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 effect of problem-based learning on the academic performance of students studying podiatric medicine in Ontario

OBJECTIVES: To investigate the effect of problem-based learning (PBL) on student achievement. DESIGN: Two cohorts of students studying podiatric medicine in Ontario were compared - one having undertaken the traditional lecture-based curriculum, and the other the problem-based learning programme. SETTING: The Michener Institute for Applied Health Sciences and The Toronto Hospital. SUBJECTS: Chiropody students. RESULTS: The performance of the students on the written Provincial Registration Examinations of Ontario was analysed utilizing independent t-tests and demonstrated that the PBL cohort of students achieved significantly higher overall examination scores (P < 0.005) than the traditional cohort. Further analysis revealed that no significant difference existed between student cohorts with respect to factual biomedical knowledge (P > 0.5), but that the PBL students performed significantly better in tests of deeper understanding and the cognitive skills related to patient management (P < 0.0005). Additionally, intragroup analysis using Spearman's rank order correlation indicated that there was no rank ordered association between performance on the multiple-choice and essay sections of the examination. CONCLUSIONS: The above results suggest that the PBL cohort of students was more knowledgeable than, and possessed superior cognitively related patient management skills, to their traditional counterparts.     

Content coverage in problem-based learning

Required learning of the basic medical sciences based on five clinical problems was compiled by teachers and subsequently derived as 'learning needs' by students during the problem-solving process. These lists of topics were compared in terms of number of lecture-hours and when these were taught in the traditional curriculum. The findings indicate that learning from problems is not entirely free-rein and can be largely determined by teachers; topics taught earlier in the course appeared more frequently than latter topics and there was a tremendous overlap of topics in both the traditional and problem-based list. Regardless of whether lectures have been given or not, students recalled facts better if they had encountered the related clinical problem. This study also reveals that problem-based learning can be as efficient as lectures in content coverage and concludes that the lecture method be retained provided the topics are selective and are derived and sequenced appropriately with clinical problems. Problem-solving should be adopted as a teaching strategy.     

The effect of compulsory participation of medical students in problem-based learning

Problem-based learning (PBL) is an instructional method that has attracted many advocates since its introduction in medical education almost 20 years ago. PBL features the use of student-directed tutorials, medically relevant problems to set study objectives, and independent learning. Educators have worried that not all students will do well with this method. This study compared a group of students who had chosen to be in a PBL curriculum with a group who had not, as they undertook a curriculum that contained both PBL and lecture-based courses. Academic performance was virtually identical regardless of learning method. Students slightly favoured the courses that featured the method they had originally chosen, but a significantly larger proportion of students shifted their preference from the lecture to the problem-based approach than vice versa. Students' academic performance does not appear to suffer when they are involuntarily enrolled in a PBL curriculum and many come to prefer this type of curriculum.     

A comparison of the effects of problem-based learning and lecturing on the development of students' critical thinking

BACKGROUND: Educational approaches are thought to have facilitative or hindering effects on students' critical thinking development. The aim of this study was to compare the effects of problem-based learning (PBL) and lecturing approaches on the development of students' critical thinking. METHODS: All 79 Year 1 undergraduate nursing students at a university in Hong Kong were randomly assigned to 1 of 2 parallel courses delivered by either PBL (n = 40) or lecturing (n = 39) over 1 academic year. The primary outcome measure was students' critical thinking disposition as measured by the California Critical Thinking Disposition Inventory (CCTDI). Individual interviews were also conducted to elicit the students' perceptions of their learning experience. Data were collected at 4 timepoints spanning 3 years. RESULTS: The overall CCTDI and subscale scores for the PBL group were not significantly different from those of the lecture group at the first timepoint (pretest). Compared with lecture students, PBL students showed significantly greater improvement in overall CCTDI (P = 0.0048), Truthseeking (P = 0.0008), Analyticity (P = 0.0368) and Critical Thinking Self-confidence (P = 0.0342) subscale scores from the first to the second timepoints; in overall CCTDI (P = 0.0083), Truthseeking (P = 0.0090) and Analyticity (P = 0.0354) subscale scores from the first to the third timepoints; and in Truthseeking (P = 0.0173) and Systematicity (P = 0.0440) subscale scores from the first to the fourth timepoints. CONCLUSIONS: There were significant differences in the development of students' critical thinking dispositions between those who undertook the PBL and lecture courses, respectively.     

