E. L. Loschen M.D. and Lark Kirchner L.C.S.W.
Much of the educational programming available for adult learners in staff training programs and even in university programs is passive and lecture based. Such programs have been noted to have many problems (Barrows and Tamblyn, 1980). Lectures are efficient ways to transmit information for the instructor, but lectures present major deficiencies for the adult learner. Information is conveyed in a manner that is different than how the learner needs to use the information. As we work with people and their problems, we use information in discrete packets that is appropriate to that problem and typically not discipline based. However, lectures typically present information from a discipline orientation which is not often in the same form that is usable in solving a problem. Problem-based learning is an educational method that uses problems that occur in the context in which the learner works to provide the framework for learning knowledge, skills and attitudes that will enhance the learner's abilities. Barrows and Tamblyn (1980) note that developing such a curricular approach enables the student to more effectively use the knowledge gained in the academic setting in their subsequent work setting. As an educational method it addresses adult learning styles, requires the learner to participate in self directed study, teaches learning management skills, and is based on active problem solving versus passive information absorption. This highly effective method is used in many medical schools throughout the world, and increasingly is being used in other professional educational settings. At Southern Illinois University School of Medicine (SIU) it is used extensively in educating medical students (Loschen, 1991, Loschen, 1997). This method of education is also applicable to a number of other disciplines and now includes entire university programs at Maastricht in the Netherlands and Roskilde in Denmark, and most recently is being adapted for high school students in several settings in the United States (Barrows & Kelson, 1995). Mentoring is an interpersonal relationship between two individuals who are at different stages in their professional development. Mentoring is often used in business environments and other areas including medical schools, social worker, and other health professions.
In Illinois, there was concern expressed at several levels that information about psychiatric disorders in persons with developmental disabilities was not being taught adequately in more traditional approaches to staff development training and often old information about developmental disabilities was still being applied to this population both in state operated facilities and in community programs. Additionally, we hypothesized that often personnel do not get the experience of mentoring with disciplines who have an expertise in this arena. The Southern Illinois University School of Medicine Department of Psychiatry's Division of Developmental Disabilities (Division) adapted the problem-based learning (PBL) approach for use with community organizations and state facility personnel who work with individuals with a dual diagnosis. These concerns led to the Division's development of curriculum and educational activities with the support of the Illinois Department of Mental Health and Developmental Disabilities (IDMHDD).
The total project has been under development for three years with major support provided by IDMHDD. The initial project year focused on information gathering, concept formation and preliminary educational activities with two local community-based agencies which volunteered to participate in development of a curriculum for mental retardation professionals and direct care staff. The second year focused on the development of two major cases for the instructional program and pilot work with adapting the problem-based learning approach to instruction with these groups. The third year focused on the full development of the problem-based curriculum using both the complete cases and the use of more limited case scenarios.
The initial project year involved selecting two large Midwest community providers who agreed to have their case-managers, primarily qualified mental retardation professionals (QMRP's) and selected clinicians, participate in an educational program that would focus on individuals with a dual diagnosis. Both organizations provide services to individuals with developmental disabilities in a variety of service settings including residential, vocational, and case coordination services. The planning efforts were done in conjunction with SIU faculty clinicians, the agency training personnel, agency clinical staff, and agency administrators including the executive directors. These planning sessions were held to determine what outcomes the organizations identified as pertinent to the job responsibilities of their personnel.
General course goals, objectives and curricular areas for the course were designed that were mutually agreed upon between SIU faculty and the agencies. Some of the objectives and curricular areas included: how to do an intake regarding individuals with psychiatric disorders including a level of safety risk assessment; terminology associated with understanding psychiatric assessment and intervention; myths and stereotypes about mental illness; how to use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1994) in the QMRP's work; how to administer, select, and understand specific structured assessment tools; how to do and use a social history; understanding the purpose of specific psychiatric interventions such as psychotropic medications and the use of psychotherapy as these interventions related to specific Axis I diagnoses; how to recognize mental illness in individuals with developmental disabilities; a basic understanding of the various categories of Axis I diagnoses and their symptoms as well as the presentations often seen in this population; and the role of various members of the psychiatric team in assessment and intervention. Also included in the course content and very important to the problem-based method of education was the identification of how to approach a clinical problem. In order to develop these self directed learning skills, the curriculum addressed the specifics on how to develop hypotheses, identify learning issues, identify objective data or facts, and to develop a plan for problem resolution. Included within this process was identifying educational resources such as libraries, Internet, experts, various publications specific to these topics and how to critique the learning resources.
