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Problem-Based Learning: An Innovative Approach to Audiology Education Anne Marie Tharpe Judith A. Rassi Vanderbilt University School of Medicine and The Bill Wilkerson Center, Nashville, TN

Gautam Biswas Department of Computer Science, Vanderbilt University

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n recent years, there has been considerable discussion about the quality and quantity of education provided for audiology students preparing for clinical work (AAA, 1989, 1991; ASHA, 1988, 1991, 1992; Binnie & Goldstein, 1991; Cox, Bankson, Kidd, & Burkard, 1992; Cunningham, 1992; Goldstein, 1989, 1992; Humes et al., 1992; Humes & Diefendorf, 1993; Van Vliet, Berkey, Marion, & Robinson, 1992; Yates, 1989). Not only has there been a call to change the curriculum for entry-level clinical audiology students, but also a plea for innovative teaching techniques (Cunningham & Windmill, 1990, 1991; Rassi & McElroy, 1992a). Such concerns appear to be widely recognized by practitioners and educators and imply a pressing need for improving the preparation of clinical audiologists. However, reports that discuss results of improved classroom, clinical, and laboratory teaching have not been forthcoming (Rassi & McElroy, 1992a). This article presents an initial framework for a novel educational methodology in this virtually unexplored area.

Background The lack of research in both audiology and speech-language pathology education is striking, especially when considered in light of what has been accomplished in comparable professions such as medicine (e.g., Jason & Westberg, 1982;

Knopke & Diekelmann, 1981), nursing (e.g., de Tornyay & Thompson, 1987; Johnson & Purvis, 1987), psychology (e.g., Garb, 1989; Sklare, Portes, & Splete, 1985), social work (e.g., Cunningham, 1982; Kahn, 1981), and other allied health professions (e.g., Arand & Harding, 1987; Foley & Smilansky, 1980). Most educational investigations in communication disorders have examined only the clinical supervisory process and have focused primarily on speech-language pathology rather than audiology. Thus, an entire facet of the field of audiology education remains unexplored. Research that has already been conducted in higher education and professional preparation in other disciplines offers a foundation for initiating audiology education improvement efforts. The challenge is threefold: First, current practices in audiology education need to be analyzed to identify its problems. Second, innovative methods employed in related disciplines, especially medicine, present opportunities for improvement in audiology education. Last, experiences in building educational tools in related domains can be integrated with knowledge of audiology education to define a framework that combines important aspects of classroom, laboratory, and clinical education in audiology.

Audiology and Medical Education Audiology education programs and medical schools have similar missions and objectives and often encounter similar problems in achieving their goals. For example, both disciplines cover a significant amount of background knowledge in the basic sciences and pathology before embarking on instruction in effective clinical practice. Therefore, models for medical education can be adapted for audiology education. Several parallels are considered here. One parallel between education in audiology and medicine is the combined use of classroom, laboratory, and clinical teaching. Students obtain theory necessary for developing a broad knowledge base in their field from classroom instruction. Laboratory settings teach students specific skills and techniques and the use of sophisticated equipment and instruments. They provide opportunities for putting into practice concepts discussed in the classroom. Finally, clinical experience allows the student to integrate, apply,

