Artikel A case-based , small-group cooperative learning course in preclinical veterinary science aimed at bridging basic science and clinical literacy

INTRODUCTION AND BACKGROUND The Foresight study report of the Association of Veterinary Medical Colleges of the United States of America concluded that it is imperative to change the way we educate tomorrow’s veterinary students. Veterinary school curricula have to become more flexible and adaptive to the rapidly changing demands on veterinarians or otherwise the veterinary profession may become irrelevant to the society it serves. The focus is for curricula to be able to respond to changing demands for professional veterinary services within a relatively short period of time. This objective places renewed emphasis on an effective educational vehicle or pedagogical base to deliver these innovative curricula. The way in which knowledge and learning are introduced and the role of the student in such a process should be considered and conceptualised in the curriculum. Traditionally, pre-clinical veterinary curricula have been heavily biased towards didactic lectures. There is a move towards supplementing lecture-based courses with student-centred courses that focus on integrated problem-based, self-directed and cooperative learning. An example of such a course that was introduced in 1999 at the Faculty of Veterinary Science of the University of Pretoria in South Africa is the case-based learning course: Introduction to Clinical Studies 400 (ICS400). Problem-based learning (PBL) has many and varied interpretations, ranging from a narrow definition describing pure PBL to an all-inclusive definition encompassing many alternatives. For the purpose of this discussion PBL in medical education is defined as a student-centred method of learning that uses clinical cases as problems to serve as challenges for self-directed, independent and cooperative study in a small-group setting. This approach is also in line with recently formulated key features of PBL as described by Newman and Shanley. Pure PBL is a process of learning where students take responsibility for their own learning under the guidance of a tutor, whose role is to facilitate learning in a non-directive way. The course described in this article is an adaptation of the pure PBL defined above. Rather than facilitating learning non-directively, the tutors intervene to set and maintain the quality of both the process of learning and the learning resulting from the process. They act as facilitators guiding the group learning process and also provide expert knowledge related to the case. Recent studies have highlighted concerns about pure PBL as a method of learning. Of paramount concern is the perceived lack of effectiveness of PBL to contribute to the knowledge base and clinical skills of medical students. Some of the other difficulties reported are the lack of indepth learning and the unevenness of preparation among students as well as the high cost and difficult logistics. Another disadvantage of case-based, small-group PBL includes the considerable demands placed on teaching staff, because it is a time-consuming method of teaching and requires a full range of specific skills from the tutors in constructing and presenting an appropriate casebased challenge. Discomfort and anxiety about and resistance to self-directed learning on the part of the students, as well as the interpersonal difficulties that may arise from small-group learning (as summarised by Miflin) and the difficulties with assessment of individual performance in a team environment, are some of the other problems with PBL as a method of teaching. The aim of this article is to describe the structure and objectives of the Introduction to Clinical Studies Course and to report the results of the assessment of the students’ perceptions on some aspects of the PBL component of the course. This is the 1st report describing the application of PBL to facilitate the integration of different disciplines and to assist in bridg-


