Project-Based Learning Adapted as a Physiology Teaching Strategy for the Sophomore Undergraduate Medical Students

Abstract

Context

Project-based learning (PBL) is a teaching strategy in which students work as a group to identify a problem and discuss ideas for its solution. It is an educational approach to teaching and learning that involves groups of students working together to solve a problem, complete a task, or even create a product based on a project. It places the student at the center of the teaching–learning process and stimulates their engagement to transform learning into knowledge.

Proposal

The aim of the present study was to use an adapted PBL approach as a physiology teaching strategy for sophomore medical students. For this, at the end of the semester, 148 students were organized in groups and were instructed to develop projects on the topics of cardiorespiratory physiology and metabolic physiology. Evaluation was made of the development and presentation of the projects, comparing the grades with those obtained in tests taken individually by the students at the beginning of the semester. The opinions of the students about the strategy were analyzed using a questionnaire answered individually. The results showed that different strategies were developed by the students to present their projects, notably employing question and answer board games, card games, and videos simulating interviews with clinicians. The mean scores for the collaborative group activities were significantly higher than for the tests performed individually by the students. The answers given in the opinion questionnaire indicated that most of the students considered the strategy useful for their learning, since it stimulated research, study, and discussion on the topics studied. Most of the students believed that working as a group was beneficial and that the time allocated for the project development was sufficient.

Conclusion

Therefore, use of the adapted project-based learning as a physiology teaching strategy was viewed positively by the students and improved their performance in learning about cardiorespiratory and metabolic physiology.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02092-y.

Introduction

Health professionals worldwide encounter patients with chronic conditions who are more active and can participate in efforts to improve their health [1–4]. The care of these patients requires coordinated working of medical practitioners in integrated multidisciplinary teams. For these reasons, teaching strategies that encourage integration among students during medical education must be properly carried out for the training of future professionals who possess the technical and personal skills necessary to meet the demands of the population [5].

Clinical performance is essentially collaborative. However, the assessment of clinical performance is predominantly individual. In a clinical work environment, the professional is part of a collaborative team, so performance in this environment cannot be defined individually [6]. Consequently, it is necessary for lectures to be able to use a range of teaching, learning, and evaluation strategies for medical students. Keeping students at the center of the teaching–learning process is essential to make them co-responsible for their learning. Starting at the beginning of the medical course, it is important to provide a stimulating, collaborative, and integrated working environment that fosters debate, allows for learning error, and enables immediate feedback [7–12], so that the future professional can meet the clinical and social demands of the population. When teachers select the best pedagogical strategies adjusted to the course curriculum, providing adequate guidelines for the execution of these strategies, and students demonstrate commitment and dedication, solid foundations are formed for the teaching–learning process.

Studies have highlighted that active forms of learning are more effective than traditional teacher-centered learning [10, 13–18, 45]. Nonetheless, despite being considered passive forms of learning, there are students who prefer traditional theoretical classes [44]. At the same time, it is essential that the students show interest, engagement, and responsibility for their own learning.

Project-based learning (PBL) is an effective way to engage students with the taught content. Projects with realistic themes, based on specific topics of the discipline contents, providing engaging and motivating tasks, are effective strategies to stimulate learning and problem-solving in students working as a collaborative group [19, 20]. The student strategies are integrated into the PBL, with the aim of providing them with autonomy in the development of the project and increasing their motivation to work on problem-solving [21]. Bender [20] highlights some tasks that are carried out in the PBL and that can be adapted according to the course curriculum, including the following: (a) promoting brainstorming to define possible solutions; (b) identifying topics for the collection of information; (c) dividing responsibilities and determining periods for collecting information; (d) researching possible solutions for topics/problems; (e) synthesizing the collected data; and (f) making collaborative decisions for completion of the tasks.

