Problem-based learning in medical education: Developing a research agenda

While the use of problem-based learning (PBL) methods continues to increase in medical education, three literature reviews of PBL have appeared in the past several years which come to different opinions about their merits. This analysis summarizes the research evidence regarding PBL by examining how well it has met its originators' goals, what we know about how PBL works, and how PBL fares in a goal-free comparison with conventional curricula. A research agenda is suggested to refine our understanding of well-documented effects of PBL, to probe for other possible longer term PBL outcomes, and to examine if and how PBL affects knowledge acquisition and retention. Consistency of evidence from a variety of PBL implementations can help decide whether the effects seen can be attributed to PBL or are the results of other curricular features unique to one setting.     

Student perceptions of a virtual learning environment for a problem-based learning undergraduate medical curriculum

OBJECTIVE: To investigate the effects of a virtual learning environment (VLE) on group interaction and consultation of information resources during the preliminary phase, self-study phase and reporting phase of the problem-based learning process in an undergraduate medical curriculum. METHODS: A questionnaire was administered to 355 medical students in Years 1 and 2 to ask them about the perceived usefulness of a virtual learning environment that was created with Blackboard for group interaction and the use of learning resources. RESULTS: The students indicated that the VLE supported face-to-face interaction in the preliminary discussion and in the reporting phase but did not stimulate computer-mediated distance interaction during the self-study phase. They perceived that the use of multimedia in case presentations led to a better quality of group discussion than if case presentations were exclusively text-based. They also indicated that the information resources that were hyperlinked in the VLE stimulated the consultation of these resources during self-study, but not during the reporting phase. CONCLUSIONS: Students indicated that the use of a VLE in the tutorial room and the inclusion of multimedia in case presentations supported processes of active learning in the tutorial groups. However, if we want to exploit the full potential of asynchronous computer-mediated communication to initiate in-depth discussion during the self-study phase, its application will have to be selective and deliberate. Students indicated that the links in the VLE to selected information in library repositories supported their learning.     

Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study

Since its first implementation in a medical programme at McMaster University, Canada, problem-based learning (PBL) has become a well-established means of teaching and learning medicine. Extensive research has been conducted and a number of strengths of the method are well supported. Several items, however, remain unclear although there is evidence that no relevant difference exists in factual knowledge among students from PBL and traditional curricula, a controlled, randomized study has not been conducted to address this issue. The Medical Faculty of the University of Cologne is in the process of integrating elements of PBL into its curriculum. In the spring term of 1997, after seven semesters of experience with PBL supplementing the traditional course of basic pharmacology, we did for the first time use PBL instead of the lecture-based course (LBL) and conducted a controlled prospective study to determine the effects of this intervention. One-hundred and twenty-three students were randomly assigned to either PBL (n = 63), with tutorial groups of up to nine students, or to the traditional, lecture-based course (n = 60). Analysis of the results of both groups in the examination of basic pharmacology, consisting of multiple-choice and short-essay questions, revealed similar scores with a tendency favouring PBL students in the category of short-essay questions. Hence, it seems clear that PBL does not imply a disadvantage in terms of factual knowledge. Students considered PBL to be an effective learning method and favoured it over the lecture format. Furthermore, students reported positive effects of PBL in terms of use of additional learning resources, interdisciplinarity, team work and learning fun.     

