Comparison of Three Parallel, Basic Science Pathways in the Same Medical College

Since 1970, the Ohio State University College of Medicine and Public Health has offered medical students a choice between two basic science pathways, lecture discussion (LD) and independent study (IS). Since 1991 the college has offered entering students a choice among three pathways, LD, IS and problem-based learning (PBL). Most of the literature on implementing alterantive basic science curricula has focused on the comparison of USMLE Step 1 test scores between different curricular methods. The purpose of this study was to investigate outcome measures (other than USMLE test scores) such as student activities and achievement in clinical education, and affective measures of student and faculty satisfaction. Additionally, we sought to assess the effect of pathway choice on admission, and to determine the factors influential in determining student pathway choice. Ours is the only medical school in the country where entering students have a choice of three preclinical pathways, making it fertile ground for comparison of the effects of different curricula. Learning objectives, content material, and structure (organ-based organization) are very similar across all three pathways. The three also share faculty, staff, and administrative oversight. What differs across pathways are the teaching and learning methods. In 1997–98 the college formed a task force to study the benefits and overall desirability of maintaining the three preclinical pathways. Specifically, the task force was charged to look at all three pathways in terms of their educational importance, student and faculty preferences, and participant satisfaction. Until recently, the traditional LD was the most commonly chosen pathway among the 210 matriculating students each year. The primary mode of teaching in this pathway is large-group lecture supplemented with small-group discussions and labs. The IS pathway, established in 1970 as the first alternative to the LD, offers students the flexibility to learn on their own through the use of highly structured reading materials, computer-based materials, and diagnostic practice examinations. The PBL pathway, established in 1991, emphasizes student-centered, self-directed learning. Unlike IS students, PBL students are introduced to basic science concepts through the analysis and discussion of clinical cases during small-group meetings. Students then work independently on learning issues that are defined by the group before coming back together to discuss their studies. Literature Review Like any educational innovation, both IS and PBL programs have had to prove their effectiveness as alternatives to the traditional lecture-based teaching. Lecture-based teaching has existed primarily for its efficiency, not necessarily for its effectiveness. As medical schools struggled to develop alternatives to lectures, investigations comparing alternatives to traditional lecture curricula such as IS and PBL were reported in the literature. Such investigations have generally found little or no difference in examination scores or clinical performances when comparing lecture-based courses with alternatives. Way et al. compared alternative curricular approaches in one college and confirmed that no difference in average USMLE Step 1 scores existed across alternative basic science pathways when controlling for pre-matriculation differences.1 The literature on IS in the health professions reveals the following: There is little or no significant difference in learner performances as measured by examinations and patient care compared with traditional lecture-based curricula.2,3,4,5,6,7,8,9,10,11 IS offers both faculty and students more flexibility and portability in learning when compared with lecture-based learning.2,3,8 IS promotes lifelong, independent learning, self-pacing, and self-responsibility in learning.2,11 Students who participate in IS tend to pursue more research and full-time faculty positions than students in lecture programs.2 After start-up costs are accounted for, IS costs the same as or less than traditional lecture-based courses.2,3,7 The literature on PBL in the health professions reveals the following: There is little or no significant difference in learner performances as measured by examinations or patient care compared with traditional lecture-based curricula.12,16,17 Differences that have been reported generally indicate the same or less factual knowledge but better clinical performance and patient management for PBL students.13,14,15,19 Both faculty and students find PBL more enjoyable and prefer PBL to “traditional” lecture courses.12,13,14,16,18,19 PBL students tend to use “backward” reasoning (working from clinical information back to theory) when solving clinical problems, whereas traditional students reason “forward” (from theory to clinical practice).13,15,21 PBL students have a greater tendency to use evidence-based medicine practices (more journals and literature searches) than “traditional” students.14,15 Method This article reports part of a larger, more comprehensive institutional research project conducted by a task force of clinical and basic science faculty supported by consultants from the College of Medicine's Office of Academic Services (OAS) for Medical Education. methods: document analysis, survey methods, and interviews with key educational staff members. Annual reports dating back to 1991 from each of the three pathways were reviewed and summarized by task force members. Surveys for both students and faculty were developed, pilot tested, and summarized by task force members with help from OAS consultants. Surveys were administered in spring quarter of 1997 to all students. First- and second-year students were surveyed in their respective class locations, as a group; third- and fourth-year students received paper copies in their college mailboxes. Return rates were much lower for clinical-year students due to clinical assignments and time of the survey. Faculty surveys were distributed through internal mail services to faculty with 50–100% academic appointments. Likert-type survey items were analyzed using descriptive statistics: frequencies, percentages, cross-tabulations, means, and standard deviations. For reporting purposes “very satisfied” and “satisfied” were combined into “satisfied,” and “very unsatisfied” and “unsatisfied” were combined into “unsatisfied.” Documents, interview notes, and other qualitative data were analyzed using domain analysis of key words and phrases.20 Results Academic Outcomes. No difference across pathways was observed for graduation rates or grades on clinical rotations, but more IS students were in Alpha Omega Alpha (24% IS, 17% LD, 14% PBL) and higher percentages of both IS and PBL students received more departmental awards than did LD students. Student Survey. The student survey was designed to learn how students choose their pathways and assess their satisfaction with their choices. The students were also asked to comment on their impressions of all three pathways. Of the 839 student surveys distributed, 467 usable responses were returned (55.6%). The return rate was biased toward the basic science classes (year one = 92%, year two = 76%, year three = 43%, and year four = 11%). Return rates by basic science pathway for each class surveyed resembled the proportion of students enrolled across pathways (LD = 69%, PBL = 17%, and IS = 12%). Because so few fourth-year students returned the survey, their data were not used. Having a choice of pathways was a significant factor in the students' decisions to come to the college: 56% of the respondents agreed that choice of basic science pathway influenced their decisions to attend the school. Based on the students' responses, the factors that contributed to a student's choice of pathway were learning style, experience with nontraditional learning methods, personal and family needs, and needs for socialization. Sixty-two percent indicated that the LD pathway was their first choice. Many students stated a preference for it because it is a method with which they were familiar. Some felt that because of perceived weaknesses in their basic science backgrounds they needed the structure provided by LD. Social factors that contributed to pathway choice were distance from campus, need for contact with students and teachers, and need to make friends and network. The PBL is the only pathway that caps enrollment at 35. Twenty-eight percent of the survey respondents (131 students) identified the PBL as their first choice of pathway; of these, nearly 40% (52 students) matriculated into other pathways. Students stating preferences for the PBL said that they either had had experience with group work in the past or believed that through PBL they could learn clinical reasoning skills early. Nine percent of the respondents identified IS as their first choice. However, 12% reported participating in the IS pathway. Some students from the PBL wait list had chosen the IS pathway once it was determined that they would not be admitted into the PBL pathway. The students who chose IS as their first choice cited the flexibility of the pathway as their primary reason. This pathway tends to attract more nontraditional students such as older students with families, married students, or students interested in the MD-PhD program. Many stated that they would not have been able to complete medical school without the flexibility offered by the pathway. Others appreciated the opportunity to manage their own time by either accelerating or decelerating their pace through the basic sciences. Overall, student satisfaction with their basic science pathways was high: almost 82% were satisfied with their pathways; only 9% reported being unsatisfied. Across the three pathways, PBL students reported being the most satisfied (91%), and 93% of the PBL students would have chosen it again. The IS students were almost as satisfied with their pathway, with 86% reporting satisfaction, although only 76% said that they would choose it again. The LD students were the least satisfied, with 79% stating that they were satisfied and only 63% said that they would choose that pathway again. No difference across cohorts was observed. The proportion of students expressing a preference for a given pathway was the same for each class: 42% said that they would pick LD, 41% said they would pick PBL, and 17% said they would pick IS. Overall, 52% of the students felt they had missed something offered by the other pathways (54% of LD, 41% of PBL, 51% of