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Using Problem-Based Learningto Teach Forensic Psychiatry

R. Andrew Schultz-Ross, M.D.Amy E. Kline, Ph.D.

Problem-based learning (PBL) is a method of teaching that uses hypothetical clinical cases, individual investiga-tion, and group process. This pilot project used a PBL approach to teach forensic psychiatry to psychiatric resi-dents. The change in the residents’ level of comfort with ve major domains of forensic psychiatry were evalu-ated at pre- and posttraining stages. The residents’ level of comfort with the educational issues of testimony,liability, and competence, as well as subjective ratings of their forensic knowledge base, improved signicantly.Postcourse satisfaction with the PBL method was moderately high. (Academic Psychiatry 1999; 23:37–41)

Dr. Schultz-Ross is Associate Clinical Professor, Universityof Hawaii John A. Burns School of Medicine, Department of Psy-chiatry. Dr. Kline is Afliate, Faculty, Clinical Studies Program,University of Hawaii, Department of Psychology. Address cor-respondence and reprint requests to Dr. Schultz-Ross, Alef Ani,75-5995 Kuakini Highway #311, Kailua-Kona, HI 96740.

Copyright 1999 Academic Psychiatry.

P roblem-based learning (PBL) is an educationalmethod that is growing in use in medical schools(1–3). PBL has been used and evaluated in medicalschools to teach a broad variety of topics, includingthose related to psychiatry (4,5). There are far fewerreports of its use in residency education, although itcould be argued that clinical case supervision is simi-lar to PBL (6). A PBL curriculum replaces most or alllectures with group meetings in which a clinical prob-lem is examined (7). Learning issues are identied,and the students seek information from publishedmaterial and faculty. Each student then returns to thegroup and reports his/her ndings as the group triesto understand and manage the clinical problem. Thegroup leader’s role is to facilitate the process ratherthan to give answers. PBL was developed to addressthe difculty of ever-expanding medical information;PBL models a method of learning and investigationto be continued after graduation (8).

Most published reports on the effectiveness of PBL are favorable. Recent research has suggested that

clinicians educated in PBL as medical students hadmore knowledge in the treatment of hypertensionthan their colleagues taught in a traditional format(9). PBL students may learn a different method of thinking, which could limit the accuracy of compar-isons with students educated in traditional formats(10). Nonetheless, those comparisons have indicatedthat PBL students may score better on more clinically

oriented tests, but lower on examinations that em-phasize basic sciences (11). A meta-analysis of studiescomparing PBL with traditional education supportedthis nding and revealed that PBL was rated morehighly in students’ evaluations and clinical perfor-mance, and rated about equal in clinical and factualknowledge (12). Although PBL appears to be able tocover necessary topics, students and faculty worryabout missed material, perhaps because traditionallectures cover topics in a more organized format (13).

It is probable that residency education in forensicpsychiatry is conducted primarily through lectures,except when a faculty member supervises a residentin the evaluation or treatment of a defendant or pa-tient (14–17). This direct exposure to forensic casesvaries among programs and individual resident ex-periences. There are efforts to standardize a didacticforensic psychiatry curriculum, but programs prob-ably still vary in terms of the number of sessions,depth, and focus of the lectures given to residents.Although forensic psychiatry is a recognized subspe-cialty with a growing number of fellowship pro-grams, educating general psychiatrists (and other

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physicians) about medicolegal issues is still an im-portant task of the academic forensic psychiatrist (18–21). The authors noted that whereas residents’ inter-est in actual cases was rather high, interest in thedidactic issues varied.

To evaluate its effectiveness, PBL was used in apilot project to teach forensic psychiatry to psychiat-ric residents. The residents were given written prob-lem descriptions and read them as a group. They at-tempted to solve each of the problems by reasoning,investigation, and sharing knowledge, with some re-source material provided by the facilitator. Our hy-pothesis was that the residents would report an in-creased comfort with forensic psychiatry issues at theconclusion of the PBL course.

METHODS

Participants

The participants were 23 residents in psychiatry.The residents’ mean age was 35.7 years (standard de-viation [SD]: 4.63 years). The residency is an Accred-itation Council for Graduate Medical Education-ap-proved university program, with a mixed urban/rural multisite setting anda multicultural population.The PBL program was offered over 2 consecutiveyears. There were 11 trainees in the 1993 section and12 in the 1994 section. There were no signicant dif-

ferences between the participants’ precourse comfortwith forensic issues or in their knowledge base be-tween the two years’ sections. Five residents were intheir rst year of residency, 13 in their second year,and 2 in their fourth year. Three individuals were vis-iting medical students or declined to identify the yearof residency.

Materials

The PBL materials consisted of four writtenprob-lems involving hypothetical patients. Each problem

had multiple page breaks to serve as pauses for thegeneration of incipient hypotheses, learning issues,and discussion. The rst problem involved a youngwoman who was vague and approximate in the tell-ing of her history, then more clearly psychotic.Shortly after initial antipsychotic treatment, she wasobserved outside of the clinic appearing very well.The psychiatrist then was asked to testify regarding

a previously unrevealed criminal matter. The issuesof malingering, tardive dyskinesia, Ganser’s syn-drome, and testimony as a treating clinician wereidentied as potential learning issues. The secondproblem involved a manic patient on a surgical ser-vice who initially refused surgery. After an alliancewas formed, he admitted to a prior violent felonyandthoughts of hurting someone else. The issues in thiscase included condentiality, competence in medicalsettings, reporting of prior felonies, and Tarasoff du-ties. The third case was of a young prisoner referredto a psychiatrist for violence. The man complainedabout prison rape. There were indications of plannedviolence on his part, but then a history of epilepsywas revealed. The case ended with a request for thepsychiatrist to conduct a forensic psychiatry evalua-tion of the man’s dangerousness. Identied learning