INTRODUCTION AND BACKGROUND
The Foresight study report 32 of the Association of Veterinary Medical Colleges of the United States of America concluded that it is imperative to change the way we educate tomorrow's veterinary students.Veterinary school curricula have to become more flexible and adaptive to the rapidly changing demands on veterinarians or otherwise the veterinary profession may become irrelevant to the society it serves 26 .The focus is for curricula to be able to respond to changing demands for professional veterinary services within a relatively short period of time.This objective places renewed emphasis on an effective educational vehicle or pedagogical base to deliver these innovative curricula.The way in which knowledge and learning are introduced and the role of the student in such a process should be considered and conceptualised in the curriculum.
Traditionally, pre-clinical veterinary curricula have been heavily biased towards didactic lectures.There is a move towards supplementing lecture-based courses with student-centred courses that focus on integrated problem-based, self-directed and cooperative learning.An example of such a course that was introduced in 1999 at the Faculty of Veterinary Science of the University of Pretoria in South Africa is the case-based learning course: Introduction to Clinical Studies 400 (ICS400).
Problem-based learning (PBL) has many and varied interpretations, ranging from a narrow definition describing pure PBL to an all-inclusive definition encompassing many alternatives 16,19 .For the purpose of this discussion PBL in medical education is defined as a student-centred method of learning that uses clinical cases as problems to serve as challenges for self-directed, independent and coopera-tive study in a small-group setting.This approach is also in line with recently formulated key features of PBL as described by Newman 21 and Shanley 29 .Pure PBL is a process of learning where students take responsibility for their own learning under the guidance of a tutor, whose role is to facilitate learning in a non-directive way 17 .The course described in this article is an adaptation of the pure PBL defined above.Rather than facilitating learning non-directively, the tutors intervene to set and maintain the quality of both the process of learning and the learning resulting from the process.They act as facilitators guiding the group learning process and also provide expert knowledge related to the case.
Recent studies have highlighted concerns about pure PBL as a method of learning.Of paramount concern is the perceived lack of effectiveness of PBL to contribute to the knowledge base and clinical skills of medical students 5,7,23 .Some of the other difficulties reported are the lack of indepth learning and the unevenness of preparation among students 10 as well as the high cost and difficult logistics 29 .Another disadvantage of case-based, small-group PBL includes the considerable demands placed on teaching staff, because it is a time-consuming method of teaching and requires a full range of specific skills from the tutors in constructing and presenting an appropriate casebased challenge 27 .Discomfort and anxiety about 4 and resistance to self-directed learning 27 on the part of the students, as well as the interpersonal difficulties that may arise from small-group learning (as summarised by Miflin 19 ) and the difficulties with assessment of individual performance in a team environment 27 , are some of the other problems with PBL as a method of teaching.
The aim of this article is to describe the structure and objectives of the Introduction to Clinical Studies Course and to report the results of the assessment of the students' perceptions on some aspects of the PBL component of the course.This is the 1st report describing the application of PBL to facilitate the integration of different disciplines and to assist in bridg-ing the gap between basic science and clinical literacy in the field of veterinary medicine.

Objectives of the Introduction to Clinical Studies Course
The veterinary curriculum at the University of Pretoria currently consists of 6 years of predominantly lecture-based courses and a 7th year comprising clinical rotations.The ICS 400 course is part of the 4th year of study, by which time the students have completed anatomy, physiology, genetics, immunology and virology amongst other basic science courses.
The ICS 400 course affords the students the opportunity to integrate the evergrowing information data-base in a casebased manner.They are presented with the information pertaining to 4 cases throughout the year and the tutor (lecturer) guides them through the process of structuring old and new information into a logical and useful conclusion.The intention is to facilitate the transition from obtaining and memorising information (a skill honed by traditional lecture-based teaching and assessing) to seeking information to solve clinical problems.
The core learning objectives of the ICS400 course are listed in Table 1 and the ancillary learning objectives in Table 2.

Structure of the Introduction to Clinical Studies Course
The course spans 1 academic year.It commences with traditional lectures on aspects of the clinical examination of canine, bovine and equine patients.The class is then divided into 5 groups of approximately 20 students each.Over the next 3 weeks these groups attend 3 practical sessions on the clinical examination of canine, bovine and equine patients respectively.Table 3

1.
Students should be able to identify abnormalities in a patient and develop an appreciation for the degree of abnormality.

2.
Students should become familiar with the correct terminology applied to these abnormalities.

3.
Students should be able to relate these abnormalities to the underlying disturbed function (i.e.disease or pathophysiological processes).

4.
Students should develop the vocabulary and logic to group these underlying alterations in function, disease or pathophysiological processes into ranked problem statements, stated at the correct level and based on the available evidence.

1.
To enable students to develop clinical reasoning skills in a low-risk environment 4 ; 2.
to enable students to identify what they already know that is pertinent 13,21 and to challenge students to recognise the need for additional facts, skills and conceptual understanding 27 ; 3.
to enable students to integrate basic and applied knowledge from previously taught courses, facilitating interdisciplinary integration 13 ; 4.
to set a context for the acquisition of knowledge applicable to future requirements for case management and problem solving 21,30 ; 5.
to enable students to structure knowledge in a clinical context by developing an integrated, progressive and consistent approach to cases 6,20,25 ; 6.
to enhance students' ability to work in a cooperative manner and to introduce students to the positive aspects of cooperative small-group learning 20,21 ; 7.
to motivate students in their preclinical years and to increase their enthusiasm for learning 13,21,30 ; 8. to encourage students to assume more responsibility for their education and to develop their self-learning skills 4 .

