Internet–based Problem–based Learning: International Collaborative Learning Experiences

Yasuyuki Suzuki ,
Masayuki Niwa ,
Toshiyuki Shibata ,
Yuzo Takahashi ,
Khamboonruang Chirasak ,
Anura Ariyawardana ,
Jutti C. Ramesh ,
Phillip Evans

Introduction

Problem-based learning (PBL) nurtures the ability of learners to solve real-life problems and fosters communication and cooperation among students across a wide variety of disciplines. By adopting PBL in medicine, students—through peer discussion and individual learning—not only actively acquire medical knowledge but also develop logical thinking and experience authentic medical problems through case studies. PBL also promotes the development of communication and leadership skills, which are essential for medical professionals, and motivates students to learn medical skills and develop professional attitudes. While regular meetings in the traditional classroom setting is fundamental to PBL programs, they are constrained by, for example, the requirement for several small rooms and the presence of tutors at designated times. Every medical school has a limited number of facilities and tutors. Moreover, it is difficult for each medical school to prepare and provide a PBL-based curriculum that covers all medical fields.

Such limitations may be overcome by the new communication technologies. Internet technology, for instance, enables students and teachers to communicate with each other regardless of time or place, domestically or internationally. An Internet-based PBL program operated jointly by several medical schools would enable us to provide a unique PBL curriculum that would be difficult to implement in the traditional classroom setting. And students with diverse backgrounds—be they geographical, professional, ethnic, or cultural—would be able to participate in such programs. Similarly, we would have tutors with different backgrounds and experience acting as facilitators and coaches. It is anticipated that Internet-based PBL programs will become a part of the globalization of education.

An electronic mailing list would be a convenient and economical tool for launching an Internet-based PBL program. However, it is difficult to optimize the system, administrate its usage, or analyze the learning outcomes. A web-based PBL system, on the other hand, can be equipped with functions that an e-mailing list cannot provide, including security features, participant profiling, uploading of case scenarios, discussion boards, web-site or journal listing boards, and email notification of new postings.

Here we describe our Internet PBL project, which was launched in 2001 using an e-mailing list system but has since progressed to a web-based system.

Pilot Study: Mailing List-based PBL System

In 2001, we began a pilot study of an Internet-based PBL program in Japan using an e-mailing list (Suzuki et al., 2002a), with the Medical Education Development Center of the Gifu University School of Medicine serving as the center of the program. Students and tutors were recruited nationwide. Mailing lists were prepared for discussion groups each consisting of 10 to 20 students and several tutors. Unlike the regular and mandatory PBL sessions, the groups had a larger number of students and tutors, as it was felt that some of the students would find it difficult to participate fully in the activities but would only read the content on the course web site. From 2001 to 2004, 20 courses were conducted (Table 7.1), all but one domestically and in Japanese. Cases were sent to the participants once a week by email or uploaded onto the web site. The tutor’s guide was supplied to the tutors separately. Discussion took place between students and tutors through a mailing list. After reading each case scenario, students discussed what they found interesting, what they could not understand, and so on from their school or their home. The tutors advised students on how to go about solving the problem, gave comments or suggestions, and shared their own experiences. The course directors and resource persons also offered guidance on learning, provided relevant information and suggestions, and summarized the discussions. Responses could be made anytime.

Mailing List-based International PBL Study

An international PBL program conducted in English through an e-mailing list was launched in February 2002 (Suzuki et al., 2002b). The theme chosen for this first international trial was HIV (human immunodeficiency virus) infection and AIDS (acquired immunodeficiency syndrome), a widespread and serious problem faced by countries worldwide. Course directors and resource persons from Japan and Thailand defined the general objective of the course, designed case scenarios, and prepared the tutor’s guide including suggestions. The general objective of the course was “to encourage and stimulate medical students to continue self-directed learning about basic scientific knowledge on HIV/AIDS, and to communicate with Asian students in English.” Faculty members and student participants came from several Asian countries.