Using real patients in problem-based learning: students' comments on the value of using real, as opposed to paper cases, in a problem-based learning module in general practice

OBJECTIVES: To explore the feasibility and value of using real patients as trigger material in problem-based learning (PBL). DESIGN: A questionnaire was given to all students participating in a PBL module including a question about 'the added value of using real, as opposed to paper cases', in problem-based learning. Resources used by students and assessment of feasibility were recorded by the course tutors. SETTING: A 7-week student-selected problem-based module in general practice in the fourth-year undergraduate medical curriculum, University of Newcastle upon Tyne. SUBJECTS: 69 students participating in the module over 2 years. RESULTS: All students valued the use of real patients. A total of 10 categories were identified, all congruent with accepted educational principles for effective adult learning. Real patients stimulated the use of a very wide range of resources and imaginative presentation of what had been learned. CONCLUSION: Real patients are potent trigger stimuli in problem-based learning. The use of real patients in this general practice-based module presented no organizational or ethical difficulties. Their use should be considered more widely.     

A lesson from the introduction of a problem-based, graduate entry course: the effects of different views of self-direction

OBJECTIVES: Difficulties in the early years of a new curriculum are to be expected as staff and students come to terms with new structures, and with different approaches to teaching and learning. During the first year of implementation of the Graduate Medical Course at the Graduate School of Medicine, The University of Queensland, we experienced our share of 'teething troubles'. One source of difficulty was different interpretations of the concept of 'self-directed learning' as it was to be applied in the new course. This paper presents an analysis of the effects of these differences on the development of the curriculum. DESIGN: An orientation programme was designed to introduce students to staff, facilities and the PBL process. SETTING: The University of Queensland. SUBJECTS: Problem-based learning (PBL) tutors, medical students. RESULTS: The overall effect was to place in jeopardy the achievement of student self-direction and commitment to lifelong learning as a goal of the course. To counter the undesirable effects of different interpretations, we have developed a conceptual framework to promote an agreed understanding of the meaning of self-direction, and to guide review and further development of the curriculum. A further paper describes the framework. CONCLUSIONS: Consistency in interpretation of key concepts is an important factor in the success of problem-based curricula.     

Early effects of a new problem-based clinically oriented curriculum on students' perceptions of teaching

OBJECTIVES: To compare the course experiences of medical students in a new problem-based (PBL) undergraduate medical course with those of their peers in a conventional curriculum. DESIGN: Whole class questionnaire survey using a pre-validated research instrument. SETTING: University of Liverpool, UK. SUBJECTS: First and second year medical students RESULTS: New curriculum students were more satisfied with their course when compared to their conventional course peers. Problem solving, team working and motivation scores were significantly higher amongst new course (PBL) students. New course students were more anxious about clarity of objectives and standard of work required. CONCLUSIONS: Early evidence suggests that curriculum reform from conventional teaching to a small group problem analysis programme results in improvement in student satisfaction with teaching and the development of appropriate learning skills.     

Problem-based learning: a case study in providing e-health education using the Internet

The current trend among many universities is to increase the number of courses available online. However, there are fundamental problems in transferring traditional education courses to virtual formats. Delivering current curricula in an online format does not assist in overcoming the negative effects on student motivation which are inherent in providing information passively. Using problem-based learning (PBL) online is a method by which computers can become a tool to encourage active learning among students. The delivery of curricula via goal-based scenarios allows students to learn at different rates and can successfully shift online learning from memorization to discovery. This paper reports on a Web-based e-health course that has been delivered via PBL for the past 12 months. Thirty distance-learning students undertook postgraduate courses in e-health delivered via the Internet (asynchronous communication). Data collected via online student surveys indicated that the PBL format was both flexible and interesting. PBL has the potential to increase the quality of the educational experience of students in online environments.     

