Int J Intg Med Sci 2015;2(5):121-27.

ISSN 2394 - 4137 121 

International Int J Intg Med Sci 2015, Journal Vol of 2(5):121-27. Integrative Medical ISSN 2394 Sciences, - 
4137 Review Article 
DOI: http://dx.doi.org/10.16965/ijims.2015.117 

Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb) Kumar Ponnusamy *1, Jegathambigai Rameshwar Naidu 
2, Ravindra Kumar Boddeti 3, Prejna Barki 4. *1 Department of Biochemistry & Genetics, ST 
Matthew’s University School of Medicine, Grand Cayman Islands, BWI. 2 Department of 
Biochemistry, Asia Metropolitan University School of Medicine, Malaysia. 3 Department of 
Anatomy, International Medical School, MSU, Shah Alam, Malaysia. 4 Department of 
Physiology, ST Matthew’s University School of Medicine, Grand Cayman Islands, BWI. 
ABSTRACT 
E-learning can be used to enhance and aid the implementation of problem-based learning (PBL). Through 
e-learning, learning can take place anywhere and anytime through the communication tools that it has. This feature 
provides a channel of communication among medical students and content experts in medicine that is not bounded 
by the class time and physical presence. Therefore, e-learning has been identified as a learning system that can 
greatly enhance the implementation of PBL among undergraduate-medical students. Concept- maps can be 
successfully used to teach conceptual thinking, thus increasing students’ competence in critical thinking in the 
modern paradigm. The purpose of this paper is to put forth effective strategies for utilizing e- learning in PBL for 
medical and allied health science education with a model PBL on Retinoblastoma (Rb). Some effective strategies 
that have been identified are: (a) the use of online-learning tool to deliver structured assigned independent e-PBL 
problems to students, (b) content expert-facilitator-initiated communication for the PBL case scenario on the 
e-learning platform, (c) frequent availability of content expert on-medical education online for facilitation, and (d) 
the use of online resources such as relevant case scenarios, videos, research component such as review journal for 
reflection, construction of concept maps and assessment. These strategies will enable a more efficient and effective 
implementation of out-come based self-directed structured assigned independent learning e-PBLs related to 
difference modules of medicine, with relatively less number of content experts and in short time for large group of 
medical and allied health sciences students. KEY WORDS: e-learning, e-problem based learning, Medical science 
education, Interactivity, Supplemental digital content, Research components, Concept mapping, Retinoblastoma. 
Address for correspondence: Dr. Kumar Ponnusamy, Department of Biochemistry & Genetics, ST Matthew’s 
University School of Medicine, Grand Cayman Islands, BWI. E-Mail: gautamgkl@yahoo.com 

Online Access and Article Informtaion 

Quick Response code 
International Journal of Integrative Medical Sciences 
www.imedsciences.com 
Received: 27-04-2015 Review: 27-04-2015 
Accepted: 22-05-2015 
DOI: 10.16965/ijims.2015.117 

Published: 31-05-2015 
Source of Funding: Self Conflicts of interest: None 
Self-Directed  Structured  e-Problem  Based  Learning  on  Retinoblastoma  (RB):  The  exponential 
growth  of  knowledge  is  one  reason  that  strategies,  such  as  problem-based  learn-  ing  (PBL),  are 
becoming popular, and technology support can be so valuable [1]. PBL is a method of instruction 
that uses patient prob 
lems  as  a  basis  for  developing  students’  problem solving skills and their knowledge of basic and 
clinical  sciences.  Students  work  together  to  understand  a  patient’s  medical  prob-  lems.  Usually, 
PBL  occurs  in  small groups of six to eight students with a faculty tutor as a facilitator who offers 
appropriate feedback and 
 