In the present case, the physiology course for sophomore medical students was organized with teaching strategies including theoretical classes, dialogic classes, group dynamics, and constant stimuli to encourage collaboration and interaction among the students [9, 10, 22–25]. The PBL approach allows student groups to participate in project planning, research, investigation, collaborative work, and application of new knowledge to solve problems. Therefore, the hypotheses adopted here were that PBL as an educational approach would encourage collaborative and integrative work among students and, in a complementary manner, the adaptation of PBL for assessment of the students in topics related to cardiorespiratory and metabolic physiology would improve their performance, compared to the performance of the same students in individual assessments. In addition, analysis was made of the opinions of the students regarding the effectiveness of the project-based learning strategy applied to the selected course content.

Methods

Study Participants and Ethics

The participants in this study were 148 medical students enrolled in the disciplines of Physiology and Biophysics II (Module 2 (M2)) and III (Module 3 (M3)), in the second semester of 2022, at the University of Araraquara (UNIARA) in São Paulo state, Brazil. All the students authorized the use and analysis of their responses to the questionnaire and their scores in tests, without disclosing personal data. This study was approved by the Research Ethics Committee of UNIARA (CAAE 40019820.9.0000.5383).

Groups of Students for the Activity

The practical activities of the Physiology and Biophysics II and III disciplines of the UNIARA medical course were carried out in the laboratory, with the students working in groups that were organized either by the students themselves or by the lecturers. When the groups were formed by the students, it was noted that the selection of individuals was mainly based on personal affinities. For the present study, the student groups (five to seven students per group) were organized by the lecturers, mainly based on the grades that the students obtained in a practical test at the start of the semester. This enabled those students with learning difficulties and lower grades to work together with students that had higher learning abilities and achieved higher grades. Consequently, the possibilities for interactions and collaborations among the members of the group could be reflected in improved performance of the students with some difficulties in learning about physiology and biophysics, since they could be assisted by fellow students with better learning abilities.

Settings

The activities were carried out in two different classes of sophomore medical students, at the end of the second semester of 2022. Module 2 students (n = 74, 21 men (28.38%) and 53 women (71.62%), 21 ± 2.13 years old), developed projects related to the cardiorespiratory physiology topic, while Module 3 students (n = 74, 17 men (22.98%) and 57 women (77.02%), 22 ± 2.53 years old) developed projects related to the metabolic physiology topic. The topics were based on the curriculum of each module and were studied during the traditional theoretical classes and dialogic teaching, concomitant to development of the projects. Topics on cardiovascular and respiratory physiology were covered in Module 2. Topics on endocrine physiology and neuroendocrine control of intermediary metabolism were covered in Module 3.

The assessment system of our medical course comprises both summative and formative evaluations, related to learning, skills and competencies, and attitudes. Students undertake individual and group tests throughout the semesters. This work was carried out as a practical assessment activity at the end of the semester, for both classes (M2 and M3).

The time that each group had to carry out the activity was 9 h of laboratory time, divided into 3 h per week. The classes developed their projects on different days of the week, on Wednesdays for M3, and on Thursdays for M2. Between 3 and 4 weeks before the start of project development, both classes studied the topics (physiology of the cardiovascular, respiratory (M2), nervous, and endocrine (M3) systems) during traditional theoretical and dialogic classes.

First Laboratory Meeting

During the first meeting of each class with the lecturers, the activity dynamics and objectives were presented to the students and the groups were formed. Each class (M2 and M3) was held in the laboratory, for 3 h, on different days of the week, during 3 consecutive weeks. A time of 45 min was allowed for providing the students with the main guidelines (Table 1) and forming the groups. During the remaining time (2 h 15 min), the groups started their work. Table 2 shows the topics and the number of students per group for each class.

Table 1.

Guidance received by the students in the first laboratory meeting for project development

• Explanation of pedagogical topics making up the project-based learning

• Explanation of why the PBL pedagogical strategy was used as an evaluation activity for collaborative groups

• The evaluation criteria, including the following: the engagement of each student with the other members of the group; whether the students fulfilled the tasks that were determined by the group; the strategies used by the students for the project presentations; and, most importantly, the explanations provided of the physiological mechanisms related to the project topics

• All groups should organize projects related to the proposed topics for each class

• Time for execution and presentation of the projects

• Project presentation deadlines

• Instructions on research sources for development of the project

• The use of a seminar as a project presentation strategy was not allowed, since both classes had already held seminars at the beginning of the semester

Table 2.

