Team-Based Learning: PMS vs. PMDD, Sexually Transmitted Infections, Pelvic Organ Prolapse and Menopause
|9710||February 13, 2014||10|
This team-based learning (TBL) module will instruct obstetrics and gynecology clerkship students on diagnosis and initial management of PMS, PMDD, sexually transmitted infections, pelvic organ prolapse and menopause. This module is ideally suited for an active learning curriculum in which students are accustomed to preparing ahead of time and working through questions and cases in the classroom. The module includes a Readiness Assessment Test to be taken individually and as a team, an Application Test to be taken as a team and the various forms we use logistically to deploy the module. The advantages of this module are: 1) less faculty preparation time is required 2) students are actively engaged in application of the material 3) no traditional lecturing is required. Students are assessed using multiple choice questions, and their group interactions are assessed by their peers. This module can be scaled to any size group greater than a minimum of 10 since students form teams of 5-7 for the exercise
Chuang A, Wang N, Belch J. Team-Based Learning: PMS vs. PMDD, Sexually Transmitted Infections, Pelvic Organ Prolapse and Menopause. MedEdPORTAL Publications; 2014. Available from: https://www.mededportal.org/publication/9710 http://dx.doi.org/10.15766/mep_2374-8265.9710
To formulate a diagnostic approach to patients with PMS, PMDD, sexually transmitted infections, pelvic organ prolapse and menopause.
- To distinguish PMS, PMDD and major depressive disorder.
- To administer standardized tools for diagnosis of PMDD.
- To explain the role of the wet prep in evaluation of vaginal symptoms.
- To identify major manifestations of common sexually transmitted infections.
- To define menopause and list the consequences of menopause.
- To classify various types of pelvic organ prolapse and to list additional steps of the physical exam for evaluation.
To outline an initial treatment plan for patients with PMS, PMDD, sexually transmitted infections, pelvic organ prolapse and menopause.
- To list indications and contraindications, risks and benefits of hormone replacement therapy.
- To list effective treatments for PMS and PMDD.
- To identify appropriate resources to find effective STI treatments.
- To describe the role of lifestyle interventions in the treatment of urinary incontinence.
- Premenstrual Syndrome, Premenstrual Dysphoric Disorder, Sexually Transmitted Infections, Pelvic Organ Prolapse, Menopause, Team-Based Learning, TBL
Obstetrics & Gynecology
Female Pelvic Medicine & Reconstructive Surgery
- Female Pelvic Medicine & Reconstructive Surgery
- Obstetrics & Gynecology
Interpersonal & Communication Skills
Knowledge for Practice
Personal & Professional Development
Evidence Based Practice
- Clinical Reasoning
Team-based Learning (TBL)
- Clinical Skills/Doctoring
- Medical Student
Authors & Co-Authors
Alice Chuang, MD
University of North Carolina at Chapel Hill School of Medicine
University of North Carolina at Chapel Hill School of Medicine
Duke University School of Medicine
Effectiveness and Significance
We feel Team-based Learning (TBL) enables students to be more active learners compared to our previous didactic structure, PowerPoint-driven lectures. We have worked hard during our 6 week clerkship to create a series of active learning sessions to “flip the classroom.” We hope this method will deliver material effectively and utilize the precious time we spend with students to work on clinical reasoning skills and the nuances of clinical care. Our are modeled after the process described by Parmalee et al (2001)
The implementation from a faculty and resources standpoint works well. Only one facilitator is needed for the whole session, usually myself or a generalist, and a content expert, who does not need to prepare any materials. This overall has been a rewarding experience for students, the facilitator and the content expert.
Special Implementation Guidelines or Requirements
Successful implementation of TBL requires the multiple steps listed above. These steps are by design constructed to create a learning experience which requires advanced preparation and encourages active participation with a focus on application of knowledge and skills.
The major limitation is time, which not only dictates how many readiness assessment questions and application questions can be included as part of the module but how many modules can be included during a busy clinical course.
TBL removes one factor which is often a limitation, faculty resources. It requires very few faculty. We have found that faculty are energized by these types of interactions with students and prefer this over giving traditional PowerPoint lectures.
Our hope is that by publishing our modules and the accompanying results, we will be add to the growing enthusiasm for TBL and active learning.
It should be noted that in the currently revised format, iRAT question 2, 3, 4, 5, 6, 10, 15, 16, 17, 18 and 19 have been significantly altered. Other questions may contain small grammatical edits. The analysis below is, of course, based upon the module prior to the currently submitted revisions. To date, 147 students comprising 26 teams have completed the TBL module, with an average of 72.8% (range 53-92%) on the iRAT; 94.33% (range 86-99%) on the gRAT; 53.33% (range 60-100%) on the App. (The file from one session of the TBL with 9 students comprising 2 teams was corrupted; thus, the data could not be analyzed. The scores from this session are not included in the analysis.) We made several revisions particularly in the first few sessions; most consisted of grammatical edits to clarify concepts. The submitted iRAT, prior to current revisions, was last updated on June 12, 2013. The submitted App, prior to current revisions, was last updated on May 2, 2102.
