The efficacy of self-directed learning versus problem-based learning for teaching and learning ophthalmology: a comparative study

Figures & data

Table 1 Mapping of the ophthalmology and ENT courses within the curriculum

Phase I	Phase II		Phase III
First year Levels 1 and 2	Second year Levels 3 and 4	Third year Levels 5 and 6	Fourth year Levels 7 and 8	Fifth year Levels 9 and 10	Sixth year Levels 11 and 12
English	Orientation to integration	MSK system	History taking, communication skills	Rheumatology and orthopedic	Critical care
IT skills	Human body	Nutrition and growth	Physical examination	Neurology and neurosurgery	Family medicine
Scientific thinking skills	Principle of disease	GIT	Medical reasoning	Hematology and oncology	Health care management
Learning and study skills	Blood system	Urinary system	Laboratory medicine	Dermatology and plastic surgery	Forensic medicine
Introductory course	Immune system	Primary health-care	Basic imaging	ENT; two credit units	Research presentation
Communication skills	CVS	Research methodology	Gastroenterology and GIT surgery	Ophthalmolog; two credit units	Selective subspecialties
Physical education	Respiratory system	Volunteer services	Cardiology and cardiac surgery	Research publication	Patient with multiple problems
Natural premed sciences	Principle of research	Nervous system and special sense	Pulmonology and thoracic surgery	Women health	Emergency medicine
Health education		Endocrine system	Endocrinology and endocrine surgery	Child health	Elective III
Easy and research writing		Reproductive system	Nephrology and urology	Mental health
		Behavioral sciences Integumentary system Basic emergency Biostatistics and bioinformatics	Data management Elective I	Elective II
27 credit units	35	39	36	37	36
Total credit units of whole program		210

Abbreviations: CVS, cardiovascular system; ENT, ear, nose and throat; GIT, gastrointestinal; IT, information technology; MSK, musculoskeletal system; Premed, premedical.

Table

A 35-year-old convenience store manager with a history of non- insulin-dependent DM for 5 years presents to the Eye Clinic for his annual visit. He admits to a progressive blurring of vision since his last visit a 1 year ago. Reading street signs while driving seems more difficult. He is unsure of which eye seems worse. He does not wear contacts and uses over-the-counter reading glasses. He denies any flashes or floaters, diplopia, eye discomfort, or pain. The patient reports that he has been going through some tough times recently, with a difficult divorce approximately 6 months earlier. As a result of all the stress, his blood sugars have not been under good control and he feels he has been making this worse by eating a lot of junk food and not always taking his diabetic medications. His blood sugar has been as high as 400 and he was admitted to the hospital 3 months back for diabetic ketoacidosis. Past ocular history: No prior eye surgeries, no history of eye trauma, amblyopia, or strabismus. No prior diabetes findings in the eye. Ocular medications: None. Medical history: Hypercholesterolemia, obesity, DM Type 2, and hypertension. Surgical history: None. Family ocular history: Negative for macular degeneration, glaucoma, diabetic retinopathy, or blindness. Social history: 30 pack-year smoking history and drinks alcohol socially. Medications: Lisinopril, hydrochlorothiazide, metformin, and simvastatin. Allergies: None. Other systems: Normal. Ocular examination: Visual acuity: OD: 20/40, OS: 20/40. Intraocular pressure: OD: 16 mmHg; OS: 15 mmHg. Pupils: Equal, round, and reactive to light. No APD. Extraocular movements: Full OU. No nystagmus. Confrontational visual fields: Full to finger counting OU. External: Normal, both sides. Slit lamp examination: Normal. Dilated fundus examination: OD: Clear view, CDR 0.35; neovascularization of the disc involving ~50% of the disc; flat macula with multiple microaneurysms and hard exudates >500 microns away from the fovea, no clinically significant macular edema; multiple dot-blot hemorrhages in the retinal periphery in all four quadrants without retinal detachment. OS: Clear view, CDR 0.40 with sharp optic disc margins; flat macula with multiple microaneurysms and hard exudates >500 microns away from the fovea; no clinically significant macular edema; peripheral retina with multiple dot-blot hemorrhages in the periphery in all four quadrants.

Objectives: at the end of PBL sessions, all students will be able to:

1. Define diabetic retinopathy (DR)

2. Identify the pathogenesis, CP, classification, risk factors, and management of DR

3. Perform visual rehabilitation of patients with advanced DR.

Abbreviations: APD, afferent pupillary defect; CDR, cup disc ratio; CP, clinical picture; DM, diabetes mellitus; OD, right eye; OS, left eye; OU, both eyes; PBL, problem-based learning; Premed, premedical.

Table

SDL: Ocular tumors

Short-case scenario: A 45-year-old male patient presented with leukocoria plus DV and unilateral eye protrusion in his left eye. OCT revealed an ocular mass. How to manage this case?

