Role of Problem-Based Learning (PBL) in Medical Education

Problem-Based Learning (PBL) is a teaching method used in many medical schools in Sri Lanka and worldwide. This article describes this method, its importance and impact on medical education.

What is PBL?

“A learning method based on the principle of using problems as a starting point for the acquisition and integration of new knowledge.”

                                                            -H.S. Barrows 1982

Problem-based learning is a student-centered teaching method, mostly used during the pre-clinical phase of medical curriculum.

In this approach a clinical problem is given to a small group of students, to discuss on it over several sessions. Analysing the problem helps to identify the knowledge gaps and acts as a stimulant to explore, not only the basic scientific and clinical facts, but also the social, psychological, ethical or professional issues.

Pioneering this approach, McMaster University describes PBL as “a pedagogical approach, which uses cases, and problems as the starting point for acquiring the desired learning objectives”.

History of PBL

The philosophical roots of PBL go back to Socrates, who utilized problems with his students and help them to explore “their assumptions, their values and the inadequacies of their proffered solutions”. Similarly, Aristotle suggested that students begin problem‐solving by determining both their perceptions and beliefs.

In medical education, PBL is one of the most pioneering innovations of the past 40 years. It was introduced by Barrows and Tamblyn at the medical school program at McMaster University in Hamilton, in response to teacher-centered and discipline-based preclinical medical education prevalent in the 1960s.

The PBL curriculum was designed to stimulate learning by allowing students to see the relevance with application to future roles. It was Barrows’ desire to bridge the gap between theory and practice in the clinical setting and to increase clinical reasoning abilities. He believed medical skills that most important for treating patients were problem-solving skills, not the memorization of facts.

This method of teaching and learning spread fairly fast within a few years of its inception. As the McMaster model became known, staff from Maastricht (Netherlands) and Newcastle (Australia) spent time at McMaster in the 1970s before returning to implement PBL at their new medical schools. In 1979, The University of New Mexico medical school offered a PBL curriculum as an alternative track. Over the next two decades, established schools like Harvard, Sherbrooke (Canada), Manchester and Liverpool (U.K.) changed their traditional curricula to incorporate PBL. In 2003, 70% of U.S. medical schools used PBL in the preclinical years to some extent. According to McMaster University, out of 125 medical schools in the United States, 120 follow a PBL curriculum. PBL has seen the most widespread application in the first two years of medical school, where it replaces lecture‐based approaches to core courses. As medical schools worldwide adapted PBL into their curricula, variants arose depending on the school, staff preference and local constraints. This resulted in a diversity of PBL models. Those different variants are practiced in Sri Lanka as well.

Why PBL?

PBL can be considered of as a small group teaching method that combines the acquisition of knowledge with the development of generic skills and attitudes.

Following are the positive facts in PBL in preparing students for professional practice,

Ø  encourages independence as they identify and meet individual learning needs

Ø  stimulates reflection and self-direction for life-long learning

Ø  supports on-going self-assessment

Ø  introduces clinical reasoning, later refined with clinical experience

Ø  enhances critical thinking and evidence-based decision-making

Ø  ensures that knowledge is transferred, applied and retained by providing a relevant, integrated context

Ø  offers practice and experience in introducing professional concepts and medical language

Ø  supports effective teamwork and peer communication

  

How PBL is conducted?

PBL tutorials are conducted in several ways. Most of the Medical Schools in Sri Lanka and in the region follows the Maastricht “seven jumps” process, which is inspired by a Dutch folk dance, which has seven steps of jumps.

The seven steps are:

1. Clarify concepts
2. Define the problem
3. Brainstorm (analyse the problem)
4. Systematic classification
5. Formulate learning objectives
6. Self study
7. Discussion

In short, it is identifying what they already know, what they need to know, and how and where to access new information that may lead to the resolution of the problem.

A typical PBL tutorial consists of a group of students (usually 8 to 10) and a tutor, who facilitates the session. The length of time (number of sessions) that a group stays together with each other and with individual tutors varies between institutions. A group needs to be together long enough to allow good group dynamics to develop and may need to be changed occasionally if personality clashes or other dysfunctional behaviour emerges.

Students elect a chair for each PBL scenario and a “scribe” to record the discussion. The roles are rotated for each scenario. Suitable flip charts or a whiteboard should be used for recording the proceedings.

During first PBL session, students use “triggers” he problem or case scenario to define their own learning objectives. Subsequently they do independent, self-directed study before returning to the second session to discuss and refine their acquired knowledge.

Observing an effective tutorial group in action provides an opportunity to experience the basic characteristics. The initial impression is usually of an open, lively and free-flowing discussion in which all participate. The atmosphere is friendly and informal.

Characteristics of an effective problem-based learning group

An effective group is cohesive, motivated, mutually supportive and actively engaged in learning. The group understands and energetically pursues its task. Members respect each other's contributions but examine them critically. Discussion flows as students cooperate rather than compete. Individuals are supported during times of personal stress.

The atmosphere is friendly and good-humoured. Discussion is open but tactful and constructive. Difficulties that arise are not ignored, but dealt with sensitively in a climate of mutual tolerance.

Roles are shared; all take turns in scribing, leading discussion or accepting responsibility for acquiring information. If the tutor is delayed, well-established groups confidently start the tutorial and proceed effectively.

Who is a good PBL tutor?

“Poor teaching is bad, but poor PBL is worse”

-Kwan and Tam

The role of the tutor is to facilitate the proceedings (helping the chair to maintain group dynamics and moving the group through the task) and to ensure that the group achieves appropriate learning objectives in line with those set by the curriculum design team. The tutor may need to take a more active role in step 7 of the process to ensure that all the students have done the appropriate work and suggest a suitable format for group members to present the results of their study. The tutor should encourage students to check their understanding of the material by asking open questions to explain topics in their own words or by the use of drawings and diagrams.

The role of the facilitator is critical for PBL to function effectively. Effective tutors do not dominate or instruct. She/ he quietly monitors the process, ensuring that all are included and interactions focus on relevant issues.

What is a trigger?

Well-designed problems are underpinned by a structure for reasoning, equally explicit to tutors and students.

Typically;

Ø  A trigger initiates the problem (on video, paper, computer)

Ø  Groups brainstorm to identify cues and key issues

Ø  Broad thinking produces a rich array of possible explanations or mechanisms

Ø  Hypotheses are critically explored through reasoning and organized by priority or likelihood

Ø  Hypotheses are tested and refuted or supported by further information sought from the tutor or progressively revealed

Disadvantages

The major disadvantage to this process involves the utilization of resources and tutor facilitation. It requires more staff to take an active role in facilitation and group-led discussion. It is resource-intensive because it requires more physical space and more accessible computer resources to accommodate simultaneous smaller group-learning.

Students also report uncertainty with information overload and are unable to determine how much study is required and the relevance of information available. Students may not have access to teachers who serve as the inspirational role models that traditional curriculum offers.

Conclusion

PBL is an effective way of delivering medical education in a coherent, integrated programme and offers several advantages over traditional teaching methods. It is based on principles of adult learning theory, including motivating the students, encouraging them to set their own learning goals, and giving them a role in decisions that affect their own learning.

PBL does not offer a universal panacea for teaching and learning in medicine, and it has several well-recognised disadvantages. However, students from PBL curriculums seem to have better knowledge retention. PBL also generates a more stimulating and challenging educational environment, and the beneficial effects from the generic attributes acquired through PBL should not be underestimated.

References

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