Timing Time frame Traditional lecture or practical Objective
Prior to practical session Approximately 80 minutes

Lectures on the aspects of the clinical examination of a bovine patient
To enable the student to approach the practical session with enough theoretical knowledge to examine a bovine patient

Lectures on the aspects of the clinical examination of an equine patient
To enable the student to approach the practical session with enough theoretical knowledge to examine an equine patient

Lectures on the aspects of the clinical examination of a small animal patient
To enable the student to approach the practical session with enough theoretical knowledge to examine a small animal patient Practical session with a demonstration of the examination of a small animal patient followed by all students examining small animal patients in turn To enable the student to examine a small animal patient the student-centred, case-based component of the course.The 1st of 4 real-life cases with a wide range of abnormalities is then handed out to the students.The case typically consists of transcripts of the history, the signalment and the clinical examination of the patient, as well as the applicable laboratory findings including haematological, biochemical, urinalysis and faecal examination data.For the purpose of discussing the cases, the students are divided into groups of approximately 7 students each.Three tutorial sessions are allocated to the 1st case and 2 tutorial sessions to each subsequent case.Each group discusses the case that has been presented to them in the group, establishing a check list of learning issues.
Learning issues are particulars of the case at hand where the students are unsure about the 'what', 'why' or 'how' of (1) the terminology used and/or (2) the manner in which the presence of clinical signs and other pertinent information is usually established and recorded and/or (3) the degree of severity of the abnormality.
Students then have to seek resources cooperatively and independently (without tutor guidance) to provide answers to the learning issues raised -i.e.identifying and grading the abnormalities.A list of core resources is provided in the library.The students will schedule a meeting with the designated tutor.At this session, which lasts approximately 1 to 1.5 hours, these abnormalities are discussed in the group and the tutor will determine whether the students have correctly identified and graded the relevant abnormalities using the appropriate scientific terminology.
Following the 1st tutorial meeting, the students will cooperatively attempt to group and rank the abnormalities and establish the common pathophysiological mechanisms or disease processes underlying these abnormalities.The group will schedule a 2nd tutorial meeting with the tutor.At the 2nd session, which lasts another 1 to 1.5 hours, the pathophysiological processes underlying the abnormalities identified during the 1st tutorial meeting are discussed in the group under the guidance of the tutor.A report-back session is subsequently scheduled.
The students will then collaborate, with the aid of resources, to produce the Master Problem List.A Master Problem List (MPL) comprises the grouping of related abnormalities into major problems.See Table 4 for an example of how related abnormalities are synthesised into master problems.
The report-back session lasts approximately 30 minutes.The tutor will determine whether the students have correctly established a MPL based on the pathophysiology discussed at the 2nd tutorial meeting.The preparation and participation of the group is subjectively assessed by the tutor and expressed as a percentage.As a rule the group is allocated an overall mark assigned to each individual student, but poor or outstanding contributions by individual students can be reflected in lower or higher marks for the particular student.
In total, these groups are presented with 4 cases throughout the year: 2 small animal cases, 1 bovine and 1 equine case.As students gain experience and confidence in what is expected of them, the 2nd tutorial and the so-called report-back session can be combined into 1 session lasting approximately 2 hours.After the completion of the 4 cases, a 5th and final case is handed out to the students 4 weeks prior to a written examination at the end of the year.The students are expected to prepare this case cooperatively and in the same fashion as the previous 4 cases.The preparation, however, takes place without the guidance of the tutor.A written examination ensues, comprising an open-book format and multiple-choice questions.See Table 5 for a summary of the case-based component of the course.

METHODS
A questionnaire was devised as an instrument to evaluate this course.The questionnaire was provided to the students in person just after their final examination.The questionnaire was developed to research the students' perception of the teaching and their academic self-perception.The students' perception of the lecturers/tutors, their perceptions of atmosphere and their social self-perception were not evaluated as they were not relevant to the objectives of the project.The study was approved by the Research Committee of the Faculty of Veterinary Science, University of Pretoria.
Three specific areas were addressed with 4 questions pertaining to each area: 1. the ability of the course to enhance the students' problem-solving skills; 2. the volume and scope of the work; 3. the clarity of the learning objectives.
See Table 6 for a list of the questions grouped into the above categories post hoc.
A 5-point Likert scale was used, where '1' meant that the student strongly disagreed with the statement and '5' meant that the student strongly agreed.This translated into '1' indicating a very negative response through to '5' indicating a very positive response.The data were adjusted to account for negative statements.Quantitative questionnaire data were imported into a statistical package for the social sciences (SPSS 14, SPSS Inc., Chicago, Illinois).Mean scores for each of the 3 specific question areas were calculated.These mean scores of the 3 specific question areas were compared within the whole group with the 1 sample t-test for related samples.Gender was dichotomised into male and female and age into 4 ordinal groups: 20-22 years old; 23-24 years old; 25-26 years old; older than 26 years.Mean scores were compared between groups with the ANOVA for multiple age groups and the independent samples t-test for the 2 gender groups.Significance was set at P < 0.05.

