INTEGRATING ICTS TO PBL METHODOLOGY WITH

APPLICATION IN THE FIELD OF GYNECOLOGY AND

OBSTETRICS

Valdecir Bertoncelo, Laudelino Cordeiro Bastos

Cesumar/PUCPR, Guedner Avenue, 1610, Maringa, Brazil

Flávio Bortolozzi, Ana Paula Rodrigues

Department of Computing, Cesumar/PUCPR, Guedner Avenue, 1610, Maringa, Brazil

Keywords: Problem-based learning, ICTs, Education.

Abstract: This study is an analysis of a support system for learning the Gynecology and Obstetrics discipline in a

Medicine course using the PBL methodology. Its objective is to point out a computer model that can

measure the similarity index between the patient’s anamnesis as done by the student and the solution

proposed by the professor. The study also presents concepts of the PBL methodology and its several

applications, as well as the techniques used in learning with the use of this methodology. Additionally, it

shows the actual iteration of ICTs with the PBL methodology. It is this hoped that the investigative analyses

and the implementation of this system offers students possibilities to experience in anticipation the daily

routine of their future profession, with the aim of aiding them in the teaching-learning process by creating

the conditions to help the instructor in evaluating the student’s performance, while giving the student the

chance to debate the solution proposed by the professor.

1 INTRODUCTION

We live in a world in constant change, powered by

great technological advances, of which education

could not possibly be immune. Currently,

Information and Communication Technologies –

ICTs are greatly aiding the teaching/learning

relationship in education, and the Internet has been

decisive in presenting new alternatives for teachers

and students alike. Many educators and researchers

have been using new methods and paradigms in the

education field. In the medical field, new

methodologies for teaching and learning have

appeared; among them is Problem-Based Learning –

PBL. Besides to the diversification of the areas in

which PBL has been applied, the introduction of the

ICTs has created new virtual platforms, and new

software programs are integrating solutions and

adaptations for the development of PBL-based

teaching and learning.

Medical education in particular has taken a more

direct approach in this field, and today there are

several success stories in the formation of physicians

and healthcare professionals.

The presentation of clinical cases is one of the

main points in the teaching of medicine using the

PBL methodology. The premise for the use of this

methodology is to offer students the possibility of

experiencing in advance the daily routine of their

future profession, with the objective of facilitating

their learning process by creating the ideal

conditions for both the professor (in evaluating the

student’s performance) and the students themselves

(by allowing them to discuss the solution proposed

by the professor).

In (Rodrigues, 2006), a study was conducted to

guide students and professors in developing teaching

and learning strategies in Gynecology and Obstetrics

according to the PBL method. This study was

developed as part of the Learning Program in

Gynecology and Obstetrics at the Pontifícia

Universidade Católica do Paraná – PUCPR, for the

Women’s Health discipline. After a detailed analysis

of the research, a need was detected to incorporate

into the system an instrument to measure the

329

Bertoncello V., Cordeiro Bastos L., Bortolozzi F. and Rodrigues A. (2009).

INTEGRATING ICTS TO PBL METHODOLOGY WITH APPLICATION IN THE FIELD OF GYNECOLOGY AND OBSTETRICS.

In Proceedings of the International Conference on Health Informatics, pages 329-336

DOI: 10.5220/0001555003290336

 SciTePress

similarity in the paths followed by the students in the

course and that predetermined by the professor. This

congruence was recorded into the system after an

analysis by the faculty member responsible for the

Gynecology and Obstetrics course. Student data and

the professor’s answer sheet have been stored into a

data base.

Considering the data contained in the data base,

the need was verified to obtain an automated or

semi-automated solution, in an adequate format, in

order to provide a greater level of autonomy for

students in the teaching/learning relationship. In

other words, it was necessary to add into the system

a module that allowed for a match between the path

taken by the student – step-by-step, from the

beginning to the end of the clinical case – and the

solution proposed by the professor, thereby

presenting a similarity index between the two

approaches.

In this manner, the system contains a

computational model that allows the measurement of

the similarity index between the patient’s medical

history and the solution proposed by the professor.

