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HOW MEDICAL STUDENTS ADAPT LEARNING STRATEGIES

TO PROBLEM-BASED LEARNING

By

Inkyung Lee

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Educational Psychology and Special Education

1996

ABSTRACT
HOW MEDICAL STUDENTS ADAPT LEARNING STRATEGIES
To PROBLEM-BASED LEARNING
By

InkyungLee

This study investigated how second-year medical students adapt their learning
strategies to changes in the instructional context. During the second year of the preclinical
program, students in the College of Human Medicine at Michigan State University
experience problem-based learning (PBL), while during the ﬁrst year, they attend large
lectures.

The researcher interviewed 12 students, including 8 students who participated in a
pilot study of ﬁrst year medical students. The researcher also administered the Learning
and Study Strategy Inventory (LAS SI) to a larger sample of medical students.

Both interviews and LAS SI data were compared with those of the pilot study
(lee, Yelon, Doig, & Smith, 1994) to observe the adaptation of students’ learning
strategies. Qualitative analysis showed that exams drove students’ learning-strategy
choice more than the curriculum did. Students used PBL classes as an arena in which to
discuss exam materials. Demands or conditions of the context, such as amount of material
to study and time constraints, also inﬂuenced students’ choices of learning strategies. In
general, second-year students added only one new strategy - use of computer programs.
Instead of adding strategies, they changed the extent to which they used certain strategies.

For example, they used more group study, more integration strategies such as making

charts, and fewer memorization strategies such as mnemonics. Results of Multivariate
Analysis of Variance of LAS SI data indicated, although students changed their learning
strategies signiﬁcantly during their ﬁrst year, they did not change those strategies
signiﬁcantly during their second year. This could mean that students who are entering a
diﬂ'erent instructional context in which a large amount of content must be learned in a
limited time may need to adapt their learning strategies more than they needed to change
their learning strategies for a diﬁ‘erent curriculum in medical school.

In terms of the eﬁ‘ect of PBL, qualitative analysis showed that the PBL curriculum
achieved some of its goals. While students thought that PBL classes provided a clinical
context for learning, encouraged active learning, and helped develop small-group working

skills, they did not think PBL classes provided a model of problem-solving.

Copyright by
Inkyung Lee
1996

iii

Dedicated with respect to my Parents and Husband

who always love and support me unconditionally.

 

ACKNOWLEDGMENTS

I would like to aclmowledge the committee members, without whose support and
help this dissertation would not have been completed.

First of all, I can only attempt to express my thanks to Dr. Steve Yelon, my
committee chair and advisor. Throughout my study at Michigan State University, and of
course during the production of this dissertation, he provided a model of an educator. He
provided expertise, intellectual stimulation, and understanding throughout this study. His
intellectual insights and care for students provide me with a lifelong goal. I feel lucky to
have such a wonderﬁil advisor.

I would also like to thank Dr. Jack Smith for his critical suggestions for my paper.
His intellectual and scholarly advice, which made me work hard and take time, contributed
to the quality of this paper. His feedback on my paper and other advice have been
invaluable.

To Dr. Kathy Doig, I would like to give a special thanks. She helped me to ﬁnd
the subjects of the study, support from College of Human Medicine, and gave intellectual
advice regarding the medical context. Without her eﬁ‘ort and generosity, this work could

not have been done.

I am also grateful for the valuable help and constructive advice of Dr. Betsy
Becker. Her statistical expertise and editorial comments have added signiﬁcantly to the
quality of this dissertation.

My extensive thanks go to Dr. Betty Werner, who provided help in ﬁnding
subjects and in inventory administration. Her expertise in the problem-based learning
context contributed to my study.

I also wish to express my appreciation to medical students at the College of
Human Medicine. I especially thank those who participated in interviews for this study.
Their cooperation and kindness gave me a major source of data for this study.

I also wOuld like to thank my family for their continued encouragement and
support. Special thanks go to my parents who always love and believe in me. I thank my
parents-in law for encouraging and supporting my study. I am also grateful to my
husband, Joonho, who always gave mental and emotional support and gave intellectual
advice. Lastly but most importantly, I would acknowledge my lovely daughter Yoojin,

who always gives me pleasure and joy in life.

TABLE OF CONTENTS

Page
LIST OF TABLES .................................................................................... x
LIST OF FIGURES ................................................................................... xiii
Chapter
I. INTRODUCTION .............................................................. 1
Statement of the Problem .................................................... 1
Purpose of the Study .......................................................... 3
Assumptions ....................................................................... 4
Rationale for and Signiﬁcance of the Study ......................... 5
Summary and Overview ...................................................... 7
II. REVIEW OF THE LITERATURE .................................... 9
Introduction ........................................................................ 9
Deﬁnitions of Learning Strategies ........................................ 10
General Learning-Strategy Research ................................... 11
Medical Contexts ................................................................ 13
Michigan State University Medical School ............... l3
Problem-Based Learning (PBL) ................................ 15
Research on Problem-Based Learning .................................. 29
Academic Achievement ........................................... 29
Clinical Performance ............................................... 30
Program Evaluation ................................................ 31
The Study Process (Study Habits) ........................... 33
Summary of PBL Research ...................................... 36
Summary of the Literature Review ...................................... 37
Research Questions and Working Hypotheses ..................... 39

METHODOLOGY ............................................................. 41

Introduction ........................................................................ 41
Subjects of the Study .......................................................... 41
Population ............................................................... 41
Sample .................................................................... 42
Instrument .......................................................................... 44
Interviews ............................................................... 44
Learning Study Strategy Inventory (LAS SI) ............ 46
Data Analysis ....................................................................... 51
Interview Data ........................................................ 51
The LASSI data ....................................................... 54
RESULTS .......................................................................... 56
Introduction ........................................................................ 56
Examples of Two Case Studies ........................................... 56
Jim .......................................................................... 57
Laura ...................................................................... 67
Findings Pertaining to the Research Questions .................... 76
Research Question 1 ................................................ 76
Research Question 2 ................................................ 79
Research Question 3 ................................................ 94
Research Question 4 ................................................ 97
Summary ............................................................................ 1 12
DISCUSSION AND CONCLUSION ................................. 113
Introduction ......................................................................... 113
Limitations of the Study ...................................................... 114
Research Question 1 ........................................................... 116
Research Question 2 ........................................................... 118
Research Question 3 ........................................................... 123
Research Question 4 ........................................................... 128
Interview Results .................................................... 128
LASSI Results ........................................................ 132
Conclusions ........................................................................ 136
Implications ........................................................................ 140
Implications for Theory ........................................... 141
Implications for Practice .......................................... 143
Recommendations for Future Research ............................... 145

APPE

APPENDICES .......................................................................................... 148

A Consent Form ..................................................................... 148
B. Interview Questions ............................................................ 149
C. Descriptions of LASSI scales and Sample Items .................. 151
D. An Example of the PBL Process .......................................... 155
E. PBL-Sensitive Scale Items Versus PBL-Nonsensitive
Scale Items ......................................................................... 158
F. Case Descriptions by Research Questions ........................... 163
REFERENCES .......................................................................................... 226

41

5‘4.
4!.

LIST OF TABLES

Table Page
2.1. Comparisons of learning tasks between ﬁrst-year and second-year
MSU CHM medical students .......................................................... 27
2.2. Comparisons between general PBL and MSU PBL ......................... 28
3.1. Schedule and number of subjects for interviews and LAS SI
administrations ............................................................................... 55
4.1. Key features of Jim’s learning strategies ......................................... 66
4.2. Key features of Laura’s learning strategies ...................................... 75
4.3. Resources students used to study learning issues ............................ 77
4.4. How and what students read ........................................................... 80
4.5. Reasons for doing group study ........................................................ 81
4.6. Integration strategies ...................................................................... 84
4.7. Memorization strategies ................................................................. 86
4. 8. Strategies for selecting main information ........................................ 88
4.9. Reasons for using computer programs ............................................ 90
4.10. Strategies for checking knowledge ................................................. 92
4.11. Inﬂuences on students’ learning strategies ...................................... 94
4.12. The ways in which PBL classes helped the students ........................ 96

4.13. Means and standard deviations on each LAS SI scale for students
who completed the LASSI at times 1, 2, and 3 ............................... 100

F7.
F8

F9

4.14.

4.15.

4.16.

4.17.

4.18.

4.19.

4.20.

4.21.

F.1.

F.2.

F.3.

F.4.

F5.

F6.

F.7.

F.8.

F.9.

Univariate F-Tests of Signiﬁcance of all three LASSIs using

the 10 LASSI scales ....................................................................... 102
Univariate E—Tests of Signiﬁcance at time 1 and time 2 using

the 10 LASSI scales ....................................................................... 103
Means and standard deviations on each LASSI scale for students

who completed the LASSI at time 1 and time 2 .............................. 104
Means and standard deviations on each LASSI scale for students

who completed the LASSI at time 2 and time 3 .............................. 105
Ommbus test ofsigniﬁcance at time 2 and time 3 using the 10

LASSI scales .................................................................................. 106

Means and standard deviations on the PBL-related scale and
the PBL—unrelated scale for students who completed the LAS SI
at all three times ............................................................................. 109

Means and standard deviations on the PBL-related scale and
the PBL-unrelated scale for students who completed the LASSI
at time 1 and time 2 ........................................................................ 110

Means and standard deviations on the PBL—related scale and
the PBL-unrelated scale for students who completed the LAS SI

attime2andtime3 ......................................................................... 111
Key features of Mark’s learning strategies ...................................... 168
Key features of Tom’s learning strategies ....................................... 175
Key features of Ann’s learning strategies ........................................ 182
Key features of Mary’s learning strategies ...................................... 188
Key features of Andrew’s learning strategies .................................. 194
Key features of Roger’s learning strategies ..................................... 200
Key features of Nancy’s learning strategies ..................................... 205
Key features of Janet’s learning strategies ....................................... 210
Key features of Cindy’s learning strategies ..................................... 212

 

F. 10. Key features of Susan’s learning strategies ..................................... 215

F. 1 1. Key features of Kelly’s learning strategies ....................................... 220
F.12. Key features of Jane’s learning strategies ........................................ 225

LIST OF FIGURES
Figure Page
4.1. Means on each LASSI scale for times 1, 2, and 3 ............................ 101

4.2. Means on the PBL-sensitive and the PBL-nonsensitive scales
fortime 1 and time3 ...................................................................... 107

4.3. Means on the PBL-related scale and the PBL-unrelated scale for

times 1, 2, and 3 ............................................................................. 109
5.1. Factors inﬂuencing students’ choice of learning strategies ................ 138

 

5-3316

 

CHAPTERI

INTRODUCTION

ment 1' lem

Educators do their best to construct instruction so their students will learn what is
needed to perform in the real world. For example, educators build professional education
programs with real-world-oriented general goals and speciﬁc objectives in mind.
Although medical educators want students to remember many basic-science facts,
concepts, and principles, they also want students to apply that knowledge to solve medical
problems. Thus, they design the instruction so that students will learn as much as possible
of the necessary knowledge and skill.

However, students are not passive recipients of knowledge and skill instruction.
They employ learning strategies to make the most of what is provided in the instructional
system. In the best of all worlds, educators provide instruction and students use
compatible learning strategies so they learn what is needed quickly and accurately.

But sometimes the faculty’s instructional system and the students’ learning
strategies are not compatible. Students may not have the skills to study in the most
effective and eﬁcient manner to complement the instructional methods or to attain the

goals and the objectives of the instruction. Or students may study in their own way to

an

achieve their goals regardless of the instructional goals or objectives. One could argue
that the instruction should change, and that is a possibility. However, the reality in most
situations is that the students must adapt to the instruction.

Of course, all students need to adapt their learning strategies a bit when they take
a new class with a new teacher or when they encounter a new subject. But it would seem
that students would have to adapt considerably more when the whole curriculum changes-
that is, when the mode of instruction and the goals and objectives change.

One typical example of an extreme change in curriculum can be found in the
variations in each year’s work in the medical schools. For example, at Michigan State
University, medical faculty teach according to considerably diﬁ‘erent curriculum plans in
the ﬁrst two years of medical school. The ﬁrst year, faculty teach mainly in large lectures.
Students must learn to recall and understand large amounts of basic science, which they
will eventually apply to medical practice. Even in year one, medical educators are
concerned with the way medical students adapt their learning strategies ﬁom the typical
undergraduate college classroom to the intensive learning experience of medical school.
This concern is magniﬁed for students who have not been as facile as other students in
applying learning strategies in college and who may not have as wide a range of learning
strategies to use.

As medical students enter year two, an even greater adjustment is required. Now
they are expected to learn, integrate, and apply knowledge to solve medical problems.
Furthermore, they must learn what they need to know to solve the problems on their own

and through group discussion with peers and a facilitator. This approach is called

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problem-based learning (PBL). In this context, medical educators are concerned about the
student’s ability to switch learning strategies from year one and to adapt to the new mode
of instruction and the new outcomes.

Instructional designers, curriculum developers, educational psychologists in
general, and medical educators concerned about at-risk students and those concerned with
planning medical curricula, in particular, want to know how students adapt their learning
strategies to changing instructional contexts. Ifthese professionals can understand this
process of adaptation, they can advise students about the most eﬁ’ective learning strategies
for the instructional system and can build courses in a way that will encourage effective
and eﬁcient learning strategies.

To expand the understanding of how students in general change their approaches
to study, I explored how medical students adapted their learning strategies when
instructional contexts changed. Because of the substantial changes that take place in
medical school curricula, medical students are ideal people to study to assess adjustment

of learning approaches as the instructional context changes.

W

The main purpose in this study was to examine how second-year medical students
adapt their learning strategies to changes in the instructional context. I looked at the
learning strategies of medical students who took part in a pilot study during their ﬁrst year
in a large-lecture-based curriculum (Lee, Yelon, Doig, & Smith, 1994). During the
second year of the preclinical program, students in the College of Human Medicine at

Michigan State University experience the new environment of problem-based learning

(PBL). This PBL curriculum, like others that have been adopted by some medical
schools, is supposed to encourage students to use approaches that enhance their learning
(Vernon & Blake, 1993). Because students’ perceptions of context may aﬁ‘ect their
approach to learning (Ramsden, 1984), I also probed students’ perspectives on PBL.

The pilot study by Lee et al. (1994) of ﬁrst-year medical students at Michigan
State University showed that students in a traditionally delivered, lecture-based curriculum
had enormous study loads and limited time. Through the experience of their ﬁrst semester
of medical school, most of the pilot students became more eﬁ‘ective and eﬁcient in
choosing learning strategies. For example, they ﬁequently used the strategy of selecting
important information, focusing on information that was likely to be on their multiple-
choice exams. They also became eﬁcient in time-management strategies, and were
involved in group study to exchange information or to divide the study load. This ﬁnding
is consistent with that of Malton and Saljo (1976b), who found that students adopted rote
learning or memorizing strategies for what was most likely to be on the exam when faced

with large amounts of factual information coupled with limited time.

Assumptions
This study was based on two assumptions: (a) Learning strategies inﬂuence
instructional outcomes, and (b) varied instructional contexts require changes in learning
strategies. Each of these assumptions is discussed below.
One assumption made in this study was that students’ use of learning strategies has
a signiﬁcant inﬂuence on their academic success and, perhaps more important, on the

quality of the knowledge they acquire. Researchers studying learning strategies have

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found correlations among various aspects of study methods, habits or attitudes, and
academic performance (Brown, Bransford, Ferrara & Campione, 1983; Garner, 1990;
Paris, 1988). However, these investigators have not considered the complexity and
dynamics of individuals’ learning strategies.

A second assumption made in this study was that, although approaches to learning
are determined partly by an individual’s learning style, learning strategies are also
signiﬁcantly inﬂuenced by the instructional context. The combination of learning style and
instructional context produces unique approaches to learning that are found in all groups
of students, including medical students (Newble & Entwistle, 1986). In a recent study of
the learning approaches of medical students, Arnold and Feighny (1995) found that
students’ perceptions of the instructional context inﬂuenced their learning approaches,
which in turn inﬂuenced their performance. Students must learn how to learn to meet the
changing demands of the learning environment because it is essential that students be
ﬂexible in adapting their learning strategies to the demands of the working environment.
Therefore, it is important for students to be aware of learning demands and understand
how to adjust their learning strategies to particular situations. Researchers have not

considered all the aspects of how learning strategies change as instructional context

changes.

Rati nale for nd i iﬁ use of the S
Although researchers have explored learning strategies and PBL, this study makes

several unique contributions to the understanding of both topics.

First, researchers have conducted many studies on the learning strategies of
children and undergraduate students. However, few researchers have focused on learning
strategies of graduate professional students. This study focused on medical students, a
unique subset of graduate professional students.

Second, whereas most learning-strategy studies have focused on relationships
among various aspects of study methods, habits or attitudes, and academic performance
(Brown et al., 1983; Gamer, 1990; Paris, 1988), the focus of this study was on how
learning strategies change as a function of changes in instructional context. I followed
students ﬁom their ﬁrst year of medical school to their second year, and examined how
their learning strategies changed.

Third, in previous research on PBL curricula, ﬁndings have been inconsistent
across programs in diﬂ‘erent medical schools. Thus, more studies of PBL in various areas
are needed to establish the beneﬁts of PBL. Each program is unique in its design, and the
problems or cases used in PBL are a major variable (Barrows, 1986). Thus, a synthesis of
the advantages of PBL is hard to achieve, and the careful study of each program and its
characteristics is necessary. Further, the College of Human Medicine at MSU has its own
characteristics which are different ﬁ'om other PBL schools. For example, MSU has
different assessment methods than do other PBL programs. Thus, although previous
researchers have tended to suggest that students study diﬁ‘erently under PBL, this claim
cannot be generalized to the MSU PBL curriculum. No studies have been conducted on
learning strategies of students under the MSU PBL curriculum. Thus, this study will

contribute to the understanding of the MSU

medical students’ approaches to studying under PBL curricula. Further, investigating
students’ learning approaches in preclinical years under PBL curricula will enrich the
understanding of medical students’ general learning, in which there is a growing interest.
Finally, this study explored, in part, students’ perceptions about their use of
learning strategies in diﬁ‘erent contexts. As shown in the literature review, observed
diﬂ‘erences in approaches to learning are likely to reﬂect contrasts in the educational
environment. However, it is impossible to say which components of the environment are
the most inﬂuential, as there are substantial diﬁ‘erences between PBL and traditional
courses in terms of curriculum, teaching methods, assessment, and staﬂ-student
relationships, all of which are likely to contribute in some way. Thus, it is valuable to
understand students’ perceptions of which of these aspects affect their approach to
studying in each curriculum so that this information can be used in ﬁrture instructional

designs in medical school.

mm nd 0v rview

In this study, I explored learning strategies of second-year medical students at
Michigan State University to determine how they adapt their learning strategies to a new
curriculumuproblem-based learning. I compared the students’ second-year learning
strategies with their ﬁrst-year strategies. In addition, I studied the medical students’
perceptions of PBL and its inﬂuences on their learning.

In Chapter 1, I set forth the necessity of studying how students adapt their
learning strategies in diﬁ‘erent contexts. The chapter also contained the assumptions made

in the study, purposes of the research, and four unique aspects of this study.

Chapter 11 contains a review of studies of learning strategies and the deﬁnition of
learning strategies used in this study. Chapter II also contains an explanation of medical
education in general as well as the speciﬁc medical context at Michigan State University.
For example, I explain and compare the ﬁrst- and second-year medical students’ activities,
curricula, and intellectual tasks. To consider the new context to which the students must
adapt, I also review literature related to problem-based learning. From reviewing previous
research on learning strategies, medical context, and PBL research, I formulated four
research questions with speciﬁc working hypotheses.

Chapter III contains an explanation of the research methodology. Both qualitative
and quantitative methods were used. I conducted interviews and administered a
questionnaire called the Learning And Study Strategy Inventory (LAS SI). Chapter 111
contains a description of the subjects of the study, including the population. The interview
procedures and LAS SI administration procedures are explained. Also, the data-analysis
procedures are described.

The ﬁndings of this study are presented in Chapter IV in relation to each research
question. The ﬁndings pertaining to the working hypotheses related to each research
question also are provided.

In Chapter V, the limitations of this study are set forth before discussing the study
ﬁndings. The ﬁndings are discussed in relation to those from previous studies. I also set
forth the conclusions drawn ﬁ'om the ﬁndings. Implications and recommendations for

future studies also are presented.

£811:

CHAPTERII

REVIEW OF THE LITERATURE

Introduction

The goal of this study was to examine the learning strategies of second-year
medical students who were under the PBL curriculum to determine how they adapted to a
PBL curriculum ﬁom a large-lectrrre-based curriculum. To understand and fulﬁll the goal
of this study, this chapter includes a review of literature based on three purposes.

The ﬁrst purpose of this chapter is to discuss the deﬁnitions of learning strategies
adopted in previous studies to derive the deﬁnition used in this study. Previous studies of
general learning strategies also are reviewed.

The second purpose of this chapter is to describe the types of medical contexts in
which medical students need to adapt their learning strategies. I compare the medical
context at MSU to that of other medical schools, and discuss in detail the PBL context in
order to understand students’ responses to interviews carried out for this research. In
doing this, the ﬁrst-year and second-year medical contexts in general and at MSU are
described and compared.

The third purpose of this chapter is to provide the rationale for this study, and also

to formulate the research questions and working hypotheses. Thus, previous PBL studies

10

of various topics including study approaches are reviewed in order to derive the research

questions and working hypotheses, which are presented at the end of this chapter.

Definiﬁons of Learning Strategies

Researchers have deﬁned learning strategies in various ways. Weinstein and
Mayer's (1986) deﬁnition of learning strategies is so broad that it includes all cognitive
processes. They deﬁned learning strategies as thoughts and behaviors that a learner
engages in during learning and that are intended to inﬂuence the encoding process. Nisbet
and Shucksrnith (1986) distinguished learning strategies from learning skills. They
deﬁned strategies as ”executive processes which choose, coordinate, and apply skills and
sequence of activities" (p. 1). In this deﬁnition, strategies are rather broad, general, and
goal-oriented, whereas skills are more speciﬁc or reﬂective. For example, strategies
include monitoring, revising, and checking, whereas skills include note-taking, underlining,
and summarizing. According to Nisbet and Shucksrnith, strategies improve with age and
experience, even without speciﬁc instruction; skills are more task-speciﬁc and can be
taught easily.

Kirby (1984) postulated a division of learning strategies into micro-strategies and
macro-strategies. Micro-strategies, such as underlining and summarizing, are more task-
speciﬁc and thus are closer to performance and more responsive to instruction. On the
other hand, macro strategies, such as monitoring and eﬁ‘ort managing, are more pervasive
and often are entwined with emotional and motivational factors. Whatever term

researchers choose, it seems that learning strategies are executive processes such as

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monitoring, planning, and regulating and are related to metacogrrition. They are at a more
general level than observable performances such as skimming, note-taking, or outlining.
In the present research, strategies were deﬁned as purposeﬁrl mental and physical
processes that underlie performance. Learning was deﬁned as changes in either thinking
or behavior, including both quantitative and qualitative changes. This deﬁnition of
learning includes changes in one's thinking process of which one is unaware, and that are
potentially available to consciousness. People may be able to infer their use of a strategy
alter being queried, even if they were unaware of their processing while performing the
task Therefore, learning strategies are tactics that increase the likelihood of eﬁ‘ective and
eﬁcient learning, such as helping the learner encode the information, memorize, and learn
easily. More speciﬁcally, following the deﬁnition of Weinstein and Mayer (1986), learning
strategies can be considered as thoughts and behaviors that a learner engages in during
learning and that are intended to inﬂuence the information processing. Learning strategies
include basic memory processes as well as general problem solving, and they encompass

almost all cognitive processes.

d

Query Luming-Sggtegy Resgrch

Many researchers in the late 1970s and 19805 were interested in results or
outcomes such as student achievement or grade changes brought about by using certain
learning strategies, rather than the process by which learning strategies resulted in
improved student achievement. For example, speciﬁc learning Strategies such as note-
taking (Norton & Hartley, 1986) and underlining in text (Blanchard, 1986) have been

found to inﬂuence students' ability to recall information.

12

Many researchers have found that learning strategies can be taught (Chipman,
Sega], & Glaser, 1985; Weinstein & Mayer, 1986). Also, it has been found that
metacognition can be promoted through direct instruction in classrooms and that increased
awareness can lead to better use of learning strategies (Paris, Cross, & Lipsorr, 1984).
Paris (1988) indicated that effective learners know when they need to be strategic and
when they do not. Lodico, Ghatala, Levin, Pressley, and Bell (1983) supported the
relationship between metacognitive knowledge and subsequent strategy use. In their
study, they found that instruction in general memory-monitoring principles was sufﬁcient
to eﬂ‘ect a change in strategy usage. Investigators have established strong relationships
between learning/metacognitive strategies and students' acadenric achievement (Brown et
al., 1983; Garner, 1990; Paris, 1988).

Recently, scholars have begun to investigate the critical eﬂ‘ect of college students'
independent use of learning strategies on their academic achievement (McKeachie,
Pintrich, & Lin, 1985; Pintrich, 1989). Pintrich argued that learning strategies facilitate
the storage and retrieval of information and, as a result, lead to an increase in students'
academic achievement. These studies were predicated on the assumption that academic
achievement can be improved by students’ exarrrining the strategies they use while
learning.

McKeachie, Pintrich, Lin, Smith, and Sharma (1990) suggested that use of learning
strategies can vary depending on the situation, and that these strategies can be brought
under students’ control. For example, students may choose to study diﬂ'erently for a

simple factual recall test than they would for a test that requires application and transfer of

13

the course material. In addition, research on student motivation and personality has
indicated that motivational orientation can vary in diﬂ‘erent situations and signiﬁcantly
aﬁ‘ect learning (McKeachie et al., 1990).

Most of the studies of learning strategies reviewed in this section focused on the
relationships between learning strategies and achievement, and most of them centered on
children and college students. The present study was based on the assumptions that
learning strategies are changeable and that these strategies can be controlled by the
learner. In contrast to previous studies of learning strategies, the present study concerned
learning strategies of medical students who are graduate professional students. Further, I
examined how students changed their learning strategies in two diﬂ‘erent contexts (lecture
verms problem-based learning) instead of focusing on the relationship between learning

strategies and academic achievement as most previous researchers have done.

Mﬂig antgxt
niv ' M ' ch 1

Michigan State University (MSU) has two medical schools: The College of Human
Medicine (CHM), whose graduates become MDs (medical doctors) and The College of
Osteopathic Medicine, whose graduates become DOS (doctors of osteopathy). This study
was focused on students who were pursuing an MD degree, who were enrolled in the
College of Human Medicine. Thus, the description of the medical school structure
pertains to that for MD degree students. Information on the MSU CHM Structure was

taken ﬁ'om the Mbggk for Premgical Students (1996), which is published by CHM,

l4

and from an interview with a professor in MSU CHM who is in charge of the year one
curriculum

As with most other medical schools in the United States, students who are
applying to the medical school at MSU need to have completed the baccalaureate degree
requirements. Usually, students who are applying to the medical school have science
backgrounds in their undergraduate education, although this is not always the case.
Students need to take the Medical College Admission Test (MCAT) before applying to
medical school. They also need to submit an American Medical College Application
Service (AMCAS) application with transcripts of all their academic work. Then, AMCAS
forwards a copy of the student’s application and MCAT scores to the College of Human
Medicine. MSU CHM also reconrrnends that students work or volunteer in medically
related areas and volunteer in community service areas. After the admissions committee
reviews the students’ AMCAS application, grades, and MCAT scores, qualiﬁed applicants
are asked to continue the application process by submitting a CHM secondary application,
in which students relate medically relevant professional experiences, a statement of past or
pending disciplinary actions, and plans for completing the CI-IM’S premedical
requirements. After these admission requirements are reviewed, students are interviewed.
At that time, students need to have three letters of evaluation ﬁom professionals.
Following the interview, the student’s entire application, including letters of evaluation, is
carefully reviewed by the Committee on Admissions.

Students who are admitted to MSU CHM receive four years of medical education.

In the ﬁrst year, called Block 1, medical students learn fundamental biological,

psyche-
lemurs:

arricu

Pears.

aware

15

psychological, and sociological science concepts. Block I consists mainly of large
lectures. The second year of medical school, called Block 11, consists primarily of a PBL
curriculum, which is explained in detail later in this section. The third and fourth years of
medical school are called Block 111. Block III clerkships are physician-supervised learning
experiences in which students work with patients at community hospitals and in
ambulatory settings. These clerkships are completed at one of six Michigan community
campuses, including Flint, Grand Rapids, Kalamazoo, Lansing, Saginaw, and the Upper
Peninsula. Students who successﬁrlly complete the four years of medical school are
awarded the MD degree. However, to become practicing physicians, they need further
training, including a residency program in their choice of one of several medical
specialties. Students spend three to seven years in the residency program, depending on
the medical specialty they choose. After the residency program, physicians sometimes
take part in a one- to three-year fellowship program, doing research and receiving
advanced clinical training.

This study focused on students in the second year of medical school, which

consists mainly of a PBL curriculum. PBL is described in detail in the following section.

Pr 1 -B ' B

In this section, I discuss problem-based learning including its goals and theoretical
basis. Because the adaptation of students’ learning strategies in different instructional
contexts was the focus of this study, I also discuss the differences between the ﬁrst and

second year of medical school, including curriculum and intellectual tasks.

16

EM is PBL in ggeral? The PBL approach has its roots in the discovery method
of teaching promoted by John Dewey in the 193 OS. The approach reappeared in the 19603
as the inquiry method of teaching science, heavily inﬂuenced by the work of Bruner and
Piaget (Wilkerson & Feletti, 1989). Recently, PBL has been the subject of much attention
in medical education. PBL was developed at McMaster University Medical School in the
early 19705 (Barrows & Mitchell, 1975; Neufeld & Barrows, 1974). Currently, more than
70 medical schools worldwide employ PBL (Ravitch, Golub, Altman, & McGaghie,

1994). The crucial components of PBL curricula are the ideas that problems raise
compelling issues for new learning and that students have an opportunity to become
actively involved in the discussion of these issues, with appropriate feedback and
corrective assistance ﬁ'om faculty members. The problems are not viewed as mere
supplements to lectures, but are regarded as a major part of the educational experience.

PBL can be deﬁned as learning that results ﬁ'om a process of working toward the
understanding or resolution of a problem (Alguire & Werner, 1992). PBL uses problems-
in this instance, patient cases—as a stimulus for learning, provides an opportunity for
problem solving, and allows for student-initiated searching for information.

PBL curricula are student centered to the extent that, during the course of
discussing a problem, students can identify knowledge deﬁciencies on their own and,
outside class, study to address those deﬁciencies. Coulson (1983) considered this the
process of self-directed learning. As he described the process, students working through a
problem will hit obstacles to their progress due to lack of knowledge. Each time they hit

an obstacle they make note of what they need to learn and continue with the problem until

l7

progress ceases. At this point, students develop a learning “prescription” with help from
their tutor, access learning resources to acquire the knowledge they need, and then return
to the problem either to start over or to pick up where they left oﬂ‘. In working with the
problems, students are expected to draw on previous learning and experience, to pose
questions concerning new issues, to set personal learning goals, to take responsibility for
their own learning through independent reading and study, and to teach one another V
through student-to-student discussion.

However, although the term “problem-based learning” identiﬁes a general
approach to learning, there are variations among PBL curricula at different schools. Some
medical schools such as McMaster, Maastricht, Newcastle, Hawaii, and Sherbrooke, or
“tracks” in such schools as New Mexico, Bowman-Gray, Rush, and Ohio State, have no
lectures and have only PBL curricula. Other schools such as Tuﬁs, Harvard, New Jersey,
Northwestern, Michigan State, and Medical College of Wisconsin employ PBL as one
learning modality within a curriculum that may also include lectures, large-group
discussion, and other learning formats. Schools also may diﬂ‘er in their conceptualization
of curriculum, structure, expectations of students in PBL, preparation of cases, roles of
faculty, and assessment of students (Ravitch et al., 1994). Blumberg, Michael, and Zeitz
(1990) in their structured interviews with faculty representing seven North American
problem-based learning curricula found that the examination development process varies
ﬁ'om school to school. For example, at MSU, Harvard, and Mercer, the faculty-generated
learning objectives determine the content of examinations. On the other hand, at Rush and

Bowman Gary, student-generated learning issues are collected and used in preparing

18

examinations. Further, Blumberg et a1. (1990) found that at Bowman Gary, McMaster,
New Mexico, and Rush, students are evaluated on their ability to generate learning issues.
For instance, on the ﬁrst attempt on some evaluations, students in these schools generate
learning issues and study ﬁ'om learning issues for oral exams, which follow. However, at
MSU and Mercer, the examinations are closed book and students’ ability to generate and
resolve learning issues is not evaluated.

At MSU CHM, students and a faculty tutor/preceptor meet for two hours, three
times a week The preceptor facilitates problem-based learning discussion. Preceptors are
faculty in medical school, both Ph.D.’s and M.D.’s. The principal responsibility of the
preceptors is to facilitate the discussion and learning of the small groups in PBL class.
They also evaluate the performance of each student in the group and provide feedback to
them. At MSU CHM, there is a balance between teacher- and student-centered PBL
curricula. For example, MSU PBL classes are very structured in that the learning
objectives are deﬁned by faculty and not by students. Also, students focus on speciﬁc
reading assignments provided by faculty. However, students are expected to participate
actively in class discussions. Because each school has unique characteristics within PBL
programs, it is important to keep these characteristics in mind when studying a particular
school.

W In general, PBL is supposed to let students take
responsibility for their own learning. Students develop learning strategies and habits that
will serve them well for a lifetime of learning, particularly when they encounter unfamiliar

problems. Glaser (1984) labeled these strategies and habits self-regulatory or

19

metacognitive skills. They include knowing what one knows and does not know,
predicting outcomes, planning ahead, eﬁciently apportioning time and cognitive
resources, and monitoring one's eﬁ‘orts to solve a problem or learn.

This approach also is supposed to enhance students' motivation to learn. Active
participation in deﬁning, resolving, or managing a problem points up the need to acquire
new information, attitudes, and skills. When PBL is implemented across an entire
institution, students develop learning styles commensurate with that approach and
diﬂ‘erent ﬁorn the learning styles demonstrated by students in a more traditional
curriculum (Newble & Clarke, 1986).

PBL also restructures previous learning in an attempt to accommodate new
information; new learning is organized for assimilation into existing knowledge structures
(Schmidt, 1983). Further, teachers can use PBL to encourage students to assess their own
learning. Discussion among peers allows learners to compare their answers to those of
other students, to discover errors in their thinking, and to hear how correct solutions were
derived.

PBL is supposed to promote self-directed learning skills, and the practice of self-
directed learning in the context of PBL thus enhances the probability and quality of
continued learning once the student has graduated and throughout his or her career.
Hence one might assume that the PBL experience allows students to enhance their
independent-study strategies. Also, through small-group work, PBL can promote team
efforts and the ability to work with others. This led me to believe that second-year

medical students improve their small-group skills through the PBL experience.

20

gals of the MSU model of PBL. The goals of PBL at MSU include:

1. To provide a clinical context for learning which will both anchor the
learning and motivate the student.

2. To encourage active learning: If students are in a small group and working with
a problem, they should be engaged actively in learning, not passive bystanders.

3. To provide a model of problem solving: What is learned will depend upon where
the focus is: the student may learn skills in identifying learning needs, or skills
for acquiring new information, or some other clinically relevant problem-solving
skills

4. To develop small-group skills: Since students work in a small group, they
acquire some eﬂ‘ective small-group skills. The PBL group provides a “human
laboratory” in which group process can be examined and one’s own group
behavior can serve as a focus for learning as well. (Block 11 Preceptor Training,
1993, p. 1)

Willi}; PBL has a cognitive-psychology perspective as its
theoretical base. As Schmidt (1983) and Norman and Schmidt (1992) suggested, three
major principles derived ﬁom the cognitive-psychology orientation support the rationale
and process of PBL: (a) the role of prior knowledge, (b) learning transfer, and (c)
elaboration of knowledge.

The ﬁrst principle of PBL is acknowledgment of the role of prior knowledge.
Learning, by its very nature, has a restructuring character. It presupposes earlier
knowledge that is used in understanding new information. Current learning is affected by
past learning. Well-written problems will activate students’ prior knowledge of high
school or undergraduate science. As such, a second-year medical student, while reading
and interpreting an article, will probably make use of his or her secondary-school or ﬁrst-
year medical school knowledge of biology. Thus, one of the goals of learning is to

activate a student’s year-one knowledge. Instructional methods, however, diﬁ‘er in their

capacity to activate relevant prior knowledge (Mayer & Greeno, 1972). To be successful,

21

the instructional method must activate the prior knowledge. PBL, by encouraging
students’ discussion, questions, and problem solving, is intended to activate students’ prior
knowledge for the current learning. Thus, it can be predicted that PBL allows second-
year medical students to activate their prior knowledge and hence connect their current
learning to their existing knowledge more easily than ﬁrst-year students.