The use of student journals in problem-based learning

This paper describes several examples of the use of journals in a Bachelor of Dental Surgery course. The examples cover: the use of journals in first year subjects and in later-year clinical subjects; the effect of changes in policy and practise as a result of experience with journals; and student views on their experiences with journals. The use of journals offers a means of achieving some of the more important goals of problem-based learning (PBL), particularly those requiring students to reflect upon and evaluate their experiences. When effectively integrated in a PBL course, journals have several functions: to formalize reflection; an outlet for personal feeling; an opportunity for feedback about a student's progress and about the course; to provide the student with a summary of the year's work; and a means whereby students and teachers gain insight into the learning process. However, our experience in Dentistry raises several contentious issues, especially with regard to confidentiality and assessment. We make several recommendations for the effective use of journals based on the need for frequent communication between students and staff, the development of an environment of trust, and the need for staff and student education in journal use.     

Problem-based learning: a case study in providing e-health education using the Internet

The current trend among many universities is to increase the number of courses available online. However, there are fundamental problems in transferring traditional education courses to virtual formats. Delivering current curricula in an online format does not assist in overcoming the negative effects on student motivation which are inherent in providing information passively. Using problem-based learning (PBL) online is a method by which computers can become a tool to encourage active learning among students. The delivery of curricula via goal-based scenarios allows students to learn at different rates and can successfully shift online learning from memorization to discovery. This paper reports on a Web-based e-health course that has been delivered via PBL for the past 12 months. Thirty distance-learning students undertook postgraduate courses in e-health delivered via the Internet (asynchronous communication). Data collected via online student surveys indicated that the PBL format was both flexible and interesting. PBL has the potential to increase the quality of the educational experience of students in online environments.     

Facility with the English language and problem-based learning group interaction: findings from an Arabic setting

The Faculty of Medicine and Health Sciences (FMHS), United Arab Emirates (UAE) University is in a unique position to explore issues related to English language proficiency and medical student performance. All students entering the FMHS have English as a second language. This study focused on the issues of students' proficiency in English as measured by the TOEFL test, student background factors and interaction in problem-based learning (PBL) groups. Using a modification of Bales Interaction Process Analysis, four problem-based learning groups were observed over four thematic units, to measure the degree of student interaction within PBL groups and to compare this to individual TOEFL scores and key background variables. The students' contributions correlated highly with TOEFL test results in the giving of information (range r = 0.67-0.74). The female students adhered to interacting in English during group sessions, whereas the male students were more likely to revert to using Arabic in elaborating unclear phenomena (p < 0.01). The educational level of the student's mother was highly predictive of TOEFL scores for the male students, but not for female students. Multivariate analysis was undertaken to analyse the relative contribution of the TOEFL, parental education and years of studying in English. The best predictor of students' contributions in PBL groups was identified as TOEFL scores. The study demonstrates the importance of facilitating a locally acceptable level of English proficiency prior to admission to the FMHS. However, it also highlights the importance of not focusing only on English proficiency but paying attention to additional factors in facilitating medical students in maximizing benefits from interactions in PBL settings.     

Students' Conceptions of Constructivist Learning: A Comparison between a Traditional and a Problem-based Learning Curriculum

This study investigated students' conceptions of constructivist learning activities in a problem-based learning (PBL) and a traditional curriculum. We examined whether students who have chosen for a problem-based curriculum have different conceptions of constructivist assumptions compared to students who have chosen to be enrolled in a traditional, lecture-based curriculum when they enter university. Although constructivism represents an influential view of learning, studies investigating how students conceptualize this perspective have not been conducted before. A structural equation modelling approach was adopted to test the hypothesized model in both student populations and to calculate latent means. Results suggested that students in the PBL environment agree more on constructivist assumptions of cooperative learning and the use of authentic problems, while students in the traditional curriculum acknowledge the importance of motivation to learn more. It is discussed that conceptions of constructivist learning activities can act as an important moderator of PBL effects and should be considered in examining the effects of PBL and probably in all comparative education research.     