Int J Intg Med Sci 2015;2(5):121-27. ISSN 2394 - 4137 122 

guidance.  Medical  science education and train- ing varies considerably across the world. Various 

teaching  methodologies  have  been  utilized  in  medical  science  education,  which is an active area 
of  educational  research.  Problem  based  learning  (PBL)  with  “Flying  A  Kite  Approach”  is  an 
innovative  approach  and  latest  advance  in  the  integrated  medical  curriculum  to  achieve  the 
effective  measurable  outcomes  for  the  large  group  of  medical  students  in  small  groups  with  the 
on-line  resources  available  (OLRA)  [2,3].  Case  studies  are  the  basis  of  a  well  known  medical 
education  pedagogy  called  problem-based  learning  (PBL).  Traditional  case  studies  are  paper 
based  and  contain  brief  medical  facts  about  a  patient’s  illness.  It  has  been  documented  that, 
experts  benefited  more  from visual information than did students [4]. A recent systematic review 
(2008)  described  the  effectiveness  of  Internet  based  learning  (IBL)  in  health  professions 
education.  A  comprehensive  synthesis  of  research  investigating  how  to  improve  IBL  is  needed. 
This  systematic  review  sought  to  provide  such  a  synthesis  [5].  Generally,  blended  learning 
environments  are  new  educational  media  that  can  inspire  great  challenges  and  advantages  for 
both  teachers  and  students.  They  provide  an  opportunity  to  rethink  our  teaching  and  achieve 
learning  goals  that  previously  may  have  been  beyond  our  reach  [6].  Thus  the  way  in  which 
online  activities  are  designed  and  delivered  can  add  value  and  make  a  positive  difference. 
Online,  the  PBL  tutor  plays  a  role  different  from  the  role of a tutor in a face-to-face PBL format 
[7],  although  the  general  issues  and  situations  with  which  they  must  deal  are  essentially 
identical-to  facilitate  the  process  of  active  learning  by  students  and  foster  the  skills  of  critical 
thinking.  But  the  WBL-PBL  tutor  has  to  fulfill  additional  conditions  for  successful  online 
tutoring,  which  can  be  categorized  as  pedagogical,  social,  managerial,  and  technical  [8].  The 
virtual  case  modality  may  have  enhanced  individual  learning,  since  it  al-  lows  an  individual  to 
control  his  or  her  own  view-  ing  and  reviewing  of  images  while  reflecting  on  group  discourse. 
The  duration of undergraduate medical education is 5 years. A hybrid problem- based curriculum 
is the principal educational strategy in the first 2 years. This hybrid system 
Kumar Ponnusamy et al. Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb). 

is similar to the description by [9] where the students are prepared by giving didactic lectures for 
fundamental concepts on which they elaborate in small group tutorials, facilitated by 
knowledgeable tutors who are able to provide adequate feedback on student’s understanding and 
learning [9]. The students are grouped into a number of 10-12 students, with a lecturer appointed 
as facilitator. The facilitators are manly lecturers from the basic medical sciences and 
paraclinical sciences department who have attended atleast a workshop on PBL and facilitation 
skills [10]. Problem-based learning (PBL), which focuses on spontaneity, collabora- tion, and 
flexible problem-solving skills, is such an approach that engages students in problem- solving 
scenarios. PBL programmes were more likely to plan and undertake research in their own time 
using resources that they had identified themselves rather than those identified by staff [11,12]. 
Concept maps are intended to represent meaningful relationship between concepts in the form of 
propositions [13]. High-yield cognitive concept mapping is an educational tool that encourages 
meaning and learning [14]. Fostering meaningful and self- directed learning among medical 
students is now recognized as a major goal of medical educators [15,16]. Concept mapping is an 
active, creative, visual and spatial learning activity in which concepts are organized accord- ing 
to their hierarchical relationships [17]. It has been documented that, innovative pedagogy such as 
concept mapping had improved primary medical care competencies in all aspects and the 
implications of the findings contribute to developing nursing education and improving nursing 
competencies in other contexts [18]. Concept mapping is an innova- tive classroom tool and 
technique that can deepen our curricula as students advance through an accounting program. It is 
an enabling skill to enhance the develop- ment of students’ thinking skills through more 
meaningful learning activities [19]. Whatever the clinical case may be, there was a pressing need 
to improve PBL facilitation by more rigorous training of facilitators. The “content experts” were 
tempted to teach, and “the non-content experts” sometimes felt out of 
 