RESULTS
The questionnaire was distributed to 130 undergraduate veterinary students in October 2007 -all of whom were at the end of their 4th year of study.The response rate (aided by a lottery of 2 good stethoscopes!)was 95% (124/130).115/130 (88.5%) questionnaires were complete in all respects and used in the analysis.
Thirty-one respondents were male and 84 were female.Seventy-one students were between 20  The answers to the questions pertaining to the sample's perceptions of the problem-solving skills acquired by the students in this course attained a mean score of 4.04/5.The answers to the questions pertaining to the sample's perceptions of the workload in this course attained a mean score of 3.54/5.The answers to the questions pertaining to the sample's perceptions of the clarity of the learning objectives of this course attained a mean score of 2.80/5.The mean score related to the problem-solving skills was significantly higher than the mean scores related to the workload and the course objectives, respectively (P < 0.001 for both).The mean score related to the workload also had a significantly higher score than the  The tutor assesses the group; handing out of the 2nd case.
Students are evaluated based on their preparation for and participation in the tutor guided sessions and their ability to draw up a ranked master problem list.

Preparation prior to final assessment
Approximately 4 weeks After completion of self-learning and discussion of 4 cases as set out above, a final case is handed to the students and time allowed for cooperative preparation without tutor assistance To allow the students time to study the case, define and state the abnormality using scientific terminology, study the pathophysiological processes leading to each abnormality and grouping problems together as a few master problems based on the underlying pathophysiology of each abnormality.

Final assessment Approximately 120 minutes In an open book session the students answer 3 multiple-choice type questions based on the list of abnormalities, underlying pathophysiology and master problem list
To allow the lecturer to evaluate the students' knowledge of scientific clinical terminology, interpretation of abnormalities and pathophysiology and ability to group problems together as master problems.
Table 6: The statements contained in the questionnaire grouped into 3 categories.

Statements pertaining to problem-solving skills:
• This course has enabled me to understand things which initially seem difficult.
• As a result of studying this course, I feel more confident about tackling unfamiliar problems.
• This course helped me to relate ideas in this subject to those in other subjects, wherever possible.• This course has sharpened my analytic skills.
Statements pertaining to the workload: • The work-load was too heavy.
• There was a lot of pressure on me as a student in this course.• I have generally been given enough time to understand the things I have to learn in this course.
• The volume of work in this course meant that it couldn't all be thoroughly comprehended.
Statements pertaining to the learning objectives: mean score related to the clarity of the course objectives (P < 0.001).
There was no statistically significant difference between the perceptions reported by female and male students for course objectives (P = 0.07), workload (P = 0.115) or problem-solving skills attained (P = 0.711).There was also no statistically significant difference between the perceptions across the student age groups for course objectives (P = 0.692), workload (P = 0.948) or problem solving skills attained (P = 0.287).

DISCUSSION
The students' feedback on the acquisition of problem-solving skills was very favourable.They were very positive that the course enabled them to understand concepts which initially seemed difficult.They felt confident about tackling unfamiliar problems in future and relating ideas and skills learnt in this course to other subjects.This concurs with other studies reporting on students' positive perceptions on the acquisition of problem solving skills 8,13,24 .
The students' feedback on the workload of this problem-based course was also positive.They felt that the workload was manageable and they had generally been given enough time to understand the material they had to assimilate in the course.From the results it can thus be inferred that the ISC400 course as it is structured, complements the current predominantly lecture-based curriculum, without consuming too much of the students' time.
The last aspect addressed in our study was the students' perceptions on the clarity of the course objectives.The mean score of this group of questions was significantly lower than the other 2 groups of questions.The responses reflected uncertainty as to the standard of work expected of them in this course and that they did not always have a clear idea of the expected end results.One has to bear in mind that it is the students' 1st attempt at a nontraditionally taught course and although the study guide for this course is very comprehensive, the practice is still uncertain.Students need to be informed at the outset and guided throughout regarding the objectives of the problem-based learning course and on how it will be assessed.This is in accordance with other studies evaluating undergraduate veterinary medicine students' attitude towards a non-traditional course 6,13,18,20 .
Students need to be comfortable with learning different skill sets from those they acquire from traditionally taught courses 6 .They need to be aware that their self-confidence in clinical reasoning skills will increase with practice 24 .Clinical reasoning expertise and the ability to integrate new knowledge into existing knowledge structures is only gained through multiple representations or examples of knowledge 8,11,22 .It was reported that veterinary students displayed a rapid grasp of the process and that their ability to discover and apply scientific concepts at a preclinical level impressed facilitators 13 .In the ICS400 course, the case-based component is preceded by a 40 minute lecture explaining the objectives and structure of the course.However, it would be prudent to also emphasise the rationale behind student-centred, case-based learning and its role in the attainment of the skill sets highlighted in ancillary learning objectives in Table 2 33 .