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and refine the knowledge and skills obtained in the classroom and laboratory through real experience. In both audiology and medicine, practitioners must be able to continually work through patient problems that are both complex and novel. Diagnosis, treatment, and patient care are dynamic and ever-changing, requiring lifelong learning for participants to keep updated on current research and clinical practice (Kellum & Fagan, 1992). Clinical practice requires drawing from experiential knowledge, when possible, and from factual knowledge, when one encounters a novel problem. Self-directed learning, therefore, is necessary for audiologists and medical practitioners. Another important consideration is course and laboratory content. Course content and associated laboratory experiences in audiology are usually subject-specific and circumscribed as in, for example, hearing assessment, electrophysiologic measurement, anatomy and physiology of the auditory system, psychoacoustics, amplification, and aural rehabilitation. Clinical practicum experience, on the other hand, is necessarily more diffuse, encompassing all of these topics and more, as students are engaged in diagnosis and treatment. Traditional medical school curricula have also segmented education in this manner (Jason & Westberg, 1982), that is, by presenting body systems, specialty areas, and other discrete subtopics in separate courses. This limits opportunities for students to integrate and internalize information prior to clinical participation. Students may think of course contents as separate and unrelated, or as loosely related to each other. As a result, they fail to grasp the implications of such connections, which are very important in clinical practice. A final parallel considered deals with student evaluation. In medical education, basic science teachers and clinical instructors frequently evaluate student performance differently, with the latter group opting for more practical measures such as observation of students engaged in patient care, written simulations, student feedback, and oral examinations (Jason & Westberg, 1982). Empirical evidence suggests that this difference between audiology classroom and clinical teachers (that is, clinical supervisors) also exists, but that structured practical, oral, and/or performance examinations may not be as common for audiology students as they are for medical students. Investigators in health professions education (Corley, 1981; McGuire, 1983) and in medical education (Neufeld & Norman, 1985) emphasize the importance of these kinds of examinations in promoting student problemsolving. It is reasonable to suggest that if evaluation and management of patients is the ultimate goal of audiology training programs, the assessment of clinical reasoning skills is crucial. Certainly the ability of students to recall a large body of knowledge presented in class does not guarantee that they can apply any of that knowledge in a clinical situation (Barrows & Tamblyn, 1980). The ability to consistently and accurately diagnose and manage patients, however, does imply that students are more likely to have acquired sufficient factual knowledge. An added benefit has been noted in one audiology study where students who were given interactive practical examinations reported an increased understanding of their clinical competencies and a perceived improvement in self-evaluation skills (Rassi, 1988). Not withstanding these similarities, many differences 20

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between audiology and medical training appear in the implementation of educational programs in the two fields. For example, audiology students gain clinical exposure earlier in the educational process than do most medical students. In addition, audiology students are more likely to encounter greater diversity in the patient population they are seeing at a given time. More specifically, audiology students may receive a mixture of clinical experience in pediatrics, geriatrics, hearing aids, and other areas, all during one semester, whereas medical students are more likely to follow sequential rotations specifically in pediatrics, psychiatry, and internal medicine, among others. Although the combined approach of classroom, laboratory, and clinical teaching is common in all health professions curricula, this combination can vary in emphasis and sequence (Rassi & McElroy, 1992b). Such variation can be illustrated by comparing a typical medical curriculum and a typical audiology curriculum. In medical education, basic science coursework and associated laboratory experiences are usually completed by students before clinical practicum and corresponding clinical seminars are begun. This curriculum sequence and emphasis is, thus, different from the audiology model where, although some introductory and foundation courses precede clinical observation and practicum, many classroom and clinical experiences take place concurrently thereafter. Either curriculum approach has apparent advantages and disadvantages; both, however, may contribute to fragmentation in clinical education. For example, information provided in a lecture usually has no immediate and direct relevance to specific clinical problems that students encounter later, and is, therefore, often forgotten by the time the students start clinical work. Students understand and remember better when they are able to relate information to what is perceived as their ultimate goal of clinical practice (Ausubel, 1960). Fragmentation contributes to an inability to study interactions among different problems or pathologies. As a result, it becomes difficult for students to learn which aspects of a patient problem are important, which are not, and how problems should be prioritized. In addition, students become frustrated with the basic sciences and want to get on to real clinical practice (Barbato et al., 1988). (See Kent, 1989– 1990, for an in-depth discussion of the fragmentation of clinical service and clinical science in communication disorders.)

