Problem-based learning in psychiatry for medical undergraduates: An opportunity to enrich psychiatry training in competency-based medical education

INTRODUCTION

The National Medical Commission (NMC) implemented a competency-based medical curriculum (CBME) for medical undergraduates in 2019.¹ This was to address the limitations of the earlier system of subject-centred, time-based, and knowledge-focused medical education.² CBME focuses on greater accountability, flexibility, and learner-centeredness.³ It has advocated for adopting various changes in the medical curriculum: a foundation course at the start of the course; Attitude, Ethics, and Communication module; early clinical exposure and integrated teaching; and newer teaching-learning (TL) methods like problem-based learning (PBL); self-directed learning; and flipped classrooms.¹ However, there is a dearth of Indian literature on the merits and challenges of PBL-based TL methods in psychiatry; therefore, we highlight the scope of PBL under the CBME curriculum for psychiatry training of medical undergraduates, and potential challenges in its implementation.

In PBL, learners use ‘triggers’ from the problem-case to define their learning objectives. Following this, they undertake independent, self-directed learning before returning to the group for discussion and refining their acquired knowledge. PBL differs from traditional teaching methods where topics are taught in isolation and learning is a passive process. Furthermore, PBL favours integrated teaching that can be applied in real-world settings. It is based on adult learning principles and follows a constructivist approach.⁴ For example, a patient with anti-psychotic-induced akathisia can be discussed in PBL format (Box 1).

This problem can promote active learning in terms of the likely diagnosis, potential aetiology, and management options. Furter, this can be vertically integrated with pharmacology. Similarly, organic causes (anaemia or thyrotoxicosis) of anxiety disorder can be integrated with pathology and medicine.

PBL not only favours the acquisition of knowledge but also promotes the development of generic skills and attitudes, like communication skills, teamwork, and problem-solving. It also inculcates an attitude of lifelong learning and commitment to continuous improvement of skills and knowledge, one of the five qualities of the Indian medical graduate, led by the NMC.⁵

PBL also provides a better approach to patient management. For example, a CBME entrustable professional activity on ‘management of depressive disorder at a primary level’ can promote all three domains of learning: knowledge domain (clinical features of depression, treatment protocol), skills domain (history taking and mental state examination, interpretation of laboratory investigations), and affective domain (communicating with empathy and psycho-education). The learner learns about a common mental disorder, ‘depression’, in a comprehensive manner, rather than in compartments as in the traditional medical education system. Learners are more likely to remember concepts taught through PBL and efficiently manage real-life cases.

In PBL, problems may be presented using paper-based scenarios, clippings from newspapers or journal articles, audio/video clips, a real or simulated case, etc.⁵ For instance, a newspaper clipping on the mass suicide in a family in India may trigger discussion on the ‘shared/induced delusions’.⁶ Likewise, a video clip of a patient with Tardive dyskinesia could facilitate a discussion on the adverse effects of antipsychotics (refer to supplementary files for more examples).

It must be highlighted that whatever means a teacher uses to present the problem, it needs to be appropriate to the stage of the undergraduate curriculum and the learners’ level of understanding; students must have some knowledge of the subject or part of the problem being discussed (e.g. for management of pulmonary tuberculosis, learners should have knowledge from pharmacology about the various first and second line antitubercular drugs, their indications, and adverse effects). Furthermore, it should generate sufficient interest, stimulate discussion, and promote further reading among them (e.g. a patient presented to the emergency department with altered sensorium; history reveals he lost significant weight over past few months, is a known case of human immunodeficiency virus [HIV] infection with poor response to previous antitubercular therapy, and examination reveals breathlessness, coarse crepitations, and emaciation. How would you like to approach this case?).⁷

PBL also favours better performance in examinations that assess higher-order thinking.⁸ Moreover, it can be used to conduct formative assessments and provide feedback to learners. PBL aims to facilitate learning through the process of solving a problem by a group with inputs from different group members who can identify one learning objective from the problem posed to the group. Any topic that spans pre-clinical, para-clinical, and clinical domains may be taken up for PBL and can also be integrated to promote comprehensive learning. Most psychiatric disorders, like depression, anxiety, substance use disorders, and schizophrenia, have a science component (anatomy and physiology of the central nervous system, neurotransmitters), pathogenesis (alteration in neurotransmission), epidemiology (community medicine), drugs (pharmacology), and overall management (psychiatry) involved. A small group of motivated learners, trained facilitators, and a well-designed lesson plan with specified learning objectives are the prerequisites for practical PBL sessions.^4,9

PBL can be implemented for any medical subject (an example has been provided in the supplementary file Appendix A, point C).

