Learning is a complex process that involves mental activities such as critical thinking and problem-solving ability. The medical undergraduate curriculum is comprised of many integrated subjects, broadly divided into basic sciences and clinical sciences. Clinical correlations in medical education are very important to assist medical students in connecting the concepts that they learn in basic sciences with the clinical sciences in diagnosis and management as they grow up.[1] This can be achieved only when undergraduate students in their basic medical sciences years are trained in such a way that they obtain knowledge and can retrieve it when required.[2,3] In the majority of the medical schools, basic sciences are still taught by means of conventional methods such as didactic lectures. Such a system of education is teachers centered with minimal active participation from the students and is less effective in promoting students active learning and creativity.[4] Recently efforts have been widely undertaken to promote the student-centered education which stimulates active participation of the students and thereby facilitates their self-directed learning.[5] It is a challenge for the faculty to develop a learning tool that evokes students’ interest, promotes self-directed learning, and enables learning association between a basic science concept and its applicability to medical practice in diagnosis and management.[6-8] Medical schools in different parts of the world have introduced various innovating teaching methods such as online quizzes, puzzles, and other problem-based learning activities to meet these challenges.[9-11]

Patient-oriented problem-solving (POPS) activity is one such innovative learning method that permits students to work in small groups to solve clinical problems and thereby promotes self-learning, enhances intrinsic motivation, encourages clinical reasoning, and allows for knowledge retention and long-term memory.[12-14]

Immunology is a part of the 5^th-year undergraduate 7-year MD curriculum at Oman Medical College. It is taught along with other integrated subjects, namely, Microbiology, Pathology, Pharmacology, and Physical Diagnosis and Clinical Integration. Immunology teaching involves basic definitions, terminologies, descriptions, and concepts in relation to pathogenesis and diagnosis of various immunological conditions such as autoimmune diseases, hypersensitivity reactions, transplant rejection, tumor immunology, and immunodeficiency diseases. Therefore, it is essential to teach using learning tools that enhance their conceptualization, problem-solving skills, and retention of knowledge and can be applied in their clinical practices for better diagnosis and management of diseases.

Hence, the objective of our study was to implement POPS for immunology teaching and assess students’ perception of POPS activity in effective learning of the immunology course.

The study involves 5^th-year undergraduate medical students (121 students) of Oman Medical College. The current study was approved by the Institutional Research and Ethical Committee. Informed consent from the students was obtained. For the current research, we chose hypersensitivity reactions. A POPS teaching package on an immediate type of hypersensitivity reaction, which was originally developed by Parker A Small and his associates (http://www.Micro.musc.edu/pops/cases/hypersensitivityPOPS.pdf) was used for the activity.

The topic was taught in detail in the regular lectures using PowerPoint slides and audiovisual aids. Two weeks later, POPS activity on the topic was scheduled with prior information to the students.

POPS activity was scheduled for 2 sessions of 2 h duration each with an interval of 1 week between the sessions. The batch was divided into 4 groups of 30 students each. Within each group, students were divided into subgroups of 10 each for ensuring all students actively participate in the discussion.

After briefing about rules and regulations of the activity, students were given a pre-test with 10 questions on the chapter of “immediate type of hypersensitivity” to evaluate their basic knowledge acquired during the classroom lecture. The students were then distributed a booklet consisting of clinical case scenario and set of questions as originally developed by Parker A Small and his associates. An example of the POPS exercise is given in Appendix A. Students were asked to discuss the case in detail to understand the various concepts, generate learning issues, and to solve the clinically related questions given in the booklet. At the end of the activity, all students were given a set of predetermined post-test questions to check the effectiveness of POPS activity in learning. A questionnaire on the perceptions of the students regarding the usefulness of POPS activity in teaching and learning was also distributed to all the students. The evaluation was performed on a 3-point Likert scale (3 = strongly agree, 2 = moderately agree, and 1 = disagree). The data were collected, tabulated, and statistically analyzed.

A total of 118 students out of 121 enrolled in the class of batch 2019 attended and evaluated the POPS activity. An anonymous questionnaire survey was developed to assess the student’s perceptions of POPS activity as a tool to enhance their learning. The questionnaire consisted of 10 statements with a 3-point Likert scale (strongly agree, moderately agree, and disagree) to assess the responses of the students in relation to various outcomes of the activity [Table 1]. In addition to the 10 questionnaire statements, students were asked to provide additional comments regarding the activity if they desired.

Of the 10 questions answered by the students, 90% of the students strongly or moderately agreed that POPS activity provided benefits in terms of long-lasting memory and it made them more absorbed during the activity. Over 80% of the students indicated that POPS activity facilitated self-learning, raised their interest in topic discussion, strengthened their intrinsic motivation, and improved their problem-solving skills. In addition, many of them opined that POPS is a more scientific way of medical teaching. All of these results suggested that most students were in favor of this new method of teaching. Notably, however, 24% of the students disagreed that POPS is helpful in making the diagnosis in real clinical practice. In their opinion, simulated clinical case scenarios are different from the actual clinical cases.

The aim of our study was to assess students’ perception of POPS as a creative and interactive educational means to strengthen their learning skills. In conventional teaching methods such as didactic lectures, students become passive learners. As a consequence of this, the extent of students’ motivation and curiosity in learning depends on the quality of teacher-centered performances.[15-17] In contrast to these traditional teaching methods, POPS module found to be an innovative technique introduced in medical education and is included in the curriculum of the many of the medical schools worldwide.[18,19] Previous studies have shown that POPS teaching strategy strengthens the students’ active learning by allowing them to take charge of their own learning, define learning objectives by themselves, and learn to work in a group.[2,4,20-22] The POPS also provides an opportunity to exchange information, discuss the problem with other students, and peer-assisted gathering of new information. This enhances their self-directed learning skills, critical thinking, and ability to solve clinical problems by linking multiple pieces of information and thereby it enriches their knowledge and long-term memory.[12-14,20-22] In our study, most of the students (>80%) favored the use of POPS module in teaching immunology. They stated that POPS module provided them an opportunity to interact better with classmates and enhanced their intrinsic motivation to do self-directed learning. It boosted their clinical reasoning ability and problem-solving skills. In addition, they opined that POPS improved their overall learning skills, knowledge retention, and long-lasting memory.

We believe that our study has some limitations. First of all, conclusions drawn from a single trial, needs to be enhanced by more trials and a longer time of study. Second, limited teaching resources such as shortage of teachers with enough experience in POPS may hinder wide application of the activity. Finally, preparation of POPS teaching module is time-consuming for teachers in medical universities, who have to spend great deal of time in clinical and research activities and it may affect the outcome of the activity.

From the results of our study, it can be concluded that implementation of POPS module in immunology course improves students’ motivation in learning, clinical reasoning ability, clinical problem-solving ability, and provides great opportunity to enhance their knowledge and long-term memory.