The second principle of PBL is related to learning transfer, which Schmidt (1983)
called “encoding speciﬁcity.” This principle suggests that the closer the resemblance
between the situation in which something is learned and the situation in which it will be
applied, the more likely it is that transfer of learning will occur. PBL problems use real-
life situations. Well-written problems present situations most commonly seen in practice.
Barrows (1985) contended that medical students do not remember or cannot use the
knowledge they learned in traditional basic-science courses because that knowledge was
structured into mental organizations that are not useﬁrl in a clinical setting. That
knowledge was structured around taxonomies and hierarchies, but not symptoms, signs, or
courses of illnesses. Barrows proposed that learning basic science in a PBL format will
structure the knowledge in such a way that students will remember it better and will be
able to retrieve it when they need it in clinical practice.

The third theoretical principle of PBL is the importance of the elaboration of
knowledge. Information will be better understood and remembered if there is opportunity
for elaboration (Anderson & Reder, 197 9). Examples include engaging in active
discussion, answering questions, teaching peers, writing summaries, and formulating and

criticizing hypotheses about a given problem (Schmidt, 1983). Providing opportunities for

22

elaboration is one of the main activities of PBL. Elaboration creates redundancy in the
memory structure. Redundancy can be viewed as a safeguard against forgetting and an aid
to rapid retrieval.

Overall, by encouraging students’ active participation in discussion and problem
solving, PBL facilitates students’ learning, emphasizing the active role of the learner, in
comparison with the more traditional curriculum.

CMS of the CHM curriglum.

1. First-Year Medical School

First-year medical students take biological-science courses including anatomy,
physiology, biochemistry, histology, pathology, neuroscience, pharmacology, genetics,
microbiology, and radiology. The instruction is discipline-based and is conducted in a
large-class lecture mode.

In addition to these basic-science courses, students learn basic clinical science,
which is taught in a series of clinical skills courses spanning Blocks I and 11 (three hours
per week). From these courses, students learn the dynamics of the doctor-patient
relationship, how to interview patients, and how to conduct physical examinations.
Also, they take human development courses, which are taught in the summer semester.
These courses provide a foundation for domains related to behavioral sciences such as
psychology or sociology.

2. Second-Year Medical School

The second year of medical school (Block 11) features a required PBL curriculum

designed to facilitate the integration of basic sciences with clinically relevant cases. The

23

content domains of the second year include infectious disease, disorders of development
and behavior, neurological and musculoskeletal, major mental disorders, cardiovascular,
pulmonary, renal, metabolic, endocrine and reproductive, digestive, dermatology/allergy,
and hematopoietic/neoplasia. At the beginning of each of these domains, students are
given an “unpacked content list,” which deﬁnes for them all of the content they are
expected to know and understand at the end of that domain. The lists are organized by
basic science disciplines, as is the ﬁrst-year curriculum, although they contain more
advanced and sophisticated knowledge. An eﬁ‘ort has been made to relate the content lists
to the cases as much as possible in terms of domain content. Each case is designed so that
there are pieces of the content list that naturally elaborate ﬁom that case.

In addition to the PBL curriculum, students in Block 11 participate in a year-long
serrrinar on medical ethics, health policy, and epidemiology, and learn advanced clinical
skills. They also take part in the mentor program, which focuses on the personal
development of the physician.

' 'n 'sintheMS PBLclasr rn.

Cases are usually discussed and analyzed in two or more successive
sessions. As the cases are analyzed, students deﬁne learning issues. Learning
issues provide the bridge from one session to the next. They are the agenda for
learning that the students deﬁne for themselves, the homework that students
create. They determine what the students will be prepared to discuss and examine
at the next meeting. All members of the group then focus on the learning issues in
their study between sessions. Preceptors help students to deﬁne learning issues in
ways that will make it productive for them, and not overwhelming.

The analysis of the cases proceeds in three general steps:

1. Deﬁne cues: What data are in the case that might be clues about what is going
on?

2. Create hypotheses: ideas about what’s happening, what the underlying
mechanisms or principles that might be at work in this case. The hypotheses
should be in terms of the underlying basic sciences, and not be possible
diagnoses.

24

3. Generate learning issues: areas that will be emphasized during independent
study, in order to better understand the case. This is a dynamic process. Rather
than moving in a linear fashion from cues to hypotheses to learning issues, the
preceptor helps the group move back and forth between cues, hypotheses, and
learning issues. (Black II Preceptor Training, 1993, p. 7 )

An example of each step of the PBL process is shown in Appendix D.

W.

l. First-Year Medical Students

First-year medical students’ intellectual tasks include (from discussions with the

director of Block I curriculum and the pilot study (Lee et al., 1994)):

- Mainly reading books, notes, and scribe notes. Scribe notes are notes which other
students have taken in the class and are distributed to those students who want them.
They are widely used among medical-school students.

- Solving assignments to understand the concepts, principles, and diagrams in preparation
for classes and exams.

- Taking notes during class.

- Memorizing the facts, concepts, principles, and so on (using various strategies such as
mnemonics, diagrams, and connecting to experiences) for exams.

- Discussing and asking questions during review sessions or Supplemental Instruction (SI)
sessions (optional).

- Studying with tutors (mostly for understanding the concepts)-optional.

- Interacting with patients (interviewing skills).

2. Second-Year Medical Students

25

Second-year medical students’ intellectual tasks include (ﬁ'om Black II Preceptor

Training, 1993):
W

1. Present the initial case
2. Find cues

3. List hypotheses

4. Receive additional information

5. Summarize facts

6. Generate learning issues
7. Discuss resources

8. Learn independently

9. Revise hypotheses based on
independent study

10. Review what has been learned

Tasks (Skills, Idgs)

Listen to or look for the pertinent cues
Find and organize cues

List hypotheses in terms of principles

Reduce the number of hypotheses, seek
additional cues

Summarize facts, change hypotheses
Identify knowledge deﬁciencies

Look for the resources, research skills
Independently study the learning issues
Apply knowledge to the case

Review knowledge, connect new knowledge
to previous knowledge

In addition to these tasks, second-year medical students’ intellectual tasks include:

- Learning basic-science concepts in clinical context.

- Actively participating in discussions.

- Thinking and identifying the learning issues (rdentifying their knowledge deﬁciencies).

- Doing independent study for the next session, looking for resources.

- Integrating concepts and principles for problem solving.

- Improving small group skills.

26

- Applying what they have learned in solving simulated problems.
- Asking questions.
- Interviewing patients.
- Studying for exams (multiple choice exams).
A comparison of learning tasks of ﬁrst- and second-year MSU CHM medical
students is shown in Table 2.1. A comparison of general PBL and MSU PBL is presented

in Table 2.2.

27

Table 2.1: Comparisons of learning tasks between ﬁrst-year and second-year MSU CHM

 

 

 

 

 

 

 

medical students.
First Year Second Year
Assessment Multiple-choice exams Multiple-choice exams;
essays occasionally
Learning Activities Mostly memorization of what will To b; studied
(Tasks) in Class be on the exams; selecting main Problem solving - discussion of
information; lectures; taking the case; generating learning
notes, interviewing skills, etc. issues for the next session,
solving Stimulus questions
provided by faculty members,
asking questions, etc.
(It is hypothesized that they
also focus on memorization for
exams, thus doing diﬂ‘erent
things for the class and the
exams.)
Outside Activities Solving stimulus questions that To be studied
are at the end of the course Independent study for learning
packet; attending Supplemental issues, research, etc.
Instruction (optional), (It is hypothesized that
participating in study group, students use more learning
tutoring, etc. resources such as library
facilities.)
Content Basic sciences Basic sciences
Methods Mainly large lectures PBL (mainly small-group
(Curriculum) discussion), large lectures

 

 

(optional),etc.; balanced in that
PBL has both teacher and
student centered; teachers
generate testing agendas

 

Note: F irst-year data are primarily from a pilot study of MSU students (Lee et al., 1994).
MSU second-year data come from internal documents of the MSU medical school
and ﬁ'om interviews with faculty members in the medical school.

 

28

Table 2.2: Comparisons between general PBL and MSU PBL

 

 

 

 

 

 

 

MSU PBL General PBL
Assessment Multiple choice; Usually both essays and
essays occasionally multiple choice are required
Leaning Activities To be mung Understanding oriented,
(Tasks) in Class Problem solving - discussion of problem solving, information
the case; generating learning gathering, reasoning, etc.
issues for the next session,
solving stimulus questions
provided by faculty members,
asking questions, etc.
Outside Activities Mtgtii—ed More library use (information
Independent study for learning seeking), self-directed
issues, research, etc. learning, doing research of
their own, etc.
Content Basic sciences Basic sciences
Methods PBL (mainly small-group PBL; most other programs
(Curriculum) discussion), large lectures have PBL curriculum for both
(optional), etc; balanced in that ﬁrst and second years, varied
PBL is both teacher and student depending on program, but
centered; teachers generate mostly student centered in that
testing agendas students generate learning
agendas

 

 

 

Note: General second-year data are from literature on various PBL programs.

 

29

Research 2n Problem-Based Learning
Vernon and Blake (1993) conducted a meta-analysis of PBL as compared with

traditional methods of teaching. Their study included 25 studies carried out from 1970
through 1992. Albanese and Mitchell (1993) also did a comprehensive review of writings
on PBL. They reviewed literature ﬁom 1972 to 1992 on the eﬂ‘ectiveness of PBL. The
diversity of the original studies reviewed, particularly with respect to outcome measures
and research designs, enhances the tentative nature of the conclusions they reached. The
remlts of both review studies were similar. Based on their research, the present researcher
tried to provide a more comprehensive and detailed review of studies in the various areas
of PBL.

Although students’ approaches to learning were the focus of this study, knowing
the eﬂ‘ects of PBL on other areas helps in understanding PBL and how students may

respond to it. Thus, the review of PBL research focused on several areas.

Wm

Researchers evaluating PBL have explored acadenric achievement by using several
outcome variables, including the National Board Medical Examination (NBME) Part 1,
“other knowledge tests,” and the incidence of academic failure or attrition. Vernon and
Blake (1993) analyzed data on the NBME from eight research reports. They found that
eﬁ‘ect size (ES) data suggested a signiﬁcant trend favoring the traditional teaching method.
Also, they found that traditional programs had an advantage with respect to other
knowledge tests that required factual information. However, analyses of homogeneity

among the ES measures have raised questions about the generalizability of the obtained

30

mean ES. For example, Albanese and Mitchell (1993) reported that, although the
University of New Mexico program has shown consistently negative ES (favoring the
traditional program), Michigan State University’s earlier PBL curriculum showed
consistently positive ES favoring PBL (F arquhar, Haf, & Kotabe, 1986). The University
of Colorado (N olte, Eller, & Ringel, 1988) and Mercer (Bickley, Donner, Walker, & Tilt,
1990) also showed a positive effect for PBL. Such variations might be the result of
diﬁ‘erent emphases in program goals at different schools. For example, the PBL
curriculum at McMaster and New Mexico is more student centered, which exposes
students to narrower content. Thus, they develop inadequate knowledge scaﬂ‘oldings,
which results in inferior performance on basic science examinations as compared to
students in a traditional curriculum (Albanese & Mitchell, 1993).

Another possibility is that schools may have recruited diﬁ‘erent types of students
into their PBL and traditional programs. For example, the MSU PBL program, at the time
the research was done, may have recruited students with stronger basic-science
backgrounds or interests, as compared with their traditional counterparts because the
students self-selected the PBL curriculum track, whereas the opposite pattern may have

prevailed at New Mexico (Martinez-Burrola, Klepper, & Kaufman, 1985).

W

In their meta-analysis, Vernon and Blake (1993) found that PBL increased
students' abilities in clinical reasoning, integration of clinical and basic science knowledge,
and the independent study of clinical problems. Also, in contrast to results on NBME 1,

these data showed a slight, but nonsigniﬁcant, trend in favor of students in PBL programs.

31

For example, PBL graduates viewed the quality of their training in humanistic areas and
clinical reasoning more positively than did conventional students. Conventional students
tended to rate their training in biomedical science more positively (Post & Drop, 1990).
Albanese and Mitchell (1993) found that, in all seven studies they reviewed, clinical ratings
by faculty supervisors were either more positive for students in the PBL curriculum or

nonsigniﬁcantly diﬁ‘erent from the ratings for the conventional group.

W

In their meta-analysis, Vernon and Blake (1993) found that PBL was signiﬁcantly
superior to the conventional approach with respect to students' program evaluation
(students' and faculty’s attitudes and opinions about their programs). In addition, distress
(Including depression, anxiety, hostility, and somatic complaints) was found to be lower
among PBL students than their traditional counterparts (ES = +51) (Moore-West,
Harrington, Mennin, Kaufman, & Skipper, 1989). For example, Moore, Block, and
Mitchell (1990), using interviews of students in PBL and conventional curricula at
Harvard, found that the PBL Students were more likely than conventional students to
describe their preclinical years in medical school as being engaging, diﬁcult, and useﬁrl
(p < .05). The conventional students, on the other hand, were more likely to describe their
preclinical experience as irrelevant, passive, and boring. Students seem to consistently
enjoy the small-group interactions and atmosphere created by PBL. I expected that,

through the experience of small-group interactions, students in MSU PBL classes would

develop their small-group working skills.

32

Wetzel, Rarnois, Armstrong, and Neill (1989), F eletti and Carver (1989), and
Anderson (1989) studied faculty satisfaction with the PBL program at Harvard Medical
School. Their ﬁndings strongly suggested that faculty found PBL a satisfying way to
teach. The personal contact promoted by the small-group format was one of the most
commonly perceived beneﬁts of PBL.

Moore-West and O’Donnell (1985) reported on the stress levels of second-year
medical students. The results indicated that PBL students were substantially less stressed
than their conventional counterparts. Moore-West et al. (1989) also surveyed students in
the two tracks about their perceptions of other aspects of the environment. The PBL
students rated their experience higher in terms of meaningfulness, ﬂexibility, emotional
climate, nurturance, and student interactions. However, Moore et a1. (1990) found that
PBL students at Harvard thought their preclinical experiences were more stressﬁrl than did
students in the conventional curriculum. Blumberg and Eckenfels (1988) studied students’
levels of satisfaction with the environment in a PBL and a conventional curriculum. The
most satisfying aspects identiﬁed by PBL students were problem solving, applicability,
group discussions, and clinical relevancy. Conventional students identiﬁed the balance
between individual excellence and group competence as being the most satisfying aspect.
PBL students identiﬁed the least satisfying aspects of the experience as tendencies to
encourage competition and essay examinations, whereas conventional students identiﬁed
memorization of facts, lectures, and multiple-choice tests as least satisfying.

The results of these studies, suggesting that both students and faculty generally

perceived the PBL environment as a positive one, are important because perceptions of

33

the curriculum could be a crucial factor to medical schools in deciding to make curriculum

changes.

WW

Very few studies have been conducted on the academic processes associated with
PBL. However, some research has been done on the process of learning in PBL, including
students’ approaches to learning and their use of various learning resources (e.g., the
hbrary). This research is discussed in the following pages.

WWW Marton and Saljo (1976a) studied
Swedish university students’ approaches to studying. They found that there were
qualitative diﬁ‘erences in the processing of learning-deep-level processing versus surface-
level processing. Because the following research on students’ approaches to learning
focused on this ﬁ'arnework, a detailed explanation of what Marton and Saljo meant by
deep- and surface-level processing will be helpful. They deﬁned deep-level processing as
when students are directed toward the intentional content of the learning material (what is
signiﬁed); that is, they are directed toward comprehending what the author is saying
about, for instance, a certain scientiﬁc problem or principle. The authors deﬁned surface-
level processing as when students direct their attention toward learning the text itself (the
Sign); they have a “reproductive” conception of learning, which means that they are more
or less forced to keep to a rote-learning strategy.

Following this framework, Coles (1985) and Newble and Clarke (1986) compared
the study approaches of PBL and conventional medical students, using versions of the

Approaches to Studying Inventory developed by Entwistle (1981). Both studies indicated

34

that students in PBL programs placed more emphasis on “meaning” (understanding) than
on “reproducing” (rote learning and memorization), and that the opposite pattern
prevailed among students in traditional programs. The researchers found that PBL
students were more likely to use versatile approaches (1; < .01) and meaning-related
approaches (2 < .001), and less likely to use reproduction (p < .001). They deﬁned the
surface approach as being motivated by a concern to complete the course or by a fear of
failure, and intention to reproduce factual material, which promotes rote learning.
Students using the deep approach, motivated by an interest in the subject matter, tend to
reach an understanding. Those using the strategic approach, motivated by the need to
achieve high marks and to compete with others, tend to be successful by whatever means
are necessary. Coles (1985) argued that PBL may be creating an educational climate that
enables students to learn in what seems to be a desirable manner. In contrast, a
conventional curriculum appears to constrain students to adopt poorer approaches to
studying, not only in comparison with PBL students but also as compared with their own
approaches on entry.

Also, in their study of Harvard medical students, Moore et al. (1990) found that
PBL students were less likely to engage in memorization and more likely to rely on
conceptualization as a learning method as compared to conventional students. Similarly,
Mitchell (1992) found that PBL medical students were much less oriented toward
memorization, were much more oriented toward studying by reﬂection on material, and

showed a trend toward conceptualization in their studies.

35

Van Langenberghe (1988) carried out research on a physical therapy PBL
curriculum. Using the Short Inventory of Approaches to Studying developed by Entwistle
(1981), he found that physical-therapy students in PBL in The Hague had more desirable
studying approaches than did normative students. More speciﬁcally, he found that PBL
students showed more drive to achieve, relied less on memorizing, and put more eﬂ‘ort
into understanding the subject matter. Thus, based on the PBL studies reviewed above,
one might expect that students in PBL curricula develop skill in integrating the materials
and focus more on understanding than on rote memorization.

W Nolte et al. (1988), Rankin (1992), and Saunders, Northup,
and Mennin (1985) studied the eﬁ‘ect of introducing a PBL course on neurobiology into
the medical curriculum. They found that library use increased 20-fold and that student
attendance at formal instructional sessions increased ﬁ'om 65% to 90%. The researchers
found that the PBL group and the traditional group differed in their use of learning
resources in ways that were plausible and that favored PBL. Speciﬁcally, PBL students
(a) placed more emphasis on journals and on-line searches as resources; (b) made greater
use of the library; (c) made greater use of self-selected, as opposed to faculty-selected,
reading materials; and (d) more ﬁ'equently felt competent in information-seeking skills.
These ﬁndings led me to believe that students in PBL classes would evidence increased
use of learning resources such as the library and self-selected reading materials.

Blumberg and Michael (1992) studied PBL as related to self-directed learning.
They did not ﬁnd diﬁ‘erences between groups in terms of study time, but they did ﬁnd that

the PBL group and the traditional group relied on diﬁ‘erent resources for studying.

36

Compared with their conventional peers, the PBL students reported greater use of
textbooks, journals and other books, and informal discussions with faculty or peers. They
reported signiﬁcantly less use of cooperative lecture notes (p < .001).

In general, the ﬁndings from these reports suggest that there is a greater degree of
independent study in PBL programs than in traditional programs, as well as greater
emphasis on depth of understanding rather than on rote learning and memorization. Most
of the studies done in this area had static-group research designs (traditional students’
ratings of their courses were compared with the ratings of nonequivalent PBL students) or

relied on questionnaires.

Sm of PBL Rmch
Most of the PBL research in this area favored PBL over traditional programs.

However, there are drawbacks in how the outcomes were measured. For instance, most
researchers have used the standardized achievement tests of the NBME, but standardized
examinations measure only the exarninees’ ability to recognize the correct answer ﬁ'om a
limited list of potentially correct answers and are heavily oriented toward recall. PBL
proponents have argued that such measures do not assess study approaches aimed at the
deep learning that PBL promotes (Albanese & Mitchell, 1993).

Further, not all of the views of PBL are favorable. For instance, in her review of
PBL research, Berkson (1993) expressed a pessimistic view of PBL. Although many
researchers have suggested that PBL promotes deep approaches to study, which enhance
understanding, Berkson argued that most students are ﬂexible in their choice of learning

strategy, and PBL can provoke highly strategic rote, or reproductive, learning behavior.

37

She argued that tasks that require comprehension for a successﬁrl conclusion, whether
they occur in PBL or traditional curricula, will encourage the use of a comprehension-
directed, or deep, cognitive learning approach. Concerning motivation, Berkson argued
that interest (motivation) is important to learning behaviors because it focuses students’
attention, Stimulates deep processing, sustains persistent study, and increases tolerance of
ﬁustration. However, PBL is not unique in its capacity to stimulate curiosity in students
or to create satisfying learning environments. Berkson argued that students who feel
insecure in guiding their personal learning experiences may lose interest in the subject

matter as a result of ﬁustration or peer performance pressure.

Summary of the Dream; Review

My purpose in this study was to examine the learning strategies of second-year
medical students who were under the PBL curriculum to determine how they adapted to
the PBL curriculum from a largelecture—based curriculum. To understand and fulﬁll this
goal, the review of literature and research was based on three purposes—-understand
learning strategies, which was the focus of the study; understand diﬁ‘erent instructional
contexts-lecture versus PBL; and review previous PBL research on study approaches-in
order to derive the rationale, research questions, and working hypotheses.

In this study, learning strategies were deﬁned as tactics that increase the likelihood
of eﬁ‘ective and eﬁcient learning, such as helping the learner encode the information,
memorize, and learn easily. More speciﬁcally, following the deﬁnition of Weinstein and
Mayer (1986), learning strategies can be considered as thoughts and behaviors that a

learner engages in during learning and that are intended to inﬂuence information

38

processing. Learning strategies include basic memory processes as well as general
problem solving, and they encompass almost all cognitive processes.

The review of the instructional contexts revealed that medicd Students in MSU
CHM experience varied curricula, mainly large lectures delivered by professors during
their ﬁrst year, and small-group discussion of cases or problems in PBL classes during
their second year. Further, the review of the nature of PBL in general and in MSU CHM
speciﬁcally indicated that MSU CHM has a unique Structure for its PBL classes. For
example, it was found that MSU CHM focuses mainly on multiple-choice exams as
assessment and is more structured in the sense that professors, not students, generate
testing agendas and formulate objectives, although they also allow active student
participation in small-group discussion.

The review of the PBL research in academic achievement area indicated that there
is a signiﬁcant trend favoring the traditional curriculum. However, researchers have found
that PBL students evaluated their curriculum more favorably than did conventional
students and that PBL increased students’ abilities in clinical reasoning and integration of
clinical and basic science knowledge. Further, PBL research indicated that PBL students
tended to study diﬁ‘erently ﬁom conventional students. They are less likely to study for
short-term recall and more likely to study for understanding, or to analyze what they need
to know for a given task and study accordingly. PBL students also control substantially
more of their learning eﬁ‘orts than do conventional students. In addition, PBL students are

substantially more likely to use the library and library resources to study. However, the

39

results of the PBL research have not been consistent, so further study is needed to
understand how students in PBL curricula approach studying.

The research questions and working hypotheses for this study were derived by
reviewing previous studies on PBL and diﬁ‘erent instructional contexts at medical schools.
Although hypotheses should not constrain what is understood ﬁom the data collected in a
qualitative study, having working hypotheses derived ﬁom previous studies not only
guided the analysis of data ﬁ'om a vast number of interview protocols but also helped in
comparing the ﬁndings with those ﬁom previous studies. The research questions of this
study and working hypotheses derived from the review of the literature are stated in the

following section.

March Questions and Working Hypotheses

1) What learning strategies do students use in preparation for the problem-based learning
classroom, and why?
a) Students will study diﬁ‘erently for PBL classes than for examinations.
b) Students will focus more on understanding than on rote memorization in preparing
for PBL classes.
c) Students will use many learning resources, such as library facilities, for PBL classes.
2) What learning strategies do students use in preparation for examinations (both class
exams and the licensing exam), and why?
a) Students will use strategies for integrating the materials for exam preparation as a
result of their PBL experience.

b) Students will use many memorization strategies in preparing for exams.

40

c) Second-year students will use many strategies for selecting main information because
of the large study load.

3) What do students think inﬂuences their learning strategies (such as goals, assessment of
learning, student activity, teaching method, and course content)?

a) Students will think that the PBL curriculum aﬂ‘ects their use of learning strategies.

b) Students will develop their communication strategies inﬂuenced by the PBL
experience.

4) Do second-year medical students at MSU CHM report that they study diﬁ‘erently than
they did in their ﬁrst year? Ifso, how and why?

a) Second-year students will develop skills in integrating the materials and focus more
on understanding the materials as a result of their PBL experience as compared to
their ﬁrst year.

b) Second-year students will have improved their strategies for selecting main
information because of the large study load as compared to their ﬁrst year.

c) Students will develop research skills and do more independent study as a result of
the PBL experience as compared to their ﬁrst year.

d) Students will use more learning resources, such as library facilities, self-selected

reading materials, or textbooks than they did in the traditional curriculum.

CHAPTERIII

METHODOLOGY

Introduction
This chapter contains a discussion of the methodology used in conducting the
study. The population and sample for the study are described ﬁrst. Next, the instruments
used to gather data for the study are discussed. Two data-collection methods were used,
personal interviews and the Leaming and Study Strategy Inventory (LAS SI). Data-

analysis procedures are explained last.

Suhiw of thg Stud!

89mm

The population of this study comprised all medical students who experienced PBL
curricula. Because the samples were chosen ﬁ'om medical students in the College of
Human Medicine at Michigan State University, the accessible population comprised
second-year medical students at MSU CHM (during the 1994-95 academic year). Each
year, approximately 106 students enter the CHM at MSU. About 15% are
underrepresented rrrinority students, and almost 50% are women. During their ﬁrst two

years, students study the basic sciences such as physiology, anatomy, biochemistry, and

41

42

pharmacology. This research focused on education during the second year of this two-
year preclinical period, which consists primarily of PBL classes.

Medical students were chosen for this research because studying their learning
strategies in lecture-based year one and their learning strategies in PBL based year two
was consistent with the purpose of this study. That purpose was to examine how second-

year medical students adapt their learning strategies to changes in the instructional

context.
mm
mm; Of the second-year medical students, eight students who

participated in the pilot study during the 1993 -94 academic year and four other second-
year medical students participated in interviews about learning strategies for this research.
Because two of the original eight students were not taking PBL classes at all during 1994-
95, the additional four medical students were interviewed to match the responses of the
original students who participated in the pilot study. The eight students who had been
interviewed the preceding year were matched based on their entrance exam scores
(MCAT) to account for preexisting diﬁ‘erences among students in two different groups-
students in Supplemental Instruction (81) and students who were not in SI. Supplemental
Instruction is an academic support intervention designed not only to help students master
course content but also to develop their learning strategies (Martin, Black, & DeBuhr,
1983). Of these eight students, two represented high, ﬁve represented middle, and one
represented low to middle academic performance levels. Six of the students were females

and two were males.

43

To select four additional students for the interviews, I determined second-year
medical students’ academic performance and gender so that the total group of
interviewees would represent various performance levels and both genders. However,
because only those students who agreed to participate in the interviews were selected for
the study, the interviewees did not represent various levels of academic performance as
expected. For example, most students in the low group did not agree to participate in the
study; as a result, only one interviewee represented the low performance level. In sum, of
the 12 interviewees (excluding two pilot interviewees) who participated in this study,
seven were female and ﬁve were male. Six of them represented the middle level of
academic performance, whereas ﬁve represented the high level of academic performance.
Only one student represented the low academic performance level. Thus, although I
attempted to match the interviewees by academic performance and gender, in order to
represent the population more accurately, the eﬁ’ort did not succeed as planned.

LASSI sa_mple. Most second-year medical students were administered the
Learning And Study Strategy Inventory (LAS SI), which measures students’ aﬁ‘ective and
cognitive processes. However, only those who agreed to participate in the study were
included in the sample. Most of these students were the same ones who had taken the
LASSI in the 1993-94 pilot study, in which the LASSI was administered to all students.
By administering the LAS SI to second-year medical students, I could compare students’
ﬁrst-year learning strategies at the time of the 1993 -94 pilot study with their learning

strategies during 1994-95.

mm

mm

Mgpmﬂ of m ﬂew questions. I developed the questions for the interviews
after consulting with several professors about the appropriateness of the questions for
drawing out students’ useiof learning strategies during their PBL classes. The interview
questions were intended to gather information to answer the research questions and
therefore to discover the students' learning strategies under PBL curricula, how they had
changed their learning strategies ﬁ'om what they had used during their ﬁrst year, and their
perceptions of PBL. The ﬁnal version of the interview questions is included in Appendix
B. Some of the questions used in the 1993-94 pilot study concerning learning strategies of
ﬁrst-year medical students were used because they had been successﬁrl in gathering
information on students’ learning strategies. For example, interview question 3-“How
did you study for a PBL exam you have taken recently?”-was adapted from the previous
year’s questions (except that the word “exam” was changed to “PBL exam”) because this
question had elicited the desired information on how students used their learning strategies
in studying for exams.

Several consultations with professors, as well as pilot interviews with two medical
students, were conducted to reﬁne the interview questions. The two medical students
were selected through the recommendation of a medical professor, and they agreed to
participate in the pilot interviews. As a result of the pilot interviews, I made minor
changes in the interview questions and changed the order of some questions to draw more

appropriate information from the students and to avoid repetition. For example, ﬁom the

45

pilot study, I discovered that students did not necessarily study diﬂ‘erently for PBL classes
and for exams, as expected. Thus, before asking their approaches to preparing for PBL
classes and for exams, I asked “Do you prepare diﬁ‘erently for PBL classes and PBL
exams?” Further, I determined the approximate time needed for the ﬁnal interview from
the pilot interviews.

I used open-ended questions in the interviews to elicit detailed and clear
explanations of students’ use of learning strategies. For example, I asked such questions
as “Would you describe what you do during the PBL classes?” in order to learn what
students did during the PBL classes. Also, after listening to the interviewees' answers, I
asked follow-up questions to ensure that the topics interviewees discussed pertained to the
focus of the study.

W In February and March 1995, I interviewed the same eight
students who had been interviewed the preceding year. Interviewing the same students
was important because their learning strategies for the ﬁrst and second years could be
compared, and changes in their learning strategies shown more clearly.

I explained to each participating student the purpose of the study, the types of data
to be collected, the estimated time their participation might require, and any potential risks
and beneﬁts of participating in the interviews. Only those students who signed a consent
form (Appendix A) were interviewed.

Interviews were scheduled at times and places convenient to the students, such as
before or after the class time and in the place where their class met. The interviews were

conducted during spring semester 1995. At this time, as a result of their ﬁrst-semester

46

experience with PBL, the students knew the learning strategies that they used under PBL.
Before the interviews, I informed the students that there were no right or wrong answers
to the questions, but that I was interested in their approaches to learning under the PBL
curriculum. I tape recorded with the permission of the interviewees, and I also took notes.
The ﬁrst interviews took approximately an hour each. After the ﬁrst interviews, I
analyzed the interview content and tried to ﬁnd some patterns with regard to students’
learning strategies. To obtain more knowledge regarding interviewees’ learning strategies,
to answer the research questions, and to clarify responses ﬁ'om the ﬁrst interviews, I
conducted a second interview with each participant. The interview questions for each
interviewee were not identical at the second interview. The second interviews took
approximately 20 to 30 rrrinutes each. Two students had not taken PBL classes at all that
semester”, hence, they were not interviewed a second time. Also, two interviewees could

not take the time for another interview, so email was used to clarify certain points.

An S Invento AS

ﬁlm is the LASSI? Weinstein, Palmer, and Schulte (1987) developed a
standardized self-report measure, the Learning And Study Strategies Inventory (LAS SI),
to measure college students’ aﬂ‘ective and cognitive processes. Nine years in the making,
the LAS SI appears to be soundly constructed. Weinstein et al. conducted two pilot tests
and a number of ﬁeld tests on the LASSI.

According to the LASSI User's Manual (Weinstein et al., 1987), the inventory is
designed to measure college students' use of learning and study strategies (p. 2). The

authors ensured that the LAS SI could be used (a) for diagnosis and remediation of

47

studying weaknesses, (b) as a pre- or posttest to measure student achievement and to
evaluate the success of study-strategies courses, and (c) as a counseling instrument in
college orientation courses. The LAS SI measures "both overt and covert thoughts and
behaviors related to successful learning . . . that can be altered through educational
interventions" (p. 2).

The LASSI takes 15 to 20 minutes to complete and 10 rrrinutes to score. It is a
self-report instrument; students respond to items on a 5-point Likert-type scale ranging
from "not at all typical of me” to "very much typical of me.” Approximately half of the
items are numbered ﬁom 1 to 5 whereas the other half are numbered from 5 to 1. This is
because some items are stated in a positive direction, such as “I use special study helps,
such as italics and headings, that are in my textbook,” whereas the others are stated in a
negative direction, such as “I have diﬁculty identifying the important points in my
reading.” Overall, higher scores on each scale meant that students have better learning
strategies on that speciﬁc scale. The LASSI has 77 items in 10 scales measuring different
clusters of learning strategies and study attitudes. The 10 scales of the LAS SI include
Anxiety, Attitude, Concentration, Information Processing, Motivation, Scheduling,
Selecting Main Ideas, Self-Testing, Study Aids, and Test Strategies. The evidence for
reliability is strong. Coeﬁcient alpha and test-retest correlations (3-week intervals),
calculated for each of the 10 scales, range ﬁ'om .68 to .86 and .72 to .85, respectively.

The validity of the LAS SI has been examined using several diﬁ’erent approaches.
The scale scores have been compared, where possible, to other tests or subscales

measuring similar factors. For example, Weinstein, Zirnmerrnann, and Palmer ( 1988)

48

correlated scores on the Information Processing scale of the LASSI with scores on the
Elaborate Processing scale of Schmeck, Ribich, and Rarnanaiah's (1977) Inventory of
Learning Processes (I = .60). Several of the scales have been validated against
performance measures. For example, scores on the Selecting Main Ideas scale have been
compared to students' scores on selecting main ideas ﬁom texts and other readings

(I = .40 and above) (Weinstein et al., 1988). A brief description of each LASSI scale and
sample items are included in Appendix C.

The LASSI was used as an assessment instrument in this study on learning
strategies because (a) by using this instrument, comparisons could be made with the same
students’ LASSI scores from the previous year, and (b) some scales, especially the
Information Processing, Selecting Main Ideas, Study Aids, Self-Testing, and Test Strategy
scales, were assumed to be related to the PBL curriculum, as shown in the literature on
learning processes under the PBL situation.

W. The main reason for selecting the LASSI for use in this
study was that subjects’ scores could be compared with their scores ﬁ'om the previous
year. The previous year, the CHM had used the LAS SI for administrative purposes for
the entry medical students, so it was convenient for the researcher to use this inventory.
By having LASSI scores for the same students in two different contexts, I could examine
whether and how students’ use of learning strategies had changed in relation to the PBL
experience.

Because the LASSI originally was developed for undergraduate students, to ensure

that the LAS S1 was appropriate for use with graduate professional students in PBL

49

curricula, I inspected each question on each scale in the LASSI with two medical
professors who are experts in the PBL curriculum. From the analysis of each question, it
was found that the aﬁ‘ective-domain questions, including the Attitude, Motivation, Time
Management, Anxiety, and Concentration scales, for the most part included general
questions that were not necessarily related to learning strategies that are encouraged in a
PBL class. However, the items on the Information Processing scale reﬂected learning
strategies encouraged in a PBL class.

I and two medical professors who were experts on PBL curriculum rated the
individual items of the LAS SI as being PBL sensitive or not. The professors and I
examined each LAS SI item and divided the 77 items into two scales-termed the PBL-
sensitive scale and the PBL-nonsensitive scale. Only those items that all three of us agreed
were PBL related were included in the PBL-sensitive scale. Because the analysis of the
LASSI using the individual items could not be done with all three LASSIs because of
missing data on the second LASSI, I created another set of subscores ﬁ'om the original
LASSI scales, so that one subscore represented PBL-related scales and the other did not.
The authors of the LAS SI suggested that ﬁve scales (Motivation, Anxiety, Attitude,
Concentration, and Time Management) represented the aﬂ‘ective domain, whereas the
other ﬁve scales (Information Processing, Self-Testing, Studying Aids, Test Strategy, and
Selecting Main Ideas) represented the cognitive domain. By careﬁrlly discussing the
individual items in consultation with the medical professors who were experts on PBL, I
noticed that the cognitive domain of the LAS 81 had items related to PBL participation,

whereas the aﬁ‘ective domain of the LAS SI did not.