Topics and number of students per group for each class (Modules 2 and 3)

Module 2 (n = 74) Physiology of cardiorespiratory interactions	Module 3 (n = 74) Physiology of metabolic interactions
• 12 groups: 1 group with 5 students 8 groups with 6 students 3 groups with 7 students	• 12 groups: 4 groups with 5 students 2 groups with 6 students 6 groups with 7 students

In the present study, some of the PBL topics suggested by Bender [20] were adapted. The students were instructed to start the activities with a brainstorming session to define how the group would develop the project in accordance with the proposed themes, identify the sequence of work, distribute the responsibilities of each component of the group, and start the research for execution of the project.

The lecturers delivered a template to each group and explained how it should be completed, inserting the names and codes of all the students in the group, the dates of the three laboratory meetings, and a description of the activity of the group concerning the development of the proposed project (title, objectives, and materials and methods). The completed templates were returned to the lecturers at the end of the first laboratory meeting. Finally, in the first meeting, the students started to work on the projects, discussing how they would be developed. The lecturers were present in the laboratory to resolve doubts, provide guidance about possible sources of research, and advise on the suitability of ideas in relation to the proposed project strategy.

Second Laboratory Meeting

In the second meeting, the groups continued to develop the projects, with positive discussions held within the groups and between the students and the teachers. Since the first meeting, the students in each group had discussed what they intended to accomplish and how to go about it. Therefore, most groups had already defined what to do and how to do it, and had discussed some adaptations for the project presentations with the lecturers. In this way, further PBL strategies suggested by Bender [20] were identified, such as synthesizing the ideas and data collected, making cooperative decisions about how to proceed with the work, determining possible additional information that could improve the project, and starting to organize the way that the project would be presented.

Third Laboratory Meeting

In the last meeting, the project presentations were carried out. As the students arrived at the laboratory, even before the beginning of the presentations, it was evident that they were enthusiastic to show the material that had been prepared. The time allowed for the presentation of each project was up to 15 min. The order of the presentations was randomized. Each group was free to organize their presentation, determining its dynamics and selecting the students who would present the work. At the end of each presentation, a time of 5 min was allowed for the group to answer questions from the audience. At the end of the session, the lecturers provided immediate feedback to the students regarding the physiological mechanisms involved in each project, with correction of possible errors [12] related to these mechanisms, together with complementary technical and didactic information, integrating whenever possible with previously learned physiological concepts.

At the end of the third meeting activities, an opinion questionnaire (Supplementary Material) on the strategy used was distributed to all the students in both classes. The students answered the questionnaire anonymously.

Data Analysis

The first practical tests taken individually by the students at the beginning of the second semester of 2022 were related to the topics of body fluids and blood physiology, for M2, and sensory nervous and autonomic nervous systems, for M3. The tests had open and multiple-choice questions, with a total value of 10.0. The second practical tests, adapted from PBL, were the projects presented by the student groups, with a total value of 10.0.

The average grades of the first and the second practical tests were calculated. The means were compared using the paired Student t-test. There was no comparison of individual performances or between Modules 2 and 3. The distributions of questionnaire responses were determined as percentages of the total number of students (n = 148). Statistical analyses were performed using GraphPad Prism v. 8.4.2 for Windows (GraphPad Software, San Diego, CA, USA). A statistically significant difference was indicated by P < 0.05.

Results

The results are shown as the descriptions of the projects carried out, the comparison of the average project grades (collaborative group assessment) with the grades of the individual tests carried out within each class at the beginning of the semester, and the opinions of the students about the learning strategy employed.

Table 3 shows the approaches chosen by the groups of students to present their projects, according to the topics used for each class.

Table 3.