At the end of this SDL, the students will be able to:

1. Identify eye tumors such as retinoblastoma, malignant melanoma, optic nerve glioma, and optic nerve sheath meningioma

2. Outline the management of a case with ocular tumor.

The most common ocular tumor presenting early with leukocoria is:

a) Retinoblastoma

b) Malignant melanoma

c) Optic nerve glioma

d) Optic nerve sheath meningioma.

Abbreviations: DV, defective vision; OCT, ocular computerized tomography; SDL, self-directed learning.

Table

Mohamed is a 30-year-old male from Al-Aqiq. Two years ago, he presented to Al-Aqiq Hospital suffering from nasal itching, sneezing, and mild fever. Dr Nowaf examined him and found that his nose appeared pale, the nasal mucosa was congested, and inferior turbinates were enlarged. Otoscopic examination revealed red, bulging tympanic membrane in the left ear. Based on these findings, Dr Nowaf prescribed an oral antibiotic, antipyretic, and nasal decongestant. One month following his first visit, Mohamed returned with scanty, offensive, mucopurulent discharge of the left ear. The discharge was associated with severe ear pain, hearing loss, tinnitus, and vertigo. On examination, there was a visible large posterior perforation in the tympanic membrane at the attic area with edematous mucosa of the middle ear, granulation tissue, and aural polyp protruding through the perforation. The doctor conducted good aural toilet and requested a computed tomography (CT) scan of the left mastoid bone. The CT showed a cavity within the mastoid. Two weeks later, Mohamed underwent surgery of his left ear and mastoid bone where some tissues were removed and another tissue was added. Mohammed felt good, and his hearing was restored.

At the end of the PBL session, the students will be able to:

1. Revise the anatomy and histology of the middle ear

2. Identify the etiology, clinical picture, and investigations required

4. Design the management plan for chronic and acute otitis media

5. Be aware of the risk factors, epidemiology, prevention, and control of acute and chronic otitis media.

An example of question applied

Which of the following diagnostic techniques is the most essential for otitis media?

a) Pneumatic otoscopy

b) Tympanometry

c) Tympanocentesis

d) Acoustic reflectometry.

Abbreviations: ENT, ear, nose and throat; PBL, problem-based learning.

Table

SDL: Neck mass

Case scenario: A 36-year-old female patient presented with a neck mass. The patient had a history of neck swelling since birth that remained dormant up to the previous 2 months during which the patient noticed the swelling was increasing.

At the end of SDL, the students will be able to:

1. Describe the approach to a neck mass

2. List different types of congenital neck masses

3. Describe the management of congenital neck masses

4. Categorize the types of premalignant lesions and their treatment

5. List different types of head and neck malignancies and their management

6. Identify the different types of thyroid carcinoma and their management.

Which one of the following thyroid tumors is considered a part of MEN syndrome?

a) Papillary

b) Follicular

c) Medullary

d) Anaplastic

Abbreviations: MEN, multiple endocrinal neoplasia; SDL, self-directed learning.

Figure 1 Student SDL and PBL scores for both the ophthalmology and ENT courses.

Abbreviations: ENT, ear nose and throat; Ophth, ophthalmology; PBL, problem-based learning; SDL, self-directed learning.

Table 2 Number and percentages of each group for SDL and PBL for both ophthalmology and ENT courses with statistical analysis by independent t-test

Course	Tool	High, n (%)	Moderate, n (%)	Low, n (%)	Very low, n (%)	t-test
Ophth	SDL	6 (10)	15 (25)	23 (38.3)	16 (26.6)	p-value of 0.00941 is highly significant
	PBL	14 (23.3)	20 (33.3)	15 (25)	11 (18.3)
ENT	SDL	14 (23.3)	17 (28.3)	16 (26.6)	13 (21.6)	p-value of 0.5 not significant
	PBL	16 (26.6)	17 (28.3)	10 (16.6)	17 (28.3)

Notes: p-value using t-test. Significant p-value between the two SDLs (p = 0.0308), significance obtained between SDL of ophthalmology and PBL of ENT (p = 0.03724). No significance was obtained between PBL of both courses nor between SDL of ENT and PBL of the ophthalmology course, with p = 0.3406 and 0.3340, respectively.

Abbreviations: ENT, ear nose and throat; Ophth, ophthalmology; PBL, problem-based learning; SDL, self-directed learning.

Table 3 Distribution of students according to their grades in SDL and PBL based on their total score in the ophthalmology course

Score	Tool	High	Moderate	Low	Very low	p-value using independent t-test
≥90	SDL	2	3	1	1	0.4071
	PBL	3	2	1	1
80–89	SDL	1	3	6	5	0.0196*
	PBL	7	2	3	3
70–79	SDL	1	4	11	6	0.01189*
	PBL	2	12	5	3
60–69	SDL	1	2	3	2	0.3209
	PBL	1	1	3	3
<60	SDL	1	3	2	2	0.4026
	PBL	1	3	3	1

Note:

* There are significant differences in the student group attaining score of 80–89% for SDL and PBL, and also in-between the student group attaining 70–79% for SDL and PBL with p=0.019 and 0.011, respectively.

Abbreviations: PBL, problem-based learning; SDL, self-directed learning.