Problem-based learning: a review of literature on its outcomes and implementation issues

Organizational considerations for an electronic curriculum. Part I: A rational nosology for concept management in dentistry

STATEMENT OF PROBLEM

With the use of multimedia electronic knowledge as a tool in dental education, an overriding concern has centered on how to devise an organizational model that will accommodate the vast and diverse arrays of information involved, yet be sufficiently simple enough to provide students with a rational and consistent means of accessing the information they require. By adopting the natural history of the diseases dentists are called on to address as a common organizing principle, it becomes possible to link all concepts that relate to individual problem areas through a technique of retro-mapping.

PURPOSE

The purpose of this article is to introduce learners to a cognitive "scaffolding" that will assist them in achieving a deeper cognitive dimension for problem solving.

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, interactions, 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.

An innovative problem-solving assessment for groups of first-year medical undergraduates--Think Tanks

A problem-solving assessment has been devised and used for groups of first-year medical students at Southampton University. Five cohorts of approximately 160 students have taken the assessment since 1990. The assessment was part of a Locomotor system course that integrated biological and behavioural sciences and clinical specialties. The course also included lectures, practicals and tutorials and occupied the first 7 weeks of the last (10-week) term. Other assessments of the course involved essay writing and a spotter-type practical. For the problem-solving assessment, groups of about six students ('Think Tanks') received a problem which they had to investigate during the course. The students had some choice in the problem they were to study. The problems were designed, by staff, to cover aspects of movement in the context of health and disease. A staff advisor was assigned to each Think Tank group to provide general support. The results of the investigations of each Think Tank were displayed at the end of the course in the form of a poster aimed at informing their peers. Three members of staff gave each Think Tank group a communal oral examination and the performance of the group was given a grade. Each member of the group, normally, was allowed to add this grade to their marks for the whole year.

Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools

A valid and reliable questionnaire was developed which assesses eight subscales relating to key areas of medical hospital-based work. This was used to evaluate junior doctors' perceptions of the adequacy of their undergraduate medical training to prepare them for hospital practice. Data from 139 (60%) first-year doctors (interns) showed that graduates from the problem-based medical school rated their undergraduate preparation more highly than traditional medical school graduates in preparing them for practice in the areas of interpersonal skills, confidence, collaboration with other health care workers, preventive care, holistic care and self-directed learning. These findings persisted when ratings were adjusted for the effects of age and gender. There were no differences between the intern groups for patient management and understanding science. This research suggests that educational experiences in different undergraduate medical courses are important in preparing doctors for their early working life.

The SOCRATES curriculum: an innovative integration of technology and theory in medical education

This article describes the pilot study of an innovative medical school curriculum module that utilizes a modified problem-based learning (PBL) approach to teach medical students about management of diabetes mellitus. The PBL-based curriculum incorporated computer simulations and analysis of videotaped patient encounters in addition to independent study and group discussion. At the conclusion of the study, student knowledge and clinical decision-making skills were evaluated via questionnaires and examinations. Twenty-three students completed the workshop and all evaluation assessments. Students performed well on the case-study examinations (mean score of 3.39 out of 4) but not on the short answer essay examination, which assessed basic knowledge. Students rated the quality and appeal of the activities using Likert-type scales. In general, students perceived the activities as very worthwhile, with reasonable complexity and adequate time devoted to each activity. Students were very positive about the workshop and preceptor; 15 of the 16 items used to rate workshop appeal yielded mean scores greater than 4 (on a scale of 1 to 5, with 5 being the highest). The results of the pilot study suggest future enhancements that would further improve the outcomes of the training.

A clinical rehabilitation course for college undergraduates provides an introduction to biopsychosocial interventions that minimize disablement

A two-credits per semester clinical medicine course was established in the Department of Physical Medicine and Rehabilitation (PM&R) in cooperation with the Johns Hopkins University undergraduate Human Biology faculty to present the variety of inpatient consultation personnel, units, patient diagnostic groups, and functional problems. College students spend 4 hr weekly on the PM&R consultation service as team members under resident supervision. The curriculum emphasizes student understanding of the roles of rehabilitation team members. Objectives include demonstration of working knowledge of the Biopsychosocial Model, the World Health Organization Model of disablement and interdisciplinary rehabilitation intervention. The course includes simulations of physical impairments, demonstrations of adaptive equipment, interactive chart reviews, readings, and audio lectures. A retrospective sequential review was made of the last 100 physical medicine and rehabilitation consultations with student attendance. The results confirm student exposure to many ward settings (surgery, 30%; neurology/neurosurgery, 28%; medicine, 24%; intensive care, 15%; oncology, 2%; and psychiatry, 1%), patient complexity (averaging 10 problems), and multiple ICD-9 diagnosis categories (circulatory, 36%; neurologic, 22%; musculoskeletal, 17%; neoplasms, 10%; injury, 5%; endocrine, 4%; infections, 3%; and others, 3%). The rehabilitation consultation service is particularly effective as an introduction to hospital-based medical practice due to the diagnostic variety of the patients, the functional approach of rehabilitation, and student exposure to multiple hospital settings. The Biopsychosocial Model of medical practice is demonstrated through multiple interdisciplinary perspectives of needs and interventions for patients with obvious functional deficits. This process develops a rudimentary understanding of the effect of illness on the person and the variety of medically effective therapeutic modalities.