Educational Characteristics and Improvement Opportunities A reconfiguration of the discussion above is helpful in summarizing some of the characteristics and improvement opportunities in audiology education. Table 1 contrasts current educational norms with related future educational goals. This delineation emphasizes the need for more integrated clinical and classroom training as part of the educational curriculum. In summary to this point, although the lecture format has traditionally been seen as an efficient and convenient method for imparting information to students, the ultimate educational objective of clinical competence is not addressed by this approach alone. By recognizing that March 1995

TABLE 1. Current norms/future goals in audiology education. Current Educational Norms

Educational Goals

Patient problems: novel, complex

Updated, lifelong learning

Diagnosis, treatment: dynamic, ever-changing

Self-directed, lifelong learning

Course and practicum sequence: often fragmented

Skill building

Course content: subjectspecific; limited application

Integrated, applied learning

Practicum content: broad; full application

Integrated, applied learning

Performance exams: infrequent, tests of factual knowledge

Problem-solving, self-evaluation skills

students are active learners who learn by doing and reflection, we are better able to encourage the development of problem-solving and self-directed-learning skills that are essential for effective clinical practice. These observations suggest that a new nontraditional educational approach being developed in medical education, known as problem-based learning, may be adapted to meet audiology learning needs. A description follows.

Problem-Based Learning Medical Education Model In recognizing the limitations of conventional teaching methods and practice, medical educators have experimented with an innovative educational approach called problembased learning (PBL) (Barrows & Tamblyn, 1980). In PBL, learning occurs from the process of understanding and working toward the solution of a problem. In other words, students are given a problem first to stimulate further learning rather than first being provided with the basic principles and facts (independent of a problem-solving environment). This allows students to individualize their learning by recognizing and pursuing topics and concepts in which they lack knowledge. PBL methodology assumes that when we encounter difficult or complex patient problems that require us to research the literature and consult with experts for advice, we are much more likely to retain the information that we learn. Basic principles of anatomy, physiology, and pathology are then learned in the context of solving actual patient problems. In contrast, research suggests that much of the information provided in a strict lecture format is never absorbed (Miller, 1978). Further, despite considerable studying before a test, little of the information that has been memorized can later be remembered (Levine & Forman, 1973; Norman, 1973). A PBL curriculum typically de-emphasizes the lecture format as the primary source of learning, and emphasizes hands-on problem solving skills, self-directed learning, and independent and critical thinking skills (Barrows, 1983). Traditionally, a faculty tutor facilitates the learning process with small groups of students by guiding them through the resolution of a patient problem rather than telling them what

they need to know and learn. Instead of the traditional lecture format, faculty tutors are available during specific hours to answer students’ questions and provide requested information. The students, however, accept primary responsibility for researching all aspects of the patient problem, thus developing self-directed-learning skills in the process. As a group, the students discuss various aspects of the patient problem that they have researched and attempt to integrate their findings into a diagnostic and treatment plan. Unlike a subject-specific class lecture, this approach can encourage the application of multiple subject areas to the solution of the patient problem. Several medical schools have partially or fully implemented a PBL curriculum, and this continues to be a subject of current educational research (Almy et al., 1992; Engel & Clarke, 1979; Jason & Westberg, 1982; Kaufman et al., 1989; Neufeld & Barrows, 1974; Taylor, Pels, & Lawrence, 1989; Tosteson, 1990). A randomized control trial evaluating the impact of a PBL curriculum on medical students at Harvard Medical School concluded that those students acquired distinctive knowledge, skills, and positive attitudes regarding self-directed learning. In addition, it was found that they had a more satisfying and challenging medical school experience without loss of biomedical competence (Moore, Block, Briggs-Style, & Mitchell, 1994). No difference in examination performance was found between students in the PBL vs. those in a traditional curriculum in both the top and bottom quartiles of the Harvard class (Moore, 1991). The use of PBL in the clinical health sciences is supported by learning theory and research in problem solving. Two philosophies that have had a significant impact on instruction in this country are objectivism and constructivism. Objectivism maintains that experience has little impact in the structuring of the world; that the world is completely structured in terms of entities, properties, and relations (Duffy & Jonassen, 1992). The impact of this philosophy on instruction has been to assist the learner in acquiring and demonstrating mastery of factual knowledge. Constructivism, on the other hand, argues that meaning is imposed on the world by our experiences. This philosophy supports the use of learning through real-world experiences, e.g., problembased learning. Such theorists would claim that classroom teaching decontextualizes learning, thus making it difficult to bridge the gap between theory and clinical practice. Further support for a PBL curriculum comes from the ACT theory of cognition (Anderson, 1993), a means-end problem-solving structure. This theory assumes that when a problem solver encounters a novel problem, the problem solver will try to solve that problem by analogy to a similar past example. If this theory is correct, PBL instruction may provide newly graduated clinicians with a base of problem-solving experiences from which to draw in actual clinical practice. It is important to emphasize at this point that PBL instruction is not being advocated in isolation. Not all knowledge necessary for a complete educational background can be gained through PBL. The use of classroom lectures and laboratory experiences continues to be essential in audiology and medical education. PBL, however, can provide the contextual environment that appears to be critical for integrating factual knowledge and problem-solving skills. Tharpe • Rassi • Biswas