50

Thus, I conducted a MANOVA repeated measures analysis using two subscales
(named the PBL-related scale and the PBL-unrelated scale) derived from the original
LAS SI scales. The PBL-related scale included the Information Processing, Self-Testing,
Study Aids, Test Strategy, and Selecting Main Ideas scales from the original LASSI
scales. The PBL-unrelated scale included the Motivation, Anxiety, Attitude,
Concentration, and Time Management scales.

Overall, most of the scales in the LASSI exemplify the general nature of learning
strategies and were desigrned to reﬂect large—lecture instruction. However, because the
second-year medical students also took large lectures in addition to PBL, the LAS 81 could
show whether students changed on any of the scales from the ﬁrst to the second year.
Further, the Information Processing scale nnight reveal students’ change in learning
strategies in relation to their experience with PBL. However, it is possible that students’
scores on the LAS SI would not reveal sigrniﬁcant changes ﬁom the ﬁrst to the second
year, even on the Information Processing and Self-Testing scales, which the PBL literature
supports, because it was found from the pilot study that the ﬁrst-year medical students
already had very high scores on these two scales (Lee et al., 1994).

mm. The LASSI was administered to most of the
second—year medical students in early February 1995. Because it was hard to have every
second-year medical student at one place at one time, the LAS S1 was adrrninistered after a
class that most of the students were required to take. The LASSI was administered for
research purposes only. At my request, a medical professor administered the instrument.

I notiﬁed students of when the LAS SI would be administered, the time needed to

51

complete the instrument, and the purposes of the research. I also assured them that their
responses and identities would be kept conﬁdential. Only those students who agreed to
participate in the study and signed the consent form giving permission to use their scores
for research purposes took the LASSI. Because only 45 out of 109 students took the
LASSI when it was ﬁrst adnninistered, the medical professor contacted students who were
not in class that day through e-mail. Ten more students took the LASSI the following

week; thus, a total of 55 students completed the LASSI for this study in February 1995.

Eta—AME
Wt;

Most learning-strategy studies have included variables that were theoretical
constructions imposed on the phenomenon (Svensson, 1977). Ifone’s understanding is to
be close to the phenomenon, then the terms used to describe and understand the
phenomenon should emerge ﬁom arnalyzing instances observed in people in diﬂ‘erent
situations or contexts. It is essential to recognize that a student's perception of a situation
is as important as the situation itself. Thus, in this study, I analyzed the transcribed
interview responses to gain an understanding of the phenomenon (in this case, learning
strategies under PBL), rather than using preexisting learning-strategy domains, such as the '
ones that emerged ﬁ'om the 1993 -94 pilot study.

Qualitative research is, by its nature, ﬂexible so that the researcher’s original
ﬁarneworks or assumptions do not constrain what can be understood from the data
collected. Rather, the intention is to discover patterns during the data analysis. As Tesch

(1989) pointed out, "analysis is not the last phase in the research process, rather it is

52

concurrent with data collection” (p. 95). Thus, the analysis of the interview responses was
continually modiﬁed to ﬁt the verbal data rather than ﬁtting the verbal data to the
theoretical Work or the categories that emerged ﬁ‘om the 1993-94 interviews.

The overall approach to analyzing the interview responses was drawn largely from
the work of Bogdan and Biklen (1992) and Tesch (1989). First, after collecting the
interview data, I transcribed all of the interview responses. Then I read the transcriptions,
trying to be ﬂexible in ﬁnding a new ﬁamework of learrning strategies rather than being
constrained by a preexisting conceptual ﬁamework.

I then read the irnterview transcripts several times to discover possible learning-
strategy categories. For example, I looked for similar attributes from each protocol, such
as “look at the starred objectives to ﬁnd what is important information,” and gave names
to those attributes, such as “selecting main information strategies.” I coded every learning
strategy the students mentioned in the irnterviews and formulated tentative categories of
strategies. I then applied these initial categories to the individual interview responses, and
modiﬁed classiﬁcations that did not seem to ﬁt during the process of matching the merging
categories with the data set.

While doing tlnis, I reviewed any verbal report that was confusing so that it could
be placed in any number of categories to which it was related. For example, solving
practice quizzes at the end of the coursepack could belong to either checking knowledge
or selecting main information for tests, according to how the student used the technique.

A coursepack contains articles from the medical literature and material prepared by the

53

faculty. Students purchase a coursepack for each PBL domairn, and it includes some of
the conternt that they are expected to learn.

I repeated this coding process several times to clarify the deﬁnition of each
category and to ensure the comprehensiveness of each learning-strategy category. While
doing this, I consulted with professors including my advisor several times regardirng the
names of the learning-strategy categories and individual learrning strategies that belonged
in these categories to increase the validity of the categories.

Next, I described each interviewee’s response regarding each learning-strategy
category that emerged, based on each interview question, in the form of a case study. I
recorded evidence I found in the transcripts for each case description. Then, I reviewed
each individual case to check the tentative ﬁndings in order to ﬁnd the pattern of learrning
strategies that ran through each case. For example, I tried to clarify common patterns by
making charts and counting the numbers of interviewees who mentioned a certain learning
strategy. In doing so, I also recorded typical examples from the protocols for each
learrning strategy. However, because most of the ﬁndings were based on the interviewees’
own reports, there is a possibility that some students did not report using a certain learrning
strategy even though they did use it.

Because not all of the vast amount of data found through this process could be
used for this study, I tried to make key points in each interviewee’s case that essentially
answered the research questions of this study. While doing this, I enumerated students’

reported learrning Strategies whenever possible. Thus, the irnterview responses were

54

analyzed “according to the organizing system that is predominantly derived from the data

themselves” (T esch, 1989, p. 96).

.TLQL_AS_S_LD_§Q

Scores were available from three administrations of the LASSI, two ﬁ'om 1993-94
(Year 1, time 1 and time 2) and one for the present study (Year 2, time 3). To compare
year one to year two using the entrance LAS SI scores (time 1) as a baseline, 1 used the
data ﬁ'om all three LASSIs. I used multivariate analysis of variance (MAN OVA) with
repeated measures because there were 10 dependent variables (10 scales from the LAS SI
inventory), and I was interested in seeing the changes at tlnree times. Because there were
no between-subjects variables for the research, I used only within-subject MAN OVA
repeated measures; the within-subject factor was “time.” Further, using MAN OVA
instead of 10 single t tests reduced the alpha (the type I error rate).

In addition to the MANOVA using three time points, I also analyzed the data from
time 1 and time 2, and ﬁom time 2 and time 3, in order to determine where the
diﬂ'erences, if any, existed. This also allowed me to use more data in each analysis
because only data completed for two time points is needed. Further, to reﬂect the eﬁ‘ect
of PBL on students’ learrning strategies more clearly, I analyzed the LAS SI data using
scales I derived (called PBL-sensitive versus PBL-nonsensitive scales), in addition to
analyzing the original scales of the LASSI.

The schedule and the numbers of subjects who were irnterviewed and who

completed the LASSI for this Study are shown in Table 3.1.

55

Table 3.1: Schedule and number of subjects for interviews and LASSI administrations

 

 

 

 

Time 1 (Entry) Time 2 (Lecture) Time 3 (PBL)
Interview August 1993 January 1994 February 1995

(1.1=8) (a=8) (a=12)'
LASSI August 1993 January 1994 February 1995

(n=109) (n=91) (n=55)

 

 

 

 

 

a: n = 14, including pilot interviewees

CHAPTER IV

RESULTS

Introduction

There are two sections in this chapter. First, I analyzed each irnterviewee’s
responses and described those responses in the form of a case study corresponding to each
interview question. Two examples of case studies are featured in the ﬁrst section of this
chapter. The case studies for other interviewees are included in Appendix F.

In the second section, I describe the common patterns that emerged ﬁ'om the
students’ responses to each interview question. In presenting the ﬁndings for the research
questions, I evaluated the working hypotheses whernever evidence was available. I drew
the ﬁndings regarding Research Questions 1, 2, and 3 primarily from the interview data. I

drew the ﬁndings for Research Question 4 from the interview and LASSI data.

Exam I f Two ase Studi
In this section I feature two case studies, Jim and Laura, corresponding to each
research question. At the end of each case study, I present a summary of key features. I
look closely at and comment on these two cases because Jim and Laura are representative
of the 14 interviewees (including the pilot_interviewees) in terms of gender and race (Jinn-

rrnale and white, Laura-female and black). Further, because these two students

56

I‘—e

I1!

57

participated irn the previous years’ study, I could ﬁnd rich data ﬁ'om their cases regarding
their strategies the ﬁrst and second years in medical school. Further, Jim took
Supplemerntal Instruction the previous year, whereas Laura did not. Although I chose
these two cases as examples from the 14 case studies, readers can refer to the other

irnterviewees learning strategies in Appendix F.

Li!

W: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

It is important to mention tlnat, to Jim, studying for PBL classes was not diﬂ‘erent
ﬁorn studying for exams. The only diﬁ‘erence Jim merntioned was that he studied

irrtegratively for the materials in a PBL group, whereas he tried to pick out the information

for exarrns, as shown in his statement:

PBL helpsmeto irntegateconcepts. For example, we did prrlrnonary, we did
cardiovasarlarbeforeChristmasbreak Andthenwejustdidrenal.Andageat
munberofthediseaseswillaﬁectmorethanonesystem. Sothatcertainlyhelps.Alot
ofcardiovasarlarpathologycanaﬁ‘ecttherenalsysterrtforexample, ortlnererral
systern'sirnvolved. Soleamingitirnsystemshelpstointegatethebodyasawhole.
However,theexarnsarenmltiplechoice,and1alwaysrernernberthat. Whernyouget
downtotheweekbefore,I'mpicldngoutfactsandl‘mpicldngouttheinforrnationthat
willbeontlneexam Yes,l‘mlearningtheinformation,butl‘malsofocusedondoing
my best on that exam. So there's sort of a twofold purpose to preparing. You could
haveaverygoodunderstandingofthecontentandlmowalotofit,andstillnothave
the factsto succeed on amulﬁple choice test. You know, it's narrowing downthe

edgesandreallypicldngoutthekeyconceptsthatcouldbetested.
M85123 As described in the PBL curriculum section, Jim mentioned that his
PBL group attempted to ﬁnd cues ﬁ'om the cases that were provided. He said that his

goup tried to look at “abnormal things” ﬁ'om the case or use their past knowledge in

58

order to ﬁnd cues or to form hypotheses. His PBL goup also questioned what they did
not understand irn order to probe for more information, list hypotheses ﬁ'om that
informatiorn, and ﬁnally raise learning issues. Thus, the learning strategies that Jim used
during the PBL class involved drawing information ﬁ'om his past knowledge and trying to
ﬁnd abnormal features ﬁom the provided cases.

The main learning strategy that fun used in order to combine PBL class
preparation and exam preparation was matching objectives with learning issues. Learrning
issues are the agenda for learning irn PBL classes that the students deﬁne for themselves,
the homework that students create in their PBL classes. They are the areas that are
emphasized during independent study, in order to better understand the case provided
during PBL class.

Jim mentioned that when his goup raised learning issues, they asked, “Does it ﬁt
the objectives?” If it did not, they did not spend time on it. He also mentioned that
objectives helped to direct learning issues. For example, if a learning issue was very
broad, he tried to narrow it down, based on the objectives.

Wehadrecerrtlytriedinmygouptotrytopolicetheobjectives. Likeforinstance,
they can throw in a piece of information about a case arnd we say, “OK, we're going to
writealearrningissueabouttlnis. Doesitﬁttheobjectives?” Ifit doesn‘t, wewon't
writealearnirngobjectiveaboutit, wewon‘tspendanytimeonit.
W: Jim’s main motivation in looking for learrning issues was to
participate in class. To study learning issues to prepare for the next PBL class, he usually

found books at home and did not go to the library. Jim also used computer progams to

ﬁnd learrning issues. He said that faculty in the department wrote computer progams, and

59

those progams provided “very good insight irnto what's critical to know.” Tun mentioned
that PBL classes helped to achieve objectives that were mainly on the exams because the
goup process ensured that learrning issues directly responded to the objectives. Also, his
PBL small goup discussed, questioned, debated, and pointed out the points they thought
were important during the PBL class.
35351: Questigrn 2: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?
Mg: The basic study mode that Jim mentioned was reading materials more
than twice. The ﬁrst time, he read everything critically, looking at pictures, diagarns, and
references. He also highlighted about three-fourths of the materials because doing this
made him keep track of his reading. When he read the materials a second time, he looked
at what he had highlighted and tried to correlate the coursepack and lectures. Then, he
highlighted with diﬂ‘erent colors, narrowing down the facts to what he needed to learn.
To explain his reading strategy, Jim mentioned,
I’ll read the ﬁrst time through completely. I don’t mind taking that time. Then
I’ve got a big picture in my mind. Then when I come back I’ve got a constant
reference in my mind. I can come back to the content list and say, “OK, what are
the details that I rrnissed?” Or “What is important that I didn’t get out of the
reading that I need to search for?”
Jim also took notes ﬁ'om everything he read. According to him, taking notes
and writing them down in the margins made him build up speed in the next reading and
helped him gain mastery of the material.
may: Jim studied with two other students. He said he used goup study

more the second year than the ﬁrst year. His goup study was like a small PBL class

except
before

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60

except that they did not raise learning issues. Members of his goup studied on their own
before getting together, when they met, they read the objectives and talked through them.
For example, when they studied for drug x, they talked about how it acted and where it
acted. Then they quizzed each other, correcting their misunderstandings. Jim mentioned
that goup study pushed him to go tlnrough the material one more time when he was bored
with his own reading.

W: Jim said that integation was a broader overview, an overall
picture of what’s happening. For example, he said if one explains how the system
operates and happens, it is integation. For studying concepts he needed to understand,
Jim usually drew ﬂow charts or diagams of what happened. Also, he used computer
progams that contained information he needed to integate diﬂ’erent topics, and this
helped him see the whole picture.

W: Jim thought rote memorization was knowing symptoms of
something without krnowing in what system it was occurring. For example, if one knows
the heart has two sounds and gets valve closure and memorizes these facts using
mnemonics without krnowing how the heart actually operates, it is rote memorization. To
study facts, Jim mainly read materials, talked about facts, and made charts and tables
showing similarities and diﬁ‘erences. He mentioned that he did less memorization the
second year than the ﬁrst year.

Sslecting may} infgrmatign: Jim looked for overlapping information in the
objective lists, coursepack and textbook in order to ﬁnd the main information he needed

to know. For example, electronic and mechanical coupling of heart contractions runs

seat
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61

through all inforrrnation sources because it is the gound level, and he knew this was
important information to know. Also, he gained insight into what was important to krnow
througln lectures.

On the objective lists, Jim knew which objectives were the most important by the
number of stars in each objective. For some domains, faculty prioritized the importance of
the objectives by providing stars. Ifno stars were given to the objectives provided in a
certain domairn, Jim looked for quiz questions in a coursepack because they were
formulated by those who wrote the exam questions. This also indicated that Jim cared
about information that might be covered on the exam.

W: Jim mentioned that when faculty developed computer
progams, these progams provided good irnsight irnto what it was critical to krnow. Thus,
he used computer progams as a way of selecting the main information to learn. Also,
computer progams are interactive because they give immediate feedback on quiz
questions, as illustrated by his comment:

They [computer progams] provide another source of information from the textbook.

That doesrn't make them diﬁ‘erent ﬁom the textbook but it's another source. They‘re a

littlemoreinteractive inthattheyoﬁenhavequizquestions. Becausewhatwill

happenisyou'll gotlu'oughaparticulartopicandthey'llbreakitdowninoutlinefonn.

Andthenthey‘llgiveyouthedetailsandthey’ll showyou afewpictures. Andthern

they'llaskyou, “Whatisthis?” Arndtherntheygiveyouthecorrectanswerand

feedback Not all ofthern dotlnat, but some do. But gernerally, they‘re very similarto
thetextbookbecausetheyhavethe sarnematerial inthern

Jim mentioned that pictures in the computer progarn are better than those in the
textbook because they are not restricted by the headings, as those in a textbook are. Also,
computer progams integate tlnings from diﬁ‘erent disciplines, such as physiology,

pathology, and biochemistry.

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62

thgking kngwledgs stratsgjes: When Jim read materials a second time, he asked
himself questions. For example, he asked, “Okay, what is important, what did I learn,
whataretherrnainideaslneedtotakeawayﬁ'omthis, whatwill make me happyifIgeta
‘Now, I know.”’ Also, his study goup used practice quizzes to check their krnowledge.

Lecture attendang: Jim went to lectures regularly. Rather than using scribe notes,
he took his own notes in the lectures. He thought that lectures were another way of
getting a focus on the important information as seen by experts. Lectures provided what
the lecturer thought was essential to know and also allowed Jim to ask questions. Also,
Jim was paying for his education, which included lectures, so he felt a responsibility to
attend them, as shown by this statement: .

Whngo . . .IgobecausethosepeoplehaVespenttheirtirneto puttogetheralecture

totrytogiveyouinsighttowhat'simportant, whattheythinkisesserntialtokrnow.1t's

another source of information. It provides yet another means of getting the

information Itpointsmetowhat‘simportantintheirperspective. It allowsmeto ask

questions. And I feel like I'm paying for my educatiorn, and that includes lectures. I
feel a responsibility to do it.

mm: In addition to the strategies mentioned above, Jim also
checked his coverage of the objectives. For example, he took major headings in
pharmacology from the objectives and read the textbook. Then he looked at the objective
lists again to see whether he had covered all of the detailed objectives or important things
in his reading.

Also, J'un used organization strategies. For example, he said that he wrote down
critical points while reading. He categorized things in his mind as he read, and if

something ﬁt one of his categories, he wrote it down or highlighted it. For example, for

63

tumors in pathology, he needed to krnow the incidence, gender, and age goup in which
they occur. Then he wrote those things in the margins while reading.

BMW: Jinn said he planned to take the ArcVentures progarrn, which is
a board review course. He also thought that PBL classes would help him study for the

board.

Resssgh Question 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

In thought that his old study habits inﬂuenced the way he used his learrning
strategies. He also said the PBL process “directed” his learrning. For example, when he
had a case involving a patient with diabetes, instead of reading someone else’s notes, he
learned about the disease by looking at related materials and researching the disease.

Jim’s goal was “learning the material” rather than passing the exams. He
mentioned that he would like to achieve good interaction vndth the goup and prepare for
the exam through the PBL classes. In general, he said that he liked PBL, but he did not
forget to mention that careful selection of a preceptor is important.

Theonlythinglwould liketo seeis, andIknowthisisdiﬁcult, amorecareful

selectionofthepreceptors. Ithirnktheycanmakeorbreakthegoup. Itcanbea

destructive role if there's a diﬁ‘erence betweern the instructor. Right now, I think we‘ve
hadmuslnreofgoodpreceptorsandsomeﬂnatweremediocreandsomethatwa’e
exwllent.

Jim also mentioned that PBL helped in the following areas:
1. Smlj-gsoup working skills: Jim commented that being in a PBL goup helped

him improve his small-goup skills, as illustrated by the following statement:

64

I think naturally in a goup there are pe0ple who talk and people who don’t talk
and then somewhere in the middle. I think it makes us very aware and responsible
for each other’s learning. I monitor how much I speak. Ifthere’s someone who’s
a more quiet person who wants to speak, I’ll hold back. I think that everybody has
good points; it teaches us to listen to others. It also teaches me that everyone
doesrn’t look at tlnings the way I look at them. So when I say tlnings, sometimes it
may help.

2. My: Jim mentioned that PBL classes allowed him to study more
than just those topics in the content lists, as shown by the following statement:

For instance, now I go and learn, in my goup, we learn about diseases’ pathology

and physiology for the sake of learning it, for the desire to have the krnowledge.

And then when we look at the content list, we ﬁnd that we’ve covered a lot of

those things.

3. W: Jim noted that, because cases they discussed during the
PBL classes required students to integate diﬁ‘erent diseases they learned, being in PBL
classes helped him irntegate concepts and helped him use his knowledge, as he pointed out
in the following comment:

PBL helps me to irntegate concepts. Given the case, we have an individual who

has problems, for the renal domain. But we also notice that they have a

cardiovascular problem or that they have some type of infection. And that helps us

to use our previous knowledge.

4. Wm: Jim said that being in PBL classes helped him prepare for
exams because the cases provided during the PBL classes were related to the exams. He

stated, “I know that a lot of the information is recurrent in the cases and in the exams and

in my textbooks.”

65

W: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

Jim said that ﬁrst year, he had more facts to learn and thus used more rote
memorization strategies. He stated, “I think last year, we could have gotten away with a
lot more rote memorization. Last year, realistically, you could have spent a few days just
piling information into your head and then just regurgitating it on the exam.” The content
was more conceptual and integative in second year.

Last year, it [objective list] was very speciﬁc, very factual. If we were to learn

anything about diabetes, it was to approach it from a rrnicro level, rather than

starting at the macro level and coming down. There wasn’t the irntegation that
there is. Everything was a separate science last year. This year, I start reading
about the disease and cover all the sciences, all the disciplines.

Thus, according to Jim, he used a more “macro-level approach” the second year,
which meant starting with broad issues and getting an overview ﬁrst before narrowing the
focus. He mentioned that part of the reason he felt this way was that he had accumulated
krnowledge. Also, the way the test questions were asked the second year involved more
integative knowledge, according to him. Thus, he used more goup study the second
year. He also used computer progams as a learrning resource in his second year because
they were visual and presented redundant irnforrnation without being boring.

Another diﬁ‘erence between Jim’s ﬁrst and second years was that he had more
conﬁdence the second year. He described the second year of medical school as a “sink or
swim atmosphere.” Also, because of the independent studying necessitated by the school

environment, he was more conﬁdent about his learning strategies in his second year.

Table 4.1 contains a summary of the key features of Jim’s learrning strategies.

Table 4.1: Key features of Jim’s leanning strategies

 

Ql

- Studying for PBL class and exams is the same
- Matching learrning issues with objectives
- Using books or computers to ﬁnd learrning issues, no use of library

 

Q2

- Reading twice: taking notes, writing down
1. Get a ﬁamework, highlighting
2. Narrow down facts, speed up

- Group study: check his understanding through quizzing and talking to each other,
make him keep studying when he is bored

- Integation strategies: draw ﬂow charts and diagarns, use computer proganrs

- Memorization strategies: reading, talking, using mnemonics, making charts &
tables, drawing similarities & differences

- Selecting main information: corresponding information, lectures, stars in the
objective lists, quiz questions in the coursepack, computer progams

- Use computer progams: as a way of selecting main inforrnatiorn, good picture,
interactive

- Checking knowledge strategies: quiz in a goup study and self-questions

- Lecture attendance: way of knowing what’s important information, opportunity
to ask questions

- Additional strategies: checking coverage of the objectives,
organize materials - categorize what he reads and then write down (or highlight

 

Q3

- Inﬂuences: Old study habits and PBL process
- Goals: Learrning materials
- PBL helps

1. Small-goup working skills

2. Independent study

3. Integation of the materials

4. Preparation for the exam

 

 

 

- More goup study in second year: because of the integative contents

- More use of computer programs in second year

- Macro-level approach: getting overview ﬁrst: because of the existed knowledge

- More conﬁdence about his learning strategies : because of the second-year
curriculum

 

 

67

Lsura

March Question 1: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Studying for PBL classes and preparing for the exams were not two separate
things to Laura She primarily prepared for exams, and while doing that, she prepared for
the PBL classes.

DIE—“8M3 Laura mentioned that her PBL goup read a case, picked out the
main information, formulated hypotheses, raised learning issues, and solved stimulus
questions. To pick out the main irnforrnatiorn, she tried to ﬁnd symptoms that were
signiﬁcant to patients and sometimes highlighted the important facts in the provided cases.
To raise learrning issues that she needed to krnow for the next session, Laura used her past
knowledge and objective lists. Also, stimulus questions included in the coursepack guided
what she needed to study for the next session.

Laura matched learrning issues with objectives by looking at the learning issues and
thinking, “Which objectives are related to learning issues.” Occasionally, some preceptors
suggested learning issues to look for. Laura mentioned that her goup spent time on every
learning issue early in the semester, but they thought this was a waste of time. So later, if
a learning issue was not matched with objectives, her PBL goup did not spend time
discussing that issue.

mm: Laura studied learning issues by looking at objectives and
ﬁnding those in the ﬁrst year’s textbook. She never went to the library to study learrning
issues. Usually she read books and articles to study learnning issues, trying to relate them

to the exams. Laura mentioned that because PBL class did not cover every objective, she

studie

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68

studied on her own for the exams. Thus, studying for PBL class was part of studying for
exams, as shown in her comment:

PBL picks certain topics that are listed in the objectives that we do have to know

for the exams, but they don’t cover. . .they don’t nearly cover everything we have to
know.

W: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

Rm: Laura mentioned that she tried to read everything that was related to the
exams at least once because the second year she had a vast volume of materials to study in
a linnited time. Further, because the exarrns came from very detailed materials, she thought
she should know every rrninute detail in the materials, as illustrated by the following
statement:

But you can't really say, "Well, maybe this is more important than that," because

you don't krnow what's going on in the examiner's head, and so basically you try to

know everything. And I know that sounds impossible, and sometimes it feels
impossible, but they test details on the exam. General . . . you would think that if
you have that volume of material they would focus on general concepts to see if
you got the basic stuﬂ. No. I had some of those questions, but most of them test

nrinute details or minute diﬁ‘erences between two diﬁ‘erent concepts. And so you
have to know those, and since you don't know which are going to be tested on,

you try to know everything.

IfLaura read the material more than once, she read the ﬁrst time to understand
the material. Laura mentioned understanding is “to get the mairn concepts or to get the
broad picture.” She also highlighted the materials when she read them. She used diﬂ‘erent
colors for diﬂ‘erent diseases and wrote down notes when she read. By doing this, when
she read the materials the second time, she could review and connect the materials better.

When Laura read the second time, she ﬂipped through the highlighted parts and focused

69

on memorizing them. She realized that she needed a second reading when she could not
explain what she had read the ﬁrst time. To explain her reading strategy, Laura
mentioned,
Thus, the ﬁrst time is for understanding. Understanding means to me getting the
main concepts or to get the broad picture, to ﬁgure out what they’re trying to tell
us. Second reading is for memorization. I mean, I krnow it doesn't work for me to
just read it once because the ﬁrst time I read I'm learrning it. The second time I’m
memorizing it. And, I mean, sometimes it works out that I’ll just remember one
key word. It’s like, “Okay. That’s that,” just because I happen to remember seeing
it that second time, so it’s more of a memorization type thing for that second time
around.
5193mm: Laura studied with one other person whom she had worked with
since her ﬁrst year. They read through the charts that she had made and discussed any
unclear points. They also asked questions and explained things to each other. Laura
mentioned that studying with a ﬁiend clariﬁed concepts, supported her emotionally, and
made her stay awake.
W: Laura made charts to integate the materials she studied.
For example, she made a ﬂow chart on diabetes and one particular outcome. As she
studied ﬁrrther, she found diabetes again with another outcome. She then integated those
ﬁndings and rrnade another chart so that she could see the whole diabetes picture. Also,
goup study helped Laura clarify concepts by discussing the information with her partner
and listening to her partrner explain the materials she did not understand.
Wigs: Laura typed summaries and charts that she made, using a
computer. She said that doing this helped her memorize things because She actively

thought about what she was typing. Also, reading the materials more than once provided

repetition, which helped her memorize what she needed to learn.

70

Selm’ g m infgrmation: Laura said she tried to study every objective because
even though professors said certain objectives were not important, they sometimes tested
on them nevertheless. With regard to focusing, Laura mentioned that she tried to
emphasize the objectives that had the most stars.

mum: Laura usually did not use computer progams because she thought this
was time consuming and she often got a headache. Only if she heard that a certain
computer progam was good for a certain domain and she had time did she look it up. For
example, when Laura had trouble learrning about bone disorders because they all sounded
alike, the computer progam provided a good way to diﬂ‘erentiate them through pictures.
Laura said that because she was a visual learner, pictures in a computer progam
sometimes helped her learn the material. Although she seldom used computer proganns,
she usually used a computer for typing her summaries and charts. She said it was easier to
memorize rnnicro things in this way because when she typed them, she could actively think
about them.

Qhﬁking kngwledgg smatsgies: Through goup study, Laura and her ﬁiend asked
questions and explained things to each other. This helped her clarify concepts and ensure
her gasp of the material.

WM: Laura was not attending large-goup lectures her second
year. She said she had an attention-span problem and that sitting in a lecture made her
mind wander. Shel liked the PBL class format better than lectures, as illustrated by the

following statement:

71

I thought I was a lecture—oriented person, but about the middle of last year I
started to realize that I wasn't getting as much out of lectures as I thought I was,
you know. I would faithfully, you know, at the beginning of the year go every day
and take notes, but then alter a while I started to realize, okay, the ﬁrst few hours

I'm actively involved taking notes and whatever. The next two hours my mind is

somewhere else. I'm like, okay, why am I sitting here if I'm having trouble

focusing, concentrating. I'm wasting my time basically when I could either be
reading something on my own or sleeping or something, you krnow . . . and reading
it later. And so I think this format [PBL] is a lot better because I'm not sitting in
lecture and letting my mind just wander.

W1 At the beginrning of the second year, Laura made her own
agenda for studying. But she could not contribute to the PBL classes because she could
not get to the material that would be discussed in class, based on her own schedule.
Therefore, she structured what she was going to review herself, based on the cases
provided in class, and she combined those cases with objectives.

Also, Laura wrote important words or concepts down in the margins of the
textbook or coursepack. For example, if she found pages of uniform text without pictures
when she read, she wrote down subheadings of her own so that when she looked at it
again, she could readily see what the page was about. Also, she used highlights, circles, or
underlines as means of organization. For example, she used diﬁ‘erent colors for main
headings, subheadings, and subsequent information. To distinguish between males and
females when studying general somatic-formation disorders, Laura circled the words
“women” and “men” and underlined the concepts related to each gender.

mm: Laura said she planned to take a review course for the board
exam. At the time of the interview, she said there was no time to study for the board

exam separately ﬁ-om the class exams. But she thought that studying for the domains

covered in class now would help her in studying for the board exam later.

COT.

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72

W: What do students think influences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Laura mentioned that time constraints inﬂuenced her learning strategies the most.
Also, the PBL experience had changed her study approach in that she had changed her
schedrrling. She made her own schedule at the beginning of the semester but now
combined studying for exams and preparing for the PBL class.

Laura mentioned that she had two goals: (a) having a good knowledge base for the
ﬁrture and (b) passing the exams. She said she was giving more emphasis to her ﬁrst goal
during her second year. PBL classes helped her have a good knowledge base because they
necessitated independent study and integation of the materials through cases. However,
Laura was not sure of the role PBL played in achieving her goal of passing the exams, as
shown in the following comment:

I think what I can conﬁdently say is it's helping me get a good krnowledge base,

which is my ultimate goal. I can't really say it's helping me pass the domain exams

...becausealot oftimesltlninktheexamscome downto howmuchcanyou

remember within a short period of time and how many little details can you

remember, you know, for the exams.

Laura mentioned that although having such different PBL goup members was
stressﬁrl, PBL classes also helped in the following ways:

1. SM-gtoup wgrking skills: PBL helped in terms of goup interaction; it made
Laura monitor her talking and try to contribute equally with other goup members.

2. mm: According to Laura, being in a PBL goup helped her study

independently. Because PBL classes did not cover the majority of the material, she

needed to study on her own, look up material, and search for it by herself.

yea

She

the

mat

Con:
also

of 1h

73

3. W: During PBL classes, it was easier for Laura to connect
the diﬁ'erent disciplines because students discussed all of the related materials.
mm: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

Laura mentioned that, during her ﬁrst year, she learned most information from
lectures or scribe notes. Thus, she did not have to do much reading. She read books only
if she needed clariﬁcation. Laura used more charts, tables, and ﬂashcards her ﬁrst year
than her second year because she had more time and less material to study. This second
year, she self-checked her knowledge less because of the vast volume of study materials.
She said it was important to go through everything at least once and to read more during
her second year, as illustrated by her comment:

It’s just too much work to try to get through. And I ﬁgure it’s best to get through

everything once rather than to get through some things and not the others and

really screw up on the exam because I didn’t get to the other material.

Laura also thought that she was a more eﬁ‘ective learner her second year. Part of
the reason for this was that she had previous krnowledge and hence could connect the
materials better.

Another change is that Laura quit going to the lectures her second year because of
her lack of time. She obtained scribe notes to study, however, because sometimes they
contained information for the exarrns that was not in her textbook or coursepack. Laura

also mentioned that the cases provided in the PBL classes helped her do more integation

of the materials.

74

Also, Laura made her own schedule at the beginning of the semester but now
combined studying for exams and preparing for the PBL class. She started with her ﬁrst-
year approach to studying and then changed her scheduling during the second year to
adapt to the changed instructional context.

Well, I found it to be better than what I tried to do the ﬁrst domain, which was
have my own schedule, say, "Okay. I‘m going to do all the micro ﬁrst, and then
I'm going to do all the path next and all the phys next." That just seemed to be in
conﬂict with what I was expected to do with the goup. And I'd say, "Well, rather
than ﬁght this, let me work with this," and because I found it to be really
ﬁustrating to come to goup and not be able to contribute or feel stupid because I
hadn't gotten to that portion of the material that we were discussing.

A sununary of the key features gleaned ﬁom the interviews with Laura is presented

in Table 4.2.

75

Table 4.2: Key features of Laura’s learning strategies

 

Q1

- Raise learning issues: use objective lists, past knowledge and stimulus questions

- Match learning issues with objectives: studying for PBL learning issue is part
of studying for exams

- To ﬁnd learning issues: use the previous year’s textbooks, no library use

 

Q2

- Reading more than once:

1. For understanding - highlight with different colors; review better, connect better

2. For memorization

- Group study: ask questions, clarify concepts, support emotionally, stay awake

- Irntegation strategies: make charts, goup study (clarify concepts)

- Memorization strategies: read more than once (repetition), type into computer

- Selecting main irnforrnation: stars in the objective lists

- Computer progams: seldom use computer progams; good picture

- Checking knowledge strategies: goup study (ask questions)

- Additional strategies: scheduling, organizing materials; writing down her own
headings, underlining, highlighting, circling

- No lecture attendance; get scribe notes

 

Q3

- Inﬂuences: time and PBL experience
- Goals: having good krnowledge base and passing exams
- PBL helps

1. Small-goup working skills

2. Independent study

3. Irntegation of the materials

 

 

 

- More reading in second year

- No lecture attendance in second year; use scribe notes, however

- Less use of ﬂashcards, charts, tables the second year; lack of time

- Less self-checking, more study time the second year: because of vast volume

- More irntegation the second year: cases help

- Feels she is a more eﬂ‘ective learner the second year: because of previous
krnowledge

 

 

76

Findin P inin t e R earch uestions
The common patterrns that emerged from analyzing each case study, corresponding
to each research question are discussed in the following pages. I do not present the results
of the common patterns for two subjects, Susan and Cindy, who were not talcing_any PBL

classes the semester the study was conducted, although I do present their brief case
studies in Apperndix F.
m Question 1: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

The 12 interviewees who took PBL the second year, including the pilot
interviewees, all claimed that they studied by focusing on exams rather than on PBL
classes. They said that they studied for exams, and in the process of preparing for exams,
they could contribute to class discussions.

During the PBL classes, most of the interviewees looked for odd symptoms or
symptoms that were signiﬁcant to the patient that they were studying in order to ﬁnd cues
about the provided case. Also, they used previous krnowledge to generate hypotheses
during the PBL classes. Eleven out of the 12 interviewees mentioned that they used
objectives for raising learning issues. They also tried to gear their PBL goup discussions
toward the objective lists so that they could focus their study on exams. Kelly, who was a
pilot irnterviewee, did not mention speciﬁcally that she used objectives for raising learning
issues. She tried to connect all of the information in the case, and if she could not see the
connections, she studied the missing parts after class. However, Kelly also studied for

exam preparation and not for PBL classes per se. Interestingly, Ann tried to determine

77

what teachers would think were important as learrning issues. Ann also relied on
percerntages of the exam content for raising learning issues. Ann mentioned,

Itrytopsycheouttheteachersand sort ofsay, "Giventhiscase, which ofthe

objectivesdoyouthinktheyweretryingtoget ustoleamfromthis case." Andthen

wetrytomakeleamirngissues. Likethistime, 45% oftlneexamisgoirngtobe
pathology. So when a case comes up, one of tlne learning issues will be the pathology
ofwhateverthecaseis orthe pathology ofsimilarcases.