Problem-based examining: a different approach to assessment

An attempt to achieve problem-based examining by the structured assessment of presentations is described. Students can choose to participate in the scheme in teams and then elect to use their awarded mark instead of part of the formal examination assessment. The element of choice of the study or examination method is seen as being a valuable element of the scheme. The scheme can be introduced without radical revision of existing curricula or substantial investment of staff time, and meets some of the expressed desires of the UK General Medical Council in terms of the introduction of novel methods of assessment.

The Women's Health Curriculum by a problem-based learning method for medical students at the University of California, San Francisco

OBJECTIVES

Our objectives were to (1) expand and strengthen the women's health curriculum at the University of California, San Francisco, and (2) evaluate the responses of both medical students and faculty to this curriculum.

STUDY DESIGN

A written evaluation of the curriculum in women's health was completed by both students and faculty. Variables studied included mean scores of cases, the overall course score, and the preferences of medical students for faculty specialty in teaching the small groups.

RESULTS

The overall course evaluation score was 7.81 (range 1 to 10). For those students who had both faculty from internal medicine or family medicine and obstetrics and gynecology, there was a strong preference that obstetrician-gynecologists teach the majority of the cases.

CONCLUSIONS

The new case-based curriculum in women's health was enthusiastically received by both medical students and faculty.

The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis

The "Think Aloud" seminar is a group teaching method to assist pediatric nurse practitioner students to develop critical thinking and clinical reasoning skills. Seminar proceedings simulate the iterative clinical reasoning process that occurs in an actual clinic or office visit. Students' requests for subjective and objective data must be followed by the rationale as to why the information was requested. This method is effective for teaching and evaluating students' skills in differential diagnosis and management of common illness in children. The process will be demonstrated with the presenting symptom of a sore throat followed by a description of the procedures that are used. J Pediatr Health Care.

Basic sciences in problem-based learning and conventional curricula: students' attitudes

The purpose of this study was to compare the attitudes toward basic sciences of students in a preclinical problem-based curriculum and a conventional lecture-based curriculum at the end of their second year of medical school. The results showed that the PBL class had more positive attitudes toward basic sciences than students in the conventional class. These results may reflect a learning environment where students meet many scientist role models as teachers and where basic science is learnt in the context of clinical problems.

Residents' evaluation of a problem-based learning curriculum in a general surgery residency program

METHODS

To determine residents' satisfaction with problem-based learning and its tutors, to determine how residents prepare for sessions, and to identify the characteristics of both effective sessions and tutors, we analyzed 132 evaluations from 24 residents who completed 1 or more of the 9 cases presented during the first 9 months of our program. The 38-item evaluation questionnaire asked residents to rate tutor characteristics, various aspects of the sessions, and methods used to prepare for the sessions.

RESULTS

Residents were well satisfied with the problem-based learning sessions and with the logistics of our program; they found the overall quality of the tutor more important than that of the case; they valued an active, thought-provoking tutor more than a traditional facilitator; and they most often used standard textbooks to prepare for the sessions.

CONCLUSIONS

Problem-based learning is a practical, enjoyable graduate curricular vehicle when implemented with well-written cases and active tutors.

Subject-based problem-based learning in the veterinary science course at the University of Queensland

OBJECTIVE

To assess students' perceptions of subject-based problem-based learning in the fourth year of the veterinary science course at the University of Queensland.

DESIGN

A questionnaire-based study.

PROCEDURE

Subject-based problem-based learning was introduced into parts of two fourth year subjects in a 5-year veterinary science course. The problem-based learning exercise used modified clinical cases and was computer-assisted. Students worked in groups of two to four, and small group discussion sessions were tutorless. Lectures were replaced by large group discussion and feedback sessions, led by the teacher, with approximately 85 students.

RESULTS

There was a significant increase in the percentage of students who strongly agreed that they had better understanding of the subject, and had learned to apply principles from this class in new situations. The only consistent criticism by students was directed at the extra time required compared to traditional lecture-based subjects.