Based on this index, it is possible for students to

measure and analyze where the divergence took

place between the decisions they made and those

indicated by the instructor. Thus, the results obtained

in this work can contribute to learning within the

medical community, as well as in the development

of medical students.

This study introduces the concepts of PBL

methodology and its many fields of application, as

well as the techniques used in PBL-based learning. It

also features a study on the anamnesis in the clinical

cases used in Gynecology and Obstetrics Learning

Program at PUCPR. Furthermore, it highlights the

current interaction between ICTs and the PBL

methodology. It concludes with an analysis and

discussion of the contributions this system can offer

to the medical community.

2 PROBLEM-BASED LEARNING

2.1 PBL and its Applications

PBL methodology was first developed in Canada in

1965, within the medical curriculum of McMaster

University. It represented a split from the learning

philosophies of the time, in which (Burgardt, 2000)

affirmed that the teaching of traditional medicine

was already geared towards the application and

repetition of the same practices, in a methodology

that used expository lectures, guidelines, summaries

and knowledge and the main reference points for

medical education.

Additionally, it is important to consider that

upon the implementation of the PBL methodology,

the educational process shifted towards four mental

spheres of the student – the education of behaviors

and attitudes; learning and discovering; learning

how to do; learning to coexist and learning to be

(Delors, 1998).

In the PBL methodology, traditional expository

lectures are not abandoned altogether, but take on the

purpose of clarifying unresolved issues from the

problematization stage (Behrens, 2005).

According to Ribeiro (2005), the PBL approach

is used almost worldwide, with characteristics

capable of promoting student learning, while also

aiding in the development of the professional

abilities and attitude expected. One of the greatest

benefits of this methodology is precisely that it

approaches the problem as a starting point for the

study process, focusing and motivating the learning

of new concepts.

In (Amaral, 2007), there is a description of two

experiments conducted with medical students,

aiming at evaluating whether these students could

take part in the Osce (Objective Structured Clinical

Examination), which evaluates beginning medical

students regarding their basic clinical abilities. Two

groups of students were submitted: the first group

was formed by students who had studied under the

traditional methodology, and the second was

composed of students from universities that used the

PBL methodology in their medical education

curriculum. The values were quite close, between

the two groups and between professors. The

conclusion was that students in training can be used

as reliable examiners in an exam of basic clinical

abilities for beginning students. Therefore, neither of

the two aforementioned methodologies was

responsible for the difference in student results,

which to a certain extent does not guarantee greater

development of students from one or the other

In (Johnstone, 2006), the importance of PBL is

analyzed as a method for the facilitation of learning,

and has made use of several tools to engage students

in different educational activities, such as: tutorials,

problem-solving, workshops, exercise groups, etc.

In the current decade, several technologies have

aided the education field; the Internet has certainly

had a decisive role in new solutions in the teaching-

learning relationship. Within PBL, in addition to the

diversification in the fields of application, new

virtual platforms have integrated solutions and

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adaptations for the development of PBL-based

teaching and learning.

In an article by (Amen & Nunes, 2006), a

discussion is presented on the use of ICTs as a

pedagogical option for creating a learning

environment. The article also features and evaluation

of the contributions these technologies can make to

the interdisciplinary requirements contained in the

mandatory curricular guidelines for medical schools.

According to (Amen & Nunes, 2006), ICTs can

facilitate the interdisciplinary process, as they

feature a series of advantages as compared to the

conventional learning methods and facilitate the

immediate exchange of information, the

visualization of sub-tasks as parts of wider tasks, the

tailoring of information to individual learning styles,

encouraging exploration, greater organization of

ideas, greater integration and interaction, improved

speed in information retrieval, greater power of

distribution and communication in the most varied

contexts.

The work of (Masarenti Jr. et. AL, 2006) features

a report on the use of open software in distance

education in the field of Medicine. This study

describes the technological support used by the

Edumed Institute for Medical and Health Education,

based on the six-year experience of that institution.

The support is based mainly in two Virtual Learning

Environments: Teleduc and Moodle. Teleduc was

developed by the Núcleo de Informática Aplicada à

Educação at the Universidade de Campinas

(Unicamp) (Rocha, 2002). This environment

features several tools for administration,

coordination and work, which significantly aid

professors in the authoring, follow-up and evaluation

of their learning proposals.