RECOMMENDATIONS
To ensure that students are clearer about the objectives of the course, the following is suggested: a) the 1st lecture should be expanded to include the rationale behind PBL as a pedagogical method; b) the tutors should be encouraged to emphasise the core and ancillary objectives throughout the course and; c) the group of tutors should meet to discuss each case and share insights with the course coordinator and the case author(s) before meeting with the individual student groups to ensure consistency in the interpretation of the key problems of the case.
The role of the tutor is thus of pivotal importance.A standardised approach to training lecturers for this role is not sufficient, because every problem-based learning programme is unique to each institution, as are the expectations of the students and tutors.Accordingly the type and degree of support given by the tutor differs with every PBL course.The various roles the tutor fulfills will depend on the objectives for the specific course presented by the individual institution 16 .However, a growing body of research suggests that students learn more and more deeply from guided learning than from self-directed discovery 14,28,29 .Furthermore, students need multiple examples and feedback in order to attain effective transfer of basic concepts such as an integrated, progressive and consistent approach to solving clinical cases 22 .It is believed that 1 of the major strengths of our course is the fact that the tutors are subject experts guiding the learning process during the tutorials.Nevertheless, regardless of whether tutors are subject experts or not, they should have expertise in group facilitation and selfdirected learning 2 .Formal training should be provided to tutors to facilitate the necessary expertise.In-service training by an expert on PBL from the faculty of education should be considered.

LIMITATIONS AND FURTHER RESEARCH
The purpose of this research was not so much to gain new knowledge, but rather an effort to bring about change with a view to improving the course.This study did not address the effectiveness of the course to contribute to the knowledge base and/or reasoning skills.The assessment of the effectiveness of PBL is fraught with difficulty because of the complex multi-factorial context in which the learning takes place 12,19,23 .A major problem is teasing out the effect size among disparate outcome variables 1 .Traditional quantitative research methodologies have thus far been unable to attribute success or failure to specific educational interventions 23 .Despite these reservations there is compelling practical evidence that PBL results in consistent gains in satisfaction on the part of both the lecturers and the students 3,23 .Educational theories, cognitive science and empirical research favour inductive learning above traditional lecture-based teaching methods in attaining applicable learning objectives 9,27 .
In addition, several factors limit the generalisability of this study.First, the data used are limited to the experience of 1 class only.Second, students' responses might be expected to vary with different tutors.Third, this group of students might have responded similarly to another teaching method.
Future studies should explore students' responses to different tutors and teaching methods and employ direct measures to assess students' understanding and ability to integrate knowledge.

CONCLUSIONS
The ICS400 course combines traditional lectures with practical sessions, student self-learning and guided tutorials and acts as an example of curricular innovation aimed at bridging the gap between basic and clinical sciences.The ICS400 course is essentially a method of teaching where self-directed learning and clinical reasoning skills are developed under the guidance of subject experts in a smallgroup cooperative setting.
In concurrence with previous studies 3,31 , this study concludes that students are essentially positive about their experiences with this unique model of PBL.The results of this study indicate that tutors require adequate guidance on their communication of the rationale of PBL as a method of teaching and of the course objectives.Problem solving skills are part of the professional competencies of practising veterinarians, but it is a skill that has to be developed with the ultimate goal of allowing students to become reflective professionals 15 .Further research is needed to verify the usefulness of this course in bridging the gap between basic science and clinical literacy in veterinary science and to refine the model.
a demonstration of the examination of a bovine patient followed by all students examining bovine patients in turn To enable the student to examine a bovine patient Practical session -equine 60-90 minutes per student group -c.20 students per group Practical session with a demonstration of the examination of an equine patient followed by all students examining equine patients in turn To enable the student to examine an equine patient Practical session -small animal 60-90 minutes per student group -c.20 students per group

•
It was always easy to know the standard of work expected of me in this course.• I usually had a clear idea of where I was going and what was expected of me in this course.• It was clear right from the start what was expected from students.• I am clear about the learning objectives of the course.