CONCLUSION

Students' perceptions of the learning outcome were very favourable for problem-based learning when compared to the lecture-based subject.

Training experiences immediately after medical school

Trainees in all teaching hospitals in New South Wales were surveyed using a self-completion, postal questionnaire to assess perceptions of the quality and extent of training received for interactional and technical skills. The response rate was 67.1%. Mean age was 25.4 years and 38.8% were female. Overall, training was found to be generally poor in terms of time and educational strategies used. Interactional skills were found to receive lower levels of training than technical skills both prior to and during the intern year with significantly fewer (P < 0.000) educational strategies reported for training received in interactional skills than for technical skills. Trainees' perceptions of the adequacy of training was significantly more negative for interactional than technical skills (P < 0.001). Assessment of competence was also significantly lower for interactional than technical skills (P < 0.001). On average, fewer than one in three trainees considered themselves to be competent in interactional skills compared to two-thirds who reported themselves as competent for technical skills. The findings of this study highlight the need for improved efforts with regard to both the quality and quantity of training provided during the intern year. Considerable scope exists for improved educational experiences for both interactional and technical skill areas, but particularly for interactional skills. Overall, greater use of a range of basic educational strategies such as the provision of 'observation' and 'critical feedback' is indicated. Efforts also need to be directed toward the training of clinical educators to optimize the potential of the preregistration period.

An analysis of the scope and value of problem-based learning in the education of health care professionals

Whilst on teaching practice at an institute of higher education, I became increasingly aware of the limitations of subject-based, teacher-centred courses in the education of health care professionals. My involvement in problem-based learning indicated the possibility of this innovative form of education bridging the gap between theory and practice. This investigation reveals the dissatisfaction of some educationalists with traditional training courses and the spread world wide of problem-based learning as an alternative method of developing curriculum. The process of using problem-based learning in the classroom is discussed and its strengths and weaknesses analysed for both teachers and students. This article suggests that problem-based learning is more likely to equip health care professionals to deal with the demands of a changing society than conventional courses.

Enhancing critical thinking in paramedic continuing education

Critical thinking has become a buzzword, especially in medical education. The challenge is first to determine what skills compose critical thinking and what teaching techniques promote critical-thinking skills, and then to determine how to apply these techniques effectively and efficiently to a given population in the classroom. This article begins with a working definition of critical thinking and explores the parameters and skills implied or stated in the definition. Then a teaching environment constructed around a model of critical thinking and characteristics of the audience is described. A specific teaching method, suggested by research and designed to exercise critical-thinking skills, is then applied to a specific patient problem in a continuing education class. Preliminary outcomes are presented. The purpose of this article is to propose a productive and efficient educational method for promoting and enhancing critical-thinking skills appropriate for paramedic-level continuing education.

First-year responses to a new problem-based curriculum in dentistry

The first year of a new Bachelor of Dental Surgery curriculum was introduced at the University of Adelaide in 1993. Four integrated streams replaced the previous large number of separate subjects, with an overall reduction in formal contact hours, more exposure to clinical practise, and an emphasis on problem-based learning and student self-directed learning. This report compares students attitudes to the new programme with their attitudes to the previous course. Evaluation forms were completed by 30 of 53 first-year students in 1992 and 38 of 47 first-year students in 1993. Comparisons between years, made using the Student's that, indicated significant differences for several questions. For example, the workload in the previous course was considered to be significantly heavier, with too much theory and too many topics. It was felt that the aims and objectives of the new course were significantly clearer; there was more time to understand material; more opportunities to choose areas to study; students were encouraged more to think for themselves; and staff were more understanding and supportive. The authors conclude that the new problem-based Adelaide dental curriculum has facilitated a more contextual and better-balanced learning environment for students.

Teaching ethics in psychiatry : a problem-based learning approach

During the last two decades, the teaching of ethics in the field of medicine, particularly in psychiatry, has become the subject of increased attention. For this type of training to be effective, it should be practical (as opposed to theoretical), focused on the decision-making process (as opposed to the rote learning of concepts), and, eventually, self-directed. This article suggests that a problem-based learning approach is an ideal method for reaching these goals. A case illustration is presented to underscore the effectiveness of the method, as well as a rationale for its use. This article will assist psychiatric educators in becoming familiar with this approach and will encourage them to use this method in their training programs.