issues included prison violence, prison culture andsexuality, directed violence vs. nondirected violence,the treatment of violence, and the prediction of dan-gerousness. The last case was a patient with a historyof past lawsuits. She presented with depression and back pain. After other treatments were ruled out, thepsychiatrist prescribed a monoamine oxidase inhibi-tor. The patient later fell, which resulted in a ques-tionable, but possible, back injury. Her attorney al-leged that she experienced hypotension and had not been warned about it. Alcohol may have been a majorfactor. The psychiatrist testied at her deposition andtrial. At the latter, one expert witness for the plaintiff had a very different form of clinical practice, theotherappeared to have a general stance against medica-tions. Issues raised by this case included informedconsent, litigiousness, malpractice, standard of care,and the ethics of testimony. There were three consec-utive sessions in which these cases were analyzed.The residents attempted to solve each case’s dilem-mas and identify issues for further learning.

The evaluation measures consisted of four Likert-type scales, each measuring subjective individual

comfort with the forensic issues of violence, testi-mony, liability, and competence on an ordinal scale,from a comfort level of 1 ‘‘none’’ to 5 ‘‘high.’’ Asimilar 5-point Likert-type scale was used to subjec-tively measure forensic knowledge base. As part of the course evaluation, a similar postcourse 5-pointLikert-type scale was used to register resident satis-faction with the educational program.

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FIGURE 1. Mean subjective rating of comfort with domains of forensic psychiatry and knowledge base

4.5

4

3.5

3PrePost

2.5

2

1.5

1

0.5

0Testimony Liability Competence Knowledge Base Violence

Design and Procedures

This study used a within-subjects repeated-mea-sures design. Testing occurred in two sessions. Thepretest was administered before beginning the PBLprogram in forensic issues. The posttest was admin-istered at the end of the PBL course. Data were ana-lyzed by using Statistical Program for Social Scien-tists.

A small sample size and the use of multiple mea-sures were anticipated to present some confounds tothe research design. To compensate for the likely in-ation of signicance level resulting from multiplemeasures, a Bonferroni adjustment was made, hold-ing the experiment-wise signicance level at al-pha 0.05. It was also noted that this analysis would be able to detect effect size of 0.5 SD. Small-to-mod-

erate changes in comfort level or knowledge basewere less likely to be detected.Increased knowledge was expected to result in

increased comfort with forensic issues. Thus, it wasanticipated that the residents would become morecomfortable with the forensic issues on postcoursemeasures and that there would be a concomitant gain

in knowledge base. Therefore, a one-tailed analysiswas used for these measures.

RESULTS

A number of residents did not attend all of the ses-sions. There were 12 complete sets of data. The atten-dance compared favorably with didactic sessionsgiven to the same groups in the same years. Figure 1shows the results of change in the measured domainsof forensic psychiatry.

The residents’ comfort level with the issues of tes-timony, liability, and competence increased signi-cantly (one-tailed paired t-test: t 8.4, 6.5, and 3.3,respectively, df 22, P 0.01). The mean levels of comfort for these topics were testimony: precourse:2.28 (SD 0.89), postcourse 3.33 (SD 0.97 ); liability:

precourse 2.33 (SD 0.97), postcourse 3.28(SD 0.83); and competence: precourse 2.78 (SD0.73), postcourse 3.33 (SD 0.91). The residentsalso

reported an increase in comfort with the issue of vi-olence: precourse comfort 3.11 (SD 0.83), postcourse3.33 (SD: 0.69). These values just missed the prede-termined signicance level for the analysis ( t 1.81,

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df 22, P 0.048). The subjective ratings of the resi-dents’ knowledge base in forensic psychiatry also in-creased signicantly at the end of the PBL course. Fig-ure 1 shows the increase from a mean subjectiverating of 2.50 to 3.06 on the 5-point Likert-type scale(t 1.81, df 22, P 0.01).

The residents reported a moderately high level of satisfaction with the PBL course format. The meanlevel was 4.33 (SD 1.03, df 18).

DISCUSSION

There is much less literature on PBL for resident edu-cation, compared with medical student education.Evidence from medical student education indicatesthe PBL may activate prior learning and that the dis-cussion process stimulates learning and interest (22).Some residents expressed discomfort in the transitionfrom traditional learning to PBL; this nding is simi-lar to that seen in medical students who found PBLinteresting but questioned its applicability (23). Theinitial change to a PBL program may be the most dif-cult part (24). As reported in the literature on medi-cal students, the residents in this study were worriedthat all topics were not covered. Nonetheless, the res-idents appeared to be engaged and interested, and

they gave the program moderately high ratings. Thefact that there was the least increase in comfort re-garding violence may suggest that knowing moreabout violence may lead to more caution, and thusmay mitigate ‘‘comfort,’’ although the residents’ re-ported level of comfort at the start of the course washigher for violence than for the other categories. Thisstudy addressed self-reported knowledge base,which rose, but it was not compared with an externalmeasure of forensic knowledge.

This study did not compare PBL with traditionallectures. Data from the residency program indicatedthat the PBL course was rated highly and equivalenton average to a similar didactic course given by thesame presenter at a different time. Subjectively, theresidents appeared to be more enthused when thecases were discussed, either in the PBL format or aspart of a lecture. It seems possible that forensic casesmay be more interesting than didactic forensic issues.This program seemed to successfully link the two.However, this PBL program was a supplement to di-dactic lectures given at other times (not during thePBL course). Further research may need to be di-rected at a stand-alone program of PBL education forforensic psychiatry, with direct comparisons with tra-ditional formats.

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