints. A third session, will follow, a week later, in which an expert on the disorder will present a lecture filling in details that we may have missed.
We had a separate case study this week on the use of 2,4-dinitrophenol, a dangerous drug for weight loss. The case was made directly relevant to our own lives as students, as it involved a collegiate wrestler who was taking the drug to try to make weight for a tournament. This time, we were not asked to draw up our own questions, but rather given a set of related problems to try to solve as a group. This is not quite PBL, but rather a guided form of worked examples. Worked examples are particularly useful in the early stages of medical education (such as ours, this being the first year), because they help provide information that we may not yet have gained through our theoretical study of traditional subjects like anatomy, histology, or pathology.
It being a perfect northern Italian spring day, we took the problem outside to the lawn in front of LITA, home of the IMS. I, for one, was able to think more creatively in the fresh air — and have a more relaxed rapport with my fellow students. The point of PBL and case-based learning is ultimately to think creatively, in teams, about medical problems. For, when we are finally doing our clinical rounds — and when we are practicing physicians — we are going to have to be able to cooperate, reconcile our viewpoints, and come up with novel solutions to medical problems that we may never have seen before.