Moodle is an open software program for course

management, similar to TelEduc, but which some

additional advantages – the ability to implant extra

modules, greater flexibility in the use of tools and

the selection of appearance and layout, and the

possibility of using the same user profile for other

course, according to (Dougiamas, 2003).

With the use of these technologies, several

courses have been implemented and ministered, and

many consulting jobs have been conducted by the

Edumed Institute. In regards to extending the

functionalities of Teleduc, the Edumed team

designed and implemented – among other

improvements – a system of online authorship and

management of multiple-choice and open-answer

questionnaires, integrating them to the Teleduc

menu and tools. This allows for the effective

evaluation of distance-education students that make

use of their courses.

Therefore, with the evolution in ICTs, the PBL

methodology is no longer confined to the medical

education field. It can now be applied into a much

wider scope that transcends health education and

spreads into several other areas that mold their

curricula to the medical model.

The use of the PBL methodology in Brazil began

at the Universidade de Marília in 1997. Soon after,

in 1998, it was implemented at the Universidade

Estadual de Londrina. The PUCPR Medical School

began applying PBL starting in 2000.

2.2 The PUCPR Case

The purpose of implementing the PBL methodology

at PUCPR was precisely to build an environment

where, by having students actively participate in

solving the problems presented by professors, they

would build the basis for their own learning and

professional development.

Faced with the challenge, PUCPR began to use

the PBL methodology for classes. The students are

divided into groups of 8 to 15 members, which meet

twice a week for case studies. Each of the groups has

the participation of a tutor, who plays the role of

facilitator in the teaching-learning process. The

tutors themselves meet in groups of two to conduct

theoretical classes and to complement the

knowledge acquired by students. Evaluations are

conducted every other month, with a final exam at

the end of the bimester.

All case studies presented by the tutors during

meetings with students are elaborated by the

course’s group of tutors. These cases are built with

predetermined results in structured form, and serve

as motivation for students to achieve a critical view

and develop skills for solving the problems that are

presented, as well as creating a sense of

responsibility that will aid them in their conduct as

professionals.

To believe in the principle that presenting

clinical cases is one of the main points of teaching

Medicine through the PBL methodology, as well as

the premise for using this methodology, is to offer

students the possibility to experience in advance the

daily routine of their future profession. Believing in

these principles, the PUCPR Medical School, in its

Learning Program in Gynecology and Obstetrics,

implemented the PBL methodology and began to

create a collection of clinical cases, which have been

optimized in an efficient and effective manner.

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Additionally, PUCPR has a Graduate Program in

Health Technologies, with the main objective of

integrating and using new technologies in the health

care field. Thus, the aim of this work is to give

continuity to studies on the teaching-learning

process, and is inserted in its models of research. For

this study, research works were developed beginning

with an evaluation of Internet access viability and

the interest of students in a support system that

would offer the possibility solving clinical cases in

gynecology. Next, a tool was developed to classify

exercises and practice, with the concern of creating a

user-friendly interface and matching the teaching

methods applied at PUCPR. This resulted in several

research projects, among them (Rodrigues, 2006),

whose aim was to obtain a Gynecology and

Obstetrics Teaching Support System. The main

objective was to study, specify and implement a

system, based on the Internet platform, of support

for the teaching of Medicine through the solving of

clinical cases. The tool was tested by a sample of

students of the ninth period of Medicine, who were

able to analyze the ease of use, which was

considered “easy” by 90% of students. The

applicability to the study method was also analyzed;

95% of sampled students affirmed that the tool

stimulated them to think about the clinical case, and

65% of students indicated that the case solved using

the tool has the same degree of difficulty as that

discussed in the tutorial.

This system further allows the professor to

analyze in detail the solution found by students to

the cases, using the PBL methodology. The solution

is given in graphic form, making visualization easier

and allowing tutors to check for possible hitches in

the teaching-learning process.