All of these processes that students were using to raise learning issues were geared
to exam preparation. However, Jane mentioned that she studied information for the
learrning issues even though they were not on the objective lists. Further, Ann said that
she studied learning issues that were not among the objectives if they were interesting and

easy to ﬁnd, but her focus was primarily on exams and not on preparing for classes.

Table 4.3 shows students’ use of learning resources to ﬁnd learning issues.

Table 4.3: Resources students used to study learning issues (r_n = 12)

Name Books Coursepacks Computer Learning Resource Library
Programs Center

Jim
Laura
Mark

X

x
x
Ann

X
X
X
X
X
X
X
X
X
X
X
X

Jane x
Total 12 12 7

 

Key: x = students' use of the strategy.

78

As shown in Table 4.3, all 12 interviewees reported that they read booksueither
textbooks or board review books—to study learning issues. Also, many of them used
coursepack notes and computer progams to study learning issues. However, only Jane
went to the library to look for information for the learning issues, and tlnree students
went to the learrning resource center to ﬁnd information to study learning issues. In
addition to the resources mentioned above, Roger said he read old objectives he obtained
ﬁ'om the previous second-year medical students to ﬁnd pertinent information for the
learning issues.

Most irnterviewees said they found information for the learrning issues because
studying them covered objectives that would be on the exarrns. However, Jim and Janet
mentioned that they studied learning issues for participating in goup discussion and
asking questions. Interestingly, Ann mentioned that she studied learning issues and made
charts or summaries for relating them to the goup, in order to impress the goup and to
get “brownie points.”

I tried to enumerate resources that the interviewees reported that they used.
However, it was diﬁcult to rrnake a clear-cut separation between the resources they used
in studying the learning issues for class and those they used to study for the exams because
students said they did not necessarily separate their study for PBL classes and exams.
Thus, although the irnterviewees did not report resources for the question of where they
found information for the learning issues, it is likely that they found information for the

learrning issues from the resources they used in studying for exams.

79

Burch Quﬂ'on 2: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

The second year, students focused their learning strategy mainly on reading
although there were individual diﬁ‘erences in their use of learrning strategies. Also, 10 of
the 12 irnterviewees who attended PBL classes said they studied with a partner or in a
goup. Interviewees used various strategies for memorizing, integating, and organizing
information. As in their ﬁrst year of medical school, all of the interviewees used many
strategies for selecting important information. Because of the vast volume of materials
they had to cover in a limited time, students focused on selecting important information.
Other than this, all of the students except Jane who took PBL classes used computer
progams, although they relied on those progams to varying degees. All of the students
said they checked the knowledge they acquired, using such strategies as solving practice
quizzes or asking questions. The students went to lectures less the second year than the
ﬁrst year, and 5 of the 12 interviewees had quit going to lectures entirely; however, other
interviewees attended lectures as a means of preparing for exams.

The data collected regarding how students studied for exams were the richest of all
the information elicited through the interviews. Hence, in the following pages, I present
the ﬁndings for each category of learning strategy that students used during their second
year of medical school.

Rading: The basic studying approach of most students the second year was
reading books, coursepacks, and objectives. The interviewees’ reading patterns are shown

in Table 4.4.

80

Table 4.4 : How and what students read

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name How and What They Read
J'un - First reading. to get a ﬁamework reads everything In the book,
critically highlighting things
- Second readirng: goes faster because he reads highlighted things
Laura - First reading: to understand materials, highlighting things
- Second reading: ﬂips through highlighted things for memorization
Mark - First reading: to get a general idea, reads with highlighting
- Second reading: reads highlighted ones, makes marginal notes
Torn - Reads coursepack, highlighting important points
- Reads textbook, looking for overlapping irnformation with coursepack
- Reads coursepack again with added information in the margins
Ann - First reading: to get an overall ﬁamework
- Second reading: goes faster, comprehends better
- Reads old objectives, coursepack, scribe notes, then does
computer progams, reads board review books
Mary - Reads objectives, books, and coursepack, making charts
- Memorizes those charts
Andrew - First reading: to understand, highlights testable questions
- Second reading: skims materials by making connections of concepts
Roger - Reads books sometimes, uses computer progams and goup study
Nancy - Reads books and coursepack for understanding: writing, underlining
- If she has time, reviews underlined things or writing in the margins
Janet - First reading: slowly to understand materials and answer objectives
- Second reading: reads highlighted things at a faster pace
Kelly - First reading: slowly to get the general concept
- Second reading: to memorize better
Jane - Reads old objectives to get an idea of test information

 

- First reading: to get a general overview
- Second reading: to memorize things

 

 

81

As shown in Table 4.4, most students read the material more than once during the
second year. In their ﬁrst reading, most of them focused on understanding the materials,
usually highlighting important information or facts. In their second reading, most students
skimmed the materials or read only the highlighted parts for memorization purposes. It
seems that, by reading slowly and carefully the ﬁrst time, they had an overall ﬁamework
on which to hang speciﬁc facts in their second reading. Because of the vast volume of
materials, they tried to understand the materials by reading the same information several
times.

mm: Of the 12 irnterviewees who were taking PBL classes, 10 mentioned
that they studied in a goup or with a partrner to prepare for the exams. The most

ﬁequently mentioned reasons for doing goup study are shown in Table 4.5.

Table 4.5: Reasons for doirng goup study (n = 10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Check Help Keep Pick Up Important
Knowledge Understanding Studying Information

Jim x x

Laura x x x

Mark x x x

Tom x x

Ann x x

Mary x x

Roger x x

Nancy x x x

Kelly x

Jane x x

Total (10) 9 6 5 2

 

 

Note: Because Janet and Andrew did not use goup study to prepare for the exams, they
are excluded ﬁ'om the table.

82

As shown in Table 4.5, 9 of the 10 students who used goup study did so to check
their krnowledge. Through discussing the materials in a goup, they could ascertain the
state of their krnowledge. They checked whether they had stored knowledge by asking
questions or quizzing each other. Roger mentioned, “We do that [goup study] because we
testeachotherand seeifweknowthefacts.”

Also, discussing the materials in a goup helped students integate the materials
and understand the concepts. Students said that goup study helped more with conceptual
materials than with factual materials because discussing the materials with each other
made students see diﬁ’erernt points of view or points related to other materials, which
sometimes clariﬁed the material they were studying. In explaining how he used goup
study for irntegation purposes, Tom said,

Itlninkthattlneconceptualmaterial, annmderstandingoftheconceptualmaterial, comes

withdiscussingitbystudyirnginagoupofpeople. ThefactsIlearnwhenI‘msitting

therestudyingbymyself. Ialsolearnthefactswhernl’minagoupandlhearthings.

BmtheconcepmalnrateialisﬂnemataiaereaﬂyseemmcomemgetherwhanI

studyinagoupwithotherpeople. Becauseit’shearingsomebodyelseexplainit, arnd

hearingthemlooldngatitﬁomadiﬁ‘erentangle, thathelpsbringtlningstogether.

Further, goup study forced goup members to study more when they were bored
or tired of reading the materials by therrnselves. Group study also provided an opportunity
to exchange irnforrnatiorn, which enabled students to discover what information was
important during discussion. In addition to the aforementioned reasons, a few students
said that goup study provided repetition of their study, made them see different points of
view, and helped them memorize the materials.

Most of the interviewees said they went through the objectives or coursepack

notes together by discussing, teaching or quizzing each other, and sometimes sunrrnarizing

83

important points during the goup study. Tom said he met with the goup after studying
the material by himselfbecause “Ifyou can come to the goup arnd understand things a little
bittlnernwegetthroughtlnennaterialfaster, andwe‘reabletogetthroughitmoretimes.”
Intmtign stratsg'es: Most interviewees said they thought understanding meant to
krnow how things work, to know how a certain system operates.
Ifmey[goupmenbas]makeastatemanmdﬂ‘lcanguesswhatisconﬁngnextjust

because of the logical progessiorn, arnd I know when this happens then this should
happertyoukindofﬁtittogetherthatway. Youstartpredicting, iftlnishappensthern

thisisgoirngtohappen, arndtlrisarndthisandthisisgoingtoresultﬁ-omit,thernyou

start to feel like you're nmderstarnding it. (Andrew)

They added that connecting various pieces of irnforrnation and seeing the overall picture
helped them understand how things work. Thus, irntegation and understanding of the
materials were not two separate things to most of the irnterviewees.

To integate materials for better understanding, most interviewees used a “careﬁrl
reading” strategy. They said they read materials slowly, trying to make connections with
previous subjects they had studied. For example, Kelly tried to compare and connect texts
with pictures, or texts with PBL cases, through reading. Also, reading the materials more
than once seemed to help students comprehend. Other than reading materials careﬁnlly,
students used the strategies shown in Table 4.6 to integate materials or to help them

understand the materials.

Table 4.6: Integation strategies (9 = 12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name PBL Study in Make Charts! Use Computer
Experience Group Diagrams Programs

Jim x x x

Laura x x x

Mark x x

Tom x x

Ann x x

Mary x x

Andrew x x

Beast x

Nancy x

Janet X x

Kelly x x

Jane x x

Total (12) 10 6 4 4

 

 

 

 

Although being in a PBL class was not in itself a purposeful strategy for better
understanding of the materials, as shown in Table 4.6, 10 of the 12 students reported that
the PBL experience helped their understanding by clarifying concepts and providing
contexts with the cases. Also, halfof irnterviewees mentioned that they used goup study
for better understandirng. As in PBL class, goup study helped their understanding of the
materials tlnrough discussing things with and explaining them to each other. Discussing
the materials with each other made them see diﬁ‘erent points of view or points related to
other materials that sometimes clariﬁed the material they were studying.

Four students reported that they made charts or diagams to integate the
materials. For example, Ann said that drawing charts helped her classify similarities and

diﬁ'erences and also showed patterrns that aided her understanding. Computer progams

85

also helped students understand the materials by providing visual examples associated with
a certain disease, and also by irntegating different topics. In addition to using the
strategies in Table 4.6, a few students reported that they wrote down a certain process or
an explanation of unclear points in order to help them understand the materials.

MW: Most interviewees reported that they used fewer
memorization strategies in their second year as compared to their ﬁrst year. Students had
more materials to study the second year as compared to the ﬁrst year, so they could not
spend their time memorizing nninute details. Further, the interviewees reported that,
because they spernt more eﬂ‘ort on understanding the materials the second year,
memorization followed naturally. Whereas studernts thought understanding meant
knowing how things worked and being able to connect various information, they thought
rote memorization was leamirng things that had no connection with others without
krnowing the process. Nancy called rote memorization “learning random facts.” Roger
gave examples of understanding and rote memorization. He said that knowing that “aspirin
decreases swelling” is rote memorization Understandirng would be “If one knows the reason
thattlnathappernsisbecauseyoublock sometlning calledthecerrtral oxygerric pathway
chemically, arnd that produces prostaglarndirns, which irncrease swelling So if you don't have
proxyglarndins, you don't have swelling.”

To memorize the materials, most students used repetition strategies such as
reading the same materials several times, reading diﬁ‘erent materials for the same
information, or talking with ﬁiends severa‘l times. Other than repetition of information,

students reported using the strategies shown in Table 4.7 to memorize materials.

86

Table 4.7: Memorization strategies (n = 12)

Name Writing Mnemonics Charts/ Imagery
Down Organization

Jim x
Laura
Mark
Ann

Andrew

Janet

Jane
Total 12

 

Halfof the interviewees reported that writing down facts, important points, and
similar things to diﬂ‘erentiate them helped their memorization. They mentioned that
writing is a more active process than just reading the materials and thus helps in
remembering. Sometimes students recorded information in several places, such as writing
it on ﬂashcards or on charts, typing it into a computer, and taking notes of the information
they needed to remember; this repetition aided memorization. Four students mentioned
that they made up mnemonics or acronyms using stupid and silly stories or songs to aid in
memorization. They also reported that drawing charts not only helped understanding, but
also aided memorization. Organizing materials into charts enabled students to see clearly
the similarities and diEerences of particular topics and thus helped memorization.

Andrew and Kelly mentioned that they used imagery for memorization. They reported

87

that using imagery gave context to things, which aided their memorization, as illustrated
by the following statement:

I guess you'd call me a visual learner. IfI could kind of . . . put in your rrnind what

somebody presents with . . . and you can kind of attach things onto that, and that

seems to solidify it in my mind a little better... I think it would really help me
remember things a lot better just to actually put it with . . . putting a certain
problem with a certain face, and that way . . . and the certain ramiﬁcations of that
person's problem, it would really stick with me, I tlnink, more. (Andrew)

Other than the above-mentioned strategies, students highlighted important facts,
talked in goups, and used computer progams with visual pictures. These strategies
helped them understand and remember the materials.

W99: All of the interviewees mentioned that selecting
important information was very important for them because they had to cover a vast
volume of materials the second year. They used various strategies to select important
information. By “main or important information” they meant material that would be on
the exam. Students reported that they relied on objective lists in preparing for exams and
PBL classes because the contents of objective lists were what would be on the exams.
Other than using objective lists as their study guide, students used the strategies shown in
Table 4.8 to sort out important information.

The most frequently used strategy for selecting important information was using
the relative percentages of contents on the exams provided in their coursepacks by
professors. Students focused their study on material constituting a large percentage of the
exams. Some irnterviewees said they used percentages of contents of the exams

as their scheduling guide. For example, they studied the largest percentage content ﬁrst;

then, if they had time, they studied subjects making up a lower percentage of the exam.

88

Table 4.8: Strategies for selecting main information (Q = 12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name % of Stars in Practice Computer Lectures Old
Exam Objectives Quizzes Programs Objectives '

Jim x x x x

Laura x

Mark x x x

Tom x x x x

Ann x x x

Mary x x x x

Andrew x x x x x

Roger x x x x

Nancy

Janet x x x

Kelly x x

Jane x x x

Total (12) 8 6 6 6 6 4

 

a. Old objectives are objectives ﬁ'om the previous second year, which current medical
students obtained ﬁom former second-year students.

In some domains, topics in the objective lists were starred. Topics that were given
more stars were more important than those with fewer stars. Thus, students reported that
they looked at the number of stars in the objective lists and focused their study on topics
with more stars. Students also used practice quizzes as a way of seeing which materials
the exam providers thought important, as well as a way of checking their knowledge. Six
students said they used computer progams as a way of sorting out important information.
When department faculty wrote computer progams, students could see what formation
faculty thought was important by using these progams. Further, computer progams
contained more condensed and concise information than textbooks, which helped students

select important information. Students also used lectures as a strategy for gaining

89

information that might be covered on exarrns. Laura and Andrew reported that they
obtained scribe notes ﬁom lectures even though they did not attend lectures, because
scribe notes provided them with test information.

Other than the strategies shown in Table 4.8, four students, Ann, Nancy, Andrew,
and Torrn, mentioned that they could tell what were “testable questions” ﬁom their “gut
feeling.” According to them, the common diseases or characteristics of a certain disease
were likely exam questions. To explain testable questions, Tom said,

It’skindofhardtoexplain It'sjustkindofagutfeelingwhenyou‘re studying. Whern

I'mreadingoversornethingljust saytonnyself, thatreallysounds likeatest question.

Somequestionsarejustreallyhardtoteston, arndso, ifIthinksomethingisreallyhard

totestonlwontanphasizehasnmchasdnedungsﬂnatlﬂﬁnkaremoretestable. ..

Ilneyliketoaskquestionslike,“Doesthispredisposetocancer?” Sowhenwe're

studying, wheneverweseesorrnetlringlike, “Thispredisposesyouto anadernorrna,” you

trytorernernbertlnatbecausetlnatseerrnsto comeup onexamsalot.

Andrew, Jane, and Janet mentioned that PBL classes helped them sort out
irnportarnt information because either the preceptor or classmates mentioned what was
important to know during discussions. Along the same lines, a few students mentioned
that goup study helped them select main irnforrnation. Three of the 12 studernts also said
they realized certain information was important to krnow if it was repeated in various
places. For example, Jane mentioned her approach to detecting importance as follows:

WhatItryto doisjustreadthroughthatothersomceandthenseehowitmatchesthe

objectives that they give us and tlnern all the other sources. Like I say, the overlap

betweenalltlnesources,lﬁgurethat'sgottobeprettyirnportant. Ifallthreesources
mention it, it's got to be pretty important.

Other than these strategies, many students mentioned that they highlighted,
underlined, circled, or wrote things down while reading the materials. Doirng these tlnings

helped students focus their attention on information they needed to know.

90

W: Of the 12 students who were taking PBL classes, all but Jane
used computer progams. Among them, Janet and Laura used computer programs only
when they heard the computer progams were good or followed the coursepack closely,
because using computer progams took time. Other interviewees reported that they used
computer progams very much their second year. Students’ reasons for using computer

progams are shown in Table 4.9.

Table 4.9: Reasons for using computer progams (n = l l)

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Provide Good Provide Main Provide
Pictures Information Interaction

Jim x ' x

Laura x

Mark x x

Tom x

Ann x x

Mary x x

Andrew x x

Roger x

Nancy x

Janet x

Kelly x

Total (11) 8 6 2

 

 

 

 

 

 

Eight interviewees reported that they used computer progams because the
pictures in the progams were bigger and better than those in textbooks, and thus they
enhanced understanding. Also, looking at pictures illustrating various diseases made it
easier to remember them. For example, although Laura did not use computer progams

very much, she thought they helped her in that they provided a good way of diﬂ‘erentiating

91

among similar diseases by providing good pictures. Six students said they used computer
progams as a way of selecting important information. Computer progams were
condensed and concise, hence saving time and giving only the necessary inforrnatiorn,
whereas textbooks were too wordy. Also, quiz questions in the computer progams
sometimes helped students ﬁnd important information.

Other than these ﬁequently mentioned reasons, a few students reported that
computer progams provided interaction. For example, students could have immediate
feedback when answering quiz questions on computer proganns. Also, computer
progams were another source of inforrnatiorn, which repeated the same content, so
students used them when they were tired of reading textbooks or coursepacks. For
example, Mary said, “Usually when I'll do it [computer progam] is when I‘m sick of reading.
And I'll go in there arnd I'll be like, aha, changes.” The programs provided stimulation and a
change of pace when students were bored with reading other materials.

WM: As they did in their ﬁrst year of medical school,
the interviewees used certain strategies to check their knowledge or understanding of the
materials. As shown in Table 4.10, nine interviewees said that goup study provided an
opporturnity for them to deterrrnine the state of their knowledge by asking questions and
quizzing each other. For example, Roger said, “We do that [goup study] because we test
each other and see if we know the facts.” To explain his approach to checking knowledge,
Jim commented,

Yeah, it's similar to PBL. For instance, we'll take a drug, and we'll say, “OK here's the

drug.” Andwe'll say, “Drugx,howdoesitact,wheredoesitact,whatdoesitact

like?” Andthernwequizeachother, andwetalkthrouglnitandthernifsomebodysays
the wrong answer, or maybe they got something wrong, maybe they misunderstood the

92

corncept. . .whereIthinkitwentup,wheremaybeitwentdown,inreversefeedback
orsomethingAndwetalkaboutthosethings.

Five students said they solved practice quizzes included at the end of the coursepack or in

the computer progams to see how well they understand the material.

Table 4.10: Strategies for checking knowledge (g = 12)

Name Group Study Practice Quizzes

Jim x
Laura
Mark

Ann

Jane
Total 12

 

In addition to these strategies, I rm asked lnimself questions when he read the
material a second time to see whether he understood it. Andrew said he krnew he
understood the material if he could restate what he had read and if he could tell the next
stage of something because most systems in the medical area have a logical progession.

W: Of the 12 interviewees who were taking PBL classes, 5
reported that they had quit going to lectures because they could spend the lecture time
more eﬂ'ectively studying by themselves. Most of students who attended lectures said they

did so only if the lecturer was good and let them know what to emphasize in studying for

93

exams. Even those ﬁve students who did not attend lectures obtained scribe notes and

studied them to see what the lecturer had emphasized. Students who attended lectures

gave various reasons for doing so. Lectures gave them an opportunity to ask questions
and reinforced what they knew. Also, students thought they should attend the lectures

because they had paid for them.

W: Some interviewees reported that they used certain strategies
to organize materials, check their coverage of the objectives, or schedule their study. (See
Appendix F for additional strategies mentioned by interviewees.) Further, a few students
mentioned that their motivation and conﬁdence had changed because of their experience in
medical school. For example, Roger said that doing well on exams gave him conﬁdence.
He noted, “Getting good scores always helps because you feel like you are doing the right
thing, and you feel like you can trust your judgnent about what to study and what not to
study.”

MW: Except for Susan and Cindy, who were not taking the board
exam soon because of their extension, all of the interviewees said they would be taking a
board review course to prepare for the board exam. Because of their busy study schedule
the second year, the students were not yet thinking about starting to prepare for the board .
exam. However, most interviewees believed that studying for exams and discussing the
materials during PBL classes would help them pass the board exam. Mary noted,

“Michigan State students do well above the national average on the boards.”

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94

W: What do students think influences their learning
strategies (such as goals, assessment of learning, student activity,
teaching method, and course content) ?

In the following discussion of the ﬁndings for Research Question 3, Susan and

Cindy, who were not taking PBL classes when the interviews were conducted, are

included because inﬂuences on their learning strategies were not related solely to PBL

classes. Table 4.11 Shows what interviewees said irnﬂuenced their learning strategies.

Table 4.11: Inﬂuences on students’ learrning strategies (r_n = 14)

Name Passing Previous Time Being a Good PBL
Exams Study Habits Doctor ' Process

Jim x x
Laura x
Mark

Ann

Susan
x
Jane
Total 14 4 4 3 2

 

a Students who mentioned having a good knowledge base and understanding of materials
were included in this category.

As shown in Table 4.11, interviewees mentioned various factors that inﬂuenced

their studying approach. Having limited time with a vast volume of materials to cover in

95

the second year, the pressure to pass exams, their old study approaches, and the desire to
have a good knowledge base and thus be a good doctor were the geatest inﬂuence on the
ways students studied. fun and Laura said that having the PBL experience in their second
year also inﬂuenced the way they studied because it gave them the opportunity to integate
nnaterials and made them more independent learners. Andrew thought his previous
knowledge also directed how he studied.

I also asked the interviewees about their current goals because those are integal to
what they study and how they study. Most students said that their goals were passing
class exams and the board exam, as well as having a good knowledge base and
understanding the materials. Some of them mentioned that they would like to balance
their studying for exams, their personal life, and having clinical experience for the future.
Although most students recognized the importance of having a good knowledge base in
the long run, they thought that passing exams was a more immediate goal in order to
move to the next step.

Table 4.12 shows the ways in which students thought PBL classes helped them.
Susan and Cindy are not included in the table because they were not taking PBL classes at

the time the interviews were conducted.

96

Table 4.12: The ways in which PBL classes helped the students (9 = 12)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Understanding Small-Group Indep. Get Exam Checking

(Integration) Working Study Info. Knowledge
Skills (SMI) '

Tim x x x x

Laura x x x

Mark x x x

Tom x x

Ann x x

Mary x x x

Andrew x x x x x

Roger x

Nang x x x

Janet x x x x

Kelly x

Jane x x x

Total (12) 10 10 6 3 3 2

 

 

 

 

 

 

 

 

 

a. SMI = Selecting main information

As shown in Table 4.12, most irnterviewees thought the PBL class experience
helped them integate and understand the materials by providirng a context with a case and
thus giving a clinical experience. Also, as hypothesized, most students thought that
because PBL classes were small, they developed skill in talking and listening to others.
Students said they monitored what they talked about and listened to others more careﬁrlly.
Also, they were more tolerant as a result of dealing with a wide variety of personalities in
PBL classes.

About half of interviewees said that PBL classes encouraged their independent
study by letting them search for information on their own instead of giving them all the

information, as the previous year’s lectures had done. Some students also mentioned that

97

they could obtain irnforrnation ﬁ'om classmates, such as what material was important to
krnow, and they could get different points of view. Also, the PBL class experience helped
them check their knowledge through discussion. Whereas most students said PBL classes
helped them understand and irntegate the materials, four students said that PBL class
helped them prepare for exams through discussion of relevant information. In additiorn,
Janet said that PBL classes gave her an opportnrrnity to ask questions. Ann liked PBL
classes because she could forrn ﬁiendships through them. On the whole, students thought
PBL classes helped more with their long-term goal, which was integation or
understanding of the materials, than with their current goal, which was passing exams.
W: Do second-year medical students at MSU CHM report

that they study differently than they did in their ﬁrst year?

Ifso, how and why?

In the presentation of ﬁndings for Research Question 4, both interview and LASSI
data are used. Susan and Cindy were not taking PBL classes when the interviews were
conducted because of the extension of their progams; thus, they are excluded ﬁ'om the
discussion of irnterview ﬁndings.

Isnterviﬂ ﬁndings: One notable change that students reported was that, whereas
they focused primarily on lectures and lecture notes their ﬁrst year, they did more
textbook reading and focused on understanding their second year. They mentioned that
the knowledge they accumulated during their ﬁrst year in medical school helped them to
see more of the overall picture. Also, whereas year one lecturers gave students the
necessary information with which to prepare for exams, in the second year they needed to

ﬁnd resources on their own and study them. For example, whereas students thought that

98

studying scribe notes or lecture notes meant doing well on tests their ﬁrst year, the second
year, they believed they should look for study resources outside of the lectures, such as
doing computer progams or reading reconnrnended books. Thus, they focused more on
reading the materials, as exempliﬁed by Ann’s comment:

Justbecausetlnere'ssorrnuchtlnatmernorizing oneparticularthingisawasteofenergy

usually. Usuallyyourbettertoimmerseyourselfinasmuchvohrme ofmaterial and

hope you absorb ernough of it to speak to tlne questions as they come up. So you’re
betteroﬁ'sperndingtinrereadingittryingtoreadmoreofit, orallofithopeﬁrlly, once.

It'dbenicetoreadittwice.

Having a geater volume of materials to study the second year in a limited time
also made students use fewer memorization strategies because that took time. Instead,
they tried to focus on understanding as a goal rather than memorizing the details.

Another notable change related to the above fact was that, whereas only Ann had
quit going to lectures the ﬁrst year, more students stopped going to lectures their second
year, and those who attended lectures did so less ﬁequently than their ﬁrst year. Janet
stopped going to lectures the second year; she commented,

Idon'tgotolectures,brnIreadsmbeabutIonlyreadthernatterI'vedonemyown

studying Ireadthemthedaybeforetheexam Solectureistotallyuselessto me. I

don'teverngotothelabs. Allmytimeismyownpersonaltimethatlspendstudying

arnd readirng. So Ijust take the objectives list and I go down the objectives and check
them oﬁ‘as I do them Sometimes I do the computer progams.

Students attended lectures only when the lecturer was good. The reason students
either attended ornly good lectures or quit going to lectures was lack of time. They
thought they could spernd time more eﬁ‘ectively studying by themselves. However, even

those students who did not attend lectures obtained scribe notes ﬁ'om the lectures so they

would krnow what information the lecturer emphasized, for exam preparation.

99

Whereas second-year students said they used computer progams, no interviewees
mentioned using computer progams their ﬁrst year. Students used computer progams
more the second year because they contained more condensed information and better
pictures than textbooks. Also, when students were tired of reading, doing computer
programs provided a ﬂesh approach to their study. As they did the ﬁrst year, most
students in their second year used goup study either to check their knowledge or to
understand the concepts.

In addition, some students commented on the pressure they had felt the ﬁrst year
as compared to the second year. For example, whereas Ann felt more pressure the second
year because of geater study loads, Roger and Nancy said they felt less pressure but more
conﬁdence the second year because of their experience in taking exams and receiving
good scores on them. This is illustrated by Roger’s comment:

Yealn, Ijusttellmysdfﬂnatrvetakenpmbablyahundredtestssincervebeenha'e arnd

Ihavern'tfailedyet, sowhatI‘mdoingisprobablygood. Andiflwantabreakljust

takeabreakandl'vestartedtovaluemyﬁeetimealotmore. Ifeltscaredtotakeﬁ'ee
timelastyearjustbecauselwasaﬁ'aidImightfail. Butlhavemoreconﬁderncetlnis

year.
m: The LASSI ﬁndings are divided into three parts. The ﬁrst part
contains ﬁndings ﬁ'om the LAS SI analysis over three time points (August 1993, January
1994, and February 1995), using the original LASSI scales. The second part contains
ﬁndings ﬁom analyses of individual items of the LAS SI, which I and two medical faculty
categorized as PBL-sensitive and PBL-nonsensitive. In the third sectiorn, ﬁndings ﬁ'om the
PBL-related scale versus the PBL-unrelated scale, which I and two medical faculty made

from the original LAS SI scales, are reported.

100

1. Findings fmm the original LASSI scale anglysg’

Overall analysis (using three time points).

I ﬁrst used repeated measures MANOVA(Norusis, 1993, p.132), using results
from the LASSI administered to medical students at three times (August 1993, January
1994, and February 1995). F orty-four students completed the LAS SI at all three time
points. Thus, the repeated measures MANOVA was applied to those 44 cases to see the
changes for those students who completed the LAS SI over two years.

Because there were no between-subjects variables in the research, I used only
within-subject MANOVA repeated measures. The within-subject factor was time. Table
4.13 shows the means and standard deviations for each scale of the LAS SI over time for
the 44 students included in the analysis.

Table 4.13: Means and standard deviations on each LAS SI scale for students who
completed the LASSI at times 1, 2, and 3 (g = 44)

 

 

 

 

 

 

 

 

 

 

 

 

 

Scale I Menusg)
E Timel Time2 Time3

Attention :35.9(2.93) 35.4(3.05) 35.3(2.96)
Motivation :32.0(3.83) 30.3(4.51) 30.1(4.58)
Time Management L26.4(6.35) 26.0(6.28) 24.3(7.06)
Anxiety i29.3(6.21) 30.0(6.20) 28.7(6.10)
Concentration €29.0(430) 28.7(4.77) 26.7(4.99)
InformationProcessing 130.4(4.43) 31.5(523) 30.9(5.16)
Selecting Main Information L19.7(3.00) 202(295) 20.0(2.35)
Study Aids i26.9(4.99) 27.4(427) 27.2(4.30)
SelfTesting L27.7(4.02) 27.5(4.13) 26.4(3.91)
Test Strategy 533.2(374) 33.2(3.62) 327(292)

 

101

 

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gey “kn [at tbnljonp HgMal-Aﬂd Sting lug

essi “for

Figure 4.1: Means on each LASSI scale for times 1, 2, and 3.

Note: This gaph is presented to compare the means of time 1,2, and 3 within each scale.
Comparisons among scales in this graph may be misleading because the Selecting
Main Ideas scale includes ﬁve items, whereas the other scales irnclude eight items
each.

Results of the overall multivariate test of signiﬁcance using the .05 signiﬁcance
level indicated that the null hypothesis of no change over three time periods was rejected
(2 = .004). In other words, there was a signiﬁcant change over the three time periods.
Thus, univariate tests were conducted on the 10 scales to gain insight into which scales
changed signiﬁcantly over time. The results are shown in Table 4.14. The .05 signiﬁcance
level was used to test the signiﬁcance of the changes. The univariate tests showed

statistically signiﬁcant changes in 3 of the 10 scales over time. These were the

Motivation, Time Management, and Concentration scales.

102

Table 4.14: Univariate E-Tests of signiﬁcance of all three LASSIs using

 

 

 

the 10LASSI scales
Scale Hypoth. LError LHypoth. LError LE LSig. of E *
55 L88 LMS LMS. L L
Attention 9.65 L539.02ﬁL4.83 L627 L77 L466
Motivation 90.24 L71176 L45.12 L827 L545 L.006*
TimeManagement 109.74 L1140.26 L54.87 L13.26 L414 L.019*
Anxiety 38.23 L112377L19.11 L13.07 L146 L237
Concentration 137.23 L795.44 L68.61 L925 L742 L.001*
InformationProcessing 29.60 L82774 L14.80 L962 L154 {.221
SelectingMainIdeas 6.11 L312.56 L305 L363 L.84 L435
StudyAids 6.79 L846.55 L340 L984 L.34 L709
selfTesting 41.56 L669.11 L2078 L778 L267 L075
Test Strategy 5.47 L578.53 L273 L673 L41 L667

 

 

 

* Signiﬁcarnt at the .05 level.

The means for all three scales decreased signiﬁcantly over time in a linear fashion
as shown in Figure 4.1. These results indicated that students’ use of strategies for
maintaining their motivation, their strategies to create and use schedules, and their focus
on school-related activities such as studying and listening in class decreased ﬁ'om year one

through year two.

Findings using time 1 and time 2 LASSL
Looking at the LAS SI results at tlnree times resulted in a Signiﬁcant arnount of

missing data. Hence, I ran the repeated measures MANOVA using only two time points

103

to reduce the missing data problem. Another reason for considering only two times was

that I wanted to look for changes within the ﬁrst academic year, when the students had a

lecture-based standard curriculum.

For this analysis, the MANOVA with repeated measures was run using two time

points as the within-subject factor to determine whether there was a signiﬁcant change

ﬁom time 1 to time 2. Eighty-seven students were included in this analysis. The

multivariate test of signiﬁcance using time 1 and time 2 data showed that there were

signiﬁcant changes from time 1 to time 2 (p = .000). The remlts of the univariate tests

showed that students’ scores on the Motivation, Information Processing, and Selecting

Main Ideas scales of the LASSI changed signiﬁcantly from time 1 to time 2, as seen in

Table 4.15.

Table 4.15: Univariate _F_-tests of signiﬁcance at time 1 and time 2 using

 

 

 

 

the lOLASSI scales
Scale Hypoth. LError LHypoth. LError LE :Sig. of F“
58 . Ls_s LMS Lm L L
Attention 1.39 L107560 LL1.39 L12.51 L011 L740
Motivation 157.34 £1333.65£157.34 £15.51 £10.15£.002*
TimeManagement 0.93 £2018 07£093 £23.47 £0.04 £843
Anxiety 57.94 L2213 06. £.5794 L2573 L225 L.137
Concentration 0.00 L161400L000 L1877 L000 L1.000
Information Processing 469.01 L1556 99 L469.01 L18.10 L25.96L.000*
SelectingMainIdeas 48.56 L618.44 L48. 56 L719 L675 L.011*
StudyAids 36.04 L1963 95L3605 £22.84 £1.58 £212
SelfTesting 1.39 L1751.61L1.39 £20.37 £0.07 £794
Test Strategy 47.08 £1242.92 £47.08 £14.45 £3.26 £075

 

* Signiﬁcant at the .05 level.

 

104

Means on the Motivation scale decreased sigriﬁcantly from time 1 to time 2 (see
table 4.16). On the other hand, means on the Information Processing and Selecting Main
Ideas scales increased signiﬁcantly ﬁom time 1 to time 2. The results indicated that
students’ use of strategies for maintaining their motivation decreased ﬁ'om the beginning
to the end of the ﬁrst semester of medical school. Also, the results indicated that students’
use of strategies for information processing, such as using elaboration and organizational
strategies to foster understanding and recall, increased as they experienced medical school.
Further, increases in means on the Selecting Main Ideas scale indicated that students
improved in selecting important information to concentrate on in their study from the
beginning to the end of the ﬁrst semester of medical school.

Table 4.16: Means and standard deviations on each LAS SI scale for students who
completed the LASSI at time 1 and time 2 (g = 87)

 

 

 

Scale L Mean (S_D)

L Timel Time2
Attention £35.7(2.97) 35.8(2.83)
“grams; """""" ranznaraasazzr"
“ins-images: """ Vinegar-Xian“
Lassa; """""""" L'2’9Tf(§3§)"3'0'.6(5'§7)’"'
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stray-Asa; """""" £‘2'6'T6’('5'.‘1§)"27'.2'('5.'70)’"‘
'ssﬁezan """""" TE7T€(Z.'75)"§-Z§(2752)'"‘
Kristian-y """"" 75233357336335”

 

 

105

Findings using time 2 and time 3 LASSI.

The time 2 and time 3 LASSI data were analyzed to deterrrnine whether there was
a signiﬁcant change ﬁom time 2 to time 3 (from January 1994 to February l995)-in other
words, ﬁ'om one academic year to the next. The instructional methods these students
experienced changed from time 2 to time 3 (lecture-based to PBL). Repeated measures
MANOVA was run using two time points as the within-subject factor. F orty-ﬁve students
who completed LASSIs at both time 2 and time 3 were included in this analysis. Means
and standard deviations are shown in Table 4.17. Results of the omnibus test of
signiﬁcance for time 2 and time 3 are shown in Table 4.18.