Int J Intg Med Sci 2015;2(5):121-27. ISSN 2394 - 4137 123 

depth, in addition to need of more number of content experts. Neville (1999) reported that, Mc 
Master Education Committee’s idea that the non-expert would be less inclined to emphasize 
detail and more inclined to see things from the view point of students and hence have the 
potential of becoming better facilitators [9]. It had been recognized that students view PBL from 
the point of view of passing examinations [20]. With e-learning becoming more and more 
popular [21], integrated PBLs covers the clinical relevance of the particular disease with 
different disciplines of medicine in relatively short time, which includes anatomy, pathophysi- 
ology, biochemistry-genetic basis of the disease, pathology, laboratory diagnosis, pharmacology, 
community medicine, behavioural issues at the must know level of large group phase-1 medical 
students with much emphasize on self- directed learning with the OLRA. Prioritise the learning 
issues to the most important which includes application of basic sciences in the practice of 
medicine, Clinical skills, Disease prevention and health promotion, Family and community 
issues in health care, professional- ism, ethics, and personal development, self-directed life-long 
learning & information management, critical thinking and research [2]. PBL encourage the 
students to acquire up to date knowledge and clinical-communication skills right from the 
beginning of the medical curricu- lum and inculcate life-long learning. Some educators feel that 
case-based learning (CBL) is of more value, given the dense medical curriculum and need for 
efficient use of student and faculty time [22]. Video has such a strong influence on learners 
because text actually is an abstract representation of reality [23]. Video brings the abstraction to 
a level where students can begin to describe. Dual-coding theory might suggest that having a 
visual example of abstract representations should promote retention of the concepts and assist 
students in constructing a mental model, especially when visual cues have a critical role in the 
diagnostic process. Norman found that experts benefited more from visual information than did 
students [24]. Obvious lack of clinical experience or visual examples could explain this 
difference and should encourage educators to include more 
Kumar Ponnusamy et al. Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb). 

visual examples of clinical concepts in their teaching [25]. Kenny and Beagan (2004) state that 
the use of video-based, PBL cases may be a natural complement to a commitment to thick 
narrative [26]. In combination, they have the potential to form a rich-narrative case for the robust 
exercise of PBL-based analysis, problem solving, and learning. Cases that use video rather than 
text provide information in a more realistic format and supply context to students [27]. This 
present article emphasizes the achievement of the measurable learning outcomes with the in 
relatively short time, with the structured assigned independent mode PBLs on a particu- lar 
disorder which are not covered by any other mode of teaching-learning activities including 
didactic lectures and/or seminars and so on. At the beginning of the semester 1 of medical 
curriculum at least one hands-on workshop on PBL-process-facilitation is to be provided to the 
students by the content experts (PBL working group) of medical education unit. In this article 
provided with the case study on Retinoblastoma (Rb). Rb is a rare eye tumor of childhood that 
arises in the retina. Rb is caused by a deletion of chromosomes 13, 14, 15, 21, and 22 and is a 
frame-shift deletion mutation. It is the most common intraocular malignancy of infancy and 
childhood; with an incidence of 1/15,000-20,000 live births. The two most frequent symptoms 
revealing retinoblastoma are leukocoria and strabismus. Pleotropy includes iris rubeosis, 
hypopyon, hyphema, buphthalmia, orbital cellulites and exophthalmia may also be observed. 
Sixty per cent of retinoblastomas are unilateral and most of these forms are not hereditary 
(median age at diagnosis two years). Retinoblastoma is bilateral in 40% of cases (median age at 
diagnosis one year). All bilateral and multifocal unilateral forms are hereditary. Hereditary Rb 
constitutes a cancer predisposition syndrome: a subject constitution- ally carrying an RB1 gene 
mutation has a greater than 90% risk of developing retinoblastoma but is also at increased risk of 
developing other types of cancers. The PBL Process: Day-1: PBL-Induction: Step 1-Trigger 1: 
Release of the digital copy of figure 1 shows the phenotype of patients with retinoblastoma (Rb) 
and brain storming. Step-2: Trigger 2-display of karyotype 
 
