Description of Strategy

Problem-Based Learning (PBL) was started in North America by medical educators who were concerned about “curriculum overload and inappropriate teaching methods, [and wanted to shift] the emphasis of the undergraduate curriculum away from individual disciplines…towards an integrated approach involving students in problem solving and independent learning” (Bligh, 1995). This instructional method can be traced back to the 1970s, and within Canada it was McMaster University Faculty of Health sciences that led the way, although this movement was occurring across the globe in parallel (Barrows, 1996).

PBL is an approach to medical education which allows for new ways of learning clinical material for medical learners as well as to attain and apply the knowledge. PBL is concerned with “what students learn and how they learn it” (Bligh, 1995), which is in comparison to traditional didactic lecture-based teaching and learning.

In PBL, students have the ability to define their own learning objectives, and after independent, self-directed studying they can refine their acquired knowledge by virtue of their group discussions (Wood, 2003). The group work also allows for the enhancing of other skills which ultimately prove to be important in a physician’s future career, which include “communication skills, teamwork, problem solving, independent responsibility for learning, sharing information and respect for others” (Wood, 2003).

PBL starts with the problem at hand, this may be a clinical condition that the learners need to fix or solve. In other words, PBL “places the responsibility for learning in the hands of the students” (Bligh, 1995). Problem based learning is curriculum based on clinical scenarios, which are presented to small groups generally in written form. The clinical case is then untangled into its several components of learning at tutorial-based discussions. The clinical scenarios may come from real experience of the author/facilitator or they may be hypothetical cases, but they will or should always reflect the course or program learning objectives.

The problem itself may be something that is connected to future PBLs, increasing in complexity perhaps as knowledge, or they may be problems that are independent of each other. It is also important to note that a “definitive resolution to the problem is not necessary” (Bligh, 1995). The problem may be provided to the learners some time before the actual PBL where they have an opportunity to do independent research and literature review on the topic, and then bring this information to the group sessions to brainstorm everyone else’s contributions. However, the PBL case may also just be given to the students while they are at the session. Regardless of how the problem is presented, the aim is the integration of knowledge with other students.

The aim of PBL is to stimulate active rather than passive student learning, through small tutorial based discussion groups. The small setting allows for less intimidation and theoretically greater participation in discussion as opposed to larger class-based settings. PBLs also allow for communication skills that may not be encourage during didactic lectures, and these communication skills and problem-solving skills are ultimately what they apply when they are in clinical practice.

The idea is not memorizing information but rather critical thinking and problems solving, independently and collaboratively with peers. A student may remember this experience better when faced with a similar situation clinically, rather than what they learned in lecture. It is important to note that PBL is supplemented with lectures, labs, conferences, web-based learning, as well as clinical rotations and hands on experience, which is what enhances it and makes it more effective (Bligh, 1995).

Although PBL is a teaching method first used in medicine, it has since found acceptance in a variety of educational sectors such as nursing, engineering, and even social work (Bligh, 1995). The remainder of the paper will aim to do a more in-depth analysis of problem- based learning in healthcare, including discussing learning strategies, a SWOT analysis and personal experiences directly from the field, from some of our very own authors.

Learning Environments

Although PBL has gained much success and traction since its beginnings, there are several factors related to the learning environment that are essential for PBL to be an effective teaching strategy. Some of these factors are listed below:

Group Size, Composition and Dynamics

The standard group size for PBL ranges from 6-10 students (Albanese & Dast, 2014; Wood, 2003) with one facilitator. For the group size upper limit, Albanese and Dast (2014) suggest that groups be no more than seven as it may provide too many opportunities for reluctant members to hide and not contribute. That being said, the group should be small enough so that each group member has the expectation to contribute but at the same time, has time to significantly contribute to the group’s functioning. However, group sizes of five or less may be detrimental as it may put a permanent spotlight on members and remove time to “think” critically about the case (Albanese & Dast, 2014).

With regards to group composition, it is recommended to stratify groups by academic ability (Albanese & Dast, 2014). This strategy is especially effective if the PBL session is linked to evaluations that focus on cooperative success and therefore, it is in the best interest for all members to be adequately prepared to be proficient in the content learned from the PBL case. Considering academic ability in group formation has been showed to have a lasting impact on physicians’ careers (Albanese & Dast, 2014).