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Feasibility in Audiology Education Because of the similarities between the educational models in audiology training programs and those in medical schools discussed earlier, it is reasonable for audiology educators to also consider the use of PBL curricula. It would be ideal if clinical cases to which students were exposed were always illustrative of the course content they were currently receiving. Unfortunately, that is rarely the case. As previously discussed, the sequencing of the coursework and practicum experience and the subject-specific nature of the course content contribute to disparities between coursework and practicum experience. A PBL curriculum could help alleviate that problem by providing sequenced learning that lends itself to skill building and integrating knowledge by involvement in problem solving. Many techniques for presenting students with diagnostic problems have been advocated and could easily be used in audiology training programs. Providing students experience with real patients seems to be a logical teaching approach; however, this approach has several disadvantages. First, a patient may exhibit problems that are too complex for a student to analyze at a particular time. Second, patients are only available in certain settings such as clinics and hospitals. This may be a problem for some universities that are not equipped to place students in those settings on a regular basis. Third, a frequent complaint of students is that the supervisor takes control of a case because of time constraints and other practical considerations. This may leave the student distracted by feelings of embarrassment or inadequacy, which can seriously impede the learning process. Fourth, discussions between the student and the supervisor are limited in the presence of the patient. Finally, when using real patients for teaching purposes, it is not possible to provide comparable clinical experiences for all students (Barrows & Tamblyn, 1980). This discussion is not meant to suggest that student exposure to real patients is not worthwhile. In fact, real patients provide students with an appreciation for their field and the motivation to learn. There are, however, concurrent supplemental techniques used in PBL that avoid some of the disadvantages in working with real patients outlined above. Two of the more common techniques are written case histories and patient simulations. Written case histories can describe physical characteristics and complaints of the patient as well as test results. The major advantages of this format are that the case is available for the student at any time it is needed, for as long as needed, and as often as needed. The student can leave the case, research the literature or discuss the case with others, return to it at a later time, and apply what has been learned. Although the written case format is quite flexible, it does have its limitations. To a student, a written presentation of a case is abstract and does not challenge interview or observation skills. The student is primarily challenged to interpret and analyze the data presented. The skills of obtaining relevant information are not exercised with this process. The other major format for presenting cases to a student is patient simulation. Simulated patients have been trained to simulate actual patient symptoms. They can be hired to “perform” at appropriate times throughout a course or curriculum. They behave as real patients and can describe 22