Int J Intg Med Sci 2015;2(5):121-27. ISSN 2394 - 4137 124 

of a person affected by Rb and brain storming. Step-3: Trigger 3-display of pedigree chart- 
inheritance of Rb, discussion and division of labour. Day 1-Step 4: Research component on 
Retinoblastoma-Review Article: URL. Day 1- Step 5: Matching and fine tuning of the learning 
outcomes arrived by the team, facilitated by team leader. Day 2-Step 1: Presentations and 
summarization on Rb. Day 2-Step 2: Display of video clip on RB, U-Tube URL: https:// 
www.youtube.com/watch?v=FOnZKtupBYg [28]. Day 2-Step 3: Construction of cognitive 
concept mapping and discussion, Day 2-Step 4: Spot test on matching questions. Terms to be 
Familiar With Before Start to Solve the Test: Retinoblastoma (RB), RB1 gene on chromosome 
13 (first tumor suppressor gene discovered), genetic disorder, Oncogenes, tumor suppressor 
genes, DNA-repair genes, epidemiology, mode of inheritance-X-linked, autosomal dominant 
(AD) transmission, penetrance, pedigree analysis, karyo-type of RB, frame 
shift-deletion-mutation, deletion of parts of chromosomes at 13, 14, 15, 21, and 22 [29]. Alfred 
Knudson’s two-hit hypothesis [30], biochemical-molecular basis of retinoblastoma, sporadic 
(non-hereditary) RB, familial (hereditary) RB, consanguinity, risk factors of RB, signs and 
symptoms, pathophysiology, clinical presentation of RB, congenital anomalies-dysmorphism, 
differential diagnosis, molecular etiopathogenesis, bridge to pharmacology, management of RB, 
treatment options, preventive medicine, prenatal diagnosis, amniocentesis, genetic counselling, 
behavioural issues, ethics, referral to speciality clinics [31] Memorial Sloan-Kettering Cancer 
Center, URL: http://edit.mskcc.org/pediatrics/childhood/ retinoblastoma, Memorial 
Sloan-Kettering Cancer Center, research component in RB, model review article on 
Retinoblastoma, Helen Dimaras., (2012) 32 URL: http:// 
www.sciencedirect.com/science/article/pii/ S0140673611611379, 32. PBL Process Keywords: 
PBL, Learning Management System, learning outcomes, concept, hypothesis, provisional 
diagnosis, small group learning, integrated medical curriculum, measurable learning outcomes, 
on-line resour- 
Kumar Ponnusamy et al. Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb). 

-ces, e-learning, self-directed learning, on-line reusable resources, questioning ability, clinical 
skills, higher order critical thinking, Bio-Gen Inno-vision, content experts, PBL-process, 
PBL-facilitation, group leader as facilitator- stimulating discussion, facilitators guide, 
audio-visual facility, medical dictionary, group dynamics, brain storming, team-work, peer 
value-review, division of labour, leadership quality and team player, group leader as a facilitator, 
communication skills, time- management, mono-acting as a simulated patient, parts of the PBLs: 
Step wise release of the parts of the PBL triggers-Step 1-5 and video clips, construction of 
high-yield cognitive concept mapping-innovative pedagogy, spot test-matching questions. 
Learning Outcomes: Retinoblastoma, karyo- type of Retinoblastoma, Alfred Knudson’s two- hit 
hypothesis, risk factors of Rb, amaurotic cat’s eye, Flexner-Wintersteiner rosettes, 
histopathology of Rb, differential diagnosis of leukocoria, management and prevention of Rb, 
genetic counseling and ethical issues on Rb. Research Methodology: This research article used a 
qualitative research design i.e. a case study method. Data had been collected from different 
teaching learning resources and PBL was constructed on Retinoblastoma based on “Flying A 
Kite Approach”, in the e-learning system itself. Concept maps, research component in the form 
of review article on Retinoblastoma and questions relate to integration of e-learning in PBL had 
been postulated with less number of content experts in an electronic forum and students are 
required to summarise the learning outcomes, construct the concept map and respond to those 
questions at the end of the PBL. Next steps: Although this pilot test is a limited one, more 
importantly, it sets the stage for further research. Our next step is to revise the current model and 
construct numerous e-PBLs with content experts of medical education on different modules of 
phase 1 integrated medical curriculum, perhaps through the incorporation of branched and 
interactive case material that would allow the learners to see the consequences of their decisions. 
We also plan 
 