3 THE APPLICATION

3.1 The System

The system (Rodrigues, 2006) was developed in the

Program in Gynecology and Obstetrics at the

Pontifícia Universidade Católica do Paraná –

PUCPR, has as its basic characteristics the features:

 Access - Login: each user (student or tutor) has

his own credentials for access, recording of

solutions and all actions carried out for the

solution.

 Solution: graphic representation of user-selected

variables.

 Variables can be added or removed from the

solution.

 Follow-up questions can be defined for these

variables by the tutor at the time of creation of

the clinical case.

 Diagnostic Impression: open fields for answers

on diagnostic hypotheses, differential

diagnostics, conduct and additional exams.

 Comparison: the solutions of all students and

tutors can be compared through a graphical

interface.

 Printing: all solution items are displayed, to be

printed if desired.

 Statistics: the results of solved cases are

presented with the following information:

student’s name, selected hypothesis, differential

diagnosis, exams and conduct, duration of

solution, start time, end time, number of

variables included.

The system initially interacts through the modules

presented in Figure 1, identifying the requirements

that originated the need.

ccess the

system

Functional

uirement 3

Solve Clinical Case

Functional

Requirement 1

Functional

uirement 5

Compare Solution

Functional Requirement 4

Functional Requirement 6

System

Figure 1: System Modules – first interaction – Source:

Rodrigues (2006).

server

Users

data

Figure 2: Initial system architecture – Source: Rodrigues

(2006).

After the construction of use cases was

completed, the data base model was created to store

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the clinical cases, user information and their

respective solutions.

In Figure 2, the proposed architecture is shown,

in which the tutors and students specify a URL from

a computer connected to the Internet. At the other

end of the network, there is a server that responds to

this access request.

The Access Module was developed with the

objective of guaranteeing security, with the student

using a login and password to begin the first records

of solving the clinical case. At the moment of user

authentication, the following data are recorded in

the solution of the clinical case, in the form of logs

(records of activities generated by system computer

programs):

a. Number of case being solved.

b. User code.

c. Performed action.

d. Date and time.

In order to access the system, students must

indicate a username and a password previously

registered at the site. When building the clinical

case selection module, a clinical case variable

selection screen was created, in which the clinical

findings are displayed in selection menu format.

They vary in position from case to case – at each

solution start, it is located in a different order. This

prevents students from fixing item positions instead

of selecting the variables in the sequence they

consider adequate. This structure was positioned

laterally on the screen to allow more space for the

presentation of answers to the requested questions.

In the Construction of Logs, two types of logs

were developed, in order to enable the verification

of the activities conducted by students during

solving. The two types of logs are:

 Navigation

: with the actions of visualizing case

description, solve the case, fill out diagnostic

hypothesis and compare the clinical case.

 Request

: records the activities during variable

selection, with inclusion and removal of

elements.

The objective of this module is for students to

request information about the patient based on the

selection of items from the menu. As they select the

question, the patient’s answer is displayed on the

screen.

In Figure 3, all system modules are presented in

the second iteration

with the requirements that

generated the need. It demonstrates the relation

between the impression module and the solution

comparison module. This indicates that, in order to

access this module, the comparison module must

have been previously accessed.

The remaining use cases were described to

define the new system modules::

Use Case 4: Record Diagnostic Impression;

Use Case 5: Follow-up questions

Use Case 6: Access statistics;

Use Case 7: Include new clinical case.

ccess the system

Functional

requirement 3

Solve Clinical Case

Functional

requirement 1

Functional

requirement

Record Diagnostic

Impression

Functional

requirement 8

Compare

Solution

Functional

equirement 4

Functional

requirement 6

ccess

Statistics

Functional

requirement 6

Follow-up

Questions

Functional

requirement 7

Print Solution

Functional

requirement 9

System

Figure 3: System Modules – second interaction – Source:

(Rodrigues, 2006).

The system contributed efficiently to the

insertion of ICTs in the medical education

environment, specifically in the field of gynecology

and obstetrics. This gives students a support tool that

gives them information of previous clinical cases,

which serve as reference in their professional

development for studying new case, as well as

giving them quick and specific access.