Three different cases on HIV/AIDS were prepared (Figure 7.1). One case scenario was uploaded each month to allow students, some of whom were not proficient in English, sufficient time to work on it. The first scenario depicted a girl in a rural village whose family members were infected with HIV. Her father died of AIDS, while her brother appeared to have suffered a congenital infection. Participants

discussed the case and posed questions. Their interest in the case lay not only in the scientific and medical aspects of the disease but also in the social, economic, and cultural impacts. The resource persons shared their valuable experience, while the course directors provided pertinent information, such as tuberculosis as the major opportunistic infection and the high incidence of HIV infection among intravenous drug users.

The second scenario described a director-general of a health and welfare department who is a policymaker in the HIV/AIDS prevention and control committee. The prevalence of HIV in their countries, the role of the government, the prevention strategies, and the ethics of isolating people infected with HIV were discussed by the participants.

The third scenario portrayed a research physician involved in an HIV vaccine trial. Vaccines, clinical trials, double-blinded studies, informed consent, the economics of prevention, and ethical issues faced by physicians and vaccine developers were considered by the participants.

Web-based PBL System

Although an e-mailing list is a convenient tool for communicating within a group and can be applied in an Internet-based PBL program, as described above, it does not allow one to present the entire structure and content of the course, to include essential utilities for conducting learning activities, to manage a large number of participants with efficiency, or to assess the outcome of the learning activities. To overcome these constraints, we developed a web-based PBL system that we named Rakuichi the Tutorial. Rakuichi refers to the “free market” that was established in Gifu town in 15th century Japan to promote economic and cultural exchange. Every merchant could trade in this market system without requiring authorization or being subject to tax. Our web-based system Rakuichi is built with many functions and utilities (Figure 7.2):

1. The use of user identities and passwords to secure the learning environment.
2. The capacity for any number of groups of any size or kind, which the administrator can set depending on the number and attributes of participants.
3. A space for participants to enter their personal profiles introducing themselves to the group.
4. A case scenario field that serves as the starting point of discussion.
5. A discussion board for participants to post comments and questions and which displays a list and the content of postings made by participants. Discussion can be conducted synchronously, as in chat, or asynchronously at the participants’ convenience.
6. A space for participants to list learning resources, such as web sites, textbooks, and journals.
7. An email notification function that informs all participants of new entries posted on the discussion board.
8. A function to download postings from the discussion board, which only teachers are permitted to use.

The schema of a course is shown in Figure 7.3. After registration, participants enter this system using their user identity and password. Before starting on the course, they receive guidance from the course directors and introduce themselves to other group members. After reading a scenario, they begin to discuss what the problems are and what issues to learn. The tutors give advice to the students and share their own experiences. Learning outcomes or resources are posted on the discussion board or the listing board as shown in Figure 7.2. The course directors sometimes conduct lectures on certain topics. In compulsory courses, assessment is made based on students’ reports and/or the content of their postings. The number of students in a group is usually between 10 and 20, with several tutors and/or course directors facilitating each group. In elective courses, some of the students did not participate fully in the activities of the course and were considered as “read-only members.”

Web-based International PBL Study

During the web-based PBL trial, we conducted an international course “Habit and Disease.” The main theme of this course was oral cancer, the most common form of cancer found in South Asia. In collaboration with our counterparts in Sri Lanka, Malaysia, Thailand, and Britain, we prepared the case scenarios and tutor’s guide and recruited students worldwide. A total of 36 medical and dental students and 12 teachers from these countries and from Japan participated in this program.

Two different cases on oral cancer and the betel quid chewing habit, respectively, were prepared and uploaded onto the web site. A case scenario is shown in Figure 7.4. Students were expected to discuss these learning issues: the etiology and epidemiology of oral cancer; habitual betel quid chewing and the mechanisms of carcinogenesis; oral lesions caused by betel quid chewing; genetic alterations and genes linked to cancer; and prevention of oral cancer through education, chemoprevention, change in cultural practices, and other means. As some of the participants were unfamiliar with betel quid chewing, they not only acquired medical knowledge in the process but also learned about the cultural differences between Asian countries, as shown in Figure 7.5. In the midst of this course, on Christmas Eve of 2004, a huge tsunami devastated countries around the Indian Ocean, and some of the participants could not continue with the program. The emotional bond and the compassion felt for their peers was so strong during this unusual period that it was an unforgettable experience for the other participants.