Table 4.17: Means and standard deviations on each LAS SI scale for students who
completed the LASSI at time 2 and time 3 (r_n = 45)

 

 

 

Scale ﬂ: Mean (S_D)

£ Time2 Time3
Attention L35.3(3.02) 35.3(2.93)
manila; ““““““ Tiofnzzariﬁat‘ss)‘ """
"rnzmen'ear """ L’é’sTﬂEBEf’EIEﬁTb’n)’ “““
“me; “““““““ T3076(6.’1i)"2§?‘6'(670§3’ """
canyons; """"" L'isTﬂZﬁEf’iEiéE‘é)’ """
“aromas-pim“"rnfsz§i iy'iiat's' T1)" “““
Fs'ae‘angnzn‘raa; """ L’2’071’(§.§§)"20’.6(23§)‘ """
"gracing; """"""" Tz’rfs'izaaﬁraaaz)‘ """
stiffening """""" L'2’7TI(Z.’14')"2'§3'(3790)' """
Terra-11:3 """"""" L'3’3'.2'(§.‘s§)”3'2‘i§(2.’9'ij' """

 

 

106

Table 4.18: Omnibus test of signiﬁcance at time 2 and time 3 using
the 10 LASSI scales

 

[Test Name L Value LExact E LHypoth. if L Error d_f L Sig. of 13*1

[Hotelling's £0.47323 £1.65629 110 L35 £.131 I

* Signiﬁcant at the .05 level.

No overall signiﬁcant change was found from time 2 to time 3. Because the

omnibus test results were not signiﬁcant, the univariate test results are not reported here.

2. Finding; from ingividual items on the MSSI
As discussed in Chapter III, I and two medical professors who were experts on

PBL curricula rated the individual items of the LAS SI as being PBL sensitive or not. We
examined each LAS SI item and divided the 77 items into two scales, termed the PBL-
sensitive scale and the PBL-nonsensitive scale. Only those items that all three of us ageed
were PBL related were included in the PBL-sensitive scale. Thus, 25 of the 77 LAS SI
items were included in the PBL-sensitive scale, and 52 items were included in the PBL-
nonsensitive scale. Items in each scale are shown in Appendix E.

I computed subscale scores for time 1 LAS SI and time 3 LAS SI. However, I
could not compute subscale scores for time 2 LAS SI because only overall LAS SI scale
scores were available, and individual item scores were missing. Thus, repeated measures
MAN OVA was applied only for time 1 and time 3 PBL-sensitive and PBL-nonsensitive
LASSIs. The multivariate test of signiﬁcance using time 1 and time 3 data showed that

there were signiﬁcant changes from time 1 to time 3 (p = .000).

107

Thus, univariate Ij-tests for each scale were conducted for the 50 students who
took the LASSI at both time 1 and time 3. The results showed that, whereas PBL-
sensitive scale means did not change signiﬁcantly ﬁ'om time 1 to time 3 (p = .145), means
on the PBL-nonsensitive scale did change signiﬁcantly from time 1 to time 3 (p = .007).
Looking at the means of the 50 students who were included in the analysis, one can see
that means on the PBL-nonsensitive scale decreased signiﬁcantly ﬁom time 1 to time 3

(198.2 to 187.6). Figure 4.2 shows this trend from time 1 to time 3.

mn
“U

 

manning

  

 

 
 

 

 

PBL sensitive scale PBL non-slamiﬁve sc
Figure 4.2: Means on the PBL-sensitive and the PBL-nonsensitive scales
for time 1 and time 3.

Note: This gaph is presented to compare the means of time 1 and time 3 within each
scale. Comparison of two scales in this gaph may be misleading because the
number of items included in each scale is diﬁ‘erent (PBL-sensitive scale with 25
items and PBL-nonsensitive scale with 52 items).

108

These results indicated that students’ use of learning strategies that were not
necessarily related to the experience of PBL classes decreased ﬁ'om the beginning of
medical school to the second year (see Appendix E for PBL-nonsensitive items).
Although the means on the PBL-sensitive scale did not change signiﬁcantly ﬁ'om time 1 to
time 3, the means (94.7 and 97.1 for time 1 and time 3) indicated that students improved

on the PBL-related items over time.

3. Fingingg fmm thg PBL-related scale and the PBL-unrelatﬂ scalg,
dgrived from the om ’nal LASSI scales

Because the analysis of the LASSI using the individual items could not be
conducted with all three LASSIs because of missing data at time two, I created another
set of subscores ﬁ'om the original LASSI scales, so that one subscore represented PBL-
related scales and the other did not. The authors of the LAS SI suggested that ﬁve scales
(Motivation, Anxiety, Attitude, Concentration, and Time Management) represented the
aﬁ‘ective domain, whereas the other ﬁve scales (Information Processing, Self-Testing,
Studying Aids, Test Strategy, and Selecting Main Ideas) represented the cognitive domain.
By discussing the individual items in consultation with medical professors who were
experts on PBL, I noticed that the cognitive domain of the LAS SI had items related to
PBL participation, whereas the aﬂ‘ective domain of the LAS SI did not.

Thus, I conducted a repeated measures MAN OVA using two subscales (named the
PBL-related scale and the PBL-unrelated scale) derived from the original LAS SI scales.
The PBL-related scale included the Information Processing, Self-Testing, Study Aids, Test

Strategy, and Selecting Main Ideas scales ﬁom the original LAS SI_scales. The PBL-

109

unrelated scale included the Motivation, Anxiety, Attitude, Concentration, and Time
Management scales.

Table 4.19 and Figure 4.3 show the means and standard deviations on these
subscales for the 44 students who completed the LASSI at all three times.

Table 4.19: Means and stande deviations on the PBL-related scale and the PBL-unrelated
scale for students who completed the LAS SI at all three times (n = 44)

 

 

 

 

 

 

 

Scale £ Mean (3;)
. Tim—cl TEE-2 Ting?
PBL-related scale I l37.8(l4.50) 139.8(15.63) 137.3(1391)
PBL-unrelated scale L146.1(19.68) 150.3(1903) 145.1(17.17)
M 152
i 150«
2 14s -
146 ‘
144 ‘
142 '
140 ‘
138 ‘
136 ‘
134 .

 

 

 

PBL scale nornPBL scale

Figure 4.3: Means on the PBL-related scale and the PBL-unrelated scale
for times 1, 2, and 3.

Note: This graph is presented to compare the means of time 1, 2, and 3 within each scale.
Comparison of two scales in this gaph may be misleading because the number of
items included in each scale is different (PBL-related scale with 37 items and PBL-
unrelated scale with 40 items).

110

Although students’ means on both the PBL-related and the PBL-unrelated scales
increased ﬁom time 1 to time 2, their means decreased from time 2 to time 3. To
determine whether this change was statistically signiﬁcant, I conducted multivariate tests
of signiﬁcance. No signiﬁcant change was found ﬁ'om time 1 to time 3 (p = .368). Thus,
the univariate E—test results are not reported here.

To determine whether there was a signiﬁcant change from time 1 to time 2 and/or
ﬁ'om time 2 to time 3, an analysis was conducted for each time period as was done with
the original scale described in the ﬁrst section. Table 4.20 shows the means and standard
deviations for the 87 students who completed the LAS SI at time 1 and time 2.

Table 4.20: Mearns and standard deviations on the PBL-related scale and

the PBL-unrelated scale for students who completed the LAS SI
attime l andtime2(n=87)

 

 

Scale L Mean (Q)
L Time 1 Time 2
PBL-related scale £ 136205.27) 140505.52)
'fﬁﬂErTrEﬁt'cﬁ 2&1; 'L'1'4'47221’7’. 62’)“ 3302717724?“

 

 

 

As shown in Table 4.20, means on both scales increased from time 1 to time 2. To
determine whether this change was Statistically signiﬁcant, multivariate tests of
signiﬁcance were conducted using time 1 and time 2. The result indicated that there was a
signiﬁcant change ﬁom time 1 to time 2 (p = .002). This result was consistent with the
result of the analysis on the original LASSI scales. Because the omnibus test showed a

signiﬁcant change, I conducted univariate tests on the PBL-related and the PBL-unrelated

lll

scales. Means on both scales changed signiﬁcantly ﬁ'om time 1 to time 2 (p = .003 for the
PBL-related scale, 2 = .002 for the PBL-unrelated scale). On both scales, the means of
the 87 students included in the analysis improved from time 1 to time 2, as shown in Table
4.20. These results indicated that students’ use of strategies, whether they were related to
the PBL experience or not, increased from the beginning to the end of ﬁrst semester of
medical school.

I conducted MANOVA tests for time 2 and time 3 to determine whether there
was a signiﬁcant change during this time period. Table 4.21 shows the means and
standard deviations of the 45 students who completed the LAS SI at time 2 and time 3.

As shown in Table 4.21, means on both scales decreased from time 2 to time 3.

To determine whether this change was statistically signiﬁcant, a multivariate test of
signiﬁcance was performed, using time 2 and time 3. The result (2 = 0.85) indicated that
there was no signiﬁcant change ﬁ'om time 2 to time 3. Thus, the results of the univariate
tests are not reported here.

Table 4.21: Means and standard deviations on the PBL-related scale and

the PBL-unrelated scale for students who completed the LAS SI
attime2andtime3 (n=45)

 

 

 

Scale L Mean (SQ)
L Time 2 Time 3
PBL-related scale L 139.5(1555) 137.2(1375)
”iﬁﬂﬁrirEFat‘ed "scale- ’L'i's'oTo'Ziéfé’zT T43 .‘0'(’i'770'03""

 

 

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Summagy

In Chapter IV, I ﬁrst featured two case studies from the interview ﬁndings. Then,
I presented the common ﬁndings prevailing for all of the interviewees according to each
research question of this study. Also, to report the diﬁ‘erences in learning strategies
between ﬁrst- and second-year medical students, I presented the LAS SI data in addition to
the interview ﬁndirngs.

Chapter V contains the limitations of the study, ﬁndings pertaining to each
research question, conclusions drawn ﬁ'om the ﬁndings, implications for medical

education, and recommendations for ﬁlture study.

CHAPTERV

DISCUSSION AND CONCLUSIONS

In etion

Educators construct instruction so their students will learn eﬁ‘ectively and
eﬁciently. In response, students employ learning strategies of their own to learn what is
needed in the provided instructional environment. Thus, it would be ideal if the
instruction that is provided and the learning strategies students employ complement each
other.

In most situations, students must adapt to the instructional context. Thus,
understanding how students adapt their learning strategies in diﬂ’erent instructional
contexts would beneﬁt educators, especially those who are interested in curriculum
design, those who advise students about the most eﬁ‘ective learning strategies for the
instructional system, and those who build courses to encourage eﬂ‘ective and eﬁcient
learning Strategies.

This study explored MSU medical students’ adaptation of their learning strategies.
Medical students are a useﬁrl goup to study in regard to adaptation because they
experience diﬁ‘erent instructional contexts during their preclinical years. Thus, the main

question of this Study was how medical students adapt their learning strategies to diﬂ‘erent

113

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educational contexts. During their ﬁrst year, students at MSU have a lecture-based
curriculum, whereas during their second year, they have problem-based learning.
Problem-based learning is learning that results ﬁom a process of working toward the
understanding or resolution of a problem (Alguire & Werner, 1992). PBL uses cases as a
stimulus for learning, provides an opportunity for problem solving, and allows for student-
irnitiated searching for information.

This chapter contains a discussion of how medical students adapted their learning
strategies to a changed instructional context—ﬁom lecture-based to problem-based
learning—and provides preliminary answers to how students in general may cope with
changes in the curriculum. Speciﬁcally, the discussion includes how CHM medical
students studied during their second-year curriculum, what inﬂuenced the learning
strategies of second-year medical students, and how students changed their learning
strategies ﬁ'om the ﬁrst year to the second year.

Limitations of the study are presented before the discussion of results.

Conclusions drawn from the ﬁndings are presented alter the discussion of ﬁndings for each

research question. Implications and recommendations also are made for future research.

Limitations of thg Study

There were a few limitations in this study as discussed below.
1. The LASSI was not the ideal assessment ingrument for the study: In this study, I
compared students’ learning strategies ﬁ'om the ﬁrst year of medical school and the
second year by using the LASSI in addition to interview data. The LASSI originally

was developed for undergaduate students who are under the large-lecture format of

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instruction. Although doing several analyses, including item analysis, might
compensate for the shortcomings of using the LAS SI, results from the LAS SI might
still be biased because the instrument originally was developed for undergaduate
students and because it is based on large-lecture classes. Thus, the LASSI was not the
ideal assessment tool to see the changes in the learrning strategies of medical students
~who are professional graduate students and who also experience diﬁ‘erent curriculum
during their preclinical years.

2. Not all s_t,1_rden§ complg‘tg the LAS SI all three gm es: Another limitation is that not all
students completed the inventory all three times ﬁom year 1 through year 2. Actually,
the number of students who took the LASSI decreased ﬁom time 1 to time 3. Thus,
there could be some differences between students who completed the LAS SI three
times and those who did not.

3. Intﬂ'mr’s subgm’ous bias: Although I tried to be objective in interviewing
students, I could have had a biased opinion about learning strategies based either on the
literature and/or on the pilot study conducted during the 1993 -94 academic year. Thus,
subconsciously, I could have inﬂuenced students to respond in a particular way.

4. W: Because both the interviews and the LAS SI were self-report
instruments, there is a possibility that students concealed their true use of learning
strategies. Observation of the PBL classes or use of videotape during the informal
goup study sessions could compensate for the subj ectiveness of self-reporting devices.

5. W: Medical students have successﬁrlly ﬁnished their undergaduate

program and have the academic ability to compete in medical school. Thus, they are

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relatively bright students. Further, the interviewees in this study did not represent every
academic performance level among medical students. There was only one low-
academic-performance student, whereas others represented middle to high academic
performance in medical school. Thus, there is a limitation for generalizing the results of
this study to other students. However, this research can be generalized to relatively

successful medical students.

March Question 1

What learning strategies do students use in preparation
for the problem-based learning classroom, and why?

Based on the PBL literature, I expected that students would study diﬂ‘erently for
PBL classes and for exams. However, most of Students mentioned that they did not
prepare for PBL classes per se, but focused mainly on exam preparation. Thus, the
hypothesis that students would focus more on understanding than rote memorization in
preparing for PBL classes could not be evaluated. Most of the interviewees said that they
studied for exams, and that process indirectly helped them prepare for PBL classes. They
believed that PBL classes did not directly help in their exam preparation, although they
thought PBL was a valuable experience.

During the PBL classes at MSU, students are expected to discuss a case, formulate
hypotheses, and generate their own learning issues with the help of preceptors so that they
can learn relevant information. I found that the learning issues generated during PBL
classes were geared primarily toward studying for exams. That is, what Students did

during the PBL classes was inﬂuenced by the objectives that faculty provided for the

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exam. The reason students monitored their PBL activities based on the objectives was
that they needed to study those objectives to pass the exams, and they did not have time to
study learning issues that were not relevant to the exams. And when students looked for
the learning issues, instead of going to the library and researching necessary materials as
hypothesized, they relied on their own textbooks or coursepacks recommended by faculty.
Further, when PBL classes were geared toward the exams, students were more motivated
to participate eagerly. Some students reported that they felt ﬁ'ustrated when the goup
discussed something irrelevant to the objectives.

This trend in PBL classes can be compared to K-12 education. In both contexts,
exams drive learning. However, whereas in K-12 education, exams drive teachers’
evaluation and teaching, in medical school, exams drive students’ learning. In medical
school, students have taken over the instructor’s role in their studying. They decide what
information is relevant and how to practice for mastery. For example, medical students
gear discussion in PBL classes toward objectives which are the focus of their exams. They
also decide how they will practice for the test.

In sum, students did not prepare for PBL classes but studied mainly for exams.
Through studying for exams, they could contribute to PBL class discussion. Further,
students used the PBL class as an arena to study for exams by making the learning issues
match the objectives that drove the exam questions. Thus, it can be concluded that no

matter what curriculum is used, students study for exams.

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Research uestion 2
What learning strategies do students use in preparation
for examinations (both class exams and
the licensing exam), and why?

From the interviews I found that students used various strategies to prepare for
examinations. First, I found that second-year medical students relied extensively on
reading materials, used many integation strategies and goup study, and used only a few
memorization strategies. Students’ use of these strategies will be discussed together
because the reasons for using these strategies were similar. Second, I found that second
year medical students used many strategies for selecting the main information for exam
preparation.

One of the notable things I found from the students’ interviews was that their basic
study mode in the second year was reading textbooks, whereas they relied heavily on
lecture notes and lectures the ﬁrst year. They attempted to get the overall picture and
general ideas during their ﬁrst readirng and studied details through their following readings.
Thus, reading the materials several times seemed to help them understand the vast amount
of material. By reading books and/or coursepacks, students tried to expose themselves to
as much information as possible, as shown in Laura’s comment:

It’s just too much work to try to get through. And I ﬁgure it’s best to get through

everything once rather than to get through some tlnings and not the others and

really screw up on the exam because I didn’t get to the other material.

Further, consistent with Blumberg and Mitchell’s (1992) ﬁnding that students in
PBL relied more on reading textbooks or other materials and informal discussion with

peers than did conventional students, students in this study relied more on textbooks than

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they did their ﬁrst year, and they engaged more in discussions with peers during goup
study.

Although various factors rrnight have inﬂuenced students’ use of reading strategies
and goup study, students reported they were more eﬂ‘ective learners their second year,
either because they had the ﬁrst-year medical knowledge or because they had experience
taldng exams. Also, they felt more conﬁdent about studying alone for exams as a result of
their experience of studying the ﬁrst year of medical school. Thus, rather than relying on
lectures, they focused on reading materials for understanding and goup study, mairnly
because this helped them integate and understand the materials. Group study enabled
students to talk to each other and clarify concepts, check their knowledge, and pick up
important information. Further, by providing students the opportunity to discuss,
question, and teach the materials to each other, goup study seemed to activate and
elaborate students’ prior krnowledge and connect it to new knowledge. For example, Jim
mentioned that when the members of his informal group studied for drug x, they talked
about how it acted and where it acted. Then they quizzed each other, correcting their
misunderstandings. Thus, what Schmidt (1983) argued as the theoretical basis of the PBL
was achieved through students’ PBL goup discussion or informal goup study in
preparing for the exams.

Medical students’ use of learning strategies and inﬂuences on their use of learning
strategies can be connected to Palincsar and Brown’s (1988) reciprocal teaching.
Although reciprocal teaclning is designed to help children comprehend what they read, it

shares many features with learning strategies that medical students used in this study, even

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though PBL class has a student-centered instructional format and reciprocal teaching has
teacher-guided instructional format. For example, reciprocal teaching involves four study
activities—summarizing, questioning, clarifying, and predicting-that enhance
comprehension and also afford children an opportunity to check whether comprehension is
occurring in the same way that medical students check their knowledge through discussion
and questioning during PBL classes and irnformal goup study. Reciprocal teaching also
assumes that comprehension is inﬂuenced by the extent of overlap between the reader’s
prior knowledge and the content of the texts. As medical students reported in this study,
they also connected their prior knowledge with what they learned during their second year
to help their understanding. Hence, some of the features of the PBL classes and informal
goup study that students said they used could also be found in the reciprocal teaching
instructional format.

When asked their reasons for using goup study and readings, students said that, in
their second year, they focused on conceptualization and understanding more than on
memorization. Most interviewees mentioned that they thought understanding meant
knowing how things work, krnowing how a certain system operates. They added that
connecting various pieces of information and seeing the overall picture helped them
understand how things work. Thus, integation and understanding of the materials were
not two separate things to most of the interviewees.

This ﬁnding is consistent with those of previous PBL researchers. For example,

following Malton and Saljo’s (1976a) ﬁ'arnework of deep versus surface processing of

learrning as discussed in Chapter II, researchers such as Coles (1985) and Newble and

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Entwistle (1986) found that PBL students placed more emphasis on understanding than
on rote memorization, as compared to conventional students. Newble and Entwistle
(1986) deﬁned rote memorization as “memorization of pieces of information and ideas
largely in isolation ﬁ'om the wider context” (p.165), whereas understanding means
“interconnections with other ideas and previous knowledge” (p. 167).

Studernts’ use of computer progams with visual examples connected to texts,
goup study, readings, and making charts also seemed to reﬂect their purpose of
understanding rather than memorizing the materials. Thus, the hypothesis that students
will use many strategies integaﬁng materials in their second year was supported.
However, the hypothesis that students will use many memorization strategies in preparing
for exams was not supported in this study. It may be hypothesized that students had
knowledge gained from their ﬁrst year of medical school, which allowed them to connect
the information more easily and hence increase their understanding. Further, as discussed
earlier, having a vast amount of material seemed to make students focus on understanding
the materials rather than spending time on memorizing details.

AS hypothesized, another notable leanning strategy that students used the second
year was selecting important information. Interestingly, however, the most ﬁequently
mentioned strategies for selecting the main information reﬂected the exam makers’ or
professors’ views of important materials rather than what students themselves selected
through reading. For example, percentages of the exam content, starred objectives,
practice quizzes, and computer progams are all strategies that professors provided to

students. Students just used those resources in order to select the main information.

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Students also used computer progams extensively the second year to select the main
information. Computer progams contained more concise information than textbooks.
Thus, studernts used such progams extensively to obtain important information efﬁciently.

The vast number of strategies students used to select the main information that
was likely to be on the exams was also reﬂected in students’ use of resources. Based on
previous PBL research (Nolte et al., 1988; Rankin, 1992; Saunders et al., 1985), it was
hypothesized that students in PBL classes would increase their use of library facilities for
information seeking. However, the ﬁndings of this study indicated that students did not
use the library at all in preparing for their PBL classes or exams. Rather, students looked
for those materials that were closely related to the exams, and focused on materials
recommended or provided by faculty instead of looking for materials on their own. This
may be explained, in part, by the fact that MSU has a faculty-centered PBL progam as
compared to other PBL schools, so students do not have to select their own materials to
study but are given lists of recommended materials. Also, limited time for study and the
pressure of passing class exams and board exams prevented students from making geater
use of the library.

In sunn, as discussed above, second-year medical students focused on
understanding or integating the materials as a goal instead of memorizing details. Thus,
they used various strategies for this purpose, such as reading, integation strategies,
computer programs, and goup study. The use of these learning strategies in their second
year was partly inﬂuenced by their knowledge ﬁom the ﬁrst year. Also, second-year

medical students used many strategies for selecting the main information. This was partly

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a result of their need to study vast amounts of material in a limited time to pass the exams.
Thus, they geared their study toward the objectives and used various strategies to learn
information for the exams. The strategies that students mentioned reﬂected how they
adapted their use of learning strategies to the changing demands and conditions of the
context during their second year.
Research Questions 3
What do students think inﬂuences their learning strategies
(such as goals, assessment of learning, student activity,
teaching method, and course content)?

Most interviewees said they wanted to pass the domain exams and board exams.
Also, many students said they wanted to have a good knowledge base. Although having a
good knowledge base and thus being a good doctor was their long-term goal, their
immediate goal was passing the exams. Thus, the pressure of passing the exams and
having a limited time to study inﬂuenced their choice of learning strategies. Also, 4 of the
14 students said it was hard to change their previous study habits; thus, they still used
those methods in their study. Only 2 of the 12 interviewees mentioned that the PBL
process made them change their learning strategies. Thus, in this study it was hard to
validate the hypothesis that the PBL experience affected students’ use of learning
strategies. Rather, time constraints and pressure to pass the exams seemed to inﬂuence
their strategies the most.

Because. students’ perception of the educational context inﬂuences their selections

of learning approaches (Arnold & Feighny, 1995), it was important to explore how

students in this study perceived the PBL context. Although most students said that PBL

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classes did not help in their preparation for exams, they found the experience in the PBL
curricula to be valuable in some ways.

Ten of the 12 interviewees reported that PBL classes helped them integate the
materials and hence increased their understanding. Students also thought that PBL classes
provided a valuable context for their clinical years’ learrning. As Vernon and Blake’s
(1993) meta-analysis suggested, students in this study thought that PBL increased their
irntegation of clinical and basic science krnowledge. They thought PBL classes provided
cases with contexts and thus helped them assimilate information easily into their existing
krnowledge. This corresponded to one of the main goals of PBL, which is for students to
assimilate new information irnto the existing krnowledge structures and thus integate the
materials (Schmidt, 1983).

Conforming what Norman and Schmidt (1992) and Schnnidt (1983) argued, the
PBL format may foster increased retention of krnowledge over time by stimulating the
activation and elaboration of prior knowledge through discussion, answering questions,
and teaching peers in a small goup. Norman et al. also argued that these activities in PBL
in turn can facilitate students’ comprehension of the materials. This claim matches
students’ reports that PBL helped their integation of the materials and hence will help
their long-term goal, which is having a good knowledge base and understanding the
materials.

Further, 10 of the 12 interviewees reported that being in PBL classes increased
their communication skills tlnrough small-goup discussion, as hypothesized. This result

conﬁrmed one of Moore-West et al.’s (1989) ﬁndings, which was that PBL students rated

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their experience higher with respect to student interactions. Also, this result was
consistent with that of Blumberg and Eckenfels (1988) who found that students identiﬁed
goup discussions as one of the most satisfying aspects of the PBL experience. Students
in this study reported that they learned how to convey their ideas and how to question
others critically without causing offense. As reported in Chapter IV, students thought that
PBL promoted the ability to work with others and listen to others’ opinions. Thus, one
goal of MSU PBL, which is to develop eﬁ‘ective small-goup skills, seems to have been
achieved (Black II Preceptor Training, 1993). Maybe this development of
communication skills through small-goup discussion in PBL classes contributed to
students’ use of informal goup study as a learning strategy the second year. Students
reported that they relied more on goup study their second year as compared to their ﬁrst
year. For example 10 of the 12 interviewees who attended PBL classes said they studied
withapartnerorinagoup.

About half of the interviewees said that PBL classes improved their independent
study habits, which is also one of the purposes of the PBL model. However, what
students termed “independent study” meant ﬁnding and reading books for the exams and
studying for exams by themselves instead of relying on lectures to provide all of the
necessary information for exams, as they did the ﬁrst year. Thus, what students meant by
increasing independent study did not mean using the library or doing research for their
own learrning, as hypothesized. Again, because they had so much material to study in a
given time, there was no time to do research for their own learning. This may have been a

result of the unique MSU PBL structure. For example, the MSU PBL curriculum is

126

faculty-centered in the sense that students use faculty-generated objectives and reading
lists to guide their learning of basic science concepts. Having more structured problems
and faculty-centered PBL classes, students might gear themselves toward studying those
learning objectives for the exams, rather than developing individual research skills, like
students who are in an entirely student-centered PBL environment. However, this
structure could beneﬁt students by giving them more direct guidance for their studying and
thus saving them time by focusing their study, which they thought was very important in
light of their content overload.

In addition to these advantages, students also mentioned that PBL classes provided
an opportunity for self-checking tlnrough small-goup discussion sessions. By discussing
the material with peers, Students could compare their knowledge with others’, discover
whether they had misunderstood something, get information about what they needed to
know, and determine how well they had learned the material.

Previous researchers have found that students and faculty are more favorable
toward PBL than the traditional irnstruction format (Vernon & Blake, 1993). For example,
Moore-West et al. ’5 (1989) survey of medical students showed that the PBL students
rated their experience higher in terms of meanirngfulness, ﬂexibility, emotional climate,
mirturance, and student interactions. Although most of the interviewees in the present
study knew that PBL would be useful in their clinical years, some of them felt insecure in
the PBL experience and were ﬁustrated and stressed with the unguided structure of the
classes compared to the lectures they had during their ﬁrst year. This result is similar to

that of Moore et al. (1990), who found that PBL students at Harvard thought their

127

preclinical experiences were more stressful than did students in the conventional
curriculum. However, this result contrasted with the ﬁndings of Moore-West and
O’Donnell (1985), who found that PBL students were substantially less stressed than their
conventional counterparts.

Further, interviewees in this study did not seem to think that PBL was necessarily
more valuable than lectures in preparing for the exams, which was their current goal.
Some students said they could study more eﬂ‘ectively by themselves than by spending time
in PBL classes. Perhaps, by their second year, students established their own learning
strategies and knew how to study to pass the exams and thus did not feel the need for PBL
classes for that purpose.

Overall, consistent with the other ﬁndings, I found that students thought passing
exams and time constraints inﬂuenced their choice of learning strategies. Interviewees
thought PBL was not necessarily better than lectures for achieving their immediate goal,
which was passing exams. However, interviewees believed that the PBL experience
allowed them to achieve their long-term goals which were to develop a good knowledge
base by providing a clinical context for learning, to develop small-goup working skills,
and to encourage active learrning such as discussing materials with peers, comparing their
knowledge, checking their understanding, and getting information about what they need,

which are the goals of the MSU PBL model.

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Research Question 4

D0 second-year medical students at MSU CHM report
that they study differently than they did in
their ﬁrst year? If so, how and why?

MM

From this study, I found that second-year medical students used more integation
strategies and reading than they did the ﬁrst year. Also, second-year students used fewer
memorization strategies than they did their ﬁrst year. I also found that students used more
diverse strategies for selecting the main information during their second year than their
ﬁrst year. However, second-year medical students did not increase the use of learning
resources, especially using library facilities, compared to their ﬁrst year. Next I discuss
these ﬁndings in detail.

Based on previous PBL research, it was hypothesized that second-year medical
students would focus more on understanding the materials as a result of their experience,
as compared to their ﬁrst year. As expected, in their second year, students read textbooks
more and focused more on understanding as compared to their ﬁrst year, in which they
had relied heavily on lectures and lecture notes. First, part of the reason for these changes
stemmed from the fact that most information was not covered in lectures. Second, maybe
this result was related to the source of exam questions. Whereas in the ﬁrst year of
medical school most of the test items came ﬁ'om lectures and lecture notes, in the second
year students could not pinpoint only one source for exam questions. Third, experience in
PBL classes may encourage students to use more integation Strategies. Students

mentioned that PBL classes helped them integate materials. In discussing cases with

129

peers, they had to relate many separate ideas to ﬁnd and solve the problems embedded in
the case. Fourth, partly because of the knowledge they had from their ﬁrst year, students
were able to focus more on understanding the second year. Because students did not have
to concern themselves with the vocabulary of the medical language, they may have been
able to concentrate on the relationships among the ideas. Therefore, they were more able
to use integation strategies which stressed the interrelationship of ideas. Students
reported using more strategies for integating and relating ideas, such as making charts,
reading materials, goup study, or using computer programs, the second year. In contrast,
the ﬁrst year, they had focused on numerous memorization strategies such as mnernornics,
making ﬂashcards, or repetitive reading or writing down materials.

Comparing the learning strategies that students used their ﬁrst year, which
consisted mainly of lectures, to those they used their second year, I found that most
students used strategies for understanding and integation, and they focused less on
memorization strategies as compared to their ﬁrst year. This ﬁnding is consistent with
those of Moore et al. (1990), Mitchell (1992), and Van Langenberghe (1988), who all
found that students in PBL curricula relied more on understanding than on engaging in
memorization. For example, students in this study used more informal goup study their
second year as compared to their ﬁrst year because goup study helped. them understand
the materials through discussion. Maybe the increased use of goup study the second year
wasjnﬂuenced by the experience of PBL classes. For example, Jim used the process of

PBL in his informal goup study, as evidenced in the following comment: “ I have two

130

other people that's kind of our own PBL goup. And we work much like a PBL goup does
except that we don‘t do learning issues.”

Furtlner, students’ knowledge from the ﬁrst year of medical school and their limited
time with a vast study load made them develop more integation learning strategies, with
the goal of passing the exams, rather than spending their time memorizing small details.
That is, they connected a new idea to a concept or information they already krnew, and this
led to ﬁlrther conceptualization and understanding.

I also expected that second-year students would increase their use of strategies for
selecting the main information because of the large study load as compared to their ﬁrst
year. As expected, students used strategies for selecting important information because of
content overload. However, another reason students used these strategies so widely might
be that students had multiple-choice exams and they tried to guess what types of questions
would be on those exams. Thus, they used strategies for selecting information that was
likely to be on the exams, such as using starred objectives, percentages of the exam
content, objectives, quims, and computer programs. In additiorn, the main reason some
students attended lectures the second year was to get information for the exam. In
general, students focused on studying for exams and thus concentrated on selecting
information that was likely to be on the exams.

I also hypothesized that, second-year medical students would use more learning
resources, such as library facilities, self-selected reading materials, and/or textbooks than
they did the ﬁrst year. As discussed under Research Question 2, while students

exclusively used lecture notes and relied on lectures their ﬁrst year, students relied on

131

textbooks in addition to lectures the second year. However, unlike the hypothesis,
students in this study did not seem to increase their library usage or self-selected reading
materials as compared to their ﬁrst year. This result was contrary to those of Nolte et
a1.(1988), Rankin (1992), and Saunders et al. (1985), who found that students in PBL
curricula increased their library usage and self-selected, as opposed to faculty-selected,
reading materials. It could be explained that the studernts in this study had been given the
materials to study and had books recommended by MSU faculty. Thus, they might not
have needed to make an eﬁ‘ort to go to the library to ﬁnd information or self-selected
materials for their study. Further, having limited time with a vast amount of materials to
cover may not have allowed students to spend their time on library searches. The
hypothesis that students would increase their independent study and develop research
skills their second year as compared to the ﬁrst year can also be explained in a similar way.
As discussed in detail under Research Question 3, students seemed to have no need to
increase their research skills in an environment in which they found most of the
information they needed in books or computer progams.

The above-mentioned changes reﬂect how students adapted their learning
strategies to a diﬂ‘erent instructional context. Students krnew what was expected in the
new environment they confronted and changed their learning strategies accordingly.
Further, what they had as previous knowledge seemed to aﬁ‘ect their changing learning
strategies, such as integating materials more. Students did not seem to add many new
strategies the second year because of the curriculum change, but rather they seemed to

change the amount they used certain strategies. For example, although students used

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irnformal goup study as a learning strategy their ﬁrst year, they used it more their second
year.

Having a vast amount of material to study in a limited time and having previous
knowledge seemed to make students focus on integation- and understanding-related
strategies rather than rote-memorization strategies. However, this change in learning
strategies did not necessarily reﬂect the two diﬁ‘erent curricula students experienced, as
had been expected. Although the PBL experience helped students in various ways, as
discussed under Research Question 3, whether this experience made students change their

learning strategies was not evident from the interview data.

M

I used the LAS SI in addition to interviews to determine whether medical students
changed their learning strategies through their preclinical years. From the LAS SI analysis,
I found that students changed their learning strategies ﬁom time 1 to time 2, rather than
from time 2 to time 3. During the ﬁrst year of medical school, students adjusted their
study habits more than they did from the end of the ﬁrst year through the second year.
During the ﬁrst year, strategies to promote motivation decreased signiﬁcantly, whereas
strategies to aid information processing and strategies for selecting important ideas
increased signiﬁcantly. This could be interpreted to mean that although students were
worried about succeeding at the beginning of medical school and thus used various
strategies such as self-talking to increase motivation, they used fewer of these strategies as
they gained experience in medical school, possibly as a result of reduced concern and more

content overload with limited time. This does not mean that students became less

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motivated. They simply used less strategies for enhancing their motivation. From this
data, we cannot be sure if their motivation increased or decreased.

On the other hand, with the vast amount of information they had to study for the
exams in a limited time, students needed to develop their strategies for selecting important
information—what was mostly likely to be on the exams-and for information processing,
such as elaborating or organizing information. Thus, the signiﬁcant increases in students’
mean scores on these two scales seemed to evidence a logical process.

However, there was no signiﬁcant change in students’ learning strategies between
time 2 and time 3. This nnight be interpreted to mean that students had already adjusted
their study strategies during their ﬁrst year and did not have to change their strategies any
more during the second year for the kind of assessment made. This was also shown in the
interview data, in that some students said their previous study habits inﬂuenced their use
of strategies the second year. Or this ﬁnding could be explained by the fact that the
LAS SI was developed mainly for undergaduate Students, who primarily attend large
lectures. Because medical students take large lectures during their ﬁrst year, the LASSI
could more properly represent the changes in their learning strategies, whereas the second
year is composed mainly of PBL classes, which LAS SI items do not represent well.

When I did the same analysis with the individual LAS SI items divided into PBL-
sensitive and PBL-nonsensitive scales, means on the PBL-nonsensitive scale decreased
signiﬁcantly whereas means on the PBL-sensitive scale did not change signiﬁcantly. No

time 2 data were included in the analysis because no individual item answers were

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available for time 2. Thus, the changes from time 1 to time 3 might have resulted mainly
from the changes ﬁom time 1 to time 2, as found using the LASSI scales.