Project approaches presented by the students in Module 2 (n = 74), for the cardiorespiratory physiology topic, and by the students in Module 3 (n = 74), for the metabolic physiology topic

Module 2 Physiology of cardiorespiratory interactions

Module 3 Physiology of metabolic interactions

• Laboratory experiment to relate changes in blood pressure and pulmonary ventilation with thermal stress • Video to compare blood pressure, heart rate, and respiratory rate at rest and after running 400 m • Question × answer game on a free digital platform (Kahoot) to discuss cardiorespiratory adaptations in extreme situations (high altitudes, breath-hold diving, and low and high temperatures) • Question × answer board game about cardiac and respiratory modulations on metabolic adaptations during intense physical activity • Dramatization to explain the autonomic nervous system controls on the cardiorespiratory activities during the daily routines of the medical students • Card games using questions and answers to explain cardiac and respiratory activities during physical exercises • Video on a free digital platform (TikTok) to explain cardiorespiratory adaptations in “fight and flight” situations • Video simulating a TV interview program with a physician to explain cardiorespiratory adaptations in sprinters (100 m) and marathon runners • Board game (STOP) to explain the main physiological mechanisms of the respiratory system • Dramatization to compare cardiorespiratory activities among healthy subjects versus anabolic steroid users

• Question × answer game (“Who wants to be a millionaire”) to explain the hormonal control of metabolic activities • Board games (bingo) to explain the local and synthesis mechanisms, plasma transport, and action mechanisms of some hormones • Question × answer roulette game to correlate the insulin, glucagon, and IGF-1 functions with energy metabolism regulation after eating and during fasting • Question × answer board game about the cortisol, insulin, glucagon, and adrenal catecholamines functions during physical activity and fasting • Video simulating an interview program with a physician to explain the growth hormone actions in physiological situations and in GH-doping situations • “Beer pong” game (with non-alcoholic beverages) to explain the vasopressin, atrial natriuretic peptide, aldosterone, and parathyroid hormonal effects on kidney function • “2 truths × 1 lie” card game to explain some action mechanisms of the anterior pituitary hormones, insulin, and glucagon on intermediary metabolism • Question × answer games to explain the action mechanisms of insulin and glucagon in glucose metabolism • Video of an experiment comparing glycemic measurements during fasting and 30 min after ingestion of carbohydrates and proteins, in 2 individuals (1 healthy and 1 diabetic)

The presentations (each lasting up to 15 min) of classes M3 and M2 were held on a Wednesday and a Thursday, respectively. In both classes, students from the groups that developed and presented games invited their colleagues from the audience to participate in the dynamic activity, which was highly interactive, entertaining, and stimulating. The number of approaches presented in Table 3 is smaller than the number of groups for each class (Table 1), because some groups adopted similar approaches, notably in the case of the board games. Therefore, similar activities were not described, in order to avoid repeating information in Table 3.

Figure 1 shows the mean grades of students in Modules 2 and 3 obtained in the first practical test, carried out individually at the beginning of the semester, and in the second practical test, carried out as collaborative groups, using the adapted PBL at the end of the semester.

Fig. 1.

Mean grades of classes M2 (n = 74) and M3 (n = 74) obtained in the first practical test (light columns) carried out individually, and in the second practical test (dark columns) carried out as collaborative groups using the adapted APB strategy. * P < 0.0001

For both classes, the average grade of the students in the second practical test was significantly higher than that obtained in the first practical test (Student’s t-test, P < 0.0001). For class M2, the average for the first practical test was 8.390 (± 0.21), while the average for the second practical test was 9.863 (± 0.02). For the students in class M3, the averages for the first and second practical tests were 8.324 (± 0.18) and 9.847 (± 0.03), respectively.

Analysis of the individual performances of the students in the two practical tests showed that for class M2, 53 students (71.62%) had increased scores, 9 students (12.16%) maintained their grades, and 12 students (16.22%) had lower scores in the second practical test, compared to the first practical test. For class M3, 62 students (83.8%) increased their scores, 6 students (8.1%) maintained their grades, and 6 students (8.1%) had lower scores in the second practical test, compared to the scores in the first practical test.