A model of clinical problem-based learning for clinical attachments in medicine

Context  Problem-based learning (PBL) has been widely adopted in medical curricula for early-years training, but its use during clinical attachments has not been extensively explored.
Objectives  This study aimed to develop and evaluate a new model, 'clinical problem-based learning' (CPBL), to promote learning skills, attitudes and knowledge during clinical attachments.
Methods  The CPBL model takes the principles of PBL and applies them to learning during clinical attachments. Real patient encounters are guided by a list of broadly defined case types to ensure curriculum coverage. By discussing history taking and examination in the context of differential diagnosis and problem listing, students generate learning objectives relating to clinical skills, disease mechanisms and clinical management. These are explored through self-directed learning before the second tutorial, in which the tutor takes the role of 'expert', demonstrating how learned material translates into clinical practice. We evaluated which components contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus (Delphi process) method.
Results  Students found CPBL a positive learning experience. Identification of suitable cases for discussion was readily achieved, although follow-up was sometimes difficult. The tutor's level of expertise and a non-threatening learning environment, conducive to student questioning, were highly rated contributors to successful CPBL. Comments reinforced the view that CPBL is a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching.
Conclusions  Clinical problem-based learning was well received in clinical placements. Key elements were the learning interval, the involvement of expert tutors and a non-threatening learning environment.     

A comparison of learning outcomes and attitudes in student- versus faculty-led problem-based learning: an experimental study

OBJECTIVES: To compare learning outcomes and perceptions of facilitator behaviours and small-group process in problem-based learning (PBL) groups led by students and those led by faculty. DESIGN: A prospective, Latin-square cross-over design was employed. Second-year medical students participated in 11 PBL cases over the course of the academic year. For each case, half the student groups were led by faculty and the other half by a student group member selected randomly to serve in the facilitator role. Learning outcomes were assessed by performance on objective examinations covering factual materials pertinent to the case. Perceptions of facilitator behaviours and of group functioning were assessed with a questionnaire completed at the end of each individual case. Focus-group discussions were held to gain more in-depth information about student perceptions and experience. Student-led sessions were observed at random by the investigators. SETTING: A state-supported, US medical school with a hybrid lecture-based and problem-based curriculum. SUBJECTS: One hundred and twenty-seven second-year medical students and 30 basic science and clinical faculty. RESULTS: No differences were detected in student performance on the objective evaluation based on whether the facilitator was a faculty member or peer group member, nor were there any differences in the perceptions of group process. Students gave peer facilitators slightly higher ratings in the second semester of the experiment. In the focus-group discussions, students voiced a general preference for student-led groups because they felt they were more efficient. Observation and focus-group reports suggest that groups led by students sometimes took short cuts in the PBL process. CONCLUSION: In a hybrid lecture- and PBL-based curriculum, student performance on objective examinations covering PBL materials is unaffected by the status of the facilitator (student vs. faculty). However, in peer-facilitated groups, students sometimes took short cuts in the PBL process that may undermine some of the intended goals of PBL.     

Evaluation of an integrated curriculum using problem-based learning in a clinical environment: the Manchester experience

DESCRIPTION OF COURSE: In 1994, a new problem-based leaning (PBL) curriculum for year 1 medical students was introduced at the University of Manchester. The use of PBL has continued into the clinical clerkships. Year 3 of the curriculum is based entirely in a clinical environment with PBL groups meeting in three teaching hospitals. During this year, all students undertake two integrated 14-week modules with overarching themes. Each week, groups of eight students discuss a trigger problem connected to the relevant theme. The steps the groups use in the PBL process have been amended to encourage students to link their discussion with clinical experience. EVALUATION: At the end of each module, all 309 students were requested to complete an evaluation questionnaire. The response rates were 80% (n=247) and 89% (n=275) for the two core modules. RESULTS: The students have remained 'happy with the way the course is going' (83% at the end of module 2). They were also asked to rate a number of statements on a 5-point Likert scale (5=strongly agree). Concerning PBL, the students remained confident about working in a group (median 4), producing a set of learning objectives (median 4) and linking clinical experience with other knowledge (median 4). However, there were changes over the year. Fewer students agreed at the end of module 2 that 'the working problems were stimulating' (P=0.002) or 'motivated them to learn' (P < 0.001), but the clinical firms were seen as providing more appropriate experience (P=0.01) and being aware of the new curriculum and responding to it (P=0.018). We also surveyed the PBL tutors and had 65 returns from 78 people involved in the 38 PBL groups in year 3. The great majority of these are doctors employed by the National Health service. Virtually all the responders were happy to continue being a tutor (97%) and would recommend it to a colleague (93%). CONCLUSIONS: The evaluation has been positive with PBL having been successfully implemented in a clinical environment. We have identified significant changes over the year, which we need to address as we consolidate the curriculum.     