The program design for each of these agencies consisted of six to eight weeks of on-site didactic sessions with each session lasting from two to three hours for a total of 16 to 20 hours of classroom learning. Prior to the classroom experience the faculty worked with the organization's clinical personnel and selected some cases that would be representative of the teaching objectives for the didactic sessions. An overview of the course was designed to organize the topics into an order of presentation for ease in planning. This included leaving a great amount of latitude for time to learn and to present topics which would surface during the learning sessions. These didactic sessions were conducted as small discussion, tutor group sessions with extensive interaction between the "students" and the instructor or "tutor." Also planned within the context of the eight sessions were selected topics that would be explained in depth by various experts. These topics included how to administer specific assessment tools; functional assessment; psychotropic medication and psychotherapy; overview of the mental status; and the DSM-IV and the multiaxial diagnosis system. This planning approach also assisted in selecting resources to bring to the group learning sessions and to be able to schedule specific expert resources for their presentations.
The didactic groups were divided into smaller learning groups or "tutor groups" and were given basic information about the process of identifying hypotheses, learning issues, objective data (facts), and developing a plan. Learners were also asked to identify their personal learning objectives and were asked to evaluate if they completed these at the conclusion of the didactic sessions. Faculty were the tutors or facilitators for the smaller groups.
The groups presented the case problems and using PBL techniques, learned how to develop hypotheses, identify the relevant facts and data, specify learning issues, and develop action plans for the problem and for the learning issues. These specific techniques were used consistently throughout the eight weeks. Numerous learning issues were documented relevant to all areas of the overall course objectives. Specifically, learning issues identified by the participants included assessment techniques including formalized assessments, taking a social history and applying the content diagnostically, identification of diagnostic hypotheses, recognition of symptom presentation, identifying psychiatric interventions, and being able to apply a clinical knowledge base for the selection of the interventions including pharmacological management and therapy.
Following the didactic sessions, the personnel were divided into smaller groups and worked onsite in the SIU clinics for a total of 20 hours. This experience was a mentoring experience and also used "in vivo" learning. The personnel were assigned to SIU clinical faculty where they worked on specified discrete learning tasks and worked in clinic with assigned patients under the direct supervision of SIU faculty including the attending physicians. Specific objectives for the clinical experience were designed within the context of the overall objectives. Some of the guided practice during the clinical portion included: doing intake, completing or observing portions of a mental status examination, presenting a case, identification of diagnostic criteria with use of the DSM-IV, selection of an appropriate treatment approach while providing support of a substantial rationale, obtaining data regarding symptoms, evaluating efficacy of current treatment, and reviewing pharmacological management issues. A total of 22 people participated in training during this first year project.
In the second year, these approaches were consolidated and extended. The next stage in the provision of this educational model included developing Problem-Based Learning Modules (PBLM's) using real patient problems with the copyrighted PBLM case format developed at SIU (Distlehorst and Barrows, 1982). These cases and other standardized patient cases were used with 16 advanced clinicians from Illinois state-operated Developmental Centers and from community organizations. Clinicians were paired with Division faculty and other Department of Psychiatry personnel for guided practice during the Division's outpatient clinics. The clinicians-in-training received "hands on" experience. They were, with guidance, able to assist with mental status observations and discuss the elements of the psychiatric assessment with faculty supervisors. This approach provided the learners with a safe learning environment and an opportunity to practice hypotheses development skills. Learners received immediate feedback and could correct their approach and were reinforced for positive use of applied skills. Clinical skills outcomes included intake practice, mental health assessments, observation and practice of the mental status examination, formulation of diagnostic impressions and the differential diagnostic process, use of assessment tools for dual diagnosis, use of the DSM-IV, treatment plan development, and collaboration with residents, medical students, and other professionals.
In year three of this project, the full problem-based curriculum for QMRP's was developed and implemented. Twelve persons received training as a result of this curriculum. Master QMRP trainers designated by IDMHDD were included as part of their ongoing "train the trainer" QMRP curriculum. In addition to the activities of year two, a fully self-contained manual using the developed PBLM's and additional more limited case scenarios was written and used in the training. This manual uses the problem-based approach throughout and serves as a "tutor guide" for the faculty facilitator. Each case scenario is carefully chosen to create the opportunity for the student to identify relevant learning issues appropriate to the care of persons with a dual diagnosis. These participants also attended a mentoring session conducted within the SIU outpatient Special Needs Clinics.
Subsequent to these formalized educational experiences, IDMHDD requested the Division to present monthly case based conferences in Central and Southern Illinois. The Division used a similar problem based method to introduce many of these similar concepts using crisis cases selected by the service network within the IDMHDD system. By organizing these four hour conferences in a problem-based format, it offered a physician, social worker, and psychologist the opportunity to model the multi-disciplinary approach to working with persons with difficult problems.