The opinions of the students concerning the assessment in collaborative groups, performed using the adapted PBL strategy, were analyzed considering their responses in the questionnaires (which were applied individually). Since the students from both classes answered the same questionnaire, the results were presented as percentages, combining the answers from classes M2 and M3. The majority of the students (96.73%) considered that the activities helped them in learning the topics addressed; 85.86% believed that the strategy stimulated study of the topics discussed, whether using scientific websites, textbooks, scientific papers, and abstracts (their own and from classmates); 96.73% considered that the time allowed to carry out the activities was sufficient; 79.34% preferred to work in groups of more than three members, 15.21% preferred to work in pairs, and 5.45% preferred to work alone. Of the students who favored working in groups, 68.47% preferred to form their own groups, 9.8% preferred the lecturer to organize the groups, and 21.73% were indifferent. Finally, analysis was made of whether a student stood out as a leader in the group, and whether the leader influenced the working dynamics and learning. It was found that 69.56% of the students considered that there was a leader in their groups, while 78.27% believed that the presence of the leader was positive for both organizing tasks and helping with studies.

Discussion

Daily activities are based on two important pillars, namely processes and people, and the same applies at universities. Constant education research is needed to maintain and improve the relationships between these pillars, understanding that the processes are the teaching strategies used in different courses, and that the people are the teachers and students involved in the teaching–learning process. It is essential that the medical course curriculum should be constantly analyzed and updated, ensuring that pedagogical practices in the classroom, laboratory, and hospital are optimal for teachers, tutors, and students.

The most appropriate teaching strategies must be used in the medical course curriculum, in order to meet the demands of students and provide the best opportunities for learning. Studies have suggested that traditional theoretical classes are not effective for learning, do not stimulate engagement, and do not motivate students [14, 26–28]. However, there are students who prefer traditional theoretical classes and show interest during such classes [9, 10, 14, 25, 44]. Although these students are a minority, it is evident that lecturers need to adopt a variety of teaching strategies, in order to address different needs of the students. It is necessary to adapt the teaching style to the learning style of the student, and vice versa [26, 29, 30], combining teacher-centered study and student-centered study. Therefore, the student needs to be committed and engaged with the learning process.

Active learning strategies encourage engagement of the students, so that they can understand their own learning and reflect on the learned content [30, 31]. Mehta et al. [30] asked an interesting question: “Should we, as educators, encourage those traits that make active learning a “success”, or should we design modalities that better suit the students we have in medical schools?” Based on previous studies and on the results of the present study, regarding the performance and perceptions of medical students, it seems that both options presented by Mehta et al. [30] could be used.

It has been shown that project-based learning can improve the students’ understanding of the course contents, improve critical thinking, encourage greater reflection, and increase retention for the topics covered [20, 32, 33]. The results of the present study showed that the performance of the students in the group practical tests was better than in the practical tests performed individually, although the individual performances were good for both classes, corroborating the opinions of the students in relation to learning about the topics covered. As students had previously studied the topics chosen for the projects in theoretical and dialogic classes, this group activity significantly contributed to their learning about cardiorespiratory and metabolic physiology. In addition, most of the students approved the strategy used.

The current students belong to the Gen Z (Z generation), presenting some characteristics that should be considered in selection of the best teaching–learning strategies for use in the medical course curriculum. Students of this generation are oriented towards teamwork and high performance; they are confident and demonstrate ease in using some technologies, which may favor the use of active learning strategies [34, 35]. The results presented here showed that most of the students approved of working in groups, discussing ideas, and developing collaborative activities, and they felt motivated to carry out tasks within their groups. In addition, some students used apps and computer programs, employing technology in an efficient and creative way to develop projects. The PBL approach encourages students to participate in project planning, investigations, and the application of new knowledge to solve problems [20, 36]. Furthermore, it can improve performance in evaluations, as shown by the present results. The PBL strategy provides a student-centered teaching environment, group working, and active learning in which the teachers act as facilitators, with the students being motivated and focused on developing skills [20, 37]. In the present work, these aspects were observed by the lecturers and were perceived by most of the students during the laboratory meetings held for the development and presentation of the projects.