Broad topics like HIV, tuberculosis or diabetes mellitus should be used for PBL as they will provide more space for lateral thinking (clinical features of HIV, psychosocial issues faced by the persons living with HIV/acquired immuno-deficiency syndrome [AIDS], management of HIV/AIDS including the comorbid conditions, such as tuberculosis, hepatitis C infection, etc., and laws/government’s welfare schemes for these individuals) as compared to narrow topics like ‘clinical features of tuberculosis’. A trigger sentence like ‘The person lost his job when his employer came to know of his HIV status’ can stimulate discussion on the stigma attached to this disorder.

Though the basic principles and implementation of the PBL cut across the subjects, there are some inherent opportunities or limitations of using this TL method in subjects, e.g. primary subject (general medicine) versus minor subject (e.g. psychiatry) or medical subject (e.g. general medicine) versus surgical discipline (e.g. otorhinolaryngology). For instance, implementing PBL in psychiatry can have hurdles like poor motivation of students for this subject (versus for obstetrics and gynaecology, which is a major subject and relatable to the students), for it is not a major subject (passing or failing in this will not affect students’ overall grade), there is stigma attached with this subject/patients/even mental health professionals, that students lack basic knowledge of psychiatry in pre-clinical or basic years of medical curriculum, and lack of definitive diagnostic markers or prognostic indicators. Therefore, to make the subject appealing, psychiatry teachers need to put extra effort into orienting students about the scope of psychiatry in medical practice, making the topic interesting (providing triggers that are stimulating and thought-provoking), and being well-versed in the critical aspects of the PBL. On the other hand, PBL in psychiatry is easily achievable as resident doctors (junior or senior) can act as simulators to demonstrate a given problem or for skill assessment (we have provided one of such real-world PBL sessions used in the authors’ institute; supplementary file Appendix-B).

CHALLENGES WITH THE PBL TL APPROACH

Although PBL enriches learners’ experiences and promotes life-long learning, it is not without challenges. The major problem pertains to variations of human resources, infrastructure, facilitator’s skills, and administrative support across the subjects and institutions; many medical colleges of the country do not have enough faculty training or infrastructure to implement this (consider a batch of 200 medical students with just 2–3 faculty members in each department). Since PBL is delivered in small groups comprising 8–10 students in each group, implementing 20 odd PBL sessions can be a daunting task for the faculty members especially when faculty members have (administrative, research, and academic commitments). Having said that, this problem can be surmounted by adequate faculty training, taking support from faculty members of other departments who are proficient in PBL TL methods, and integrating PBL with other subjects that have higher faculty numbers (e.g. epidemiology, diagnostics, and management of depression can be integrated with community and family medicine, pharmacology). Likewise, existing tutorials (taken by resident doctors) can be utilised to promote and implement PBL sessions. Moreover, harnessing the digital platform in terms of resource materials, problem-case generation, guest faculty, and teaching beyond the routine classes/clinical posting can help overcome the resource constraints.

Similarly, sensitization of both students and faculty about the process of PBL through workshops can be an initial effort in promoting and implementing PBL. Students and teachers are accustomed to traditional methods of didactic teaching, and thus may find it difficult to adapt to PBL-based TL.⁹ Moreover, teachers need to function as facilitators rather than lecturers. They should refrain from giving a mini-lecture (which they are quite comfortable with). Teachers also need to maintain group dynamics and control the discussion. They need to keep an atmosphere that drives learning.¹⁰

The development of a PBL module requires concerted efforts from subject experts, technical staff, and health educators. The trigger scenario also needs to be constantly updated to meet the learning objectives set at the beginning of the session. Such collaborative tasks often become daunting, particularly in settings where resources are limited.¹¹ Lastly, assessment methods should also be synchronous with PBL. The efforts put in by learners and facilitators should be rewarded; otherwise, it may be demotivating.⁹

FUTURE DIRECTIONS

Medical teachers, including pychiatry faculty members, should endeavour to attempt PBL in their settings and share their experiences. Research in this area needs to be actively undertaken. This would enrich the existing literature and guide educators and policymakers in making the necessary changes to the curriculum.