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symptoms during an interview. Physical findings can be included as slides or overheads (e.g., otoscopic findings such as perforated tympanic membrane). A well-trained simulated patient can even provide feedback to the student regarding interviewing skills and interpersonal manner. This format requires considerable planning and training time and can be costly to implement. Godden and Fey (1990), however, effectively used university drama students as simulated patients in preparing audiology and speech-language pathology students for actual cases. At Vanderbilt University, we have begun experimenting with the use of a computerized patient simulation approach (Tharpe, 1994). The advantages of such a medium are numerous. First, as with the written case history format, the patient problem is available to the student whenever desired. The student can work on the problem, leave to do research or just take a break, and return to continue work on the case when convenient. Second, unlike the written case format that provides all relevant information to the student, the computerized format allows the student to exercise inquiry skills to obtain additional patient information. Third, diagnostic processes work most effectively when feedback is available at the time of reasoning (McArthur, 1987). Techniques can be built into the computer environment to provide some of this feedback, when required. Fourth, and most importantly, a computerized format can be designed to capture, save, and provide a hard copy of the detailed steps of a student’s solution. This can then be analyzed in detail to determine how the student solved the patient problem. The process of resolving a patient problem is just as important as determining the final diagnosis. Understanding and being able to explain the underlying mechanisms responsible for a patient’s symptoms is an important goal of expert diagnostic reasoning. Such evaluation, therefore, can be useful for assessing not only an individual student’s performance, but also the effectiveness of PBL as a teaching tool. Finally, the addition of artificial intelligence technology to a computer-based case presentation format provides the opportunity to go beyond the linear presentation of cases with simple feedback schema that exist in traditional computerized learning environments (Brown, Burton, & Bell, 1974; Clancey, 1979; Hollan, Hutchins, & Weitzman, 1984; Lajoie, 1993; Nathan & Resnick, 1992). It is beyond the scope of this paper to discuss these computer tools in detail; however, a brief synopsis is useful at this point. Unlike more traditional computer-assisted instruction, learning environments: 1. support cognitive processes such as memory; 2. share the cognitive load by providing support for lower-level cognitive skills so that resources are available for higher-order thinking skills; 3. allow learners to engage in cognitive activities that would be unavailable otherwise; in other words, students could explore various situations, even hypothetical and incorrect ones, which is often hard to do in real life; and 4. allow students to generate and test hypotheses in the context of problem solving (Lajoie, 1993).

Development of Problem-Based Learning Units In an attempt to evaluate a problem-based learning strategy for developing clinical reasoning skills in master’s March 1995

level audiology students at Vanderbilt University, a representative set of PBL cases was developed. A general methodology was adopted for the design of individual cases and the case library. First, the broad domain that is to be covered must be determined. This could be auditory brainstem response testing (ABR), aural rehabilitation, auditory pathology, etc. Second, the scope of problems to be addressed within the domain must be determined. For example, we selected pediatric ABR problems that include all degrees and types of hearing losses. Third, the desired student competencies to be targeted must be identified. The general student competencies selected were derived from a clinical reasoning model developed by Barrows and Tamblyn (1980), which is summarized as follows: 1. The clinician perceives initial cues from the patient. 2. Multiple hypotheses are generated to account for the patient problem(s). 3. A history, tests, and/or examinations are conducted to refine, validate, and eliminate hypotheses. 4. The large amount of significant data collected is encapsulated to form a comprehensive explanation for the patient problem. 5. Diagnostic and treatment decisions are made. These competencies are used to assist in the selection and design of specific cases. The fourth step involves the details of specific case generation and its incorporation into a case library. By way of example, the PBL cases generated at Vanderbilt University were designed in a written case history format that allows students to interact with patient problems in a manner that reflects the clinical reasoning process. Specifically, the cases were selected to supplement the teaching of basic pediatric auditory brainstem response (ABR) testing and interpretation skills. They directly reflect the model for PBL case development provided above. First, based on the proposed statement of competencies believed to be minimally requisite for clinical applications drafted by the American Speech-Language-Hearing Association Working Group on Auditory Evoked Potential Measurements (1989), competencies believed to be relevant specifically to pediatric auditory evoked potentials were placed on a master list. These specific competencies include, among others: 1. basic knowledge of anatomy and physiology of the auditory system; 2. conditions related to the auditory and nervous system in general; 3. knowledge of limitations of ABR; 4. acoustic characteristics of the stimuli; and 5. effects of changes in stimulus parameters. Well-documented pediatric cases that used ABR testing were then selected from clinical records in the Department of Otolaryngology at Vanderbilt University and the Bill Wilkerson Center. The competencies on the master list represented by each PBL case were checked off until all competencies were represented by the PBL cases. The PBL cases were then distributed to audiology faculty at several training institutions throughout the United States in order to obtain feedback regarding their adequacy in testing and developing the desired student competencies. Expectations regarding what the students should learn through their work on these problems were based on the