I analyzed the PBL-related scale versus the PBL-unrelated scale using the original
LASSI scales; this was very similar to the individual item division. Five scales--
Motivation, Concentration, Time Management, Attitude, and Anxietyuwere coded as the
PBL-unrelated scale, whereas the remaining ﬁve scales—Information Processing,
Selecting Main Ideas, Self-Testing, Test Strategy, and Study Aids—were coded as the
PBL-related scale. The results showed that means on both scales improved between time 1
and time 2, whereas means on the PBL-unrelated scale decreased Signiﬁcantly from time 2
to time 3. This ﬁnding is consisternt with the results of the original analysis in that means
on most of the PBL-unrelated scales in the original analysis decreased signiﬁcantly. Thus,
the decreases in means on the PBL-unrelated scale when there was no change in means on
the PBL-related scale might indicate that PBL did something for the students’ learning
strategies or at least let the students keep the strategies they already had. Or it might just
be that, durirng the second year, students kept the learning Strategies they had developed
during their ﬁrst year of medical school in order to pass the exams.

The LASSI analysis showed signiﬁcant changes ﬁ'om time 1 to time 2, which was
during their ﬁrst year of medical school, rather than ﬁom time 2 to time 3, which was ﬁom
the ﬁrst year to the second year. This result was found whether I ran the analysis with the
LAS SI scale or with researcher-made scales—the PBL-related and PBL-unrelated scales.
This could be interpreted to mean that whereas students needed to adapt to a changed

learning environment their ﬁrst year of medical school (ﬁom their undergaduate

135

education to medical school), they did not have to change their learning strategies as much
during the second year as compared to the ﬁrst year.

Consistent with the interview ﬁndings, the LASSI analysis indicated that the
students’ strategies for information processing and selecting the main information
improved signiﬁcantly during their ﬁrst year. Students experiencing the ﬁrst year of
medical school may need to change their learning strategies to meet the demands of
medical school-a large volume of study materials with limited time. Thus, it is logical for
them to improve their strategies for selecting the rrnain information and for information
processing, such as elaborating and organizing information. However, although the
interview data indicated that students_modiﬁed their learning strategies to the changing
demands or conditions of the context during their second year, these changes seemed to
be less dramatic than those during their ﬁrst year, as shown in the LASSI results.

This could mean that although students were already accustomed to the general
medical school context, which required them to study a vast amount of material in a
limited time to pass the exams, they were less inﬂuenced by the curriculum changes in
using their learning strategies. This inference can also be drawn ﬁom the LASSI analysis
results-that both means on the PBL-related and PBL-unrelated scales increased during
the ﬁrst year, whereas means on both scales decreased during the second year, indicating

that the curriculum had relatively less eﬁ‘ect on students’ learnirng strategies.

136

Congusions

The overall question of this study was how second-year medical students adapted
their learning strategies to a curriculum that had changed ﬁom their ﬁrst year. The
following are the major ﬁndings of this study.

1. Exams drove studeng’ learning stratggy choice more than the curriculum did: I
found that Students did not prepare diﬁ‘erently or use different learning strategies for PBL
. classes and for exams. Rather, they used PBL classes as an arena in which to discuss exam
materials, and they prepared for classes in the process of studying for exams. Their use of
learning strategies reﬂected the eﬁ‘ect of the exams. For example, students matched their
learning issues with objectives that would be the focus of the exams and thus used the
PBL classes for studying exam-related issues. Also, students used many strategies for
selecting information that was likely on the exams, such as percentages of the exam
content, starred objectives, practice quizzes, and computer progams, which reﬂected the
exam maker’s views of important materials ratlner than what students themselves selected
through readirng.

2. ngands 9r congrg' '9ns of the cgntext $9 sgmﬂ t9 inﬂugngg mggng’ ghgicg 9f
lgrning mtggies: From this study, I found that exams drove students’ learning
strategies the most. However, demands or conditions of the instructional context also
aﬁ‘ected students’ choice of learning strategies. For example, time constraints and the
large amount of content they were required to study led students to use many strategies
for selecting the main information, as shown in both contextsulecture-based and problem-

based learning. Availability of starred objectives or computer progams in an instructional

137

context also inﬂuenced the strategies that students chose for selecting the main
information Further, exam type—multiple-choice exams in both contexts—also seemed to
play a role in students’ extensive use of strategies for selecting exam-like information
from the maker’s point of view. Availability of faculty-made objectives and
recommendation books, coupled with constraints of time, also seemed to explain students’
nonuse of library or self-selected materials.

Having prerequisite knowledge gained through the ﬁrst year of medical school
allowed students to use more strategies for integration and understanding than they used
during the ﬁrst year. The curriculum also combined with prior knowledge to inﬂuence
students’ choice of learning strategies. For example, the PBL format allowed students to
increase their communication skills tlnrough small-goup discussions of cases and learning
issues, and it also helped students integate materials by providing context to a problem.
Thus, students used more irnformal goup study in preparing for exams, which provided an
opportunity for them to activate their prior knowledge so it could be connected to new
krnowledge. Further, having existing knowledge, coupled with content overload and a
limited time to study, seemed to lead second-year students to use fewer memorization
strategies than they used their ﬁrst year.

Of course, students’ goals inﬂuenced their choice of learning strategies. Thus, the
overall pattern of students’ use of learning strategies in this study was geared toward
passing the exams, which was their immediate goal. However, their use of strategies
geared toward passing exams was made possible by other factors, such as availability of

resources and demands that are required in a certain context.

138

Figure 5.1 Shows various factors that inﬂuenced students’ use of learning

strategies found in this study.

 

Exam

    
  
 
 

  
   
 
 

 

 

Conditions of the Context ' Goals b

\ /

Choice of Learning Strategy

T

L Demands of the Context ‘

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5.1: Factors inﬂuencing students’ choice of learning strategies.
Note: a = ex: objectives, computer progams, recommended books, peers, commurnication
skills, class format, prerequisite knowledge

b = ex: passing exams, understanding materials
c = ex: time constraints, amount of content, exam type

3. Th; PBL gnrriculum hgg mixg mum in gchiging ig gggs: The four major goals

of PBL at MSU are (1) to provide a clirnical context for learning, (2) to encourage active
learning, (3) to provide a model of problem solving, and (4) to develop small-group skills.
From the interviews with students, I found that PBL classes provided a clinical context for

learning so that students could integate the materials easily. I also inferred from students’

139

reports that PBL encouraged active learning through discussing, questioning, and
evaluating problems with each other during PBL classes. The use of informal goup study
to prepare for exams also indicated students’ active learning. During the informal group
study, students discussed, questioned, and evaluated issues with each other as they did in
PBL classes. Further, students reported that PBL classes increased their small-goup
skills, such as how and when to talk and listen. These enhanced small-group skills may
have encouraged students to use informal goup study in preparing for exams their second
year. However, whether the PBL curriculum achieved its goal of providing a model of
problem solving, such as encouraging relevant problem-solving strategies through case
studies, was not evident from this study.

In general, students reported some positive aspects of the PBL curriculum that
they would use in the future and that would help them achieve ﬁxture goalsuunderstanding
the materials well enough that they apply what they learned in the clinical situation.

However, they did not think PBL was much help in achieving their immediate goal, which

was to pass the exams.
4. u did no a d man new t 'es he s nd r because of chan es in
e ° ' contex t rath r chan ed h am unt h u ertain

ﬁgtgig during the second ygr g; comngred to the first year: The study ﬁndings
suggested that second-year medical students studied somewhat diﬂ‘erently than they did

the ﬁrst year. However, their adaptation of learning strategies to the changed instructional
context was more a modiﬁcation of strategies they had used rather than a dramatic

change. The only learning strategy that students said they did not use their ﬁrst year was

140

computer proganns. Students said they used these faculty-made progams to select the
main information because the progams contained more concise information than did
textbooks. Other than using computer programs, students ampliﬁed their use of learning
strategies ﬁom their ﬁrst year. For example, students used strategies such as informal
goup study, integration, reading, selecting main information more the second year than
the ﬁrst year. On the other hand, they used fewer memorization strategies such as
mnemonics or ﬂashcards and relied less on lectures or lecture notes. Students also seemed

to keep the checking-knowledge strategies they used during their ﬁrst year but did not

increase their use of library facilities.
S.F m e I ' If n t dents han edth irlearnin strat °
more urin their f' th n urin their econd ear: The LASSI analysis

indicated that although students changed their learning strategies signiﬁcantly during their
ﬁrst year, they did not change those strategies signiﬁcantly during their second year. This
could mean that students who are entering a diﬁ‘erent instructional context in which large
amount of content must be learned in a limited time may need to adapt their learning
strategies more than they needed to change their learning strategies for a diﬂ‘erent

curriculum in medical school.

Implications
In this section, I present implications for theory and practice. I include
implications for general adaptation of learning strategy theory and PBL theory. In
implications for practice, I present implications that can be used by both medical educators

and general educational psychologists, including instructional designers.

141

Implicatigns fgr Thgg:

Recent studies have indicated that students’ approaches to learning are attributable
partly to their preferred learning style and partly to the context in which the learning takes
place (Newble & Entwistle, 1986). In this study, I found that medical students adapted
their learrning strategies to diﬁ‘ererlt educational contexts. Both the conditions that
students perceived in a context and the demands required of students inﬂuenced their
adaptation of learning strategies. For example, students’ prior krnowledge, the amount of
conternt required, time constraints, and resources available in a context all inﬂuenced
students’ choice of learning strategies. However, the most powerful inﬂuence on
students’ learning strategies was the “assessment.” Second-year medical students adapted
their learrning strategies so that they could pass the exams, which they must do in order to
move to the next step. The immediate goal that students had, in this case “passing
exams,” seemed to make students gear their learning strategies toward the exams. As
Merton and Saljo (1976) and Elton and Laurillard (1979) suggested, methods of
assessment appear to have a great eﬁ‘ect on students’ use of learnirng strategies. For
example, tests requiring only the recall of factual knowledge tend to induce a surface
approach, even in those who prefer a deep approach to studying. On the other hand,
anticipation that a test will require a geater degee of understanding encourages a deep
approach (Malton & Saljo, 1976b). One of the interviewees in this study spoke about the

eﬂ‘ect of the assessment type on her way of thinking, as follows:

142

IfeelthatI‘mlosingalotofmylogicalabilitiesbynothavingessaytestsandnotfeeling
thatI'mstudyingforanessaytest. Andevernthingsthatlreadnow, evenifit's
pleasurereadingorthenewspaper,ltend to readtlne samewayI study. I‘mpicking
outirnportantwordsinstead oftying everytlningtogetherinto anidea Ihavea
problem with that. My whole way of tlnirnking has changed with these multiple choice
exams. So I have a problem with not having essay exams. (Nancy)

Most other students, including children and undergaduate students, also realize
the importance of assessment because they need to pass exams in order to move to the
next step in their education. Thus, researchers studying learning strategies should
consider assessment as a powerful inﬂuence on students’ choice and adaptation of learning
strategies in diﬂ‘erent instructional contexts.

The study ﬁndings suggested that PBL curricula had some beneﬁts on students’
approaches to learrning. For example, students reported that the PBL experience allowed
them to improve their small-goup skills and that discussion in PBL class facilitated
irntegration and understanding of the materials by providing a context to a case. However,
this study suggested that researchers studying PBL should also consider the role exams
play in students’ approaches to studying. Although PBL structure, compared to lectures,
nnight be berneﬁcial to certain uses of desirable strategies, one should account for the
inﬂuence of assessment when considering PBL theory. Depending on the type of
assessment, the inﬂuences of PBL might change. Further, PBL might be beneﬁcial to
diﬂ‘ering degees, depending on the structure of the curriculum. Whatever the structure of
the PBL curriculum, the importance lies in the consistency among the method, outcomes,
and measure of outcome. This is true of any instructional theory.

The MSU PBL has a basically student-centered instructional format in the sense

that students, not faculty, raise learning issues and actively discuss a case, and preceptors

143

only guide and do not direct students’ class discussion. However, the evaluation format of
MSU PBL is faculty centered. As long as the evaluation remains faculty centered, the
students will do whatever they can to make the instruction format match what faculty
expect in the evaluation. For example, the medical students in this study used the classes
as a way of studying for exams, by matching objectives with learning issues. Thus, it is
importarnt to make the instruction (method), the goals or objectives of the instruction
(outcome), and the evaluation (measure of outcome) consistent when designing a course

or, more broadly, a curriculum.

li ' f r 'ce:

Students’ use of learrning strategies is a complex phenomenon that is inﬂuenced by
many factors such as prior knowledge, content amount, and time. However, as suggested
in this study, the most inﬂuential overall factor aﬁ'ecting students’ approaches to studying
seemed to be assessment. For example, students used PBL classes as an arena for
studying for exams. When the assessment is so important, considering the type and quality
of assessment is essential in facilitating students’ desirable approaches to studying.

MSU has a different student assessment method than do other PBL progams, in
that the main type of assessment is multiple-choice exams, as in a traditional curriculum.
Although multiple-choice exams can induce deep processing of inforrnatiorn, it is also true
that such exams allow students to guess the answers more easily. For instance, multiple
choice-exams might not reﬂect students’ knowledge as precisely as essay exams because

students can guess the answers. As Kelly stated,

144

I think that my test scores are not reﬂective of the information that I have. I think

my test scores are generally higher than the information that I have. There are a

lot of other people who think they know more than their test scores; I tlnink I know

less than my test scores. I’m one of those people who tests well, so when I guess,

I generally guess better than other people.

Further, second-year medical students in this study used various strategies for
selecting information that was likely to be on the exams, and they spent a great deal of
time studying “testable” components of the course, rather than focusing on practical and
clinical aspects. When the aim of medical school is to produce doctors with a wide range
of skills and a great deal of relevant knowledge so that they can apply their knowledge to
the ﬁeld, it is essential for the instructional progam to match closely the content of its
assessments to its educational objectives. Otherwise, the examinations might lead to a
mismatch between what students learn and what the school wants them to achieve.

For example, faculty intend to develop students’ problem-solving skills through the
PBL curriculum. Because the exams are the main thing for which students study, in order
to achieve these objectives, the exams should include questions that increase students’
problem-solving skills. The exams could include more questions that measure not only
the acquisition of knowledge but also students’ ability to apply that knowledge in problem
solving, such as asking the justiﬁcation or explanation of relevant underlying principles.
Further, take-home exams, open-book exams, goup projects, or brief oral interviews
would be alternative choices of assessment methods. Of course, the important thing with
the assessment is adequate feedback on performance rather than just an indication of

scores, allowing students to discuss answers and giving them the opportunity to review

each other’s performance.

145

This implication applies to general educational psychologists who are especially
interested in instructional design. When designing a curriculum, or more narrowly a
course, the designers should make the assessment compatible with the objectives and goals
of instruction so that the goals of instruction are what students want and need to study.
Further, it is important to consider students’ perceptions of instruction and what they
think is important when designing instruction rather than focusing on teachers’ point of
view. For children, who need a more direct guide from teachers as compared to
professional students, teachers’ role is even more important in inducing students to glean
the adequate knowledge that they are expected to learn.

From this study I also found that having previous knowledge helped students use
more strategies for integrating materials. Thus, having solid previous knowledge so that
studernts connect the new information more easily with what they had seemed important.
For example, having a solid curriculum for year 1, which includes more activities that
ensure students understand essential concepts and ideas, is important in medical school.
Further, for those students who are at risk academically, providing extra support such as
supplemerntal instruction, which erncourages students not only to use appropriate learning
strategies but also to learn basic science knowledge, seems very desirable so that students

can adapt their learrning strategies to a changed educational context more easily.

Rgggmmgndag'gns fgr Future Rggrch

This study concerned how second-year medical students adapted their use of
learrning strategies to a changed educational context. I explored students’ learrning

strategies under a PBL curriculum following their lectured-based curriculum the preceding

146

year. An important ﬁnding of this study was that students studied for exams no matter
what the curriculum was. Exams irnﬂuenced the most the way students studied and what
they studied. To see the eﬁ‘ect of assessment on students’ use of learrning strategies more
clearly, more research should be undertaken on students’ learning strategies and their
perceptions of the PBL curriculum in various medical schools that have adopted a PBL
curriculum, especially those schools that have different assessments ﬁom MSU CHM.
Comparing the results of that research with those ﬁom this study would give an indication
of how an individual school’s structure and the characteristics of its PBL curriculum aﬁ‘ect
students’ learning approaches.

This study showed how the same students who experienced large-lecture-format
instruction adapted their learrning strategies to a changed learning context- PBL.
However, if one is interested in seeing the effect of curriculum on students’ use of
learning strategies more objectively, research should be conducted with second-year
students in the College of Human Medicine, who are under the PBL curriculum, and those
in the College of Osteopathic Medicine, who are under the traditional curriculum. One
can ask research question such as “What is the eﬁ‘ect of curriculum on second-year
medical students’ use of learning strategies?” Because both groups share their ﬁrst-year
experience as a large-lectnrre—instruction format, one can assume that they have a similar
background regarding prior krnowledge learned through the ﬁrst year, and thus the effect
of curriculum can be seen more clearly.

Further, to verify the roles of PBL classes and the usefulness of PBL, which I

investigated based on students’ self-reports, further research should be conducted during

147

students’ clinical years, when they do not have the intense pressure of the basic science
and board exams. Such a study could be done with the same students who participated in
this study during their clinical years, with questions such as “How are your learning
strategies changed from those that you used under PBL?” “What roles does the PBL
curriculum play in your clinical years?” or “How has your perception of PBL changed, if
at all, as you experience your clinical years?” Also, a study can be conducted, comparing
students who experienced a PBL curriculum and those who did not during their preclinical
years, to see whether students who had the PBL experience develop more clinical-

reasoning skills and problem-solving ability during their clinical years.

APPENDICES

APPENDIX A

APPENDIX A
Consent Form

I agree to permit the results of the LASSI administered 2/6/95 to be used for
research on medical students' learning strategies in Problem Based Leamirng. I understand
that this research is being done by the Oﬁce of Academic Prog'ams in the College of
Human Medicine and Inkyung Lee, a gaduate student from the Department of
Counseling, Educational Psychology, and Special Education at Mchigan State University.

I understand that

1. My participation in this study is voluntary.

2. Data collected will be used for this learning strategy research and possible
publication.

3. All data collected will be kept conﬁdential and reported without individual
identiﬁcation.

4. I can choose not to answer any question or discontinue my participation in the
study at any time.

5. This research project has been approved by the University Committee on
Research Involving Human Subjects (UCRIHS).

Print Name
Signature Date

 

 

 

148

APPENDIX B

APPENDIX B
Interview Questions

1. Would you describe what you do during the PBL classes?
sub) Tell me what and how you do (such as activities, tests etc.)

* Do you prepare diﬂ‘erently for PBL classes and PBL exams?
“ What is the approximate ratio of your study time for exams and for PBL classes?

2. How do you prepare for your PBL classes ?
sub) How do you prepare for PBL class, can you describe or show me how?
Why do you prepare in that way?
How well do you think it works?
With whom do you prepare?
Where do you prepare?
When do you study?
Did you have Supplemental Instruction (SI) last year?
Ifyes, does it help you to prepare or adjust to PBL classes?

* Has the way you prepare changed ﬁom last year?

3. How did you study for a PBL exam you have taken recently?
sub) What was the speciﬁc content you had to learn?
How did you study; can you describe or show me how?
Why did you study in that way?
How well did it work that way?
With whom did you study?

149

150

What will you do for your next exam?
(For example, will you add, delete, change anything about your studying?)
Why will you make that change?

* How did your study for exams change ﬁom last year ?

Generally.
Are you satisﬁed with your approach why?
Do you use the same approach in all courses, why?
Do you use the same approach for all tests, why?
How do you intend to study for Board exam?

4. What is the biggest influence on the way you learn as a medical student? Why?
sub) What is your own goal in general?

What is your goal ﬁom PBL?

How does PBL help you to achieve your goal? (for your own understanding,
for passing the NBME, for passing exams)

How does PBL help you to prepare for exams (both class exams and board
exam)?

How does PBL make you feel?

* How has it changed ﬁ'om last year?
* How has the experience of PBL caused you to change the way you study?

5. What else do you think I should know that you think is important about your
approaches to studying?

APPENDIX C

APPENDIX C

Descriptions of LASSI Scales and Sample Items

The following information is quoted ﬁ'om the LASSI user ’5 manual (W einsteirn,

Palmer, & Schulte, 1987).
Anxiety

Current conceptions of anxiety emphasize the eﬁ'ects of our own thought
processes and how they aﬂ‘ect school performance. Items on this scale address the
degee to which students worry about their performance when conﬁ'onted with
academic tasks, such as exams. This scale shows whether students worry so much
that it is hard for them to concentrate, and whether they are easily discouraged
about grades.

Sample Items:
1. Worrying about doing poorly interferes with my concentration on tests.
2. I am very tense when I study.

We

Students' general attitudes toward school and their general motivation for
succeeding in school have a geat impact on their diligence in study, particularly in
autonomous situations in which they must study on their own. The items in this
scale contain students' perceptions of the role and relevance of college in their
lives. How clear are students about their own educational goals? Is school
important or worthwhile to them?

Sample Items:
1. I feel conﬁrsed and undecided as to what my educational goals should be.
2. I only study the subjects I like.

ncen 'n

Concentration helps students focus their attention on school-related activities, such
as studying and listening in class. Items on this scale address students' abilities to
concentrate and direct their attention to school and school-related tasks, including
study activities. Are they easily distracted? Can they direct their attention to
school tasks?

151

152

Sample Items:

1. I concentrate fully when studying.

2. I ﬁnd that during lectures I tlnink of other thirngs and don't really listen to what is
being said.

Informatign Processing

Meaningful learning is enhanced by the use of elaboration and organization
strategies. These strategies help to build bridges between what a students knows
and what he or she is trying to learn and remember. Items on this scale address
how well students can create imaginal and verbal elaborations and organizations to
foster understanding and recall. These methods range from Simple paraphrasing
and summarizing to creating analogies; using application; creating organizational
schemes and outlirning; and using inferential, analytical, and synthetic reasoning
skills.

Sample Items:
1. I translate what I am studying into my own words.

2. I try to think through a topic and decide what I am supposed to learn ﬁ'om it,
rather than just reading it over when studying.

M' tion

Whereas the attitude scale measures students' general attitudes toward school and
their general motivation for succeeding in school, the motivation scale addresses
students' motivation to perform the speciﬁc tasks related to achievement. The
items on this scale concern students' diligence, self-discipline, and willingness to

work hard. Do they stay up to date in class assignments? Do students easily lose
interest in their classes?

Sample Items:

1. When work is diﬁcult I either give up or study only the easy parts.
2. I set high standards for myselfin school.

SM’ng Main Ideas

Eﬂ'ective and eﬁcient studying requires that students be able to select the
important material for in-depth attention. Students' scores on this scale measure
their ability to select important information to concentrate on for ﬁrrther study in
either classroom lectures or autonomous learning situations.

153

Sample Items:

1. I have dimculty identifying the important points in my reading.

2. Often when studying I seem to get lost in details and can't remember the main
ideas.

Self-Tag g

Reviewing and testing one‘s level of understanding are important for acquiring
knowledge and monitoring comprehension. Items on this scale address students'
awareness of the importance of self-testing and reviewing, and the degee to which
they use these methods. Most of the items deal with some aspect of monitoring
comprehension. Do the students review before a test? Do they stop periodically
while readirng to review the content?

Sample Items:
1. I stop often while reading and think over what has been said.
2. I try to identify potential test questions when reviewing my class material.

sacrum:

Students need to know how to use study aids created by others and how to create
their own, such as making diagarns, marking the text, creating charts or summary
sheets, and underlining. There are other supplementary activities that also support
and enhance meaningful learrning. Items on this scale address the degee to which
students create or use support techniques or materials to help them learn and
remember new information.

Sample Items:

1. I use special Study helps, such as italics and headings, that are in my textbooks.
2. When they are available, I attend goup review sessions.

1mg

Eﬂ'ective test performance depends on both preparation strategies and test-taking
strategies. A student needs to krnow how to prepare for the type of performance

that will be required and how to maximize that performance. Items on this scale
address students' use of test-preparation and test-taking strategies.

Sample Items:

1. I have diﬁculty adapting my studying to diﬁ‘erent types of courses.

2. In taking tests, writing themes, etc., I ﬁnd I have misunderstood what is
wanted and lose poirnts because of it.

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Time Management

Managing time effectively is an important support strategy for learning. Most
students have various demands on their time, and only by creating realistic
schedules and sticking to them can they ﬁt in everything. Creating and using
schedules also encourage students to take more responsibility for their own

behavior. Items on this scale address the degee to which students create and use
schedules.

Sample Items:
1. I only study when there is the pressure of a test.
2. When I decide to study, I set aside a speciﬁc length of time and Stick with it.

APPENDIX D

APPENDIX D
An example of the PBL Process

The following information is quoted ﬁ'om Part I of the Preceptor Guideka for
the PBL groups (Alguire & Werner, 1992).

1. Initial Case Preserntation: It is prepared by the curriculum development goup. The
patient will be presented within a biopsychosocial context.

“Mrs. M.E., a 28 year old school teacher, presents to the ambulatory clinic during
one of your third year clerkslnips. She complains of a 2 year progressive diﬁculty
in ‘relaxing my gip,’ after shaking hands, or gasping anytlning tightly. This
problem has been a minor annoyance until the last 3 months, and its recent
progressive nature has worried her. She wants to be reassured that this problem is
nothing more serious than normal muscle cramps.”

2. Students as a goup will list “cues,” or important facts, that may be useful in learning
more about the case. “Cues” might be signs, symptoms, or signiﬁcant historical and
psychosocial data. The “cues” will be posted on the board by a member of the goup
for all students to review.

“28 year old female, school teacher, progessive problem relaxing gip over 2
years, problem recently progessive over last 3 months, worried, wants
reassurance.”

3. Students will be asked to list questions that the case raises. The questions may take
many forms but most often should be in the form of “what is the signiﬁcance,” or “what
is the relationship” or a request for more information. The question will be posted on
the board by a member of the goup for all students to review.

- Questions related to content
What is the signiﬁcance of the inability to loosen the hand gip?
What is the signiﬁcance of her sex?
What is the signiﬁcance of her occupation?
What is the signiﬁcance of the recent progession of the problem?
What is the signiﬁcance of her concern?

- Questions asking for additional irnforrnation about the patient
Is she on any medications?
What does her physical examination show?
Are there other members of her family with this problem?

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4. Students list hypotheses that might answer the posted questions. The form of the
hypotheses will be in terms of altered biological, biochemical, physiological, and
psychosocial mechanisms. The hypotheses should not be in the form of clinical
diagnoses, since the main learrning goals are biopsychosocial principles. The student-
generated hypotheses will be posted on the board by a member of the goup for all
students to review. The early hypotheses may be unsophisticated, but the eﬂ'ort of
thinking about the problem should be encouraged.

“She has a nerve problem.

She has a muscle problem.

She has muscle cramps due to overwork.

She cannot release her gip because she has arthritis.

The hand muscles lack suﬁcient energy substrate to relax.

She is anxious, and has a psychosomatic disorder.

Degeneration of the motor neurons of the spinal cord has produced
the patient’s symptoms.”

5. Students will receive ﬁom the preceptor additional information about the case. This
information will be used by the students to generate more questions, and to support or
reject the listed hypotheses. In this way, the students will begin to focus more directly
on the content to be covered in this case.

6. As suﬁcient facts accumulate, the preceptor will ask the students to create a summary
of the facts. Based on these sununarized facts, the original hypotheses can be reviewed
and altered, deleted, and new hypotheses added to the posting on board.

7. In the process of generating hypotheses, knowledge deﬁciencies will become apparent.
The process of identifying the knowledge deﬁciencies can be aided by the preceptor.
These krnowledge deﬁciencies, or LEARNING ISSUES, will be posted on the board by
a member of the goup for all students to review.

“How does muscle contract?

How does muscle relax?

What are muscle cramps?

What muscle diseases are inherited?

What does muscle use for energy?

What is necessary for proper impulse generation in nerves?”

8. To respond to the learning issues, potential learning strategies and resources are
discussed by the group. Learning strategies include, but are not limited to, lectures,
recitations, labs, faculty, texts, journals, and computer-assisted instruction. Learrning
strategies and resources suggested by the curriculum development goup are provided
to the PBL goup by the preceptor through the preceptor guidebook.

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9. Self—directed, independent learning is irnitiated by the students outside of the PBL
goup. The goal of the individual learning sessions is to respond to the learrning issues
identiﬁed by the goup.

10. Following the independent learning, the PBL goup convenes again. The case and
accumulated facts are reviewed. Based upon newly acquired knowledge, the
hypotheses are revised. The iterative process will be continued until the basic sciences
pertinent to the case are learned, the student-generated learrning issues are addressed,
or time runs out for the case.

11. By the end of the case, the students must review orally for the preceptor what was
learned by studying the case, and integate the new knowledge with learning ﬁ'om
previous cases and domains.

12. For the students’ interest and satisfaction, the preceptor may review how the patient
was actually managed and the patient’s progress or outcome.

APPENDIX E

APPENDIX E

PBL-Sensitive Scale Items Versus PBL-Nonsensitive Scale Items

* Corresponding LAS SI scales for each item is presented in the parenthesis:
ATT: Attitude
MOT: Motivation
TMT: Time Management
ANX: Anxiety
CON: Concentration
INP: Information Processing
SMI: Selecting Main Ideas
STA: Study Aids
SFT: Self Testing
TST: Test Strategies

PB . .
l. I use special study helps, such as italics and headings, that are in my textbook. (STA)

2. I try to think through a topic and decide what I am supposed to learn from it rather than
just read it over when studying. (INP)

3. I learn new words or ideas by visualizing a situation in which they occur. (INP)

4. When preparing for an exam, I create questions that I think might be included. (SFT)
5. My underlining is helpful when I review text material. (STA)

6. I try to identify potential test questions when reviewing my class material. (SFT)

7. I translate what I am studying into my own words. (INP)

8. I am unable to summarize what I have just heard in a lecture or read in a textbook.
(T ST)

9. I stop periodically while reading and mentally go over or review what was said. (SFT)
10. When I am studying a topic I try to make everything ﬁt together logically. (INP)
11. When I study, I have trouble ﬁguring out just what to do to learn the material. (T ST)

12. I try to ﬁnd relationships between what I am learning and what I already know. (INP)

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13. I key in on the ﬁrst and/or last sentences of most paragraphs when reading my text.
(STA)
14. I try to relate what I am studying to my own experiences. (INP)
15. I make drawings or sketches to help me understand what I am studying. (STA)
16. I make simple charts, diagrams, or tables to summarize material in my courses. (STA)
17. I read textbooks assigned for my classes. (MOT)
18. It is hard for me to decide what is important to underline in a text. (SMI)
19. I use the chapter headings as a guide to identify important points in my reading. (STA)

20. I memorize grammatical rules, technical terms, formulas, etc., without understanding
them. (T ST)

21. I test myselfto be sure I know the material I have been studying. (SFT)
22. I have diﬁculty adapting my studying to diﬁ‘erent types of courses. (T ST)

23. Oﬁen when studying I seem to get lost in details and “can’t see the forest for the
trees.” (SMI)

24. I try to interrelate themes in what I am studying. (INP)

25. I have diﬁculty identifying the important points in my reading. (SMI)

PBL-Nom' 've Sgge Items
1. I worry that I will ﬂunk out ofschool. (ANX)

2. I am able to distinguish between more important and less important information during
a lecture. (SMI)

3. I ﬁnd it hard to stick to a study schedule. (TMT)
4. After a class, I review my notes to help me understand the information. (SFT)
5. I don’t care if I ﬁnish school as long as I ﬁnd a husband/wife. (ATT)

6. I ﬁnd that during lectures I think of other things and don’t really listen to what is being
said. (CON)

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7. I try to identify the main points when I listen to lectures. (SMI)

8. I get discouraged because of low gades. (ANX)

9. I am up-to-date in my class assignments. (MOT)

10. Problems outside of school-being in love, ﬁnancial diﬁculties, conﬂict with parents,
etc-cause me to neglect my school work. (CON)

11. Even when study materials are dull and urninteresting, I manage to keep working until I
ﬁnish. (MOT)

12. I feel conﬁrsed and undecided as to what my educational goals should be. (ATT)
13. I come to class unprepared. (MOT)
14. I would rather not be in school. (ATT)

15. I do poorly on tests because I ﬁnd it hard to plan my work within a short period of
time. (T ST)

16. I only study when there is the pressure of a test. (TMT)

17. I compare class notes with other students to make sure my notes are complete. (STA)
18. I am very tense when I study. (ANX)

19. I review my notes before the next class. (SFT)

20. I work hard to get a good gade, even when I don’t like a course. (MOT)

21. I often feel like I have little control over what happens to me in school. (ATT)

22. Even when I am well prepared for a test, I feel very anxious. (ANX)

23. I talk myself into believing some excuse for not doing a study assignment. (MOT)
24. When I begin an examination, I feel pretty conﬁdent that I will do well. (ANX)

25. When it comes to studying, procrastination is a problem for me. (TMT)

26. I check to see if I understand what the instructor is saying during the lecture. (SFT)

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27. I do not care about getting a general education, Ijust want to get a good job. (ATT)
28. I am unable to concentrate well because of restlessness or moodiness. (CON)

29. I set high standards for myselfin school. (MOT)

30. I end up “cramming” for almost every test. (TMT)

31. I ﬁnd it hard to pay attention during lectures. (CON)

32. I only Study the subjects I like. (ATT)

33. I am distracted ﬁ'om my studies very easily. (CON)

34. I make good use of daytime study hours between clames. (TMT)

35. When work is diﬁcult I either give up or study only the easy parts. (MOT)

36. I disﬁke most of the work in my classes. (ATT)

37. I have trouble understanding just what a test question is asking. (T ST)

38. Worrying about doing poorly interferes with my concentration on tests. (ANX)
39. I don’t understand some course material because I don’t listen carefully. (CON)
40. I feel very panicky when I take an important test. (ANX)

41. When I decide to study, I set aside a speciﬁc lerngth of time and stick to it. (TMT)
42. When I take a test, I realize I have studied the wrong material. (TST)

43. I concentrate fully when studying. (CON)

44. I get so nervous and confused when taking an examination that I fail to answer
questions to the best of my ability. (ANX)

45. I put oﬁ‘ studying more than I should. (TMT)
46. I try to see how what I am studying would apply to my everyday living. (INP)
47. My mind wanders a lot when I Study. (CON)

48. In my opirniorn, what is taught in my courses is not worth learrning. (ATT)

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49. I go over homework assignments when reviewing class materials. (SFT)
50. When they are available, I attend goup review sessions. (STA)
51. I tend to spend so much time with ﬁiends that my coursework suﬂ‘ers. (TMT)

52. In taking tests, writing themes, etc, I ﬁnd I have misunderstood what is wanted and
lose points because of it. (TST)

APPENDIX F

APPENDIX F
Case Descriptions by Research Questions

M

Research Quem’gn 1: What learning strategies do students use in
preparation for the problem-based learning classroom and why?

Mark spent most of his time on preparing for the exams. He mentioned that the
ratio of his study time for PBL class and exam was about 20.30 % to 70-80%. To explain
this, he commented, “So I spend just a couple . . . I’d say two or three hours per case.
Most of my time is spent going through the content areas for the exams.”

DEL—“8M3 Mark’s PBL goup read a case, ﬁnding cues, and formulating
hypotheses. Then, they raised learning issues and solved stimulus questions. Mark tried
to ﬁnd cues ﬁom important information, such as age, symptoms, and psychosocial and
medical issues. For PBL preparation, he tried to pull out some of the big things in order
to get the whole picture and the general overview.

W: To study learrning issues, he usually looked for reference
texts and articles that were provided in the class. He sometimes went to the learning
resource center and used computer progams to study learning issues. However, he did
not use library.

Like other students, Mark tried to match learrning issues with objectives. For
example, if a case had a patient with breast cancer, the learning issue might be looking at

how the patient got this disease. He compared this learning issue to the objective list, and

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if it was on the content list, he studied all information and tried to memorize it. If it was
not on the objective lists, he did not study or may just have read once if he had time.

W2: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

Mg: Mark had read coursepack, old objectives, and books more than once the
second year. The ﬁrst time, he read tlnrough the material to get the general idea and
highlighted information. The second time, he read the highlighted passages and made
marginal notes in the book.

Maggy: After independent study, Mark met with two other ﬁiends a few
days before an exam. When they met, each person read the coursepacks and mentioned
the most important things. The others chimed in if a person forgot to mention important
irnforrnation. At the end of the goup study, they summarized the important information.
Group study gave Mark an opportunity to check his knowledge. Also, it made him
connect information.

W: Mark mentioned that understanding is to know the structure
and to know how things work. It is knowing why something is important, how each
discipline is tied in with others. On the other hand, rote memorization is learrning
something without tying it to anything. He thought that integation helps memorization
because it gives something on which to hang information. Basically, Mark read materials
carefully in order to understand them. Also, Mark mentioned that goup study helped him

connect the materials, as illustrated by his comment:

165

Because I like to really be verbal and to be able to walk round and write on the
board and stuﬁ‘. It [goup study] really just helps me facilitate things and start

putting things together.