Groups also need to be together long enough to allow for collegial group dynamics but should be monitored as personalities within the group may clash which may worsen the learning experience for the group (Wood, 2003). Effective group dynamics are successful in promoting motivation and good affect, which in turn, translates to knowledge and understanding (Bate et al., 2014). Whether the emotions experienced by the learner is positive or negative, it needs to be “activating,” to encourage the student to learn. For example, anxiety is a negative activating emotion that can serve as motivation to work and learn the material, while boredom (negative deactivating emotion) may not. In addition, the sense of autonomy and belonging to a community of practice has shown to predict higher motivation levels (Bate et al., 2014) to grasp and understand the PBL content which relates to key principles in adult learning theory. Academic motivation is a predictor of school success and failure (Pintrich, 2003). To ensure the group’s focus is on the task and to facilitate a proper discussion, it is recommended that roles are assigned to group members such as team chair, timekeeper, and transcriber (Wood, 2003).

Tutors and Facilitators

A significant factor that determines the effectiveness of PBL is the facilitator. It is widely debated whether the facilitator needs be an expert in the content related to the case for PBL to be effective (Albanese & Dast, 2014; Davis, 1999). While an expert may have the ability to guide and direct students towards achieving the learning objectives and outcomes, they may be tempted to take on a teacher-centered role and lecture the students (Albanese & Dast, 2014; Davis, 1999; Schmidt et al., 2011). To mitigate the risk of tutors not understanding the content to facilitate the group, they need to be provided with comprehensive tutorial guides with supplemental material to prevent students from deviating from the learning objectives (Albanese & Dast, 2014; Davis, 1999). Regardless, it is commonly agreed upon that facilitators need to be able to promote discussion between the students using open-ended meta cognitive questions and should not be the main providers of information (Yew & Goh, 2016). Tutors should also communicate with students in an informal manner with an empathetic attitude to promote open exchanging of ideas (Davis, 1999).

Quality of PBL Cases

The quality of the problem also dictates the effectiveness of PBL. First, problems should “provide a developmentally appropriate sequence that addresses key skills and abilities that lead students to developing competence” (Albanese & Dast, 2014), which is a notion shared by others (Wood, 2003). An indication of a well-written PBL case is when the learning objectives created by the students matches the faculty’s learning objectives (Davis, 1999; Wood, 2003). Cases should also contain prompts to stimulate discussion between students and should provide intrinsic interest for the students. Knowledge acquired from the PBL case should easily integrate into the students’ previous understanding of the material. In addition, problems should not be closed that it curtails the open discussion that is necessary for PBL to function properly (Wood, 2003).

Resources

Having the necessary resources is also crucial to ensure a productive learning environment for PBL. Ideally, all sessions should take place in the same dedicated room for PBL so it will allow students to have a comfortable and safe space to have an open discussion with other group members. For the research and self-study stage, access to online databases such as PubMed and MEDLINE are imperative to the learning process (Albanese & Dast, 2014), however it is cautioned that students’ research searches may be too narrow (Kerfoot et al., 2005). In addition, Kerfoot et al. (2005) suggests that there needs to be guidelines for using the internet as a resource to avoid having the problem-solving process undermined by quick web searches.

In summary, PBL as a teaching methodology can be very effective, however that effectiveness depends on various learning environment factors. Although the abovementioned factors are not comprehensive, they are usually the most mentioned when discussing what makes a successful PBL experience.

SWOT Analysis

Strengths

The strategy of problem-based learning (PBL) has numerous strengths when applied in the context of medical education. These strengths are what have propelled the prevalence of PBL in medical education (Jones, 2006). These strengths are measured from the perspective of student/trainee experience, educational/professional outcomes, and in comparison to traditional lecture-based learning. It has been found that problem-based learning is better than lecture-based learning (LBL) in improving the medical educational environment, as measured by the Dundee Ready Education Environment Measure (DREEM), with statistically significant differences (Qin et al., 2016). PBL students were also significantly more satisfied with their learning environment than students in the LBL groups (Qin et al., 2016). In their study, Qin et al. (2016) also stated that existing evidence supports the claim that PBL is more effective than LBL (Qin et al., 2016). Long-term effects of PBL on undergraduate education include positive changes in physicians’ competency after graduation, emphasizing the validity of PBL in enhancing practice performance (Al-Azri & Ratnapalan, 2014). According to Jones (2006), several researchers successfully argued that learners who commenced learning by focusing on problems before attempting to understand underlying principles had equal or greater success than learners using a traditional approach whereby underlying principles are presented first and then applied to a specific problem. When the learner is required to solve specific problems they are made to acquire knowledge in the process that they can later apply to similar problems (Jones, 2006). Jones (2016) argues that this acquired knowledge is of great benefit to students in their future professional life and practice.