The system evaluation in the second iteration

was conducted an acceptance test, in which the

tutoring professor, along with a group of 15 of

gynecology and obstetrics students , used the tool as

a group during a tutorial, in which they discussed the

clinical case as usual and then began solving the

case using the proposed tool. At the end of the

tutorial, the students answered a system evaluation

questionnaire, made up of five closed questions

(YES or NO) and one open question for

observations. Of the 15 students, five declared there

had been changes in the discussion of the case in

class with the aid of the tool. The students’

observations were:

 It enables comparisons among classmates and

with the professor.

 The tool required greater need for clinical

knowledge.

 Tool features easy visualization.

 It is a unique tool; it improves interest in

discussing the case.

 It promoted simultaneous discussion among

INTEGRATING ICTS TO PBL METHODOLOGY WITH APPLICATION IN THE FIELD OF GYNECOLOGY AND

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333

students.

The gynecology and obstetrics students were

questioned about their interest in working on other

cases using the tool; 73.33% answered YES and

26.67% said NO. In an interview with the tutoring

professor, she considered the tool ready for wider-

scale tests. These tests would be conducted with the

students solving clinical cases separately. This

would be considered the final step in the

development stages.

At the end of the system development stages, it was

confirmed that the system could be used by a larger

number of students. In order to validate the system,

20 medical students undergoing gynecology

tutorials took part in the process.

After the system was validated, the discussion of

cases by the students was studied. It was believed

that the students who had added and removed

variables were analyzing all possibilities in order to

form a diagnosis, in the same manner as they did in

the classroom during the tutorials.

Lastly, clinical case comparisons were made. After

filling out the entire clinical case, the complete

solved case solution is displayed, after which the

gynecology and obstetrics student can select other

answered cases in order to visually compare case

solutions. The student may not return to the case to

alter it after finishing the solution to the clinical

case.

At this stage and after analyzing the project

(Rodrigues, 2006), it was verified that there is no

comparison between the paths taken by the medical

student and that predetermined by the professor,

which was recorded according to an analysis by the

faculty member responsible for the Gynecology and

Obstetrics discipline. The data are stored inside the

system, but their analysis was not done directly.

Based on that need, we observed the

importance of proposing a solution that aims to

automate or semi-automate a process that can make

a match between the path taken by the student, step-

by-step, form beginning to end, regarding the

clinical case and the solution proposed by the

professor.

3.2 Analysis and Discussion

In item 2.1, we showed that in the current decade,

several ICTs have contributed to the education field,

and that the Internet has been decisive in presenting

new solutions in the teaching / learning relationship.

Moreover, the use of the PBL methodology, in

addition to diversifying the areas in which it is

applied, new virtual platforms and software

programs are integrating solutions and adaptations

for the development of PBL-based teaching and

learning, thus demonstrating an ever-greater

integration between the PBL methodology and ICTs.

According to items 2.2 and 2.3 and after a

detailed analysis of the obtained results, it was

verified that there is no automated or semi-

automated comparison between the paths taken by

the medical student and the predetermined path set

by the system, which was recorded according to an

analysis by the faculty member responsible for the

Gynecology and Obstetrics discipline. As the

students’ data and the professor’s answer sheet are

stored in the system data base, it is possible to match

between the student’s data and the professor’s

answer sheet automatically or semi-automatically.

With the use of math-based tools, it is possible to

compare these two paths, thus obtaining an adequate

solution to this problem: automating or semi-

automating the process that can make a match

between the path taken by the student, step-by-step,

form beginning to end, regarding the clinical case

and the solution proposed by the professor.

The main characteristic of the PBL methodology

is the use of clinical cases as study objects. The

Learning Program in Gynecology and Obstetrics at

PUCPR has been a great ally to PBL, as both

students and professors adapted efficiently to the

process. This methodology offers students the

conditions to experience in their studies what would

really be happening in their professional lives.

In order to integrate the student with reality, and

so that individual performance can be monitored and

recorded, the support system for the teaching of

gynecology and obstetrics can be further improved

to include automation or semi-automation of the

analysis of similarity indices between the solution

found by the student and the professor’s answer

sheet.