The role of basic sciences in a problem-based learning clinical curriculum

BACKGROUND: Very little is known about the use of problem-based learning (PBL) during the later years of the undergraduate medical course and how it influences further acquisition of basic science knowledge. Similarly to many other Faculties, the PBL approach is used at Manchester in years 1 and 2, but more unusually, the curriculum continues to be centred on PBL in the clinical modules. OBJECTIVES: To explore whether and how basic science learning was continued in year 3 of the PBL clinical curriculum. METHODS: 10 of the weekly problems from the two core modules in year 3 were analysed to determine: (a) whether the design teams were using basic science objectives in devising the problems, and (b) whether PBL student groups were setting basic science learning objectives. The basic science knowledge of year 3 and 4 students was also measured. RESULTS: Similar numbers of objectives were being set by the management groups for each weekly problem (Heart, lung and blood (HLB) module, median 15, range 11-20; Nutrition, metabolism and excretion (NME) module, median 13, range 9-21). In the basic sciences, there was a median of 3 objectives per problem (range 0-6) in the NME module, but only 1 objective (0-2) per problem in the HLB module. The objectives set by six PBL groups in each module were analysed. Overall, agreement was reached on 130 occasions (62%) between the design team basic science objectives and those set for themselves by the student groups. In addition, there was a median of 2 (range 1-8) new basic science objectives brought out by the PBL groups that were not listed by the HLB module design team. In the NME module, there was again a median of 2 new objectives (range 0-6). The performance of year 3 and year 4 students in the multiple-choice questions progress test was analysed. For the 65 basic science questions, the year 3 mark was 40.8 +/- 12.3% compared with 57.1 +/- 12.3% for year 4 (P < 0.0001). CONCLUSIONS: (a) The design teams are setting basic science objectives; (b) the working problems are triggering students to set learning objectives in the basic sciences; (c) most of the objectives being set by the design teams are being triggered in the majority of group sessions; (d) the students knowledge of basic sciences increases in years 3-4.     

A learning resources centre: its utilization by medical students

Innovations in medical education have led to the increasing use of problem-based learning techniques, a committee system organization, and more time for independent study in many undergraduate programmes. There has been an increase in availability of alternative methods for presentation of information. To encourage self-directed learning, resources such as computers, videos and models, among others, should be readily available to students. The University of Calgary Faculty of Medicine has provided various resources contained in one area, called the Bacs Learning Resource Centre (BLRC). Since the maintenance and further development of such a centre requires significant resources, it is important to determine student utilization of the various components used in their learning. For those who are about to set up such a learning resource centre this information gives guidance on which materials are most useful.
The utilization of the centre by 69 first year medical students was studied using questionnaires. The utilization during a specific course was determined by analysing the entries in the individual log books given to the students at the beginning of the Integrative Course. With the exception of one student, all those who responded to the questionnaire used the Centre, with 20% or less of their total study time being spent there. The BLRC was most used for the Musculo-skeletal, Cardiovascular and Reticulo-Endothelial courses. All categories of resources were found to be useful, with the tape/slides least utilized. Utilization was most influenced by the quality of resources available and recommendations by peers. The development of a centre such as the BLRC, with a variety of resources concentrated in one area, suitable for individual or group study and accessible 24 hours a day, should be considered by all medical schools to enhance self-directed learning in medical students.     

Problem-based learning improves the academic performance of medical students in South Africa

OBJECTIVES: To compare the academic performance of students on the previous, classical, discipline- and lecture-based, traditional curriculum with that of subsequent students who followed an innovative, problem- and community-based curriculum. METHODS: This was a retrospective study that analysed the records of students who enrolled on the doctor training programme between 1985 and 1995, and the records of students who graduated from the programme between 1989 and 2002. OUTCOMES: The educational outcomes assessed were the attrition and graduation rates on the traditional curriculum and those on the innovative curriculum. RESULTS: A total of 149 students on the traditional curriculum and 145 students on the innovative curriculum were studied. Overall, 23% of the traditional cohort as opposed to 10.3% of the innovative cohort dropped out of the course (P = 0.0041) and 55% of the traditional cohort as opposed to 67% of the innovative cohort graduated within the minimum period of 6 years (P < 0.001). The mean throughput period was 6.71 (0.09) years in the traditional cohort and 6.44 (0.07) years in the innovative cohort (P = 0.014) CONCLUSION: The introduction of the problem-based learning/community-based education (PBL/CBE) curriculum coincided with improved academic performance. The PBL/CBE approach to medical education may have contributed to this improvement.     