Tutoring in problem-based learning: perceptions of teachers and students

This study examined teacher and student perceptions during the first 2 years of a complete transition from a conventional to a problem-based learning (PBL) curriculum at Dalhousie University. Teaching staff who had tutored in the two pre-clinical years (n = 88) completed a questionnaire at the end of the 1993-94 academic year, and student assessments of their tutors were collated for all nine units (n = 597). Seven research questions were addressed in the study which examined the faculty, student and administrative aspects of tutoring. The results showed that faculty tutors rated PBL more highly than traditional medical school methods on eight of the nine items. Teaching staff were very satisfied with their tutoring experience, but expressed a need for further training in group facilitation, questioning, handling 'difficult' situations and evaluating students. They reported that their workload outside tutorials was cut almost in half in their second year of tutoring. Students expected a tutor to be a skilled group facilitator who would guide them in their learning, while helping to maintain a positive group climate. They did not want the tutor to teach the content as they perceived the task of learning to be their responsibility. Several major administrative factors affected tutors' and students' perceptions of tutorials, including: changing tutorial group composition and tutor every 8-10 weeks; team tutoring; end-of-unit exam; conflicting demands of basic science 'vertical' units and ongoing 'horizontal' units; departmental budgetary requirements for basic medical education; recognition of tutoring in promotion and tenure decisions; and recruitment of tutors.

Role of case structure and prior experience in a case-based surgical clerkship

BACKGROUND

As case-based methods replaced lectures in a surgical clerkship, the influences of case structure and prior experience on learning were investigated.

METHODS

Early and late third-year students randomly received different cases. "Structured" cases had data presented and summarized. "Unstructured" cases required questions to faculty for information. Multiple choice tests and differential diagnosis activities were administered. An attitudinal questionnaire gauged student perceptions.

RESULTS

In both multiple choice and differential diagnosis activities, the late rotation, "unstructured" group scored higher than the "structured" group. Conversely, the early rotation, "unstructured" group scored lower than the "structured" group. Combined, rotation, and structure significantly affected both multiple choice and differential diagnosis activities (ANOVA, P < or = 0.02). Early rotation, "unstructured" students described a more enjoyable experience, despite lower evaluation scores.

CONCLUSIONS

Surgical clerkship case-based learning is profoundly affected by case structure and prior clinical experience. Case-based curriculum should be tailored to accommodate these interactions.

[Let us start medical school again! Value of problem-based learning]

In 1993, the University of Montreal Medical School changed from an old teaching curriculum to a new one with Problem-Based-Learning as its major component. The first group of problems covers growth and development at all ages. The authors present this new learning method and discuss their experience and that of students with problems involving physiologic, psychologic and environmental learning objectives.

Using problem-based learning to enhance the psychosocial competence of medical students

This article provides an overview of adult learning principles and reviews their applicability and effectiveness in enhancing learner acquisition of psychosocial competencies. It presents a brief critique of traditional models of teaching medical students, reviews general principles of adult learning, describes the method of problem-based learning (PBL), summarizes data about outcomes of PBL, and suggests mechanisms through which PBL may enhance psychosocial learning. The author emphasizes the roles of small group interaction, exposure to diverse viewpoints, integrated presentation of psychosocial issues in cases, learning to adapt to uncertainty, and similarities with the process of psychotherapy as possible mediators for enhanced psychosocial learning through PBL.

Non-cognitive characteristics of medical students: entry to problem-based and lecture-based curricula

The effectiveness of problem-based learning (PBL) versus lecture-based learning (LBL) continues to be debated all over the world. These arguments have often been based on students' cognitive measures of performance. Little emphasis has been placed on non-cognitive factors that may directly or indirectly affect the medical school performance of students in either curriculum. The purpose of this study was to (1) document possible differences in student cognitive and non-cognitive characteristics at entry between the two curricula and (2) to explore the relationships that exist between cognitive and non-cognitive factors. Data were obtained from three medical school classes (n = 281). The results indicate that students who entered the PBL curriculum at this medical school had higher total Medical College Admission Test and undergraduate grade point average than students who entered the LBL curriculum. Students who entered the PBL curriculum were also more self-sufficient and were more likely to do well in individualistic and less structured settings. There were no strong correlations between cognitive and non-cognitive variables. Before conclusions can be drawn about the effectiveness of either PBL or LBL curricula, we need to document patterns in entry characteristics to control for a priori differences that affect student performance.

Problem-based learning in consultation psychiatry

Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.

Library use and academic achievement among medical students

Many factors play a part in determining the performance of students in examinations, but the extent to which students use library facilities does not appear to have been recently considered as a factor, in medicine or in any other academic subject. In this study, the number of books borrowed from the library by undergraduate medical students was used as a simple measure of library use, and significant differences in book-borrowing levels were found between students in different years of the medical course, students from different regions of the world, and men and women students. In the first year of the course, students who borrowed most also performed best in their end-of-year examinations, and this association was only partly explained by regional differences. No such association was found among final-year students, suggesting different study habits and different assessment criteria in the clinical years of the course.