IS students). Many LD students felt that they missed the clinical experience, case studies, and active learning that was offered by the PBL. On their own initiative, non-PBL students have started a case-study interest group in an effort to make up for this perceived need. Alternative-pathway students felt that they missed out on well-presented and organized material from content experts, comprehensive coverage, pressure to perform, and proper pronunciation of medical terms. The overwhelming response by students was that choice was very important and that students have different learning styles. They felt that choice attracts a higher caliber of students and shows that the school is a progressive medical school. Over 90% of the respondents agreed that the school should continue to offer multiple basic science pathways. Faculty Survey. All 568 faculty with 50% or greater appointments were surveyed; 133 (23.4%) responded. Of the 133 respondents, 23% were from basic science departments, 48% from clinical sciences, and 29% did not provide their departments. Nineteen percent of the respondents reported no teaching experience in any pathway. Sixty percent taught in only one pathway (LD 50%, IS 1.5%, PBL 7.5%). Fourteen percent of the respondents reported experience in two pathways (LD/IS 4.5%, LD/PBL 7.5%, IS/PBL 2.3%). Seven percent participated in all three pathways. The faculty respondents were generally satisfied with their student interactions in each pathway (54% of LD, 53% of IS, and 87% of PBL faculty). The basic science and clinical faculty disagreed on the appropriateness of the distribution of their teaching, research, and service time: 80% of the basic science faculty were satisfied with the time distribution, while only 47% of clinical faculty were satisfied. When asked, “In your opinion is it important that the College of Medicine and Public Health continue to offer three preclinical pathways?” the faculty responses of those who expressed an opinion were split almost evenly (38% yes, 39% no, and 22% no opinion). For the faculty who identified their departments, approximately half replied in the affirmative (47% of basic science faculty, 50% of clinical faculty), and 19% had no opinion. Discussion Based on student and faculty opinions from surveys and comparison of pathway outcomes for 1993 to 1997, the task force unanimously recommended that the college maintain three basic science pathways. The presence of three preclinical pathways provides the college tremendous flexibility to accommodate student learning styles and time requirements. Students highly value the commitment of the college to medical education by accommodating their different student learning styles. Providing three pathways is also an important factor in the recruitment and admission of high-quality students. Differences in outcome measures are small and may be attributed to higher pre-matriculation statistics for IS and PBL students. The three basic science pathways are important in maintaining the positive image of medical education at the college. This is true both for current medical students and for those applying. Requests for the PBL pathway from entering students averaged 46% of the entering classes of 1994–1997, and IS enrollments have increased dramatically. Faculty are generally satisfied with student interactions in the LD and IS pathways, but are most satisfied with their interactions with the PBL students. Three pathways provide for differences in learning styles, as well as offering time for independent learning, research, and outside interests. Time flexibility by pathway is greatest with IS, followed by PBL, and least with LD. Student satisfaction with their current pathways is very high: 91% of PBL, 86% of IS, and 79% of LD students were satisfied with their basic science pathways. In spite of the high satisfaction levels, however, approximately half of the students felt that they had missed something in their pathways that was available in another pathway. Student comments indicated that this lack was not one of content material but rather in the social and pedagogic opportunities with faculty and other students. Eighty seven percent (87%) of the students agreed that the college should continue to offer three basic science pathways; only 5% disagreed. Low faculty response rates, lack of teaching experience in the pathways, and “no opinion” responses make it difficult to interpret the faculty survey data. Therefore, the task force recommended educating faculty about the importance of the three pathways and their recruiting and retention benefits. Conclusions The Ohio State University College of Medicine and Public Health is well served by offering three parallel but alternative basic science curricula and will continue to do so. The large entering class size (210) and the three different pathways make the college fertile ground for comparison of alternative curricula. This study confirms previous conclusions in the literature about independent study and problem-based medical education in terms of outcomes, flexibility, choice, and student and faculty satisfaction and preferences. In addition, it established that multiple curricula are important factors in admissions, educational reputation, and accommodating various student learning styles.