When analyzing the strengths of PBL in medical education in more detail, Jones (2006) was able to identify a number of particular advantages. Firstly, PBL increases the relevance of curriculum content by centering learning around clinical, community or scientific problems. PBL also focuses learning on the core information relevant to real scenarios and reduces information overload. The implementation of PBL also fosters the development of valuable transferable skills, such as leadership, teamwork, communication, and problem solving. These skills are useful throughout the students’/trainees’ lifelong learning. In addition, PBL facilitates students/trainees becoming responsible for their own learning. This is an important skill for medical specialists to actively engage in their own continuing professional development throughout their careers. The use of PBL has also shown to increase the motivation of students/trainees to learn by focusing the learning on ‘real-life’ scenarios. Additionally, PBL encourages a deep, rather than surface, approach to learning by forcing students/trainees to interact with information on multiple levels and to a greater depth than traditional teaching approaches. Lastly, PBL uses a constructional approach to learning whereby students/trainees construct new learning around their existing understanding (Jones, 2006). Hilal and Ratnapalan (2014) also stated that previous studies have concluded that PBL can positively enhance clinical reasoning and can effectively enhance competencies and clinical performance. Social and cognitive competencies such as dealing with uncertainty, recognizing ethical issues related to health care, communication skills, and self-directed learning are also more likely to be improved by PBL methods (Al-Azri & Ratnapalan, 2014).

To more deeply analyze PBL, we will look into the strengths and advantages of certain methods of practicing PBL. One common method is online PBL. This educational strategy is perceived as effective by many physicians (Al-Azri & Ratnapalan, 2014). This is likely due to the flexibility and accessibility afforded by the online format of learning, which is advantageous for physicians with multiple time commitments and well as physicians who work in remote areas. Another PBL method that has been shown to be beneficial is project-PBL. Stentoft (2019) found that project-PBL may enhance student engagement and motivation by allowing them to direct their own learning. Secondly, project-PBL may help students develop metacognitive competencies by forcing them to collaborate and regulate learning in settings without a facilitator. Finally, project-PBL may foster skills and competencies related to medical research (Stentoft, 2019).

Opportunities

This section will explore the best areas and academic levels in which PBL can be utilized. We will first explore academic levels. PBL is recognized as a successful innovative learning method in undergraduate medical education (Al-Azri & Ratnapalan, 2014). Long-term effects of PBL on undergraduate education include positive changes in physicians’ competency after graduation, emphasizing the validity of PBL in enhancing practice performance (Al-Azri & Ratnapalan, 2014). PBL is also utilized in the education of postgraduate trainee doctors, as well as the continuing education of practicing physicians (Al-Azri & Ratnapalan, 2014). In reference to medical education, PBL can be used in the context of both undergraduate and postgraduate students, including nursing students as well as medical students (Qin et al., 2016). When deciding the best approach of implementing PBL, it should be consistent with the student’s/trainee’s stage of learning at that given time (Jones, 2006). Specifically, physicians preferred PBL and considered it a challenging and enjoyable learning method (Al-Azri & Ratnapalan, 2014). Hilal and Ratnapalan (2014) also found moderate evidence that medical practitioners were more satisfied with the PBL method.

The most apparent way that PBL can be utilized is in the way of online learning. Applying PBL in an online forum can be used to accommodate the growing need for distance learning (Al-Azri & Ratnapalan, 2014). Online PBL can also be a very beneficial and important option in the setting of physicians’ continuing education, especially for physicians in remote areas (Al-Azri & Ratnapalan, 2014). Another circumstance in which applying PBL can be beneficial is in the context of large class/group settings. Hilal and Ratnapalan (2014) found a positive effect when active PBL was utilized in large group settings where students worked in small groups within the large group setting, and then had some content delivery during discussion. This interactive method of incorporating principles of PBL in large group settings might be a good way to maximize tutors’ time and increase the number of learners (Al-Azri & Ratnapalan, 2014).

Weaknesses and Threats

Having a big group of learners could be a challenge. Sometimes the big group will take over the direction of the discussion and they will apply their theory forcefully (Rowan et al., 2008). In addition to the possibility of presence of negative attitude toward the small group by the large group Azer (2001) added that the miscommunication could be another challenge particularly if there is miscommunication or lack of support from one group to the anthers, this leads to increase the risk of stress or distraction in the group, subsequently, a gap will be created in the education process (Steinert, 2004).

Another challenge is difficulties to get everyone engaged and participate in the process of learning, this includes learner and instructor (Rowan et al., 2007). A lot of time should be secured for instructors to prepare the PBL. They need this time of material collection and information gathering.