Computer-based management of content in planning a problem-based medical curriculum

The Faculty of Medicine at the University of Sydney has undertaken a major educational change from a traditional didactic 6-year, undergraduate entry programme to a 4-year problem-based programme to which only graduates are admitted. We have used two computer-based tools which proved invaluable in developing and managing the content of the new curriculum. The first, developed using a commercial database and made available on the Faculty's Intranet, provided a means for eliciting appropriate problems, organizing content fields and searching the information. The second, based on a spreadsheet, provided a means of displaying agreed content on implementation grids, both for self-directed learning and conventional teaching sessions. Both provided ready access for scrutiny, interaction, review and planning by staff and they greatly enhanced the process of understanding the nature of the new curriculum, and thus in reassuring staff about the change. By merging the two tools, a definitive curriculum database is emerging.     

First year medical student stress and coping in a problem-based learning medical curriculum

OBJECTIVE: To examine the prevalence of psychological morbidity, sources of stress and coping mechanisms in first year students in a problem-based learning undergraduate medical curriculum. DESIGN: Longitudinal cohort questionnaire survey. SETTING: Glasgow University Medical School. PARTICIPANTS: All first year students (n = 275) in the 1997-98 intake. MAIN OUTCOME MEASURES: Scores on the 12-item General Health Questionnaire (GHQ-12), sources of stress and coping strategies. RESULTS: The prevalence of psychological morbidity and mean GHQ-12 scores increased significantly between term 1 and term 3, with no significant gender differences. Principal stressors were related to medical training rather than to personal problems, in particular uncertainty about individual study behaviour, progress and aptitude, with specific concerns about assessment and the availability of learning materials. The group learning environment, including tutor performance, and interactions with peers and patients caused little stress. Students generally used active coping strategies. Both stressor group scoring and coping strategies showed some variation with gender and GHQ caseness. CONCLUSIONS: Increased student feedback and guidance about progress throughout the year and the provision of adequate learning resources may reduce student stress. Educational or pastoral intervention regarding effective coping strategies may also be beneficial. Continued follow-up of this cohort could provide information to inform further curriculum development and, if appropriate, aid the design of programmes for the prevention of stress-related problems.     

Learning in a problem-based medical curriculum: students' conceptions

The purpose of this study was to examine students' conception of their learning in a problem-based learning medical curriculum. A multiple case study design was used with two units of analyses: two PBL lab groups; and 15 individual students within each lab group. Data collected included weekly journals by students, video-tapes of PBL sessions, focus group interviews with students, two open-ended questionnaires completed by students, and interviews with the PBL tutors. Three thematic categories of students' conceptions of their learning emerged: (1) awareness of PBL goals and expectations; (2) efficiency and expertise; and (3) the role of the tutor.     

Self-directed learning in anatomy: incorporation of case-based studies into a conventional medical curriculum

This paper reports an attempt to develop self-directed learning skills in second-year medical students by introducing case-based projects into the gross anatomy course at a long-established medical school. The programme and students' responses to a questionnaire completed at the end of the year are presented. Information on the various resources used by students to find information is given. The performance of students in the case-based components of the course has been evaluated and also in the more traditional end-of-year written examination. The data confirm that students have recognized that the projects were about obtaining a deeper understanding of the anatomy, and the programme appears to have promoted the use and study of library texts.     

Testing a Causal Model for Learning in a Problem-based Curriculum

The aim of this study was to identify the relationship between elements that are important for the tutorial group process and the individual learning process in a problem-based curriculum. The variables under investigation were student-generated learning issues, individual learning process, reporting in the tutorial group, and achievement. A questionnaire containing 22 items was developed. Data were collected in the first year (N = 195) of the Medical School of the Maastricht University in the Netherlands during the academic year 1997–1998. The data were analysed using a structural modelling approach. The results indicate that the model fitted the data well. The path coefficients were moderately high, particular between the explanation-oriented approach and the depth of the reporting in the tutorial group. High path coefficients were also found between the depth of the reporting and achievement. In sum, the model gives insight into how important variables are related and it is recommended that data should be collected to test the model repeatedly. This revised version was published online in August 2006 with corrections to the Cover Date.     

A process evaluation of medical ethics education in the first year of a new medical curriculum

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.     