Int J Intg Med Sci 2015;2(5):121-27. ISSN 2394 - 4137 125 
Day 1- Step 1: Figure 2- Trigger 1: Display of Copy of Clinical Features. 
Day 1- Step 2: Figure 3-Trigger 2: Display of Digital Copy of Karyotype of Rb. 
Kumar Ponnusamy et al. Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb). 
No DAY 1: Induction of PBL on Retinoblastoma (Rb) 
1 
The Self-Directed PBL Process Overall The PBL Process: Day 1-Step 1-Trigger 1: Release of the Digital Copy 
of Figure 1 Shows the Presentations of The Self-Directed PBL Process Overall (Day-1 Induction; Day-2 
Retinoblastoma Phenotype. Presentation) 
Day 2: Presentation on Retinoblastoma 
2 
Day 1-Step 1-Trigger 1: Release of the Digital Copy of Picture 1 Shows the Presentation of Retinoblastoma Phenotype. 
2 
Day 1-Step 2-Trigger Karyotype of Rb. 
2: Figure 2: Display of Digital Copy of 
3 
Day 1- Step 3-Trigger 3: Display of Pedigree Chart on RB. Figure 3: Genetic Features of Heritable Retinoblastoma. 
4 
Day 1-Step 4: Trigger 4: Research Component on Retinoblastoma- Review Article: URL: 
http://www.sciencedirect.com/science/article/pii/S014067361161 1379. 
5 
Day 1- Step 5: Matching and Fine Tuning of the Learning Outcomes Arrived by the Team, Facilitated by Group Leader (Chair 
Person of the PBL). 
1 Day 2-Step 1: Presentations and summarization on Retinoblasma. 
3 
Day 2-Step 2: Display of Video Clip on Retinoblastoma. URL: https://www.youtube.com/watch?v=FOnZKtupBYg. 
Day 2-Step 3: Construction of Cognitive Concept Mapping. Model Map on RB: URL: 
https://www.scribd.com/doc/263241934/Retinoblastoma- Cognitive-Concept-Map-Dr-Kumar-Ponnusamy-and-Dr- 
Jegathambigai-RN-Problem-Based-Learning-PBL-for-Large-Groups- Medical-Students. 
4 Day 2-Step 4: Spot Test on Matching Questions on Retinoblastoma. 
Day 1-Step 3-Figure 4-Trigger 4: Genetic Features of Heritable Retinoblastoma-Model Autosomal 
Dominance (AD) Pattern of Inheritance in Cancer Patients With a Family History of Retinoblastoma. 

Retinoblastoma Inheritance: Rb is inherited as a dominant trait, but it is recessive at the cellular 

level. People with familial Retinoblas- toma carry one mutated copy in all their cells. Cells that 
would get a second hit will develop Rb or later, other cancers. Day 1-Step 3-Figure 5-Trigger 5: 
Inheritance of Retinoblastoma. 
 