In order to solve this problem, the system

(Rodrigues, 2006) was provided with a module

where information related to the patient’s anamnesis

was stored. The System features logs, and was built

as follows: at each variable inclusion or exclusion

request by the user, a record is made. To that end,

two types of system logs were created: one that

records navigation, case description visualizations,

the possibility of the user solving the case, fill out

diagnostic hypothesis and compare clinical case. The

second log records activities that take place while

the variables are being selected, named requests,

Figure 1.

The log represented in Figure 3 demonstrates all

the requests made by the student and recorded in the

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334

system developed by Ana Paula Rodrigues. The log

in figure 1 contains the following data:

 Student:

the student who is performing the

patient’s anamnesis.

 Question:

the question asked by the student to

the patient.

 Action:

the action the student takes regarding the

question, whether or not it is included in the

system data base

 Date:

date and time the consultation took place.

The records are of fundamental importance, as

with their comparison and the steps established as

parameters defined by the instructor of the

discipline, a similarity comparison will be made and

we will trace the levels of correct and wrong

answers of students in a manner closer to that

described by the faculty member.

A diagnostic hypothesis screen must be filled out

in the system by the student, with a description of

the consultation, thus making it possible to describe

the differential diagnoses and the additional exams

that can be requested for the patient. These data will

aid in the creation of the comparative diagnosis.

The access request will be answered by an

architecture in which the tutors and students have

access to the Internet by accessing the URL address

of the application, which resides in a server on the

other side of the network.

Next, the similarity is measured between the

anamnesis conducted by the student (path taken in

the data base) and that proposed by the professor

(path defined by the professor – answer sheet).

Thereby it is possible to present the difference

between the two solutions, in order to aid both the

student and the professor in analyzing the student’s

performance.

To gauge the similarity between the two models

– the one defined by the student and that fed into the

system by the professor (answer sheet) – we use

mathematical models that enable us to calculate the

distance between them.

As such, the mathematical models allow us to

analyze the system logs, by making a comparison

between the entire path executed by the student

throughout the anamnesis and later compared to that

suggested by the professor. At the end, data will be

given that will greatly aid in their academic and

professional life. In (Zeferino, 2007), we can affirm

that giving feedback to students is fundamental in

the teaching-learning process. For clinical medical

education, an answer to the student regarding his

performance will give him the conditions for self-

evaluation and to take decisions that will aid in

decision during future diagnoses.

During system validation, a questionnaire was

created and sent to a group of specialists, who

analyze it and later give their verdict on its use. If

the questionnaire is approved by the specialists, it

serves as reference for evaluating the tool.

The final result is adapted to a computational

model for monitoring the performance of the

medical student during initial patient evaluation.

To that end, the anamnesis conducted by the

student is monitored, and subsequently compared to

the proposal made by the professor, who use the

faculty member and professional experience to set

the best path to be taken during the consultation, so

that the final result can be achieved with the least

possible waste, both in material resources as well as

in patient’s and student’s time.

This comparison provides a report in which the

entire process followed by the student is described,

as well as the deviation in his case analysis, both

during the consultation and after receiving the

comparative results.

It is hoped that this becomes a cooperative tool

for students in their academic and professional

development as physicians.

The final results of the calculation of the

similarity indices are in the final stage of validation,

and in the future the system will be practically

automated or semi-automated.

4 CONCLUSIONS

The discussion of the results obtained in the program

in gynecology and obstetrics study and the analysis

of the contribution that the solution contained herein

will bring to the medical community and

development of medical students will certainly be

important. This evidences the importance of

integrating ITCs with the PBL methodology in the

teaching-learning process. The use of a data base

tool can feature devices that can aid the participants

in the teaching-learning process to trace the initial

parameters of their solution to the problem proposed

by the instructor; later, they are evaluated through

the stored data and verifying the similarity index.

Based on this evaluation, the student can reach a

lower deviation index from the path proposed by the

professor. In spite of being a study with partial

results in regards to validation of the similarity

indices – the instructor’s evaluation is fundamental

to the validation of learning – in general, students

INTEGRATING ICTS TO PBL METHODOLOGY WITH APPLICATION IN THE FIELD OF GYNECOLOGY AND

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and faculty alike indicated the viability of the use of

this teaching method within the studied context.

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