Advantages and Constraints of Internet-based PBL

We have launched and investigated a series of interactive Internet-based PBL courses since 2001 to overcome constraints encountered in conducting PBL in the traditional classroom setting and to explore the potentials of online PBL for distance learning programs. We began with an e-mailing list because it was easy and relatively inexpensive to set up. However, it was difficult to add to the system other web-based functions. Hence, we developed a web-based system.

Various studies on the adoption of ePBL have been reported. The University of Sydney uses Internet-based PBL in the first two years of its medical education program (Carlile et al., 1998). Internet-based otolaryngology case discussion was found to lead to better acquisition of medical knowledge than the traditional seminar teaching approach (Carr et al., 2002). The learning outcome of students engaging in computer-mediated PBL was reported to be similar to that of traditional PBL (Dennis, 2003). An Internet-based virtual classroom and educational management software were shown to enhance students’ didactic and clinical experiences (Riley et al., 2004). Another study suggested that the interaction between facilitators and students in a web-based PBL environment was more caring and approachable than in the traditional classroom (Schoenfeld-Tacher et al., 2005).

Internet-based PBL offers many advantages:

1. It enables communication between students anywhere.
2. It facilitates learning on a global scale, which promotes not only the acquisition of knowledge and communication in English but also an understanding of the different social and cultural traditions in other countries.
3. It facilitates multidisciplinary learning, which helps nurture the spirit of teamwork and an understanding of the roles of other professionals.
4. It allows students in different academic years to participate in the same activities in a group, which gives them the opportunity to help each other out.
5. It allows faculty members from different institutions to jointly design and conduct unique learning courses, which is difficult to do in the formal curriculum.
6. It allows institutions in remote locations or with limited resources, in collaboration with allied institutions, to adopt this system to complement their formal curriculum.

However, Internet-based PBL has its limitations too, which we must take into consideration when designing such programs. The Internet infrastructure in some countries is still underdeveloped, and the facilities available to different participants may not be consistent. While an Internet-based PBL system would greatly benefit institutions and participants in remote areas, the cost of establishing the infrastructure might represent a heavy financial burden. Further, the different educational backgrounds and life experiences of participants might cause misunderstanding during online interaction. Fortunately, we have not experienced any significant emotional or cultural conflict between participants so far. However, course directors and tutors must take care to adopt an appropriate theme for the program and pay attention to the mood of the discussions. Another problem is that not all members will be active. Some may hesitate to make comments or ask questions on the discussion board and would resign to being mere observers. These participants might be uncomfortable with using the new communication tools. Although participants introduce themselves by posting their personal profiles on the web site, this may not be sufficient to break the ice. Asians generally tend to be more reserved and to not question authority. For some students, a limited command of the English language might be an obstacle. Ice-breaking activities to promote communication would be necessary.

E-learning is set to become a major component of medical and science education, not only while in school but also in continuing education after graduation. The University of Edinburgh, for instance, has already made considerable investment in the Edinburgh Electronic Medical Curriculum (Eemec), for which it received recognition from Queen Elizabeth II in 2005 for excellence in e-learning. IVEMEDS is a further example of such a project (Harden, 2005). The key steps in developing an effective web-based education system are as follows: conducting a needs analysis, securing technical resources, obtaining commitment from participants, designing the content of courseware, conducting a pilot study before full implementation, encouraging and facilitating usage of the system, and monitoring online interactions (Cook & Dupras, 2004). Our web-based interactive PBL system, Rakuichi the Tutorial, has been shown to be a promising tool for conducting international, multidisciplinary, collaborative, and active shared learning.

Acknowledgments

The authors thank the participants of the Internet PBL courses for their active participation. This study was supported in part by Grants-in-Aid for Scientific Research (16390298) from the Ministry of Education, Culture, Sports, Science and Technology of Japan.

References

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