Conducting the symphony: a qualitative study of facilitation in problem-based learning tutorials

Context  Tutors in problem-based learning (PBL) tutorials have a complex role to play in facilitating students' learning. This includes providing support for students' acquisition of content knowledge and skills in critical thinking, coaching of group processes and modelling of reflective practice. Few studies which investigate the key role of tutors in the PBL tutorial process are qualitative in design.
Methods  This study explores the nature and technique of facilitation provided by PBL tutors from the students' viewpoint. Data were obtained from written responses to an open-ended question asking students about the effectiveness of their PBL tutor(s) and from in-depth interviews carried out with two randomly selected students.
Results  Three main themes arose from the inductive analysis of qualitative data: (i) role confusion by tutors; (ii) tutor management of sensitive issues, and (iii) facilitation 'style'. The theme of tutors' facilitation style was dominant and three sub-categories were apparent. These were: (i) managing the learning in PBL tutorials; (ii) facilitating group processes, and (iii) guiding group discussion.
Conclusions  Findings highlight the need for tutors to regularly review the PBL tutorial processes and group dynamics within the tutorial setting. These findings have implications for tutor training and programmes of ongoing professional development for PBL facilitators.     

Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills

OBJECTIVES: A recent review of problem-based learning's effect on knowledge and clinical skills updated findings reported in 1993. The author argues that effect sizes (ES) seen with PBL have not lived up to expectations (0.8-1.0) and the theoretical basis for PBL, contextual learning theory, is weak. The purposes of this study were to analyse what constitutes reasonable ES in terms of the impacts on individuals and published reports, and to elaborate upon various theories pertaining to PBL. DESIGN: Normal theory is used to demonstrate what various ESs would mean for individual change and a large meta-analysis of over 10 000 studies is referred to in identifying typical ESs. Additional theories bearing upon PBL are presented. RESULTS: Effect sizes of 0.8-1.0 would require some students to move from the bottom quartile to the top half of the class or more. The average ES reported in the literature was 0.50 and many commonly used and accepted medical procedures and therapies are based upon studies with ESs below 0.50. CONCLUSIONS: Effect sizes of 0.8-1.0 are an unreasonable expectation from PBL because, firstly, the degree of changes that would be required of individuals would be excessive, secondly, leading up to medical school, students are groomed and selected for success in a traditional curriculum, expecting them to do better in a PBL curriculum than a traditional curriculum is an unreasonable expectation, and, thirdly, the average study reported in the literature and many commonly used and accepted medical procedures and therapies are based upon studies having lesser ESs. Information-processing theory, Cooperative learning, Self-determination theory and Control theory are suggested as providing better theoretical support for PBL than Contextual learning theory. Even if knowledge acquisition and clinical skills are not improved by PBL, the enhanced work environment for students and faculty that has been consistently found with PBL is a worthwhile goal.     

以问题为中心的学习法在《健康促进》课程中的运用

在护理学专业的《健康促进》课程中开展以问题为中心学习法的教学实践,并通过问卷调查和期末考核评估以问题为中心学习法的教学效果.结果显示以问题为中心的学习法有助于护生团队协作能力、沟通能力、自主学习能力等的提高,同时在教学课时的安排上还应做出更加合理的安排.