Collaborative learning is not simply synonymous with students working in groups. It is necessary that the students should perceive a clear and positive form of interdependence, with a high degree of interaction among group members, individual responsibility, and the need for social skills [8, 38, 39, 45]. During the laboratory meetings for development of the projects, lecturers observed these characteristics of collaborative learning in almost all the groups. When necessary, the lecturers provided guidance, explaining the importance of these characteristics. As pointed out by Laal and Laal [40], the lecturer should be available to advise on doubts, assist the learning process by requesting frequent feedback from students about the progress of the group, facilitate discussions about group dynamics, and help with conflict resolution.

In recent years, medical schools have increased the size of classrooms to serve a greater number of students [41]. Project-based collaborative learning requires students to work in groups to solve problems. Therefore, working collaboratively in groups in classrooms with a larger number of students could be a good strategy. Given this possibility and the requirement for students to sometimes work in groups, could the group size be important? Previous studies suggest that the size of the group is not important for student learning [7, 41, 42], since teachers are able to choose the appropriate pedagogical strategy, providing the groups with guidance and enabling achievement of the didactic objectives. The results obtained here showed that a majority (79.34%) of the students preferred to work in groups of at least three people, while 15.21% liked to work in pairs, and a minority (5.45%) favored working alone. Interestingly, the students showed better performance in the group practical tests than in the individual tests, even in the case of the students who preferred to work in pairs or alone. Furthermore, although 68.47% of the students preferred to organize their own groups, the results showed that organization of the groups by teachers improved their performance in the tests. This suggested that students who learned easily could have contributed to the learning of group colleague with learning difficulties. Another important point was that the students realized that there was a natural leader in each group, whose presence was positive for the group work, since this person played an important role in organizing the activities. Therefore, the finding indicated that the pedagogical strategy used in the present study was suitable for achieving the proposed objectives for sophomore medical students.

The ICAP theoretical model is a tool that can be used to understand collaborative learning. This model is based on specific behaviors of the students, related to different types of cognitive engagement during learning [43]. The four behavioral models are described as passive (P), active (A), constructive (C), and interactive (I), and each model can be associated with different teaching strategies. Noerholk et al.⁴¹ showed that when students work alone, they present more active behavior in developing an activity, compared to students who work in pairs, trios, or quartets. However, the student working alone shows little constructive behavior, and no interactive behavior. On the other hand, students who work in pairs, trios, and quartets have more constructive and interactive behaviors. In the present case, during the laboratory meetings, the lecturers observed fewer students with passive behavior in the groups; active, constructive, and interactive behaviors were predominant, including constant interactions among lecturers and students. The physiology laboratory activities in the medical course involved the students working in groups, stimulating active, constructive, and interactive behaviors. In addition to these group laboratory activities, students also complete other individual assessment activities throughout the semester. Thus, different teaching and assessment strategies are used throughout the semester to monitor students’ development in the teaching–learning process. The results showed the effectiveness of this approach, as evidenced by the good performance of the students in practical tests carried out either individually or as collaborative groups with project development.

Conclusions

Collaborative working in groups, adapted from project-based learning strategy, was used as an evaluation activity for sophomore medical students studying the topics of cardiorespiratory physiology interactions and metabolic physiology interactions. This approach stimulated the engagement of the students with the topics and improved their performance in practical tests. The students had positive opinions regarding the activity dynamics, the time available for producing the projects, the collaborative working in groups, and their learning of the topics studied.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

LHM and CLTP conceived, designed research, and performed experiments; CLTP analyzed data; LHM and CLTP interpreted results of the experiments; LHM prepared figures and drafted the manuscript; LHM and CLTP edited and revised the manuscript; LHM and CLTP approved the final version of the manuscript.

Declarations

Competing Interests

The authors declare no competing interests.

Disclaimers

The content of the article is the sole responsibility of the authors, and does not necessarily represent the views of any institution.