Memorizatign wages: Mark mentioned that he did not use speciﬁc learning
strategies because that took extra work. Rather, being exposed to the materials several
times gave him a repetition that made him memorize the materials, as evidenced in the
following comment:

I don’t like doing all that extra work like making charts or making ﬂash cards, so I

just try to read. I do a lot of reading and that, you know, reading objectives,

reading books, you know, three and four diﬂ‘erent times, and that’s what works for
me.

W: Mark used an objective list as a guide for his study.
However, he did not pay attention to the starred objectives. Rather, he focused on the
percentage content of the test. For example, if pathology had a 45% weight in the exarrn,
he emphasized study in this are. Sometimes lectures and computer programs helped him
know what important information was. Also, through goup study, Mark and the other
goup members told each other important information and corrected each other if
someone was missing important points.

W: Mark used computer progams because they were more
condensed and concise than textbook and thus provided main information. He mentioned
that it was like having a coursepack along with pictures. Computer progams stimulated
him because they involved more activity, such as playing around with the mouse.

W: Mark used group study as a way of checking his
knowledge. Group members told each other what they studied and corrected each other if

some information was missing or wrong.

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Mg gtendance: Mark went to about half of the lectures. He mentioned that if
the professor was good, it helped him pass the exam He listened to the lectures but did
not take notes. The lectures introduced him to the materials and indicated what he should
emphasize in his studying.

Wm: When Mark read the materials, he highlighted characteristics
of a speciﬁc disease because doing that helped him to distinguish certain things ﬁ'om
others.

W: Mark mentioned that he planned to take a board review course
to prepare for the board exam.

Wagon—3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Mark mentioned that his goals, which were to be a competent doctor and to
understand the material, inﬂuenced the way he studied. From PBL, he liked to get clinical
aspects and a good interaction with people. He thought that PBL helped to achieve his
goals and forced him to work as part of a goup. However, he thought that to prepare for
exams, personal study and goup study helped more than PBL. Generally, he liked the
PBL format better than lectures because it helped him integate the materials, but
sometimes he felt lost when there was little direction ﬁom the preceptors. However,
Mark mentioned that PBL classes helped in the following ways:

1. Smil-grgup wgrking skills: Through the experience of the PBL classes, Mark

became more patient because it was not a “personal business.”

167

2. Independent Study: Mark always carried a dictionary to look up words for
clariﬁcation. Also, PBL classes forced him to ﬁnd additional resources on his own. He
mentioned that “ It [PBL] forces you to go out and look material up instead of a professor
just giving you scribes.”

3. Integatgn' g materials: Mark said that cases helped him integate the materials.
Further, by giving a big picture with a clinical context, the cases helped him understand the
materials.

It just puts everything together. Like it goes through each disease, and it’ll give

you in stepwise fashion these are the symptoms, these are the clinical signs, this is

how you diagnose it, this is how you treat it. So it gives you the big picture of
how all these diﬂ‘erent tlnings ﬁt together.

W: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

During his ﬁrst year of medical school, Mark did not read books much and used
them only for clariﬁcation purposes. He relied primarily on lectures and scribe notes.
Second year, he put no geat emphasis on lecture and scribe notes, but spent most of his
time reading objectives and textbooks. Also, he spent less time on memorization the
second year than the ﬁrst year. Thus, he used fewer memorization strategies such as
ﬂashcards and mnemonics, because they required extra work. Mark focused more on
integation of materials so that all “things fall into place.” He also thought he needed
more study time the second year because of the vast volume of materials he was required

to cover.

Table F .1 contains a summary of the key features about Mark’s learning strategies.

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Table F. 1: Key features of Mark’s learning strategies

 

Q1

- PBL preparation : exarrns = 20-30 % : 70-80% study time

- Matching learning issues with objectives

- Using reference texts, articles, learning resource center, computers, and no use of
library for learning issue study

 

Q2

- Reading more than once:
1: Get a general idea, highlight
2: Read highlighted passages, make marginal notes

- Group study: check his knowledge, help integration

- Integation strategies: read careﬁrlly for understanding, goup study

- Memorization strategies: several readings - give repetition, do not use much

- Selecting main information: percentages of exam contents, lectures, goup study,
and computer progams

- Computer progams: more concise than textbooks, stimulating - more active

- Checking knowledge strategies: goup study

- Lecture attendance: gives introduction to materials and what to emphasize

- Additional strategies: organize materials by lnighlighting characteristics of things

 

Q3

- Inﬂuences: his goals
- Goals: being a competent doctor and understanding materials
- PBL helps

1. Small-goup working skills

2. Independent study

3. Integation of the materials

 

 

 

- More reading and integation the second year

- Less emphasis on lectures and scribe notes the second year

- Fewer memorization strategies the second year; takes extra time
- More study time the second year: vast volume to study

 

 

.‘_

169

Tom

W: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Tom said he did not prepare for PBL classes separately from the exams because
there was no time, as illustrated by his comment, “I don’t really prepare that much for the
PBL classes. I don’t really prepare, read ahead for the PBL class at all just because I
don’t have time.” Torn studied mostly for exams, and studying for exams helped him
prepare for the classes.

W3 Tom’s PBL goup read a case, looking for cues. He found cues that
were abnormal or were based on his previous krnowledge. Then, the group developed
hypotheses and diagnosed them, based on their previous knowledge, and raised learning
issues.

mm: Tom mentioned that sometimes the preceptor directed
students in fornning learning issues. Tom looked for learning issues if he had time. Usually
he used reference books, textbooks, and computer programs. He said that by using
computer progams it was easy to ﬁnd irnforrnation. Tom did not go to the library to ﬁnd
learning issues, but he sometimes went to the learning resource center for medical texts.
He knew which texts to look for by talking to classmates or by consulting the list of
recommended texts.

Tom matched learning issues with objective lists. If learning issues did not match
the objectives, he did not study them because there was no time. PBL classes helped him

achieve the objectives because the learning issues usually coincided with the objectives.

170

Thus, by discussing learning issues, students could cover the objectives or at least they
could have an introduction to the materials.
Rugmh Questign 2: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Mg: Tom said that his general way of studying was reading materials. He
read the coursepack ﬁrst highlighting what was important. Then he read the textbook,
looking for what was in the coursepack, because textbook usually explained the same
information better and more completely. Also, doing this gave him repetition. While
reading, if he found something that was not in the coursepack but in the textbook, he
wrote it down in the coursepack. For example, if an objective said to know four
orgarnisnns that cause strap throat and the coursepack listed three causes of strap throat, he
found the fourth cause ﬁ'om the textbook and wrote it in the coursepack. Tom then reread
the coursepack with the information he added in the margins. He said that rereading the
same information helped in memorization.

W: Tom met with two ﬁiends for group study. They talked and quizzed
each other. They started with the ﬁrst page of the coursepack and discussed it. They
took turns talking and listening because they thought talking helped them associate better
and remember longer. Each goup member studied alone ﬁrst because in that way they
could go over the material faster when they met as a goup. They met several times and
went through the coursepack a couple of times. Tom mentioned that his gades had gone

up since he had started Studying with the goup. Group study gave him a chance to hear

171

something explained diﬁ‘erently, which helped him understand better. He thought this was
a good way to study conceptual materials.

Integraﬁgn Meg’es (mnc_eptualization): Tom said that discussing conceptual
materials in a goup helped him understand the material because by hearing somebody else
explain it, he could see the same concept ﬁom a diﬁ‘erent perspective. Tom said he
studied more by himself if the material was factual. He also read the textbook to
understand the material.

Memgrizing strategies: Tom wrote important facts ill the margins while he read the
material to help him memorize better. However, he explained that he did not use many
memorization strategies, such as mnemonics, because he integated the materials more,
and integration helped his memorization.

MW: Tom focused on the objectives in his studying, “Yeah,
I stick to the objectives, because tlnat’s what’s going to be on the exam.” He knew which
were the important objectives by the number of stars on the objectives. More stars
signiﬁed more important objectives. Sometimes Tom sorted out important information
through his “gut feeling” and found the testable questions. For example, Tom mentioned
that, “Does this predispose to cancer?” was a likely testable question; thus, when he
studied, he focused on statements such as “This predisposes you to an adenoma,
carcinoma, etc.” Also, percentages of exam topics determined his focuses. Torn studied
large-percentage topics ﬁrst to make sure he got through them. He also used practice
quizzes as a way of selecting information because they included what teachers thought

important for the test.

‘-

172

ngputer prom: Tom thought that computer programs were not very different
from the textbook, but he used those progams because they provided repetition. He read
the textbook ﬁrst and then used computer progams. He thought that computer pictures
were better than those in the textbook because the screen was large, colorful, and
sometimes showed different pictures than the textbook did.

WW: Tom studied for the exams with two ﬁiends.
They quizzed each other during goup study, which gave him a chance to check his
knowledge.

W: Tom attended the lectures because professors indicated which
information was important; this gave him a study focus. Sometimes professors used
pictures and slides, and Tom associated those with pictures in the textbook and the
coursepack when studying. Also, professors sometimes explained things diﬂ‘erently from
the coursepack, which made him understand the materials easily. However, he mentioned
that the quality of the lectures depended on the professors.

W: When Tom read the materials and wrote down notes, he
used diﬁ‘erent colors of ink to indicate different sources so that he could remember where
he got the information.

Bgard prgpamtion: Tom said he planned to take a board review course to prepare
for the board exams. Although he had already bought board review books, he had hardly

used them yet.

173

Mg: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

To Torn, doing well on the exams was his main goal, and this inﬂuenced his way of
studying the most. He perceived PBL as another way of having someone explain things to
him, and he said that PBL helped him conceptually. Torn tried to pick information ﬁ'om
PBL classes to prepare for exams, as evidenced in his comment, “I need to tailor my
information toward what it takes for me to get through the exams as much as what I’m
interested in or what I think is important.”

In general, Tom liked the PBL format better than lectures because PBL was more
interactive. He also said, “I learn more in an hour of PBL than I do in an hour of lecture.”

Tom mentioned that PBL classes helped in the following ways:

1. WM: Tom had to be sensitive to goup dynamics and to
know when to speak or listen in PBL classes.

2. Lagging materials: Tom said that PBL classes helped him integate various
disciplines through discussion and helped him understand the concepts. “1 would have to
say that PBL helps me more conceptually than it does factually,” he remarked.

March Qgestjgn 4: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

Tom mentioned that he had not prepared for the lectures and studied what was
emphasized in lectures for the tests the ﬁrst year. The second year, he focused more on

integration of the materials. Also, he was more organized, did more reading, and used

more textbooks the second year. Whereas he tried to learn everything the ﬁrst year, he

174

focused more on exams and hence used objectives more for selecting main information the
second year, as shown in the following comment:

I tlnink I’m learning a lot more of what is on the exam. Last year I tried to learn
everything, whereas this year I’m just learning more of what I see on the exams.

Tom also mentioned that he used fewer memorization strategies the second year because
he had previous knowledge, which gave him a context to help him memorize better.
A summary of the key features gathered from the interviews with Tom is presented

in Table F.2.

 

175

Table F .2: Key features of Tom’s learning strategies

 

Q1

- Studying mostly for exams and not for PBL classes: because of lack of time

- Matching learning issues with objectives

- Using reference books, textbooks, computer, sometimes learning resource center,
and no use of library for learning issue study

 

Q2

- Reading:
1: Read coursepack with highlighting
2: Read textbook, adding information in coursepack
3: Read coursepack with added information in the margins
- Group study: talking, listening, and quizzing each other
- Integation strategies (understanding): goup study, reading
- Memorization strategies: writing down important facts, goup study
- Selecting main information: objectives, stars ill the objectives, gut feeling (testable
question), lectures, percentage of exam contents, and practice quizzes
- Computer progams: give repetition, better picture
- Checking knowledge strategies: goup study - quiz each other
- Lecture attendance: selecting main information, easier understanding
- Additional strategies: organize materials using diﬁ‘erent colors and sources

 

Q3

- Inﬂuences: doing well on exams
- Goals: doing well on exams
- PBL helps

1. Small-goup working sldlls

2. Irntegation of information

 

 

 

- More reading, more textbook use the second year

- More organized the second year

- Focuses more on exams the second year: use objectives more for selecting main
information

- Fewer memorization strategies and more integation the second year: because of
previous knowledge

 

 

176

It is important to mention that Ann had extended her progann, so she was taking
just some of the PBL classes. She said she had extended her progam for her personal
reasons and also for the philosophical evaluation of herself.

W: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

Ann said she studied for the exams and not for PBL class per se. She stated, “Very
smallforthePBLclass, mostlyforthetest AndthatberneﬁtsPBL, bnrtit'snot forthePB .”
Because there was so much material to learn with limited time the second year, She
focused on studying objectives rather than doing research for the PBL classes to survive.
Ann estimated that the approximate ratio of study time for PBL classes and exams might

be 1:50. She stated,

Idon‘treallystudyspeciﬁcallyforgoup. BecausePBLgoupdoesn‘treallygetyou
readyforthetestandifyoufocustoomuchenergyonthePBLgoupyou‘renot

going to be ready for the test.

W: Ann’s PBL goup read a case, ﬁnding clues. Her goup sorted out
important clues by discussion. Then she formulated hypotheses based on her basic science
knowledge and to be conguent with other hypotheses. Before the class ended, the goup
raised learning issues, trying “psyche out” teachers to see which objectives they wanted
students to learn. “ We try to psyche out the teachers and sort of say, ‘Given this case, which
oftheobjectives doyouthinktheyweretryingto get usto leamfromtlnis case.”’ Also, she
raisedlearningissuesifitwasanodd symptom, and alsobasedonpercerntage oftheexarn

corrternt.

177

W: Ann said she usually did not study the learning issues
because they got her “distracted ﬁ'om my basic mode of studying.” Usually she did not
study than because others would look them up. However, if a learning issue was
interesting and easy to ﬁnd, she sometimes she studied it, although she never went to the
library to ﬁnd information for learning issues.

Ann contributed to the goup when learning issues matched the objectives because
she studied the objectives. She raised a learning issue, and then narrowed it, based on the
objective. Ifleaming issues and objectives did not match, she did not study them. Ann
stated,

Wetryto stayprettyfocusedasfarasﬁyingtohrcorporateﬂneobjecﬁvesﬂnatwe‘re

givenforwhat'sgoingtobeontheexam. Wetryto keep ourdiscussionfocused

arourndthat, eventhoughwe'redisarssingthiscase. Wetrytolearnthingsﬁomthe
casetlnatwillalso answerquestions forourleaming objectivesforus. Becausethe
learningobjectivesiswhatwegettestedon.

Ann found condernsed information from pictures and from ﬂowcharts in the books
or coursepacks, and made charts, diagrams, or summaries. Then, in class, she wrote them
on the board to “impress” the goup, and to get “brownie points.” She found the
irnformation and made those charts in the process of studying for exams.
W2: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Reading: Ann’s basic study sequence was ﬁrst reading old objectives, reading the
coursepack, reading scribe notes, doing the computer progam, and then reading board
review books. In this way, she could get the same materials ﬁ'om different angles. She

usually did not read textbooks because reading coursepack and objectives was a more

178

condensed approach in a limited time; also, she tried to read them twice. She said that
when she read things a second time, she could go faster because she comprehended better
and had an overall ﬁ'amework.

mum: Ann met with other students before the exams, and they went
through the objectives together. This helped when she was too tired to study. She said
that group study worked well only when she already knew the material. During group
study, people who knew more usually led the discussion and asked questions.

W: Ann mentioned that she knew integration had been achieved
ifshe could see the similarities between things and ﬁnd a pattern. To ﬁnd patterns and
similarities, she often made charts and reviewed them just before the exam. Sometimes
Ann used another person’s charts ﬁ'om the previous year, which had a summary and the
association of information.

W: Ann used fewer memorization strategies than she did her
ﬁrstyearbecause shethoughtthatmemorizingoneparﬁcxdarﬂringwasawasteofenergy.
She tried to immerse herselfin a large volume ofmaterials instead. She also wrote down notes
for easier memorization, as illustrated by this statement:

Likeadnrgthatis, it'shardformetoremernberdmgnames, soI'llwriteitdownsoI

canrernernberit. Oriftherearetwodiseasesthatareverysimilarandlwantto
diﬂ‘erenﬁatetlml‘llmitedown one ortwo words. Idon‘twritedown biglistsor

anything, butjustifit'ssomethingthatlcantellit'sgoingtobeanitpickythingthatl

needtolarowandltlrinklnriglrtforgetl'llwriteitdown.

Selecting main information: Ann chose the important materials based on the
percentage of the exam content and studied those with the highest content ﬁrst. Among

those materials, she tried to focus on more common and higher ﬁ'equency diseases because

179

that knowledge would also be more beneﬁcial in practice. Also, she used practice quizzes
to focus on the important information. Sometimes computer programs helped her focus
on important information because they were more concise than textbooks. Ann also
mentioned that highlighting was a way of sorting out the important information to study,
as illustrated by her statement:

Even if I never go back and read it, it [highlighting] really helps me to mentally

highlight what’s important. To mentally go back and have to be able to ﬁgure out

what to highlight makes me think about it.

W: Ann mentioned that computer programs are more concise,
contain more and bigger pictures, and explain materials better than textbooks. Therefore,
she did not read textbooks, which were too wordy for her, but used computer programs as
a way of saving time and selecting information to study.

WW: Ann did practice questions to check her
knowledge. She also asked questions during group study to check her knowledge.

mm: Ann did not go to lectures at all, as she pointed out in the
following comment:

Idon'tgoto lecture. It'sawasteoftime. I'maslowreader, butlcanstillreadascribe

fasterthanlcanlistentothemlecture. Itdoesn‘ttakemeanhour, usually, toreada

scribe.

MW: Ann said she sometimes used other people’s objectives
because by studying other people’s summary objectives with answers, she could limit
what she studied ﬁ'om each objective. Another notable thing that Ann mentioned was that

her motivation had changed ﬁ'om the ﬁrst to the second year. She studied to escape from

180

marriage and to prove herself to her parents the ﬁrst year. But during her second year,
Ann studied for herself and thus had an inner motivation to earn the degree.

Board pmaration: Ann said that she planned to take the board review course to
prepare for the board exam.

Research Quﬂ'on 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Ann said she was a slow reader and did not like to do more work than she had to,
which inﬂuenced her way of studying. Her primary goal was to pass the exams, but she
also wanted to comprehend the material to pass the boards. From the PBL classes, she
liked to get connection with other students, friendship, and the contexts of diseases. Also,
Ann liked to have good preceptors whom she could look to as mentors.

In general, Ann perceived a big discrepancy between PBL classes and exams. She
enjoyed the PBL experience, but she did not think it helped in passing exams. She
preferred lectures to the PBL format because lectures gave her a focus to study, especially
when there was a large volume of materials to study. Ann said that although PBL tried to
make students togooutanddoresearch, shecouldnotdothisbecausetherewastoo much
materialtostudyinalimitedtirne, asillustratedbythisstatement:

As far as doing some extracurricular independent research, no, because we don‘t have
time. It's like drinking water from a ﬁre hydrant. It would be nice to go wade in the

creek but you'rejust trying to survive.
However, Ann said that PBL classes did help her in the following ways:

181

1. SM-grgup working skills: She had to listen and talk in response to group
dynamics.

2. Providrn' g context: PBL classes gave practical implications of trying to manage
the case, given the typical resources that will be available to you in the hospital.

3. ngm' g with other ﬁdents: The PBL experience had provided her with
ﬁiendships.

Rgearch Qgestign 4: Do second-year medical students at MSU CHM report

that they study differently than they did in their ﬁrst year?

If so, how and why?

Ann did not go to the lectures at all the second year, as she had the ﬁrst year.
Also, she said she used fewer memorization strategies the second year because of the vast
volume of material to study; so memorizing the speciﬁcs wasted her energy. Ann tried to
immerse herselfin as much material as possible and thus tried to read more the second
year than the ﬁrst year.

Ann said she felt lost the second year because of the large volume of material and
lack of precise guidelines in PBL classes. According to her, the second year was like
“guess work.” She was more anxious the second year so she tried to participate in some
totally nonschool activities as a survival strategy. In her ﬁrst year, her goal was to do well
on exams, and by studying scribe notes she achieved that goal on tests. But the second
year, her goal was to survive and to expose herself to the large volume of materials. She
mentioned, “Last year was much more emotionally fulﬁlling and aﬁrming. This year there's
practically none of that, and it's ﬁustrating.”

Table F .3. contains a summary of the key features of Ann’s learning strategies.

182

Table F.3: Key features of Ann’s learning strategies

 

Q1

- Extending program: personal, philosophical re—evaluation of herself

- Studying for exams basically, not for PBL: lack of time

- Raising learning issues: psyche out teachers to see what they think important,
based on percentage of exam content, odd symptoms

- Matching learning issues with objectives

- Learning issue study: in the process of studying for exams

 

Q2

- Reading twice: does not read textbook
1: Get overall ﬁ'amework,
2: Read faster and comprehend better
Reading sequence: old objective - coursepack - scribe notes - computer
programs - board review book; gives same materials with diﬂ'erent angles,
- Group study: makes her keep studying, ask questions (check knowledge)
- Integration strategies: makes charts or gets another person’s charts
- Memorization strategies: writing down
- Selecting main information: percentage of exam content, common and high-
ﬁequency diseases, practice questions, highlighting, and computer programs
— Computer programs: more concise, better explained, good picture
- Checking knowledge strategies: practice questions and group study
- No lecture attendance
- Additional strategies: limit study scope, motivation change

 

Q3

- Inﬂuences : slow reader - old study habits
- Goals : 1: passing exams, 2: comprehension
- PBL helps

1. Small-group working skills

2. Give context

3. Friendship

 

 

 

- Fewer memorization strategies and more reading the second year

- Feels lost, more anxious the second year: large volume of materials, lack of
precise guidelines in PBL classes

- First year: studying scribe notes - good scores on exams

 

 

183

M

Research Qgestion 1: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Mary said she tried to relate PBL preparation to preparation for exam. She said
the emphasis changed throughout the domain period. That is, a domain consisted of a
three week periods; during the ﬁrst week, she focused more on PBL cases, and later she
focused more on exams. On the average, however, she focused more on exams.

Elli—HEM: Mary mentioned that her PBL group was not very structured. They
read a case and formed hypotheses, and then raised learning issues in line with the
objectives. For example, if a case was about a man who took a lot of aspirin and thus had
stomach problems, the learning issue might be “know the normal GI track.” Then, she
went over the objective lists during class to match the learning issues. Mary’s PBL group
did not discuss learning issues that were not on the objective list even though they had a
clinical value, as illustrated by her statement:

Wealsotrytokeep ourlearningissuesinlinewiththeobjectiveslist. So ifthere's

sornethingthat'snotdirectlypertainingtotheobjectiveslist,thatmaybemoreclinical,
thatwedon‘trreedtolnrowfortlieexamwe'llusuallyaxit.

W: To ﬁnd learning issues, Mary read books and then took notes
to recount to the class. In this way, she could understand and retain the material better.
She used books ﬁ'om her own library, usually her ﬁrst-year textbooks. Sometimes she
read the coursepack and pertinent articles. She mentioned,

Well, generally I take a learning issue and open up a book and just start reading.

And then often I take notes because I want to be able to tell my classmates back at
PBL.

184

PBL classes helped Mary achieve her objectives in two ways. First, they covered
the objectives through discussion of learning issues during the class. Second, they kept
her going and kept her up to date with her studying.

W: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Mg: Mary read the objectives, books, and coursepacks, making charts as she
did so. Then she memorized the information in those charts before the exams. When she
read, she underlined important things and writes them down in the margins. She tries to
relate important details to other information while reading.

mm: Mary studied with one other student one or two days before an
exam; they talked about exam materials together. For example, they might ask “Tell me
all of the cancers that are in the thyroid” and then discuss the answer. Group study helped
Mary conceptualize the materials because talking with a ﬁiend helped her see several
reasons why a certain system worked the way it did. Also, talking with a friend conﬁrmed
her own knowledge.

W: Mary ﬁequently made charts the second year. After making
charts or frameworks from the objectives, she would use textbook information to ﬁll them
in. She would construct a chart and picture it in her mind, trying to integrate the
materials. Doing this also helped her memorization. Also, talking with people in group
study helped her understand conceptual materials.

W: To memorize facts, Mary read the textbook and made a

ﬁ’amework, and then associated two or three examples or facts with each frame. Then she

185

memorized the facts that ﬁlled up the charts. Making charts helped her memorize the
material because charts imposed organization and helped associate information.

Seloom' g m' information: Mary looked for stars in the objective lists to see
which were more important materials to study. Sometimes she gleaned important
information ﬁom lectures, especially when the lecturer was the one who wrote the test
questions. She also used percentages of exam content to select the important information
and did not study materials that constituted a low percentage of the exams. Mary also
underlined, starred, and circled the important things in the textbooks and charts,
highlighting information in the charts that was important medically.

W: Doing computer programs enabled Mary to see what
professors thought was important because the same ones who wrote the test questions
devised the computer programs. Also, test questions in the computer programs helped
her. Computer programs had more pictures than textbooks and provided a change when
she was tired of reading. Mary thought that doing computer programs was a more passive
way of studying than reading textbooks and making charts because she could let the
computer teach her.

Checking knowledge mes: Mary’s study group asked each other questions. This
conﬁrmed her knowledge.

We attondance: Mary attended lectures because she paid for them. Even
though she did not like this teaching style, she could still get information because the

teachers were experts in the ﬁeld.

.i‘

186

W: Mary thought that choosing resources was important this

year because so many resources dealt with the same information.
OneofthebiggestproblemslfoundwithPBListhatthere‘s sornuchto knowand
there'ssomanydiﬁ‘erentresources, you couldﬁndthesameinformationinabillion
things, diﬂ'erentbooks. Soit'sreallyirnportanttopickyourresourcesand stickwith
ﬁlernbecauseoﬂlerwiseyougetoverwhelmed. Andwealreadyhavesomanybooks
ﬁom ﬁrst year, basic physiology and pharmacology and microbiology, we already have.
You've got all the answers already pretty much

W: Mary said she planned to take a board preparation program.
She believed that studying for exams would help her with the board exams.

Reschh Qoﬂ'on 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Mary said she had spent a year in England, and that had inﬂuenced the way she
studied. In England, she had experienced a tutorial—based, one-on-one teaching
environment. Thus, she liked PBL curriculum because it was an active learning
experience; that is why she came to MSU.

Mary said goal was to pass the board and class exams, and to know the materials.
She thought PBL classes helped more in understanding the materials than in passing class
and board exams. She said the experience in PBL was very valuable because it related the
material to patients and gave a context for the material. However, she also felt pressured

by PBL because she had to attend sessions three times a week. But Mary did say it was

ﬁm, and sometimes she could get information from the group.

187

According to Mary, PBL classes helped in the following ways:

1. SM-grouo working skills: Mary mentioned that because her PBL class was
composed of just a few people, she had to watch the dynamics of the group.

2. W: In PBL, Mary had to generate her own questions, and
sometimes she felt scared because she did not know what was supposed to have learned.

3. Mon : Mary said that PBL helped her do well on the exams. She
said, “I always remember the things that I look up for PBL; I always remember for the
exam.” Explaining the material to the group in PBL class was more “functional” than just

reading or memorizing because she had to know the content in order to talk about it to the

group.

W: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

Whereas Mary focused mainly on coursepacks the ﬁrst year, she tried to ﬁnd
resources by herself the second year. Before ﬁnding resources, she thought about which
resources the person who devised the test consulted. Mary made a lot of charts but she
wrote down less the second year than the ﬁrst year because there was not much time.
Also, she nwded to read all of the information at least once during her second year. Thus,
her studying was not as focused as the ﬁrst year. She said, “It’s more of a survival instinct
than anything this year.” Also, whereas her goal was to learn as much as she could the
ﬁrst year, her goal the second year focused more on passing the boards as the time for

board exam drew near.

Table F.4 contains a summary of the key features about Mary’s learning strategies.

\

188

Table F.4: Key features of Mary’s learning strategies

 

Q1

- Relating PBL preparation to exam preparation

- First week of the domain: focus more on PBL; later: more focus on exams

- Matching learning issues with objectives

- Learning issue study: use the previous year’s textbooks, articles, and coursepack
- Studying learning issues: read books - take notes - relate to class

 

Q2:

- Reading: read objectives, coursepacks, and books
making charts, underlining and writing down important words

- Group study: helps conceptual materials, checking knowledge

- Integration strategies: make charts, group study

- Memorization strategies: associate facts with framework, charting

- Selecting main information: stars in the objectives, lectures, percentages of the
exam content, and computer programs, underline, star mark, circle, highlight

- Computer programs: choose important information, test questions help her, good
pictures, change pace when she is tired

- Checldng knowledge strategies: group study

- Lecture attendance

- Additional strategies: choosing resources

 

Q3

- Inﬂuences: old study approach
- Goals: passing exams and knowing the materials
- PBL helps

1. Small-group working skills

2. Independent study

3. Help doing well on exams

 

 

 

- First year: mainly coursepack

— Second year: ﬁnd resources based on test giver’s material

- More charting second year

- Less writing down - because oftirne limits

- Change goal: from learning as much as she can to passing class and board exams

 

 

189

Andrew
Ram Qoestion 1: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

Andrew said he did not study diﬂ‘erently for PBL classes and exams, but he
focused primarily on studying for exams. He mentioned that PBL discussion reﬂected
little on how well one did on exams.

m: Andrew’s PBL group read a case, ﬁnding abnormal cues. Then they
formulated hypotheses from their previous knowledge of the area. Before the class ended,
they raised learning issues. Andrew tried to match objectives with learning issues, as did
most of the other students, by raising learning issues and seeing whether they matched the
objective list. Thus, Andrew tailored the learning issues to the objectives; if two not
match, his group did discarded the learning issues.

mm: Andrew studied learning issues by reading the coursepack
and textbooks. He never went to the library to ﬁnd learning issues. Usually, Andrew’s
PBL group discussed conceptual materials. His group did not discuss information that
required more memorization, but sometimes they categorized facts for easier
memorization.

W: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Rooﬁng: Andrew read the material more than once, as did most other students in
this study. When he read the material the ﬁrst time, he tried to understand and make

sense of it. When he read it the second time, he skimmed it and tried to make

190

connections. When he read, he also highlighted such things as “the most common cancer
of the female” or “this is 20% of the cancers” because these would be testable questions.
W: Andrew did not study in a group. However, because he lived with
two other students, he asked them for help if he had questions when he studied.
Mom: Andrew studied conceptual materials ﬁrst because this
provided a ﬁ'amework onto which to place facts. To learn conceptual materials, basically
be read and made a connection with previous materials; if he could not make connections,
he went back and carefully reread the material. He mentioned that concepts stayed with
him longer, so he saved memorizing facts for the last minute, as illustrated by this
comment:
I ﬁgured if I got the concepts down that would give me more of a ﬁamework to
put the pathology down upon it, and also concepts stay with you longer, whereas
just the pure facts, pure memorization stuff I save for last.
MW: Andrew sometimes used mnemonics for memorization.
Also, the cases he got ﬁ'om PBL class sometimes helped him remember facts longer
because they gave a context to which he could attach facts. He mentioned,

Puttingacertainproblemwithacertainfact, andthatway. . . andthecertain
ramiﬁcations of that person’s problem, it would really stick with me more.

Andrew also used imagery for memorizing facts, as illustrated by this comment, “If you
look at it on the page long enough, you kind of remember where it is on the page in your
mind.”

MW: Andrew looked at stars in the objective lists to see
which were the important objectives. Ifthere were no starred topics in an objective list,

he went by the major headings and the most common items. He also used the percentage

191

of the exam content. He used the previous year’s objectives, and sometimes PBL classes
helped him know what to focus on when he heard the preceptor or classmates talking.
Also, although Andrew did not go to lectures, the scribe notes he obtained gave him the
important information for the exam. Sometimes quiz questions also indicated what to
study for the tests. Also, he sorted out testable questions through highlighting.

W: Andrew mentioned that computer programs helped him
understand the material and memorize the side eﬂ‘ects of diseases better than the textbook
because the programs contained good pictures. For example, whereas textbook pictures
just showed the uterus or the adrenal glands, computer pictures showed the actual clinical
appearance of a person with a certain disease. That is, computer programs provided a
visual images to help students memorize materials. Also, they contained quiz questions,
which helped Andrew see the importance of certain information.

MW: Andrew knew he understood something if he
could repeat what he had read, or if he could guess what was coming next because most
of the medical information was in a logical progression.

W: Andrew did not attend the lectures “because they’re all in
the morning, and I like to sleep in.” He said that in the morning it was peaceful and quiet
at home, so he could use that time to accomplish most of what he needed to do.

WI Andrew planned to take a board review course to prepare for
the board exam. He said he would pay for the review course, so this gave him extra

incentive to be there.

192

W: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Andrew mentioned that time and his previous knowledge guided the way he
studied. His goal was having a balance among doing well on exams, having an outside
life, and having a good knowledge base. Andrew thought PBL classes helped him get a
good knowledge base and relate hard science to clinical situations, but that they helped
little for exams. He believed that the value of PBL depended largely on preceptor. In
general, he preferred PBL classes to lectures because PBL gave him ﬂexibility in
scheduling.

According to Andrew, PBL classes helped in the following ways:

1. SM-grooo working skills: He mentioned that the PBL group gave him
experience in interacting with others.

2. W: PBL group discussion gave Andrew a good idea of how
much he knew compared to his classmates, and also let him know whether he was
concentrating on too superﬁcial and detailed things in his study. Also, it gave him some
indication of where to start in the vast volume of material he had to cover.

3. Indoogdent §t_uoy: Whereas lectures provided everything the ﬁrst year,
Andrew was searching for important information by reading books, articles, and the
coursepack the second year. To explain this, he commented, “Last year it was all lectured
to you. Everything was on the lecture, so it was all there. This year at least you have to

ﬁnd it.”

193

4. 11M: Through PBL group discussion, Andrew could get a diﬂ‘erent
point of view. Hearing someone explain something helped him understand the materials.
Also, it gave a context through which he could get the framework for what he was
learning.

5. $9153.98. importoot information: Andrew said that sometimes he could tell what

was important information, either by hearing it ﬁom preceptors or through discussion with

classmates.
MW: Do second-year medical students at MSU CHM report

that they study differently than they did in their that year?
If so, how and why?

The ﬁrst year, basically all test questions came ﬁ'om the lectures. Hence, Andrew
attended the lectures, and if they were not good he just got scribe notes because they
contained the material on which students were tested. The second year, Andrew did not
attend the lectures. He also said that what his PBL group talked in class reﬂected very
little of what was in the coursepack or books. However, he gained a good understanding
of the material through PBL discussion. In his second year, Andrew’s scheduling had
changed, and he could spend his whole time on one subject. He studied more the second
year because there was a greater volume of material and the class was less structured.
Other than that, he claimed there had been no big change in his learning strategies.

A summary of the key features that emerged in the interviews with Andrew is

contained in Table F.S.

‘i .

194

Table F .5: Key features of Andrew’s learning strategies

 

Q1

- Do not study diﬂ‘erently for PBL class and exams: study primarily for exams
- Matching learning issues with objectives

- Using coursepack and books to ﬁnd learning issue; no use of library

- Discussing conceptual materials during PBL class

- Categorizing factual materials for easier memorization

 

Q2

- Reading: more than once: highlighting testable questions
1: For understanding,
2: Making connections and skimming

- No group study

- Integration strategies: reading, computer program pictures

- Memorization strategies: mnemonics, imagery, case study (gives context), and
computer program pictures

- Selecting main information: stars, major headings or common things if no stars,
percentages of exam content, old objectives, PBL class, quiz questions, scribe
notes, and computer programs; highlighting

- Computer programs: good pictures, help selecting main information

- Checking knowledge strategies: if he can restate what he reads or can guess
what is coming next

- No lecture attendance

 

Q3

- Inﬂuences: time and previous knowledge
- Goals: balance among doing well on exams, having outside life, and having
good knowledge base
- PBL helps
1. Small-group working skills
2. Checking knowledge
3. Independent study
4. Understanding
5. Selecting important information

 

 

 

- First year: attending lectures and studying scribe notes for exams
- Second year: does not attend lectures
- Study more second year: more volume and less structure

 

 

195

Base;

Wool: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Like most of the other students in this study, Roger said that he studied primarily
for exams and not for the PBL classes per se.

W: Roger’s PBL group discussed cases, pulling out relevant facts based
on their independent study before class and raising learning issues. At the beginning of the
semester, Roger’s PBL group assigned learning issues to students. But they found that
this method did not prepare them for the exams, so now students studied what they
wanted. Nowadays, they geared the learning issues toward the objectives by opening up
the objective lists and looking at them. Usually, if learning issues were not on the
objective list, Roger’s group ignored them or did not focus on them during group
discussion.