As a part of the project, each trainee in year three of the project was asked to evaluate the program using both structured and open-ended questions. The questionnaire consisted of seven questions asking for ratings of the experience and 12 open-ended questions asking about both the quality of the program and an assessment by the trainee about their own strengths, weaknesses and needs as a result of the program. Open-ended questions were categorized into response sets by one of the authors and frequencies of responses counted. For a list of items used in the evaluation see the Appendix.
Experience with the problem-based learning method in this arena demonstrates that similar learning issues and concepts will be identified between various groups of students. During years one and two, the feedback from clinicians was excellent although easily quantifiable data is not available. However, one organization extended the approach developed during year two and developed case conferences for complex clinical problem cases using PBL methods regarding generation of hypotheses, identifying the facts, establishing learning issues as a means for staff development and identifying a learner plan for the staff and an action plan for the person. Both organizations identified key learning areas that they believed their staff had gained in terms of knowledge. One very specific outcome was the realization that the organizations needed resource materials for their personnel specific to psychiatric illnesses, including the need to purchase DSM-IV's for the staff and to order reading materials.
In the third year of the project, we did, however, collect formal written evaluations from all the participants. Twelve persons completed the training and were very positive in their feedback. On a five point scale (with five being a rating of superior), the average rating for usefulness and content of the materials by the 12 people completing the final evaluation form was a five. Nine out of twelve individuals indicated that the materials studied were either new or a mixture of new and review materials. All trainees responded that course objectives and curriculum goals were met. All trainees felt the material was presented clearly and adequately.
The results indicated that the personnel did learn and acquire information regarding psychiatric disorders in individuals with developmental disabilities. In response to the question asking what learning issues were most realized, nine of twelve trainees identified specific aspects of learning that had occurred. Nine of twelve persons also identified specific learning resources as being helpful to their learning. The specific items mentioned included use of criteria in making a psychiatric diagnosis and the method of making a psychiatric diagnosis using clinical reasoning skills. In response to the question about improvement in clinical reasoning skills, three of twelve individuals mentioned the use of specific assessment techniques and six individuals noted the use of the problem-based learning approach to working with clinical problems. Eight participants felt that the tutor's provision of a role model was most helpful. Eleven persons felt that they had interacted with the tutor group in a positive manner.
The feedback from participants during all three years was excellent. The combined methods of PBL and mentoring provided needed information about individuals with dual diagnosis while concurrently providing the learner with self-directed learning techniques. This advantage is clear and affords the practitioner with tools necessary to continue learning especially as information becomes more available and is complex in nature. The mentoring opportunity provides clinicians with immediate feedback and the possibility of affecting clinical practice outcomes for individuals with a dual diagnosis.
Too much of the staff training that we provide is passive and lecture based in format. We present information in condensed, distilled packets within relatively brief periods of time. Most often the information is presented in ways that are not immediately useful to the trainee. For example, we often give lectures on diagnostic categories such as "schizophrenia." However, recipients of services do not typically appear with a label attached to them. Most often they present with some type of disturbed behavior such as aggression or self-injurious behavior. The problem with this is, of course, that such symptom complexes may be symptomatic of any number of disorders including schizophrenia. The staff person is then left to sort through any number of concepts gathered from lectures in an effort to understand this recipient's problems. This is not how experts reason or think about problems. As has been described by Barrows and Tamblyn (1980), the expert starts with the problem and identifies an inquiry strategy to gather data to support or refute a number of hypotheses. The expert calls upon a wide divergent set of concepts in developing this set of hypotheses and the resulting inquiry strategy. The expert typically seeks to learn new knowledge in the same way, i.e., by hooking concepts to problems that the expert has confronted. If we wish to have staff behave more professionally in their clinical work, then it only makes sense that we educate them in that way.
We have found in medical education (Barrows, 1986, Loschen, 1997) that the use of problem-based education is highly motivating to the trainees involved. Students typically enjoy the approach because it puts them in charge of their own learning, and because they are working with real problems from their chosen field, they typically feel that the approach is pertinent and relevant to their personal needs. This study clearly extends these findings to working with QMRP's and other professionals working with individuals with a dual diagnosis. By motivating our staff to learn more about the individuals they serve and to use the techniques of self-directed learning, we also have an impact on the quality of life of those persons we all serve. PBL is a technique that meets those goals effectively and efficiently.
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Loschen, EL (1997), Student-centered, teacher guided medical education, Placing the Student at the Center: Current Implementations of Student-Centered Education, Maastricht, the Netherlands: Maastricht University, 129-133.
Earl Loschen, MD
Department of Psychiatry
Southern Illinois University
751 North Rutledge Street
Springfield, IL 62702