Overall, the RAT questions functioned well because the gRAT scores were so high, i.e. students arrived at answers to these foundational questions after discussion. The gRAT items missed most frequently, specifically more than once or twice, are graphed below, with item number along the x-axis and number of times this item was missed by the 26 total teams along the y-axis. (see Instructor's Guide for graph...data included here.)
Item 4: 11
Item 9: 12
Item 12: 5
Item 14: 14
Item 17: 7
All of these 5 questions were missed based on student misunderstanding of the concepts tested, respectively the importance of a menstrual diary in diagnosis of PMDD, the multiple anatomic areas of involvement in pelvic support defects, the high impact of lifestyle interventions in the treatment of urinary incontinence, the role of ovaries in menopause, and the high incidence of Chlamydia in the US. Since the first run of the module, appeals have been entertained and approved for questions 12 and 14 consisting of small wording changes. Student initiated questions and discussion frequently center around questions 2, 4, 8, 9, 10, 11, 12, 14, 17 and 18.
As far as App, students most frequently miss question 2 and rarely miss question 1, 4 or 5. There is rich discussion surrounding all of the questions. For question 1, students do usually understand that depression is part of the differential and that suicide risk should be assessed. Question 2 is often missed because students fail to see the acute nature of this patient’s symptoms and miss the significance of the history of a new sexual partner. Additionally, they often do not recognize the atypical presentation of HSV. Despite not knowing exactly what the POP-Q tells us, the students most frequently answer question 3 correctly. Perhaps this is because they remember question 12 on the RAT, which indicates lifestyle changes can improve urinary incontinence the majority of the time. Question 4 and 5 refer to the same clinical scenario. Though students rarely miss these, it is a great opportunity to discuss the implications of the Women’s Health Initiative, the role of hormone replacement therapy and appropriate postmenopausal preventive care.
When considering our TBL modules in general, allowing students to vote on scoring percentages was originally implemented to help the students feel invested in the process. Over time, these varying percentages have not affected participation, component averages, consistency or learning so this could be eliminated.
The content expert for these sessions rarely spends much time, if any, preparing for the discussion. We deliver in advance a copy of answers and provide one at the session as well. They express enjoyment of these sessions because of the interactive nature. As well, they enjoy eavesdropping on student discussion and can identify areas of misinformation by doing so.
Other uses for the module include a formative knowledge assessment using the RAT questions. App questions could serve as a framework for informal discussion between students and residents or students and faculty.
These particular topics are grouped together because of logistics. With a 6 week clerkship and multiple subspecialists, we originally had a particular subspecialty division responsible for all lectures on a given afternoon. Thus, the topics were naturally grouped in this way…obstetrics, endocrinology, urogynecology, etc. Our full lecture series was originally developed with expert input from our departmental educators. More recently, we updated it by surveying residents and faculty about the 58 Association of Professors of Gynecology and Obstetrics Educational Topics to assess priorities for formal didactic, focusing on topics that are vital but unlikely to be uniformly encountered during the clinical rotation, such as ectopic pregnancy, and topics that are so important they need to be systematically reviewed in formal didactic, such as preeclampsia. Over time, we have transformed our lecture series into a TBL series with a subspecialty content expert available for each session, i.e. maternal fetal medicine, reproductive endocrinology, urogynecology, etc. Currently our whole didactic series is made up of 5 TBL session, a Values Clarification session run by our Family Planning Division and gynecology oncology case review, as well as opportunities for self-directed learning. Of the TBL sessions, 1 has been accepted to MedEdPortal (2013-0380, accepted December 19, 2013), 1 is in review (MEP-2013-0381.R2, accepted for review December 27, 2013), this one is in the process of revision (submission ID MEP-2013-0382.R1, due back with revisions required January 30, 2014), and 2 still need to be submitted.
All topics are not equally represented in the RAT or App questions. We did not plan on evenly distributing the topics when writing the questions. We hoped to write questions which would cover the objectives, some of which are harder to grasp or harder to assess.
When comparing final course assessments such as the National Board of Medical Examiners exam, summative Objective Structured Clinical Exam, final clinical performance grades, students who have participated in TBL perform similarly to those who have not with no statistically significant differences. Thus, this approach has not disadvantaged students. Faculty and students, however, report higher levels of engagement and enjoyment during the session. Fewer faculty resources are required to run the session compared to a lectures series on the same topics.
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