Team Based Learning: Fibroids, Normal and Abnormal Uterine Bleeding, Amenorrhea and Infertility
|9715||February 13, 2014||1|
This Team-based Learning (TBL) module will instruct obstetrics and gynecology clerkship students on diagnosis and initial management of amenorrhea, fibroids, abnormal uterine bleeding and infertility. 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, Beckham A. Team Based Learning: Fibroids, Normal and Abnormal Uterine Bleeding, Amenorrhea and Infertility. MedEdPORTAL Publications; 2014. Available from: https://www.mededportal.org/publication/9715 http://dx.doi.org/10.15766/mep_2374-8265.9715
To formulate a diagnostic approach to patients with infertility, abnormal uterine bleeding, fibroids and amenorrhea.
- To characterize the hormone changes and fluctuations of a normal menstrual cycle.
- To characterize the hypothalamic-pituitary-gonadal hormone axis and describe causes of different pathological disruptions of the axis.
- To distinguish normal and abnormal uterine bleeding.
- To describe uterine leiomyomata subtypes and associated risk factors, symptoms and treatment approaches.
- To define pathophysiology and clinical presentation of different types of infertility.
- To describe indications, normal findings and expected pathologic findings for different diagnostic procedures including: pelvic ultrasound, endometrial biopsy, saline infusion sonohysterogram and hysterosalpingogram.
To outline an initial treatment plan for patients with infertility, abnormal uterine bleeding, fibroids and amenorrhea.
- To list consequences of untreated amenorrhea.
- To list medications used and their mechanisms of action.
- Fibroids, Leiomyomata, Leiomyoma (MeSH), Team-based Learning, TBL, Normal Menstrual Cycle, Abnormal Uterine Bleeding, Amenorrhea (MeSH), Infertility (MeSH)
Obstetrics & Gynecology
- Reproductive Endocrinology/Infertility
- Obstetrics & Gynecology
Interpersonal & Communication Skills
Knowledge for Practice
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
University of University of North Carolina at Chapel Hill 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
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 in the series during one rotation. Additionally, the scope of the readiness assessment and application questions can be improved upon and expanded either to include more subtleties or to involve more components in the answer.
Our hope is that by publishing our modules and the accompanying results, we will be able to garner more feedback from other institutions and experiences in order to improve the module.
Additionally, sometimes the students are uncomfortable with the peer feedback portion of the exercise. Over time, we have observed that students become more familiar and comfortable as this has become more common across our school's curriculum.
To date, 199 students comprising 34 teams have completed the TBL module, with an average of 80.1% (range 50-100%) on the iRAT, including 4 perfect scores; 99.26% (range 96-100%) on the gRAT; 57.6% (range 20-80%) on the App. We made several revisions particularly in the first few times we ran the session, many just simple wording changes to clarify concepts. The submitted version, prior to revisions, (last updated September 18, 2013) had 20 questions.
We ran statistics for the initially submitted questions. 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. After major revisions based on reviewer feedback, question 12 was removed and question 20 put in its place to preserve the integrity of the IF AT used for this exercise. The gRAT items missed most frequently are listed below
Questions 6 and 11 were frequently missed because in their original format, the stem contained the negative words EXCEPT and NOT respectively. This has been edited in the current submitted version. Questions 8 and 16 were missed based on students’ misunderstanding about establishing normal ovulatory function and treatment of anovulatory bleeding. Appeals have been entertained and approved for questions 3 and 13 consisting of small wording changes. Student initiated questions and discussion frequently center around questions 3, 8, 13 and 16.
As far as App, students most frequently miss question 2 and rarely miss questions 1 and 4. There is rich discussion surrounding all of the questions. For question 1, students debate the necessity of a myomectomy. For question 2, discussion centers around the correct sequence and indications for these tests, the absolute risk of hyperplasia or carcinoma and the distinction between pelvic ultrasound and saline infusion sonohysterogram. For question 3, students struggle with the exact hormonal abnormality in this patient. Though students often guess the correct answer to question 4, they often do not truly understand endometrial ablation. For question 3, the students debate the appropriate order of the testing as well as the costs.
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 five TBL sessions, a Values Clarification session run by our Family Planning Division and gynecology oncology case review, as well as opportunities for self-directed learning.
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.
This information is made available under the Creative Commons license.