Models of faculty development for problem-based learning

Learning an innovative teaching method such as a problem-based learning is difficult for most faculty members because the method is based upon assumptions about learning that are often at variance with their beliefs. Faculty development can challenge assumptions about learning, provide experience with a new technique, and offer specific pedagogical skills that are needed to succeed as a tutor. A comprehensive approach to faculty development, derived from the literature in higher education, would include: instructional development, professional development, leadership development, and organizational development. Research on faculty development indicates positive results of such efforts. Faculty members who choose to learn about problem-based learning appear to progress through predictable stages of development that include: understanding and valuing the rationale for problem-based learning, acquiring general and content-specific tutor knowledge and skills, developing advanced skills in problem-based learning, and developing leadership and scholarship skills. Each of these steps, plus organizational vitality, are described along with recommendations for implementing such programs. Finally, five models of faculty development derived from medical schools with problem-based learning curricula are examined.

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.

Comparative study of medical education as perceived by students at three Dutch universities

Objective. The aim of the present study was to identify the differences that may exist in professional satisfaction and skills (clinical patient management and psychosocial skills) in students and graduates from two traditional medical schools and their counterparts from a problem-based medical school in the Netherlands. Also their satisfaction for their training was investigated. Method. Questionnaires were designed containing items reflecting the earlier mentioned differences between the students. Following an initial pilot study, the questionnaire used in this study was constructed accordingly. Sample. The questionnaires were sent to 180 near and recent graduates of these three schools. Results. A total of 127 questionnaires were returned (response rate of 70.5%). The students of the PBL curriculum felt better prepared in psychosocial and interpersonal skills. They felt more satisfied with their training, but were less enthusiastic with the profession. The results also suggest that in their own opinion students and graduates from the three schools do not differ in clinical patient management skills acquired in medical school. Conclusion. A limitation of this study lies in the fact that results are based on actual self-assessment of the students. One must be aware that self-assessment does not always provide for objective information. However, since this limitation applied equally to respondents of all three medical schools, the differences between the schools can be considered indicative of the effects resulting from the different curricula.

Crafting cases for problem-based learning: experience in a neuroscience course

Clinical cases for problem-based learning should capture the relevance of patient encounters, and not serve merely as a 'take-off' point for scientific study. As a vehicle of learning, the case should drive the science and the science should drive the case. Decision points elicit intellectual commitment, and help to raise the level of inquiry. Our cases are focused, avoiding clinical complexity and reliance on pattern recognition. We emphasize formulation of evidence-based mechanistic hypotheses. The case does not stand alone, but must suit its position in the course and curriculum.

The changing context of undergraduate medical education

It has long been recognised that intensive efforts are needed to reform medical education in order to meet the future needs of populations worldwide. Pressure for changes to the organisation, content and delivery of both undergraduate and postgraduate medical education has greatly increased in the last two decades. The experience of innovative medical schools, the emergence of learner-centred teaching methods and the implications of health-care reforms in North America and Britain are major factors influencing calls for change. The pace of change has accelerated to such an extent in recent years that progress towards widespread reform appears to be more attainable than ever before. This article provides an overview of the changing context of health-care, some patterns of existing medical education and some strategies for change.

Clinical competence of interns. Programme Evaluation Committee (PEC)

A clinical supervisors rating form addressing 13 competencies was used to assess the clinical competence of graduates one year after qualification in New South Wales (NSW), Australia. Data from 485 interns (97.2%) showed that graduates from the problem-based medical school were rated significantly better than their peers with respect to their interpersonal relationships, 'reliability' and 'self-directed learning'. Interns from one of the two traditional NSW medical schools had significantly higher ratings on 'teaching', 'diagnostic skills' and 'understanding of basic mechanisms'. Graduates from international medical schools performed worse than their peers on all competencies. These results were adjusted for age and gender. Additionally, women graduates and younger interns tended to have better ratings. Junior doctors have differing educational and other background experiences and their performance should be monitored.

A response to the ACME-TRI report: the Dalhousie problem-based learning curriculum

With the class of 1996, Dalhousie University Faculty of Medicine instituted a totally revised curriculum. The revisions transformed an entirely traditional curriculum to a student-centred curriculum, which is based on learning in context, and incorporates a problem-based approach to the entire curriculum. This paper describes our experience in the actual implementation of our revised curriculum, in the context of the Association of American Medical Colleges Assessing Change in Medical Education--The Road to Implementation (ACME-TRI) Report.