Int J Intg Med Sci 2015;2(5):121-27. ISSN 2394 - 4137 126 
Kumar Ponnusamy et al. Problem Based Learning (PBL) for Large Groups Medical Students e-Problem Solving Test: A 
Mutation Causing Retinoblastoma (Rb). 
Day 1-Step 4 - Trigger 6: Release of Research Component on Retinoblastoma-Review Article: URL: http:// 
www.thelancet.com/pdfs/journals/lancet/PIIS0140- 6736(11)61137-9.pdf Day 1- Step 5: Matching and 
Correction of the Learning Outcomes Arrived by the Team, Facilitated by Group Leader (Chairman of the 
PBL Process). 

Matching Questions on Retinoblastoma Inheritance: 

Matching Question on Retinoblastoma Inheritance 
No Column A Ans Column B 
1 
Alfred Knudson’s two-hit hypothesis 
H 
A. Associated with retinoblastoma containing deletion of chromosome 13. 
4 FISH C D. Tumor suppressor gene (TSG) loss. 
5 Variable expressivity B 

CONCLUSION 
B. Variation in clinical features (type 
2 Osteosarcoma A 
and severity) of a genetic disorder between affected individuals, even within the same family. 
E. RB1 mutation is present in all of the somatic cells. 
6 Germinal retinoblastoma E 
F. Within a single individual or tissue, the occurrence of two or more cell lines with different genetic or chromosomal 
constitutions. 
7 
G. The presence of an altered gene within the egg or sperm (germ cell), such that the altered gene can be passed to subsequent 
generations. 
9 
Hereditary pattern of familial retinoblastoma 
J 
H. Two separate loss of function mutations 
8 Mosaicism F 
are required to inactivate both the homologous loci of the RB gene for malignant phenotype to be expressed. 
The critical events has most likely resulted from an aberration involving chromosome 13 leads to a 5- month-old girl has 
bilateral retinoblastoma 
I. A condition characterized by a whitish reflex within pupil. It is secondary to cataract, Coat’s disease, retinoblastoma, 
retrolental fibroplasias, persistent hyperplastic primaryvitreous, ect. 
10 Germline mutation G J. Autosomal dominant (AD) inheritance. 
11 
D 
Cytogenetic Location of K. Retinoblastoma 
Multiple, often seemingly unrelated, M 
physical effects caused by a single altered gene or pair of altered genes. L. The proportion of individuals with a mutation causing 
a particular disorder 12 Pleotrophy K 
who exhibit clinical symptoms of that disorder; most often refers to autosomal dominant conditions. 
13 Penetrance L M. 13q14.2. 
Ans: 1-H ; 2-A ; 3-I ; 4-C ; 5-B ; 6-E ; 7-J ; 8-F ; 9-D ; 10-G; 11-M; 12-K; 13-M . 

to  test  future  iterations  with  medical  students  within  an  established  curriculum.  Our  aim  is  to 
learn  more  about  how  self  directed  structured  integrated  e-PBL  case  studies  can  recreate 
authentic  situations  that  replicate  the  human  experience  in  which  medical  professionals  practice 
every day. 
This  exploratory  study  explains  that,  how  the  mode  of  e-PBL  case presentation will be effective 
for critical thinking of groups using the e-PBL format. Students who learned in a virtual 
modality with digital on-line resources, which includes the cognitive concept mapping, research component in the 
form of review article on a particular ailment, video, relevant case studies engaged in more critical thinking. Norman 
and Schmidt (2000) suggested that the quality of the case in PBL relates to group functioning through which time 
spent on individual study relates to achievement 24. We have explored a few aspects of case quality, its mode of 
presentation. We believe our data support that the cognitive concept mapping and video will enhances critical 
thinking in either face-to-face or virtual PBL groups. Previous e-learning medical education research data suggest 
that the concept maps and implementation of research component and video enhanced critical thinking in both face- 
to-face and virtual PBL groups. Abbreviations: PBL- Problem Based Learning, OLRA- On-line resources available, 
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How  to  cite  this  article:  Kumar  Ponnusamy,  Jegathambigai  Rameshwar Naidu, Ravindra Kumar 

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2015;2(5):121-127. DOI: 10.16965/ijims.2015.117