Problem-based learning (PBL) is an educational approach that utilizes the principles of collaborative learning in small groups, first introduced by McMaster 1Medical University. The shift of the higher education curriculum from traditional, lecture-based approaches to an integrated, student-centred approach was triggered by the concern over the content-driven nature of medical knowledge with minimal clinical 2application. The PBL pedagogy uses a systematic approach, starting with an authentic, real-life problem scenario as a context in which learning is not separated from practice, as students collaborate and 3 learn in this approach. The tutor acts as a facilitator who guides the students’ learning, while students are required to solve the problems by discussing them 4with other group members. The essential aspect of the PBL process is the ability of the students to recognize their current knowledge, determine the gaps between their knowledge and experience, and bridging them 5with new acquired knowledge. PBL is a holistic approach that gives students an active role in their learning. There are numerous studies describing the prevalence of empathy decline, depersonalization, emotional exhaustion, and other psychological 6,7stressors among physicians. The causes of these factors remain incompletely understood, but studies have linked them to the demands for time and emotional investment that physicians face. 

Given this background the present investigation was designed to assess the knowledge, attitudes and skills of the interns and to determine the effectiveness and perception of hybrid problem-based learning (PBL) approach in sensitizing the interns to empathy in the context of doctor-patient relationship.

MATERIALS AND METHOD 

The present study was conducted in the department of Psychiatry, Geetanjali Medical College & Hospital, Udaipur, Rajasthan. After obtaining approval from the institution ethics committee, 30 consecutive consenting interns posted in the department of psychiatry were recruited for the study. The study was conducted for a period of six months between September 2019 to March 2020.

The learning of empathy was facilitated by adopting a hybrid problem-based teaching-learning approach in a half day workshop format. Before conducting the workshop, departmental faculty sensitization was done.

A workshop was conducted with pre-test evaluation with 10 multiple choice questions (MCQs) (over 15 minutes). Then all interns were introduced and divided into four small groups of six to eight participants (30 minutes). A case was introduced in small groups and a faculty member facilitated a focused group discussion (over one hour), where, a) initial reactions of the group to the case were obtained, b) the underlying doctor-patients relationship and empathy principles of the case were elicited, c) specific Learning Objectives (SLOs) and reading material was provided, d) learning tasks were assigned to the group members and e) learning resources were identified. Then presentation of case and discussion among groups was conducted (over 45 minutes), followed by interactive lecture (video clip, power point presentation, role play, think pair share etc) reinforcement (one hour). Post test was conducted to evaluate the effectiveness of problem-based learning. The workshop was closed with reflection writing (RW) by the study participants for qualitative analysis. A specifically designed and validated feedback questionnaire with Likert scale rating was completed by the participants. 

Data analysis: The data obtained was analysed using descriptive analysis and student t-test. P value less than 0.05 was considered significant.

RESULTS

Total thirty interns were evaluated pre and post workshop based on PBL. The mean score of pre-test was 3.86±(1.2) and post test was 4.9±(1.9). The gain by interns after workshop was statistically significant (p<0.02).

Majority of the interns strongly agreed on all the questions, on few questions they were agreed and neutral but no one was disagreed or strongly disagreed on various question for feedback.

Majority of RW responses (Table 1) were quantified as “Empathy helps in better communication” (36.66%), empathy can be learnt (33.33%), it increases patient and doctor satisfaction (33.33%). It also increases the diagnosis accuracy and treatment adherence (26.66%) and interns wrote that they have understand difference between sympathy and empathy (13.33%) and it decreases the malpractice (10%). 56.66% of interns want to imbibe empathy, it would increase work satisfaction (26.66%), doctor is a healer (13.33%), it would decrease burnout (23.33%) and it would help in built relationship with patient (13.33%).

DISCUSSION

The Indian medical graduate (IMG) is unable to communicate empathetically. Reduced empathy decreases the trust between doctor and patients, increases violence against doctors; it also reduces treatment compliance and follow-up. Hence the competency “ethics empathy in doctor-patients relationship” has been added to the new competency based medical curriculum. The present study was conducted to find out effectiveness of problem-based learning to teach empathy.

The traditional method to teach students is to deliver a lecture. Nevertheless, moving from the linear way of thinking, a new advancement in organizing and delivering a lecture is needed which focuses on understanding, motivation, and analytical way of thinking. Problem based learning (PBL) is a method of learning in which the learners use a systematic, 8 learner -centered inquiry process to solve a problem. It was developed basically in medical education to help shifting from a subject or lecture-based curriculum to an interdisciplinary one guided by the real-life problems. Medical education and practice require a cognitive ability that includes problem solving, critical thinking, decision-making, clinical judgment, team work and communication. This is needed to prepare a competent IMG. 

In the present study, a workshop was organized to sensitize interns regarding empathy based on PBL. Pre workshop mean score was 3.86±1.2 and it was found 4.9±1.9 in post-test. The gain by interns was statistically significant. When compared to other studies, various researchers had found effectiveness of PBL. Because of its effectiveness numerous 13,14 medical schools have adopted PBL into their educational program following the lead of McMaster University Medical School in Ontario, Canada (1960s), and more than 80 % of medical schools in the United States of America now have some form of PBL in their programs.

The importance of feedback has received extensive emphasis on medical education literature. Medical educators consider feedback as the cornerstone of medical education. In current study, interns’ feedback 11 on a five- point Likert scale was taken for teaching learning method and to sensitize interns regarding ethics-empathy.

Many researchers have emphasised the use of RW in medical education. Reflective writing could be a powerful means of developing empathy and developing their philosophy of care. Additionally, 12 some authors stressed these empathetic skills and 13, 14 “humanistic” competencies as essential to care for patients effectively. In the present study, interns 15 wrote narratives on ethics-empathy workshop based on PBL. Majority of interns 56.66% want to imbibe empathy, it will increase work satisfaction (26.66%), doctor is a healer (13.33%), it will decrease burnout (23.33%) and it will help in built relationship with patient (13.33%). Cherie Tsingos-Lucas et al found that RW is predictor of academic success at the end of unit test, semester written examination as well as oral examination but not for video counselling.

CONCLUSION

Hybrid problem-based learning approach is an effective teaching-learning method for empathy in doctor-patient relationship. The use of reflective narratives, role plays and movie clips are perceived by learners to be effective in learning empathy in doctorpatient relationship. Now it is time to incorporate PBL in medical ethics education.

Conflict of interest: None

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The authors declare that they received Institutional Review Board / Ethics review or approval.

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