Knowles’ (1975) noticed some of the difficulties PBL brings as well. For an example, Instructors whom previously were teachers have to be a co-learner rather than expert masters. They have to take off the “protective shield of authority” and get exposed to arguments and debates (Knowles, 1975). Sometimes this is a challenge especially for teachers whom may struggle with change fatigue.

Funding of the PBL scenario could be another challenge. The PBL better to be well designed to be able to get funded (Azer, 2001). On the other hand, simulation and e learning in some scenario quickly become outdated and needed to be reevaluated and validated from time to time. This creates a lot of efforts from the educational institutes (personnel and funding challenges) to maintain efficient PBLs (Hitchcock & Anderson, 1997).

Facilitators whom were not educated in the PBL style and its philosophy will be reluctant to participate (Azer, 2001). This leads to push back from a certain group of teachers and makes the PBL not a popular method of teaching. Those teachers who are not welling to learn the new educational options tend to fall within their comfort zone (Azer, 2001).

In some PBLs, students may face difficulties in remembering the ideas and the aim across the PBL process. Sometimes the knowledge is overwhelming. Williams (1999) suggested that students often lacked confident when they perform technical duties and they could not differentiate between is important and linked to this PBL and what it is not.

Williams (1999) mentioned another challenge carries budget concerns to maintain the quality of PBL. Williams cites anecdotal evidence from students showed their dissatisfaction with less formal structure of this method of teaching. It did not match their expectation. They though that self-directed learning would work better with more formal teaching (Banning, 2005; Kenny & Beagan, 2004; Williams, 1999).

Tales from the Field

Dr. Nan Aftab – Family Physician:

“My first exposure to problem-based learning was in first year Medicine. It will be important to know that I did my medical training in Ireland, however, with the development and evolution of PBL in Medical Schools around the world, there is a common foundation and structure that is followed as was described in the paper above. We only had PBL training in the first and second years of medical school in a five-year program. Initially, I found PBL quite daunting and overwhelming. Although my peers were at the same educational level as me, it was intimidating to work with a facilitator who was an experienced physician, and to try not to feel that your questions or responses weren’t thought of as dumb or wrong. Our PBL style was based on getting the problem scenario one week in advance, and the expectation was that all members of the group would do self-directed independent studying, whether that included textbooks, audio-visual resources such as YouTube or a small literature review. The self-acquired information and knowledge would then be brought to the group discussion, where a broad diversity of thoughts and ideas would be formulated. In the end, we tried best to come up with group-based solutions to the presented problem. However, it should be noted that this was not always achieved and that was perfectly okay as well, as it did represent real-life clinical practice, where all members of healthcare team may not agree on the best way to proceed but will manage a patient based on the common goal of optimizing patient care. I really found PBLs to be very useful, especially early in medical training, as they allowed me to develop my communication, problem-solving, critical thinking and collaborative team building skills. These are skills that I use to this day in my clinical practice.”

Dan Huynh – Psychiatry Resident:

“During my first and second year of medical school, I had the opportunity to learn through PBL. Every two weeks, we were split into small groups and were given a clinical case that related to our classroom lectures. At the time, I thought PBL was a great learning strategy to combine cooperative learning, action learning, and self-directed learning to translate my superficial knowledge acquired from lecture to a deeper understanding of the material. Furthermore, I thought PBL was an effective way to bridge the gap between theory and clinical application. However, as I reflect on my previous experiences, there were major pitfalls to the way PBL was delivered at my institution. I believe the most significant shortcoming to the PBL process was the fact that each group member was assigned a specific section to learn which would be later taught to the group after finishing their self-study research. As such, this encouraged students to only research their given section (eg. diagnostic criteria) using a resource that summarizes information, such as UpToDate. Using this strategy, I often found that my understanding of the topic was superficial and narrowed. I also found that when it was time to teach the other group members about their section, the information shared was superficial. Furthermore, our groups consistently changed throughout the year which left an inadequate amount of time to develop cohesion within the group. I remember not feeling comfortable sharing my opinions in some groups as there were students who I perceived as extremely judgmental. On the surface, PBL appears to be a great method to allow students to acquire a deeper understanding of the material. However, there are many intrinsic and extrinsic factors that need to be optimized for PBL to be fully effective.”

References

Al-Azri, H., & Ratnapalan, S. (2014). Problem-based learning in continuing medical education. Canadian Family Physician, 60(2), 157 LP – 165. http://www.cfp.ca/content/60/2/157.abstract

Albanese, M. A., & Dast, L. C. (2014). Problem-based learning (pp. 57–68). https://doi.org/10.1007/978-94-017-9066-6_5

Azer, S. (2001). Problem-based learning: Challenges, barriers and outcome issues. Saudi Medical Journal, 22, 389–397.

