Answer to "Should we implement PBL and at what stage of the curriculum is it best to use PBL?"

These are no straightforward answers to these questions. The individual context needs to be considered in terms of physical resources, intended learners and existing educational expertise and leadership.  The original conceptualisation of PBL (i.e. pre-clinical phase of graduate-entry medicine) is also important.  In terms of the thinking required at this pre-clinical level, Barrows and Tamblyn (1980) wrote the following: “The analytical or evaluative process aimed at determining the cause or nature of a patient problem (as contrasted to the therapeutic processes concerned with management or treatment). It does not refer to the arriving at a specific or refined ‘diagnosis’ or a ‘differential diagnosis’”.

 

It must also be remembered when PBL was designed, cohorts were small. In addition, graduates were carefully selected for such an approach. It is thus likely that they were motivated, committed and relatively autonomous and with a clear vision of where they wanted to be and what they needed to do to get there.

 

Over the past 40 years, PBL has been widely adopted not only in medicine, but also on other health professions, engineering, biological sciences and in K-12 schools. Importantly, many medical colleges that have adopted PBL offer undergraduate programmes, with most students about 18 years of age and may thus have little life experience and probably no clinical knowledge. While at face value, working through a ‘patient’ case may appear authentic, potentially motivating learners as they are ‘doing’ medicine, the learning outcomes in the early years of an undergraduate programme are likely to be largely the medical sciences (i.e. Anatomy, Physiology, Biochemistry, etc.). In such circumstances, PBL might then not be the most appropriate early pedagogical approach as prior knowledge and experience might be limited, making it difficult for many learners to engage in the brainstorming and hypothesis generation steps in the PBL process. This may result in angst amongst young learners, particularly if there are older more experienced students in the group.

 

Several other small group learning approaches have been developed such as team-based learning (TBL) and case-based learning (CBL) and, in many instances, are replacing PBL. While there are pedagogical reasons for this change, the resource-intensive nature of PBL (and hence sustainability) is also a factor. TBL is being increasingly viewed as more appropriate in the early stages of an undergraduate programme for several reasons:

  • There is a guarantee that all students will be aware of the expected learning outcomes as these are advertised and the relevant resources provide for students to prepare

  • The individual summative assessment guarantees that each student engages with the prescribed preparatory material

  • Group work is emphasized

  • Only one instructor or facilitator is required to oversee many groups in a large setting

  • There is an application phase during which students can apply what they have learnt.

 

Readers should consult the AMEE Guide (Parmalee et al. 2012) and the Twelve Tips articles (Gullo, Ha and Cook 2015) on TBL and the Thistlethwaite and colleagues’ (2012) BEME Guide on CBL for further information on these approaches. The reference list provides two recent articles relating to how CBL has been implemented (Fortun et al. 2017; Hassoulas et al. 2017). Srinivasan and colleagues’ (2007) article provides a useful graphic for comparing PBL and CBL.

 

Implementing PBL does not happen overnight. There needs to be a common understanding of the intended philosophy and there needs to be commitment from faculty. Leadership is important to drive and support the process.  In 2010, Albanese concluded his chapter on PBL as follows: “Beginning a PBL curriculum is not for the faint-hearted. There is much infrastructure that needs to be put in place and there may need to be increased costs”. (p. 52).

 

References

ALBANESE, M.A. (2010). Problem-based learning. In: An Introduction to Medical Teaching. W.B. Jefferies and K.N. Huggett (eds).  Springer: New York. p. 41-53.

BARROW, H.S., and TAMBLYN, R.M. (1980). Problem-based Learning: An Approach to Learning. (New York: Springer).

BURGESS, A., BLEASEL, J., HAQ, I. et al. (2017). Team-based learning (TBL) in the medical curriculum: better than PBL? (BMC Med Edu. 17:243.) https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-017-1068-z.

HASSOULAS, A., Forty, E., HOSKINS, M., WALTERS, J., and Riley, S. (2017). A case-based medical curriculum for the 21st century: The use of innovative approaches in designing and developing a case on mental health. (Med Teach. 39(5):505-511.

FORTUN, J., MORALES, A.C., and TEMPEST, H.G. (2017). Introduction and evaluation of case-based learning in the first foundational course of an undergraduate medical curriculum. (J Biol Educ. 51(3):295-304).

GULLO, C., Ha, T.C., and Cook, S. (2015). Twelve tips for facilitating team-based learning. (Med Teach 37(9):819-824).

LIM, W.K. (2012). Dysfunctional problem-based learning curricula: resolving the problem. (BMC Med Educ. 12:89). https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-12-89.

PARMALEE, D. MICHAELSEN, L.K., COOKE, S. and HUDES, P.D. (2012). Team-based learning: a practical guide: AMEE Guide no. 65. (Med Teach. 34(5):e275-e287).

SRINIVASAN, M., WILKES, M., STEVENSON, F. et al. (2007). Comparing problem-based learning with case-based learning: Effect of a major curricular shift at two institutions. (Acad Med. 82(1):74-82).

TAYLOR, D., and MIFLIN, B. (2008). AMEE Guide No. 36. Problem-based learning: Where are we now? (Med Teach. 30:742-763).

THISTLETHWAITE, J.E., DAVIES, D., EKEOCHA, S., KIDD, J.M., MACDOUGALL, C., MATTHEWS, P., PURKIS, J. and CLAY, D. (2012). The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. (Med Teach. 24(6):e421-e444).

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