ASHA competencies and the clinical reasoning model presented above from Barrows & Tamblyn (1980). In addition, this model provided the basis for individual case structure. This structure divides the case into two components: (a) a set of presenting conditions that represents information to be presented initially to the students, and (b) the rest of the case information, both relevant and irrelevant, that is held back until the students inquire about it. This structure enables students to take the factual information that they have previously obtained through a lecture/laboratory format and apply that knowledge through the active process of problem solving. A specific PBL case example describes a 10-month-old infant with a history of premature delivery and subsequent complications including asphyxia and mild jaundice. The implemented case format, as discussed above, initially provides the student with only presenting case information, that is, parental concern regarding the hearing of their 10month-old. The student is then required to inquire further about case history, thus developing inquiry skills. At this point, the student begins to form intermediate hypotheses based on the growing quantity of data. Next, the student can obtain test results that will validate or refute the hypotheses, requiring the student to revise and refine the hypotheses accordingly. In this case, the test results initially appear to be contradictory, as acoustic reflexes are consistent with normal or near-normal hearing, but the ABR testing results in an absent wave V. When all of the history and test data are obtained, the student will be challenged to encapsulate the data, formulate a final hypothesis explaining the patient problem, and decide how to proceed with case management. The teaching goals of this unit include introducing the effects of prematurity on infants, reinforcing the limitations of ABR testing and, more specifically, the effects of neurological damage on the ABR, and reinforcing the importance of a test battery approach in pediatric assessment. The expectations for student performance are modified based on the individual student’s level of experience and background knowledge. PBL cases can be selected by instructors from the generated case library to initiate class discussion or they can be specifically selected to accompany a class lecture and highlight learning goals. Whether in a computer format, live patient simulation, or presented on paper, the cases can be indexed by domain concept(s) or by desired student competencies. Beginning audiology students can be provided a patient problem, break into small student groups for discussion and generation of hypotheses, research various aspects of the patient problems, and then independently conduct research on the patient problem before reassembling with other students. More advanced students may need less structure, hence work more independently, make initial hypotheses, and conduct research, that is, participate in selfdirected learning. Evaluation of a student’s problem-solving skills following PBL instruction can take a number of forms (Almy et al., 1992; Painvin, Neufeld, Norman, Walder, & Whelan, 1979; West, Umland, & Lucero, 1985). As discussed earlier, a computer format can incorporate sophisticated techniques to save details of a student’s problem-solving process for later analysis. Dartmouth Medical School has adopted an Tharpe • Rassi • Biswas

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evaluation procedure that uses a simulated patient (Almy et al., 1992). This procedure, referred to as the “Five Step” evaluation, occurs over a 5-day period. During this time, students interview a simulated patient, construct a list of problems and research issues, conduct the research, obtain information from the examiner as needed, and, finally, present oral and written reports on their research and patient management plan. The examiners then judge student performance based on fixed criteria. A prototype of a computerized learning environment has been designed to provide realistic problem-solving challenges to students and capture their reasoning steps throughout the process (Tharpe, 1994). This environment provides an artificial, but realistic, medium for experimenting with complex test equipment, and provides a set of patient problems for students to solve. As users solve the patient problems, hard-copy records of their problem-solving processes are stored for future analysis. Preliminary studies conducted with this system have resulted in the development of expert and student models that characterize problemsolving abilities in audiology. The identification of these characteristics of experts and students is essential to the ultimate development of effective audiology training strategies.

Conclusions Problem-based learning (PBL) is a teaching-learning method designed to develop independent, self-directed, problem-solving skills. This technique has been successfully used in medical schools throughout the world and warrants consideration as an addition to audiology training programs. PBL can be used to enhance lecture-format classes, or an independent PBL course can be designed to facilitate learning in specific or general areas of study. Indeed, the emphasis in this approach is on the facilitation of learning rather than on teaching. The fact that the practice of clinical audiology is shaped by a combination of scientific information, clinical manifestations, and diagnostic and treatment procedures, experimentation with problem-based learning integrated into audiology training programs appears to be a logical educational pursuit.

Acknowledgment The authors wish to thank James W. Hall, III, Noel D. Matkin, and Donald J. Schum for their earlier review of the problem-based learning units developed at Vanderbilt University. This work was supported, in part, by a Department of Education grant, #H029K30010.

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Key Words: problem-based learning, education, computer-assisted instruction, computerized learning environment

Tharpe • Rassi • Biswas

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