Learning logo gody: Iflearning issues did not directly match the objectives,
Roger studied just those learning issues that did match the objectives. To study learning
issues, he read the coursepack if it was good. Ifit was not good, he read textbooks and
board review books. Roger also used old objectives to ﬁnd pertinent information, and
sometimes he used computer programs. However, he did not go to the library because
there were no up-to-date books there.

W: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?
Riding: Roger’s basic study mode was using computer programs and talking with

maple. He usually read the material once, used computer programs, and then talked

196

about the materials with other students. Sometimes he did not even read the material once
but just used computer programs and talked with classmates.

goup study: Roger sometimes got together with another person during the week
before an exam and they would test each other. They would go over their notes and ask
each other questions about the material they had reviewed. This also helped him identify
unknown facts. Roger used group study as a way of checking his knowledge.

W: Roger said that writing things down, such as process, helped
his understanding. He also wrote explanations of unclear things in the margins of his
coursepacks. For instance, if a coursepack said “stress ulcers are physiological stress,” he
wrote “not psychological stress” in the margin. Roger said that if he understood the
process, he did not need to memorize. For instance, knowing the fact that “aspirin
decreases swe ' g” is memorization, but if he knew the reason why this occurred, the
memorization followed naturally. Sometimes, teaching or explaining to others during the
group study helped him understand the materials better.

W: Roger highlighted things he did not remember well or
that he had not known before. He sometimes used mnemonics but used fewer
memorization strategies the second year than the ﬁrst year because he understood more
the second year. Also telling each other the story about something several times in the
study group helped him remember better.

53W: To select important information, Roger used objective

lists, percentages of exam content, computer programs, and starred objectives.

197

Sometimes the professor told students what was important to know in the lectures. Roger
also highlighted important things, as illustrated by his comment:
As I’m going through it I’ll see it and I’ll say, “Oh, yes, there it is again.” Or

“That’s the most important thing.” And then I’ll take the test at the end, and most
of the time the things that I get wrong are the things I didn’t highlight when

highlighted.

Computer program: Roger said that computer programs contained very precise,
condensed, and focused information. They were developed by department faculty and
included no extraneous information. Thus, he could recognize important information
through doing computer programs. If Roger did not understand the material through
computer programs, he looked it up in the textbooks.

WW: Roger used group study to check his knowledge.
Group members ask each other questions and explained things to each other, which helped
him know whether he understood material or not.

Mum: Because some test questions were drawn ﬁ'om lectures and
the lectures reinforced what he knows, Roger sometimes attended lectures. However, if a
professor was not good, Roger did not go to the lectures.

mm: Roger said that doing well on exams gave him conﬁdence, as
illustrated by this statement:

Getting good scores always helps because you feel like you are doing the right

thing, and you feel like you can trust your judgment about what to study and what

not to study.

Boom orooogtion: Roger planned to study with the group to prepare for the board

exam. He planned to take the board review course. He believed that studying for exams

the second year would help him pass the board exam.

198

Lgearch Qogtion 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Roger said that exams were the greatest inﬂuence on the way he studied. Also, his
exam scores inﬂuenced the way he studied. His goal was to do well on the board exam, as
well as on the domain exams. Roger wanted to get important information for the domain
and board exams from PBL classes. However, he seemed to think that PBL classes did not
help him with his goal of doing well on exams, as he pointed out in his comment, “In the
class it makes me feel kind of like I’m wasting my time, like I could be doing other things
that would be more helpful.”

Roger said that, at the beginning of the semester, PBL helped him because he did
not have much information, but by now everyone knew what they had to do, so they just
went to PBL classes because they were required to do so. He stated,

Atthebeginningoftheyear, thePBLclasseswereveryhelpﬁllbecausewe didn'tlmow

anythingaboutwhatwasgoingon, butatthispoint, everyonekindofknowswhat's

going on, andtheygoto thePBL classesbecausetheyhaveto. AndIthinkitwould
bebetterforrne, andbetterforourgroup asawhole, ifweactuallydidn't go, because
we don‘t really learn a whole lot during the PBL classes. So right now they don‘t really
help too much with our studying.

However, Roger thought that PBL classes helped_small-group working skills

because he had to learn to be more tolerant of others.

Rggrch Question 4: Do second-year medical students at MSU CHM report
that they study diﬂ'erently than they did in their first year?
If so, how and why?

Roger focused mostly on lecture notes and used textbooks only when he did not

understand the material in his ﬁrst year. exams. In that way, he could score well on the

199

exams. Also, he was more anxious about tests and was less sure about what it was
important to know the ﬁrst year. The second year, Roger found that PBL classes were
not necessarily related to the exams. He was busier and thought the material was harder
the second year However, ironically, he had more free time the second year because he
was more effective in his study approach. Roger said the experience of taking tests and
achieving good grades gave him conﬁdence and helped him be an eﬁ‘ective learner.

Table F .6 contains a summary of the key features of Roger’s learning strategies.

200

Table F.6: Key features of Roger’s learning strategies

 

Q1

- Studying for exams, not for PBL classes

- Matching learning issues with objectives

- To ﬁnd learning issues: Using coursepack, computer programs, and old
objectives; no use of library

 

Q2

- Reading: once sometimes; basic study mode is doing computer programs and
talking with people

- Group study: asks questions, identiﬁes unknown facts

- Integration strategies (understanding): writes down the explanation of unclear
things such as a process; explains to others during group study

- Memorization strategies: mnemonics, talks with friend several times, once he
understood, then memorization follows

- Selecting Main information: objectives, percentages of exam content, lectures,
stars in the objectives, and computer programs; highlighting

- Computer programs: precise, condensed: way of selecting main information

- Checking knowledge strategies: group study

- Lecture attendance: if professor is good

- Additional strategies: good exam scores give him conﬁdence

 

Q3

- Inﬂuences: exam
- Goals: do well on domain and board exams
- He feels he can study by himself now, and going to PBL classes wastes time.
- PBL helps
1. Small-group working skills

 

 

 

- Relies on lecture notes and sometimes used books the ﬁrst year

- More anxiety on exams and less sure of selecting main information the ﬁrst year

- Has more ﬁ'ee time and conﬁdence the second year because of test experience and
good test scores

 

 

201

Earls!

W: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Nancy said she focused more on exams than on preparing for PBL classes. The
approximate ratio of time that she studied for PBL classes and exams was 1:50.

W: Like other PBL groups, Nancy’s group also read the cases,
suggesting ideas and cues by looking at whole clinical picture and based on previous
knowledge. Then they raised learning issues. Nancy tried to match learning issues with
the objectives, as illustrated by her statement, “One thing that we do in our group is make
our learning issues reﬂect the objectives that we’re given in the PBL class, for the exam.”

mm: Nancy found information for studying learning issues ﬁom
coursepacks, textbooks, and computer programs. She did not use the library. Nancy said
that PBL classes helped achieve the objectives by giving a real clinical context to what
they were learning. Having a context made the material interesting and understandable.
Also, asking questions during the PBL class helped Nancy understand objectives better.
W: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Raging: Nancy mentioned that she rarely found time to read the material more
than once. She mainly read textbooks and coursepacks, and if she found time, she
reviewed what she underlined or written in the margins or ﬂashcards that she had made.

9113M: Sometimes Nancy studied with ﬁiends; group study provided
repetition and kept her interested. Also, she could check her knowledge when group

members quizzed each other. She could also pick up information because she studied with

202

students ﬁ'om another PBL class. Nancy said, “It’s neat to study with someone who’s in
another PBL group because you can pick up diﬂ‘erent stuﬁ‘ between the groups.”

Intogrg’ on Mogi es (understandmg' ): Nancy read textbook carefully, trying to
understand what she read. Also, studying cases in PBL class helped her understand the
material better by giving them a clinical context.

W: Nancy wrote down little facts down that she found
interesting, whether they were important or not. For example, if she read a sentence like
“peptic ulcers occur more often in males,” she would write in the margin “Males more
common.” Writing helped her memorize easily. She said she sometimes made ﬂashcards
and memorized what was on them.

Selecting mam information: Nancy said that if she saw a certain topic in more than
one category, this indicated it was important information. For instance, information on
ulcers appeared in pathology, pharmacology, and psychosocial materials; thus it was
obviously an important thing to know. She emphasized the objectives that interested her
the most. She also said she could recognize good test questions from the notes and thus
focused on those. She stated, “The most common cancer in teenagers is” would be a
likely exam question. Also, studying with other PBL group students gave Nancy
information about the importance of materials her group did not discuss.

Comoutor programs: When Nancy was bored with reading the coursepack, doing
computer programs give a nice change in studying the same materials. She mentioned that
pictures and diagrams associated with the materials in computer programs also helped her

study.

203

Checking knowledge strategies: In group study, Nancy and her friends quizzed

each other, and that helped her check her knowledge.

Lecture at_tendance: Nancy said she attended the lectures because she liked to hear
the professor discuss the material even though she did not grasp them at her ﬁrst sitting.
Also, she felt a responsibility to go to the lectures because she had paid for them; they
were a good way be social with classmates, as well.

Mm: Nancy mentioned that she switched to diﬁ‘erent sections and
jumped all over the place in order to maintain her interest because studying one section in
a domain for a long time was boring. Another notable thing that Nancy mentioned was
that she thought the exam format in medical school had changed her way of thinking. She
said that multiple-choice exams made students be less logical and made them pick out
important words and concepts for the tests instead of overall ideas.

W: Nancy planned to take a board review course to prepare for the
board exam.

Wong: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

To Nancy, passing the exams inﬂuenced her learning strategies the most; the
multiple-choice exam format also inﬂuenced the way she studied. She said she tried to
pick out important words and major concepts but not ideas in studying for exams.
Nancy’s goal was to be a good physician. She also wanted to have good interaction from
her PBL classes. In general, Nancy liked the PBL format, especially because it gave a

context to a case, which helped her understand the materials. She commented,

204

IlikePBL. Ican‘t stresshowmuch moreIlikethisyearthanlastyear. Lastyearwas

justsomuchmore stressﬁrl. Idon't knowwhyitwaslikethat. Icanseewhere, ifyour

PBL group isn't very forthcoming or doesn‘t work well together PBL can be a

nightrnareforyou. Butl‘vebeenhrckyenoughtobeinareallygoodgroup andwe

work really well.

Nancy also noted that PBL classes helped in the following ways:

1. Small-ggouo working skills: The small-group discussions enabled Nancy to stay
on track; she tried not to disagree too much. She said, “It’s been interesting to see
everybody’s role develop in the group”

2. Undgsjﬂng’ of the materigs: By giving a context to a case, PBL group
discussion helped Nancy understand the materials.

3. Exam prooaration: According to Nancy, talking and arguing about the materials
not only helped her ﬁgure them out but also helped her prepare for the exams because
what the group discussed was related to the exams.

March Qogjon 4: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

Ifso, how and why?

Nancy said that test items had come from lectures and she relied heavily on the
lectures the ﬁrst year. Also, exams imposed pressure and inﬂuenced her studying more
the ﬁrst year than the second year. Nancy read and understood more the second year than
the ﬁrst year. Also, she used fewer memorization strategies the second year than the ﬁrst
year.

A summary of the key features gleaned from the interviews with Nancy is

presented in Table F .7 .

205

Table F.7: Key features of Nancy’s learning strategies

 

Q1

- Focusing on exams, not on PBL classes

- Matching learning issues with objectives

- Learning issue study: uses coursepacks, textbooks, and computer programs; no
use of library

 

Q2

- Reading:
1. Usually reads textbooks and coursepacks once,
2. Review things underlined or written in the margin, or ﬂashcards if she has time

- Group study: quizzes each other, gives repetition, keeps her interested, checks
knowledge, and picks up information

- Integration strategies: careﬁrl reading, PBL discussion

- Memorization strategies: writes down facts: interesting things, ﬂashcards

- Selecting main information: corresponding information, testable questions, and
group study

- Computer programs: uses them when she is bored with reading coursepacks,
good pictures

- Checldng knowledge strategies: group study

- Lecture attendance ,

- Additional strategies: reads jumping over all over the place, exam format changed
her way of thinking

 

Q3

- Inﬂuences: passing exams and exam format
- Goal: to be a good physician
- PBL helps

1. Small-group working skills

2. Understanding of the materials

3. Exam preparation

 

 

 

- Relied on lectures and lecture notes the ﬁrst year
- Exam had more inﬂuence and more pressure on studying the ﬁrst year
- Fewer memorization strategies, more reading, and understandings the second year

 

 

206

Janet
W: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

Janet studied primarily for exams and not to prepare for the PBL classes. When
she studied for the learning issues, she tried to gear them toward the objectives, which
were the focus of the exams.

m: Janet’s PBL group read a case, picking out cues from all the
available data, such as gender, race, signs, symptoms, and psychosocial details. Then they
discussed hypotheses ﬁ'om their previous knowledge. Janet mentioned that her group had
two nurses, including herself, and could contribute more information for discussion. Then
they raised learning issues for the next session and did the stimulus questions at the end of
each case.

Janet tried to match learning issues with the objectives by referring to the
objectives during small-group sessions. Thus, she did not prepare diﬁ‘erently for the
objectives, which were mainly covered on the exams, and learning issues.

W: To ﬁnd information for the learning issues, Janet read
textbooks. Like most of the other students in this study, she did not go to the library. She
studied learning issues in order to contribute to the group and to ask questions, which
reinforced what she knew. Janet commented,

For PBL, I try to get what information I need for the class, but I try to keep it

streamlined so I don’t get waylaid and get away from the objectives, cause that’s
real easy to do.

207

Rggrch Qggtion 2: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

Rm: Janet read everything twice. The ﬁrst time, she read the material
carefully at a slow pace trying to understand it. She tried to answer questions and ﬁlled
the objective list with resources. She highlighted the materials when she read them the
ﬁrst time. The second reading went faster because she only read the highlighted passages.
She picked up things she did not understand at her ﬁrst reading. She used the objective list
to check whether she had covered all of the objectives.

My: Janet said she did not study in a group. She was too busy reading
on her own and taking care of her children, so she studied whenever she had time.

WW: Janet mentioned that seeing visual examples
of materials such as paths ﬁom computer programs helped her understand them better.

W: Janet looked at the objectives to see which information
was important. She said that if an objective list was good, it was easy to ﬁnd the main
information; however, if the list was poor, she had a hard time ﬁnding the main
information. Janet studied material comprising the largest percentage of the exams ﬁrst.
Sometimes, she used practice quizzes and old objectives to glean important information.
She also mentioned that PBL classes informed her of what she needed to know.

W: Janet used computer programs only when she heard from
others that certain programs followed the coursepack very closely. Visual path examples
in computer programs helped her make sense of what she read. But Janet stated that
computer programs were no better than the textbook so she used them only for

supplemental studying.

208

Checking gowlﬂge strategies: Janet solved practice quizzes in the coursepack in
order to check her knowledge.

No lme sgendooce: Janet did not attend the lectures because she thought she
could use the time more eﬁ'ectively studying by herself. However, she obtained scribe
notes and read them before the exams because they gave framework to the scope of her
study.

Board omaration: Janet planned to take a board review course to prepare for the
board exam. She also believed that doing well on the domains now would help her do
well on the board exam.
gmh Question 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Janet mentioned that the pressure to pass domain exams and the board exam
inﬂuenced the way she studied. However, in a sense, it also kept her motivated. Her
primary goal was to ﬁnish medical school, and her secondary goal was to be a good
doctor. Her goals from the PBL experience included contributing more to the group and
getting reinforcement. She thought PBL helped in gaining diﬁ‘erent perspectives on issues
but that it did not help her prepare for exams. In general, she enjoyed the PBL experience,
but she preferred to study by herself , as illustrated by this statement, “I feel like small
group is not really a great part of my learning. I economize my time. I feel like if I had

that six hours to myselfI could study more.”

209

Janet said that sometimes PBL class distracted her ﬁ'om her own studying when
her group discussed issues that are not pertinent to the objectives. However, Janet
thought that PBL classes helped in the following ways:

1. sm-ggouo working skills: To interact with a wide variety of personalities in a
group, Janet had to develop skills in working with people.

2. Checking knowledge: Janet said she asked questions during PBL class, and that
reinforced what she knew, as illustrated by her statement, “It [PBL class] reinforces what I
know. And sometimes it may let me know that I don’t know something and I’ll go back
and research it.”

3. WM: Janet mentioned that PBL class discussion
made her realize what she needed to know. Sometimes she could ﬁnd a good book, based
on someone else’s recommendation.

4. W: PBL class helped Janet integrate the materials by

providing contexts to cases.

Research Qoﬂ'on 4: Do second-year medical students at MSU CHM report

that they study differently than they did in their fast year?

If so, how and why?

Because the ﬁrst year was lecture-based, Janet basically read scribe notes and read
textbooks once in a while. There were fewer materials to study, and they were easier the
ﬁrst year than the second year. The second year, Janet read textbooks more than the ﬁrst
year. Also, she did not attend lectures because there was more pressure on her time the

second year. Janet said she used more strategies for selecting main information the second

year than the ﬁrst year because she had to ﬁnd information by herself instead of having a

210

lecturer give it to her. Also, she did not use ﬂashcards the second year because they took

too much time. Janet was more self-disciplined, independent, and diligent about studying

the second year than the ﬁrst year. Further, she said she could see the connections and

relations between topics better the second year than she could the ﬁrst year.

A summary of the key features that emerged in the interviews with Janet is

contained in Table F.8.

Table F.8: Key features of Janet’s learning strategies

 

Q1

- Studying for exams and not for PBL classes
- Matching learning issues with objectives
- Learning issue study: uses textbooks and no use of library

 

Q2

- Reading: more than once
1: Careﬁrlly, slow pace: ﬁlls blank of objectives with resources, highlighting
2: Read highlighted passages: goes faster
- No group study, No lecture attendance
- Integration strategies: read careﬁrlly, computer programs
- Selecting main information: objectives, percentages of exam content, quizzes, old
objectives, and PBL classes
- Computer programs: only when they follow coursepack closely
- Checking knowledge strategies: practice quizzes

 

Q3

- Inﬂuences: passing domainand the board exams
- Goals: ﬁnish medical school and to be a good doctor
- PBL helps

1. Small-group working skills

2. Checking knowledge

3. Giving information of what to know

4. Integration of the materials

 

 

 

- Used scribe notes primarily, rarely used textbook, less volume the ﬁrst year

- More textbook reading, more integration, more pressure on her time, and more
selecting main information strategies the second year

- No lecture attendance the second year

- Fewer memorization strategies the second year: because of time

- More self-disciplined, independent, and diligent the second year

 

 

211

.ngy

Cindy was not taking PBL classes the semester the interviews were conducted
because she had extended her program. She lengthened her program because she was
engaged and thus needed time to plan the wedding. Also, she said she needed less school
time and more free time. She took only clinical skills, social context class, and mentor
which met once a month, with no PBL classes or lectures.

W: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

Not applicable
W: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

Cindy mentioned that she had no exams this semester. Only papers were required
for the classes she was taking. Also, because Cindy needed to take PBL classes before
taking the board exams, she had no plans to prepare for the board exam preparation yet.
W: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

The primary inﬂuence on Cindy’s learning strategy was time. Because she had
more time the second year, she had less pressure and could read more. Her goal was to
ﬁgure out what were the most important materials for her to know versus what was okay
for her to know. It seems that she realized the importance of selecting the main

information in a limited time.

212

W: Do second-year medical students at MSU CHM report

that they study diﬂ’erently than they did in their first year?

Ifso, how and why?

Cindy had no exams the semester the interview was conducted but did have some
in the previous semester in her clinical skills and social context classes. When I asked
Cindy about her exam preparation in her ﬁrst year as compared to the previous semester,
she said she started earlier, used fewer rote memorization strategies but more concept
understanding the previous semester than the ﬁrst year. She also wrote out objectives and
read more before lectures the previous semester than she had during the ﬁrst year. By
writing out what she read, she learned better. She stated that there were so many materials
to study the ﬁrst year, she could not write as much then as she did when the interview was
conducted. All these changes had occurred because she had more time the previous
semester than she did the ﬁrst year and thus could learn the material better. She stated, “I
actually got out textbooks and read the chapters and I did a lot more with learning the
whole concept instead of just trying to memorize facts for the exam.”

Table F.9 contains a summary of the key features about Cindy’s learning strategies.

Table F .9: Key features of Cindy’s learning strategies

 

Q1 - Extending her program: no PBL classes, no lectures, only takes clinical skills,
social context classes, and mentor

 

Q2 - No exams this semester, only papers are required

 

Q3 - Inﬂuence: time
- Goal: ﬁgure out important materials

 

Q4 - The previous semester: had clinical skills exams: easier, more time than the ﬁrst
year — thus starts earlier, uses rote memorization , more integration, more reading,
more writingdown of objectives than the ﬁrst year

 

 

 

 

213

§_u_sor_r

Susan took no PBL classes because she had extended her program in order to
adjust to the medical environment and to catch up as a result of having no biochemistry
background. Also, her marriage plans were another reason for her extension. She was
taking ﬁrst-year lectures and hence had more time than other interviewees in this study.
March Question 1: What learning strategies do students use in

preparation for the problem-based learning classroom, and why?

Not applicable
W: What learning strategies do students use in preparation

for examinations (both class exams and the licensing exam), and why?

W: Susan mentioned that she used “three time exposure” to the
materials, as she had done the ﬁrst year. That is, she ﬁrst exposed herselfto the material
through lectures. Then she read her notes, arranging materials, making structures, and
highlighting- Finally, she memorized facts just before the exam. Susan said she usually
did not read textbooks but instead read scribe notes.

W: Susan tried to integrate scribes notes, her own notes, and
the textbook. She mentioned that she used a structure to help her remember facts. She
stated,

With immunology, any kind of immunological response you have various

mechanisms, an integration of activity that all happens when a pivotal event

occurs. So I learn all the minutia that happens along the way of one pathway of

response, and then once I learn all those little steps, the important part, the
structure part is that I condense all those parts.

214

W: Susan said facts aloud in order to memorize them, as
illustrated by this comment:
When it comes time to memorize facts, I say out loud the facts that I have to
memorize and what their association is. I have it all laid out on a desk and I’ll go
over and get a piece of it and then I’ll just talk and then walk and memorize it and
then go get the next piece. So it’s probably visual and kinesthetic because I’m
moving around.
Also, she used structures in order to memorize facts easily.
MSW: Susan said she asked the professors questions if she had any.
And if a professor’s lectures were confusing, she did not attend them but just obtained the
scribe notes.

mm: Susan had no speciﬁc plan to prepare for the board exam yet

because she nwded to go through PBL classes ﬁrst.

March Qoestion 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

What inﬂuenced Susan’s learning strategies most was her desire for success.
Susan’s goal was to achieve a balance among academic success, clinical experience, and
her personal life. She said that lectures did not help with clinical experience, so she looked
forward to having PBL classes next year.

Rgoorch Quosto'on 4: Do second-year medical students at MSU CH1“ report
that they study differently than they did in their that year?

If so, how and why?

Susan had a tutor the ﬁrst year but she did not the second year. She mentioned

that she was more relaxed the second year because of the experience in medical school.

 

Sh

llO

 

 

215

She knew what she could accomplish in a certain amount of time and had more conﬁdence

now that she could do it.
A summary of the key features that emerged in the interviews with Susan is

presented in Table F. 10.

Table F. 10: Key features of Susan’s learning strategies

 

Q1 - Extending her program: no PBL classes: adjustment to medical school,
no biochemistry background, and marriage plans

 

Q2 - Reading: lecture notes or scribe notes, no textbooks

- Basic study mode: three-time exposure: lectures -notes - memorization
- Integration strategies: uses structure

- Memorization strategies: says aloud, uses structure

- Additional strategies: gets help from professor

 

Q3 - Inﬂuence: desire for success
- Goals: balance among academic success, clinical experience, and personal life

 

Q4 - No tutor, more relaxed, more conﬁdent the second year

 

 

 

 

216

Kﬂy (ﬂ ot §tudy)

Resg_rc_h ngtioo 1: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Kelly said she did not study for PBL classes per se. She tried to relate PBL classes
to exams; thus, studying for exams prepared her for the classes. She stated,

I study for the exam ﬁom the beginning and then if we happen to talk about

something in the group that I’ve already studied for the exam that’s wonderful. If

we talk about something I haven’t studied yet, I can ﬁle it away in my head as
something I need to look at. I study my way, and when the PBL classes ﬁt into my
way of studying then that’s great. When they don’t, that’s too bad.

Mom: Kelly mentioned that her PBL group was relaxed and less formal
than other groups. They read cases and discussed them together, generating hypotheses.
But they did not write formal hypotheses on the board. Through case studies during the
PBL class, Kelly tried to connect all the information, as illustrated by her statement:

WhatIﬁyanddoisﬁymdexplainevaydﬁnginﬂrecaseandnnagineinmyheadhow

allthesediﬂ‘erartthingsarecomrected. AndifIcan'tdothat,thenIassumethatIdon‘t

lawwuloughmdlhavemgoreseamhmomsolcanseehowaﬂthesediﬂ‘aemdﬁngs
areconnected.

W: To prepare for the PBL class, Kelly looked at the big picture
of the case and tried to make connections among materials. Ifshe could not see the
connections, she realized she had missed something and studied those things after class.
However, she did not go to the library for her research. What she did was reading

relevant parts in a textbook.

217

W: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

1_{_oa_d_ir_lg: Basically, Kelly read textbooks and the objectives twice. The ﬁrst time,
she read textbooks with no pressure or hurry, to get general concepts and to understand
what she read. The second reading, she could remember better because the material was
familiar through her ﬁrst reading, as illustrated by this comment, “You read through
something once, and [when] you read through it the second time everything will seem
familiar and so you’ll remember it better.”

mm: Kelly studied with her boyfriend because doing that kept her
motivated and made her keep studying.

W: Kelly read careﬁllly, trying to understand the materials. She
tried to compare texts with pictures, and texts with PBL cases, in order to integrate the
materials for better understanding. When she studied, she tried to connect the materials
just as she would in the PBL class. For example, when Kelly reads about a disease, she
would think, “OK, if I were to get a case about this disease, what would this person look
like?” and then she tried to think back about what she had learned. Also, using computer
programs helped Kelly connect the materials better and hence aid her understanding.

W: Kelly made up stupid songs or silly acronyms or
mnemonics to help her memorize facts. Sometimes, she imagined things to aid in
memorization. Also, Kelly highlighted passages or wrote things down in the margins
while reading. She said that doing these things was more active than just reading because

she had to actually think about what she was reading and this aided her memorization.

218

She read the material twice, and this gave familiarity to the materials and hence helped her
memorize them.

Selecting main information: Kelly used the previous year’s objectives as a way to
select information for study. If objectives were not speciﬁc but very broad, such as “know
the anatomy of the heart,” she relied more on the textbook, whereas if objectives were
good, she read the previous year’s objectives. Kelly also used the percentages of the exam
content to determine the relative importance of the materials; then she studied the large-
percentage objectives ﬁrst.

W: Kelly used computer programs because they had better
pictures than the textbooks. Through computer programs she could move backward and
forward easily and could connect the materials and pictures easily, which helped her
understanding.

MW: Kelly did practice quizzes in the coursepack the
night before the exam in order to see whether she remembered what she had studied.

W: Kelly did not attend the lectures because she thought she
could use that time more eﬁ‘ectively studying on her own. Also, she said she was not a
morning person, and most of the lectures were in the morning.

W: Kelly stated that she read the objective lists ﬁrst to see what
information she had to look for when she studied. Then she read textbooks and old
objectives with the answers. Aﬁer doing that, she reread the objective list to see whether

she had missed anything. In this way she checked her coverage of the objectives.

219

Boord preoa_rotion: Kelly planned to attend a board review course to prepare for
the board exam. She also believed that studying for the domain exams now would help
her pass the board exam.

Rum Question 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Kelly mentioned that her old study habits inﬂuenced how she studied now. It
seemed hard to change her own study approaches. Her goals included passing the domain
and board exams, as well as getting the big picture. She believed that PBL classes helped
her get the big picture, but did not help much with exams. Kelly liked to match basic
science knowledge to clinical situations through PBL classes.

In general, Kelly liked PBL better than lectures. She said that PBL class was fun
and big-picture oriented, whereas exams were detailed oriented. Also, she mentioned that
PBL classes helped her integrate the materials through the discussion of cases provided
with a context. Kelly also tried to connect the textbooks, pictures, and PBL cases when
she studied for exams as evidenced by her statement:

I’m really making an eﬁ‘ort to connect the things, just like I would if I was in PBL.

When I read about a disease, I think, ‘OK, if I were to get a case about this
disease, what would this person look like?”’

3mm: Do second-year medical students at MSU CHM report
that they study diﬂ'erently than they did in their ﬁrst year?
Ifso, how and why?
The ﬁrst year, Kelly went to lectures regularly and studied exclusively the

coursepack notes, rarely using textbooks. She said she read the textbook more the second

220

year than the ﬁrst year. Also, whereas her main goal the ﬁrst year was solely to pass the

exams, she was focusing more on understanding and integrating the materials the second

year.

Table F.11 shows a summary of the key features about Kelly’s learning strategies.

Table F.11: Key features of Kelly’s learning strategies

 

Q1

- No PBL preparation; relates it to exam preparation
- Learning issue study: usually reading textbooks and no use of library

 

Q2

- Reading twice: read textbooks and objectives
1: Get general concept, to understand
2: Remember better because it is familiar through ﬁrst reading

- Group study: keeps her motivated, keeps her studying

- Integration strategies: careful reading; tries to connect picture, text, and PBL
case; uses computer programs

- Memorization strategies: uses acronyms, mnemonics, imagery, and highlighting
writing - more active; reading twice - familiar, gives repetition

- Selecting main information: the previous year’s objectives and percentages of

exam content

- Computer programs: better pictures, easier to understand

- Checking knowledge strategies: practice quizzes

- No lecture attendance

— Additional strategies: checks the coverage of the objectives

 

Q3

- Inﬂuences: old study habits
- Goals: passing exams and getting the big picture
- PBL helps

1. Integration

 

 

 

- First year: regular lecture attendance, exclusively studied coursepack notes
- Second year: more use of textbooks
- Goal changes: exclusively passing exams -> more understanding

 

 

221

Jge (Lilot Study)

gearch Qoosg'on 1: What learning strategies do students use in
preparation for the problem-based learning classroom, and why?

Jane mentioned that she did no study separately for PBL classes and for exams.
She thought that what she learned ﬁ'om PBL classes was what was on the exams because
her group stick to the objective lists. Jane did not study much for PBL class per se if the
materials were not likely to be on the exam as shown in her comment:

I don’t really spend that much time on the PBL things that aren’t on the test.

Everydiinglstudiedwasdirectedtowardtheobjectives, soitwasreallygearedtoward

the exam

W3 Jane’s PBL group discussed cases with each other, and preceptors
asked questions. They established a ground rule for their group to stick to the objective
lists when they discussed the cases, and the learning issues they raised had to match the
objectives.

W: To ﬁnd learning issues, Jane usually read books, taking
notes. However, depending on the domain, she looked for materials diﬂ’erently. For
example, although the professor gave them good coursepacks that covered everything for
physiology class, for cardiology she researched diﬁ‘erent sources or books to look for
information. Sometimes Jane went to the library or the learning resource center to ﬁnd
the information for learning issues. When researching books in the library, she tried to
ﬁnd the parts that matched the objectives. However, even though a learning issue might

not be related to the exams, if it was interesting, she looked for the information.

222

Research Quosﬂon 2: What learning strategies do students use in preparation
for examinations (both class exams and the licensing exam), and why?

R__eodi_r_lg: Jane mentioned that she read the previous year’s objectives with answers
to get an idea of what she needed to know for the test. If she found information that she
could not understand while reading the old objectives, she read textbooks and took notes.
Jane mentioned that she tried to get a general overview during the ﬁrst week of the
domain, and she took notes and tried to memorize things during the second week of the
domain.

mm: Jane said she studied with her ﬁiends, and they asked each other
questions. Doing this helped her check her knowledge. Jane focused more on group
study if the material was conceptual because by writing, drawing things on the board, and
talking to ﬁiends made her think about pathways more actively.

MW: Jane integrated the materials through group study. For
studying conceptual materials, she mentioned,

We found that it really helped us, talking things through together, you know,

drawing stuﬁ‘ on the board to ﬁgure it out. So, I spent a lot more time studying

with pe0ple.

W: Jane used ﬂashcards or charts to memorize things. She
read one source of information, took notes, wrote the notes on ﬂashcards, and retyped
them. She then rewrote them on a chart. Doing this provided repetition of the
information, which aided her memorization.

WM: Jane said she ﬁgured out the important information by

solving practice quizzes, as illustrated by her statement:

223

They do give us quizzes, and the same people who write the test questions write
the quiz questions. So they usually give us a pretty good idea what’s going to be
on the test.

Jane used old objectives to see what were in the previous year’s exams. Also, she
knew that certain information was important if it was given in several diﬂ‘erent sources,
such as lectures, textbooks, and objectives. Sometimes, lectures helped her determine
what was important information. And having a physician as a preceptor in PBL classes
helped Jane focus on what was important.

9mm: Jane solved quizzes because they gave a good idea
of what would be on the test. Through doing quizzes, she also could check how she was
doing with her study. Also, her group asked each other questions, which helped her
ascertain the state of her knowledge.

W: Jane said she went to the lectures and obtained scribe notes
because they sometimes made her focus on important information.

W: Although Jane was not studying for the board exam yet, she
believed that what she was studying now would help her pass the board exam. Also, she
planned to attend a board review course to prepare for the board exam.

Resoth ngtion 3: What do students think inﬂuences their learning

strategies (such as goals, assessment of learning, student activity,

teaching method, and course content)?

Jane said her goal was to be a good doctor. Also, she wanted to learn the material

well enough so that she could apply it in the ﬁeld. She also hoped, that ﬁ'om the PBL

class experience, she would be able to integrate the materials better.

224

In general, Jane liked the PBL format better than lectures because it provided
integration of the materials and she could learn well ﬁ'om the discussion in PBL classes.
Jane also mentioned that PBL classes helped in the following ways:

1. MM: Jane mentioned that PBL classes encouraged and motivated
her to look for materials when it was something related to the clinical setting. She said
that even though something was not on the objective lists, if the material was interesting,
she went to the library and researched it.

2. W: Jane mentioned that PBL
classes helped her prepare for the exams in that they focused on important information in
discussion. Sometimes the physician preceptors helped her pick out the important material.

3. Woo: Jane mentioned that talking with people during
PBL classes and explaining things to each other helped her understand and integrate the
materials. She stated, “So I think for me that's how PBL is good because it connects the
clinical aspects and the physiology and the pathology, ties them all together.”
kgrch Qoostion 4: Do second-year medical students at MSU CHM report

that they study differently than they did in their first year?

If so, how and why?

Because exams were based on lectures the ﬁrst year, Jane read coursepacks and
scribe notes, but she did not read textbooks. Also, the teachers sorted out the information
to learn the ﬁrst year. The second year, she had a greater volume of material to study, and
she had to ﬁgure out what were the important things to study on her own. Jane said she
was big-picture oriented the second year. Also, she said she could focus on one topic at a

time the second year because, the exams were scheduled that way.

225

Table F. 12 shows a summary of the key features about Jane’s learning strategies.

Table F. 12: Key features of Jane’s learning strategies

 

Q1

- No separate studying for PBL class and exam: studying for PBL class is a part of
studying for exams

- Matching learning issues with objectives

- Studying learning issues if they are interesting. even though they are not on the
objective lists

- Learning issue study: reads books and coursepacks if they are good, uses library
or learning resource center

 

Q2

- Reading: reads old objectives with answers ﬁrst to get an idea of test information-
if she cannot understand, reads textbooks and takes notes
- First week of a domain: gets a general overview
- Second week of a domain: memorizes things

- Group study: asks questions, checks knowledge, focuses on group study for
conceptual material

- Integration strategies: group study

- Memorization strategies: ﬂashcards, charts, repetition (reads- takes notes- writes
on ﬂashcards- retypes - rewrites on chart)

- Selecting main information: practice quizzes, old objective, lectures, overlapping
information, and PBL class

- Checking knowledge strategies: practice quizzes and group study

- Lecture attendance: focusing information

 

Q3

- Goals: to be a good doctor and learn materials well so that she can apply in the
ﬁelds
- PBL helps
1. Independent study
2. Exam preparation (selecting main information)
3. Understanding and integration

 

 

 

- First year: lecture based: read coursepack, scribe notes, no textbook use,
teacher selected main information

- Second year: more use of textbooks, select main information by herself, more big
picture oriented, study one topic at a time

 

 

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