Implementing a problem-based learning curriculum in occupational therapy: A conceptual model

Problem-based learning in occupational therapy education has enjoyed increasing attention in recent years. Drawing on concepts from general systems theory and organizational theory, this paper presents a conceptual model of an occupational therapy education program as an open and dynamic system that interacts with and is responsive to the external environment. The model is described in the generic context of developing, implementing and evaluating a problem-based learning curriculum. The Bachelor of Health Sciences (Occupational Therapy) program at McMaster University in Canada is used to provide a practical illustration of the various components of the model. The model is considered to be sufficiently generic and adaptable for use by any occupational therapy program in any sociocultural environment in the world, and will be of particular interest to those who are considering problem-based learning as an alternative to traditional educational approaches.     

Techniques used by "expert" and "non-expert" tutors to facilitate problem-based learning tutorials in an undergraduate medical curriculum

BACKGROUND: There is inconclusive debate within the literature as to whether the best problem-based learning (PBL) tutors are subject experts or not. The debate hinges on whether knowledgeable tutors are tempted to intervene too often in PBL discussions compared to non-expert tutors, and whether the latter may not be able to sufficiently challenge the students' level of understanding. PURPOSE: To describe approaches used by tutors in PBL tutorials and to identify differences between tutors from medical and non-medical backgrounds. METHODS: The research reported in this paper was undertaken during the academic session 1999-2000 at the University of Liverpool Faculty of Medicine. A qualitative exploratory case study method was used and two PBL groups were observed. One of these groups had a medically qualified tutor and the other had a tutor from a humanities background. The focus of the observation was the discourse between tutor and students, which was analysed using a framework drawn from linguistics. Results were fed back to both the tutors and the students to check their perceptions of the interactions. RESULTS: Analysis of the tutorial group interaction revealed that tutors from both backgrounds used similar techniques to raise students' awareness, facilitate the group process and direct students' learning. Differences were noted between the two tutors: the medical tutor set out to raise students' awareness by using questioning techniques herself, whereas the non-medical tutor expected students to question each other. The non-medical tutor was observed to facilitate the group process more often than the medical tutor. CONCLUSIONS: Qualitative analysis of spoken discourse in PBL tutorials provides valuable insights into the processes involved in PBL, thereby generating material which is useful for both training of and giving feedback to PBL tutors.     

Recruiting problem-based learning (PBL) tutors for a PBL-based curriculum: the Flinders University experience

OBJECTIVES: To examine the contribution made to problem-based learning (PBL) by individual teachers and by departments in years 1 and 2 of a new graduate-entry medical programme (GEMP) with a PBL-based curriculum. METHODS: We compiled a database on all PBL tutoring undertaken in years 1 and 2 during the first 3 years in which the GEMP was delivered. This allowed us to quantify and analyse the contribution made by individuals and by departments. RESULTS: At 3 years following introduction of the GEMP, 136 (25.9%) of the school's 525 staff had trained as PBL tutors and 98 (18.7%) had tutored. Both individuals and departments differed greatly in the amount of time devoted to PBL tutoring. Staff who tutored once tended to tutor again in subsequent years. Compared with staff in clinical departments, those in non-clinical departments (who constituted 12% of the total) made a greater relative contribution though a smaller absolute contribution to tutoring. CONCLUSIONS: These findings prompted us to develop a formula that distributes the PBL tutoring load more evenly across departments. This was successfully introduced in 1999. It recognizes the fact that only a minority of staff will volunteer to become PBL tutors. Strategies that might encourage more staff to tutor are briefly discussed.     

Initial responses of first-year medical students to problem-based learning in a behavioural science course: role of language background and course content

A trial of problem-based learning (PBL) was conducted with first-year undergraduate medical students who had no background knowledge of behavioural science and who included a substantial proportion with a first language other than English. Responses to standardized and open-ended evaluation questions showed greater variability and there was no clear preference for PBL over traditional methods. Students found the PBL exercise time-consuming and felt they needed more guidance. Feedback from clinicians and working in groups were seen as positive aspects of the exercise. Students with a first language other than English reported that language, but not cultural background, was an impediment to effective participation. It is recommended that this group of students be offered extra support for PBL in a subject-based setting, and that all students would benefit from a formal induction session.