Banning, M. (2005). Approaches to teaching: Current opinions and related research. Nurse Education Today, 25(7), 502–508. https://doi.org/10.1016/j.nedt.2005.03.007

Barrows, H. S. (1996). Problem-based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning, 1996(68), 3–12. https://doi.org/10.1002/tl.37219966804

Bate, E., Hommes, J., Duvivier, R., & Taylor, D. C. M. (2014). Problem-based learning (PBL): Getting the most out of your students – Their roles and responsibilities: AMEE Guide No. 84. Medical Teacher, 36(1), 1–12. https://doi.org/10.3109/0142159X.2014.848269

Bligh, J. (1995). Problem-based learning in medicine: an introduction. Postgraduate Medical Journal, 71(836), 323 LP – 326. https://doi.org/10.1136/pgmj.71.836.323

Davis, M. H. (1999). AMEE Medical Education Guide No. 15: Problem-based learning: a practical guide. Medical Teacher, 21(2), 130–140. https://doi.org/10.1080/01421599979743

Hitchcock, M. A., & Anderson, A. S. (1997). Dealing with dysfunctional tutorial groups. Teaching and Learning in Medicine, 9(1), 19–24. https://doi.org/10.1080/10401339709539808

Jones, R. W. (2006). Problem-based Learning: Description, Advantages, Disadvantages, Scenarios and Facilitation. Anaesthesia and Intensive Care, 34(4), 485–488. https://doi.org/10.1177/0310057X0603400417

Kenny, N. P., & Beagan, B. L. (2004). The patient as text: a challenge for problem-based learning. Medical Education, 38(10), 1071–1079. https://doi.org/10.1111/j.1365-2929.2004.01956.x

Kerfoot, B., Masser, B., & Hafler, J. (2005). Influence of new educational technology on problem-based learning at Harvard Medical School. Medical Education, 39, 380–387. https://doi.org/10.1111/j.1365-2929.2005.02105.x

Knowles, M. S. (1975). Self-directed learning: a guide for learners and teachers.

Pintrich, P. R. (2003). A Motivational Science Perspective on the Role of Student Motivation in Learning and Teaching Contexts. In Journal of Educational Psychology (Vol. 95, Issue 4, pp. 667–686). American Psychological Association. https://doi.org/10.1037/0022-0663.95.4.667

Qin, Y., Wang, Y., & Floden, R. E. (2016). The Effect of Problem-Based Learning on Improvement of the Medical Educational Environment: A Systematic Review and Meta-Analysis. Medical Principles and Practice, 25(6), 525–532. https://doi.org/10.1159/000449036

Rowan, C. J., McCourt, C., & Beake, S. (2008). Problem based learning in midwifery – The students’ perspective. Nurse Education Today, 28(1), 93–99. https://doi.org/10.1016/j.nedt.2007.02.014

Rowan, C. J., McCourt, C., Bick, D., & Beake, S. (2007). Problem based learning in midwifery – The teachers perspective. Nurse Education Today, 27(2), 131–138. https://doi.org/10.1016/j.nedt.2006.03.006

Schmidt, H. G., Rotgans, J. I., & Yew, E. H. J. (2011). The process of problem-based learning: what works and why. Medical Education, 45(8), 792–806. https://doi.org/10.1111/j.1365-2923.2011.04035.x

Steinert, Y. (2004). Student perceptions of effective small group teaching. Medical Education, 38(3), 286–293. https://doi.org/10.1046/j.1365-2923.2004.01772.x

Stentoft, D. (2019). Problem-based projects in medical education: extending PBL practices and broadening learning perspectives. Advances in Health Sciences Education, 24(5), 959–969. https://doi.org/10.1007/s10459-019-09917-1

Williams, A. F. (1999). An Antipodean evaluation of problem-based learning by clinical educators. Nurse Education Today, 19(8), 659–667. https://doi.org/10.1054/nedt.1999.0369

Wood, D. F. (2003). Abc Of Learning And Teaching In Medicine: Problem Based Learning. BMJ: British Medical Journal, 326(7384), 328–330. https://doi.org/10.1136/bmj.326.7384.328

Yew, E. H. J., & Goh, K. (2016). Problem-Based Learning: An Overview of its Process and Impact on Learning. Health Professions Education, 2(2), 75–79. https://doi.org/10.1016/j.hpe.2016.01.004