Effect of a community oriented problem based learning curriculum on qu
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《英国医生杂志》
1 McGill University, Montreal, QC, Canada H3A 1A3, 2 McGill University Health Centre-Montreal General Hospital, L10.520, Montreal, QC, Canada H3G 1A4, 3 Medical Council of Canada, Ottawa, ON, Canada K1G 3H7, 4 Clinical and Health Informatics Research Group, McGill University, 5 Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada J1K 2R0, 6 Centre d'évaluation des sciences de la santé, Université Laval, QC, Canada G1K 7P4
Correspondence to: R Tamblyn robyn.tamblyn@mcgill.ca
Objective To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease.
Design Historical cohort comparison study.
Setting Sherbrooke University and three traditional medical schools in Quebec, Canada.
Participants 751 doctors from four graduation cohorts (1988-91); three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151).
Outcome measures Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice.
Results After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition.
Conclusion Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.
Tamblyn RM. Is the public being protected? Prevention of suboptimal medical practice through training programs and credentialing examinations. Eval Health Prof 1994;17: 198-221.
Whitcomb ME. Research in medical education: what do we know about the link between what doctors are taught and what they do? Acad Med 2002;77: 1067-8.
Albanese M. Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills. Med Educ 2000;34: 729-38.
Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med 2000;75: 259-66.
Norman GR, Schmidt HG. Effectiveness of problem-based learning curricula: theory, practice and paper darts. Med Educ 2000;34: 721-8.
Dolmans D. The effectiveness of PBL: the debate continues. Some concerns about the BEME movement. Med Educ 2003;37: 1129-30.
Farrow R, Norman G. The effectiveness of PBL: the debate continues. Is meta-analysis helpful? Med Educ 2003;37: 1131-2.
Morgan W....but not all do. BMJ 1995;311: 1643.
Patel VL, Groen GJ, Norman GR. Effects of conventional and problem-based medical curricula on problem solving. Acad Med 1991;66: 380-9.
Des Marchais JE. A student-centred, problem-based curriculum: 5 years' experience. CMAJ 1993;148: 1567-72.
Des Marchais JE, Dumais B, Lacombe G, Charlin B, Chamberland M, Grand'Maison P, et al Learning to become a physician at Sherbrooke. Maastricht, Netherlands: Network Publications, 2001.
Grand'Maison P, Lescop J, Rainsberry P, Brailovsky CA. Large-scale use of an objective, structured clinical examination for licensing family physicians. CMAJ 1992;146: 1735-40.
Tamblyn RM, Lavoie G, Petrella L, Monette J. The use of prescription claims databases in pharmacoepidemiological research: the accuracy and comprehensiveness of the prescription claims database in Quebec. J Clin Epidemiol 1995;48: 999-1009.
Wilchesky M, Tamblyn R, Huang A. Validation of diagnostic codes within medical services claims. J Clin Epidemiol 2004;57: 131-41.
Tamblyn R, Abrahamowicz M, Dauphinee WD, Hanley JA, Norcini J, Girard N, et al. Association between licensure examination scores and practice in primary care. JAMA 2002;288: 3019-26.
Salive ME, Guralnik JM, Brock D. Preventive services for breast and cervical cancer in U.S. office-based practices. Prev Med 1996;25: 561-8.
Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, et al. Preventable hospitalizations and access to health care. JAMA 1995;274: 305-11.
McGavock H, Wilson-Davis K, Niblock RWF. Unsuspected patterns of drug utilization revealed by interrogation of a regional general practitioner prescribing database. Pharmacoepidemiol Drug Saf 1992;1: 73-80.
Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997;31: 529-33.
Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151: 1825-32.
Kurth RJ, Irigoyen MM, Schmidt HJ. Structuring student learning in the primary care setting: where is the evidence? J Eval Clin Pract 2001;7: 325-33.
Haggerty J, Tamblyn RM, Abrahamowicz M, Beaulieu M-D, Kishchuk N. Screening mammography referral rates for women aged 50 to 69 years by recently licenced family physicians: physician and practice environmental predictors. Prev Med 1999;9: 391-404.
Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
Hartert TV, Windom HH, Peebles RS Jr, Freidhoff LR, Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med 1996;100: 386-94.(Robyn Tamblyn, professor1, Michal Abraha)
Correspondence to: R Tamblyn robyn.tamblyn@mcgill.ca
Objective To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease.
Design Historical cohort comparison study.
Setting Sherbrooke University and three traditional medical schools in Quebec, Canada.
Participants 751 doctors from four graduation cohorts (1988-91); three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151).
Outcome measures Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice.
Results After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition.
Conclusion Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.
Tamblyn RM. Is the public being protected? Prevention of suboptimal medical practice through training programs and credentialing examinations. Eval Health Prof 1994;17: 198-221.
Whitcomb ME. Research in medical education: what do we know about the link between what doctors are taught and what they do? Acad Med 2002;77: 1067-8.
Albanese M. Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills. Med Educ 2000;34: 729-38.
Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med 2000;75: 259-66.
Norman GR, Schmidt HG. Effectiveness of problem-based learning curricula: theory, practice and paper darts. Med Educ 2000;34: 721-8.
Dolmans D. The effectiveness of PBL: the debate continues. Some concerns about the BEME movement. Med Educ 2003;37: 1129-30.
Farrow R, Norman G. The effectiveness of PBL: the debate continues. Is meta-analysis helpful? Med Educ 2003;37: 1131-2.
Morgan W....but not all do. BMJ 1995;311: 1643.
Patel VL, Groen GJ, Norman GR. Effects of conventional and problem-based medical curricula on problem solving. Acad Med 1991;66: 380-9.
Des Marchais JE. A student-centred, problem-based curriculum: 5 years' experience. CMAJ 1993;148: 1567-72.
Des Marchais JE, Dumais B, Lacombe G, Charlin B, Chamberland M, Grand'Maison P, et al Learning to become a physician at Sherbrooke. Maastricht, Netherlands: Network Publications, 2001.
Grand'Maison P, Lescop J, Rainsberry P, Brailovsky CA. Large-scale use of an objective, structured clinical examination for licensing family physicians. CMAJ 1992;146: 1735-40.
Tamblyn RM, Lavoie G, Petrella L, Monette J. The use of prescription claims databases in pharmacoepidemiological research: the accuracy and comprehensiveness of the prescription claims database in Quebec. J Clin Epidemiol 1995;48: 999-1009.
Wilchesky M, Tamblyn R, Huang A. Validation of diagnostic codes within medical services claims. J Clin Epidemiol 2004;57: 131-41.
Tamblyn R, Abrahamowicz M, Dauphinee WD, Hanley JA, Norcini J, Girard N, et al. Association between licensure examination scores and practice in primary care. JAMA 2002;288: 3019-26.
Salive ME, Guralnik JM, Brock D. Preventive services for breast and cervical cancer in U.S. office-based practices. Prev Med 1996;25: 561-8.
Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, et al. Preventable hospitalizations and access to health care. JAMA 1995;274: 305-11.
McGavock H, Wilson-Davis K, Niblock RWF. Unsuspected patterns of drug utilization revealed by interrogation of a regional general practitioner prescribing database. Pharmacoepidemiol Drug Saf 1992;1: 73-80.
Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997;31: 529-33.
Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151: 1825-32.
Kurth RJ, Irigoyen MM, Schmidt HJ. Structuring student learning in the primary care setting: where is the evidence? J Eval Clin Pract 2001;7: 325-33.
Haggerty J, Tamblyn RM, Abrahamowicz M, Beaulieu M-D, Kishchuk N. Screening mammography referral rates for women aged 50 to 69 years by recently licenced family physicians: physician and practice environmental predictors. Prev Med 1999;9: 391-404.
Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
Hartert TV, Windom HH, Peebles RS Jr, Freidhoff LR, Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med 1996;100: 386-94.(Robyn Tamblyn, professor1, Michal Abraha)