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When I was a medical student, problem-based learning (PBL) was relatively new and comprised only a small proportion of the curriculum. Since then, there has been an increased use of PBL in medical curricula in the UK, with some medical schools now offering courses which almost solely employ PBL as the learning method. These tutorials follow a structured framework (Appendix 1).
More recently, we have seen the development of clinical PBL (CPBL), which is designed to complement ward-based clinical teaching. The main differences between PBL and CPBL are listed in Appendix 2.
I am asked to facilitate PBL and CPBL at St. George's (SGUL) on a regular basis. I selected this teaching experience as the topic of this assignment, in order to consider the role of this student-centred approach within undergraduate medical education and how to maximise the learning experience for the students.
SGUL runs three separate undergraduate courses, two of which that are relevant to this assignment; the traditional five-year course, which accepts both school leavers and graduates and the four-year course, which is only open to graduates. I shall refer to these courses as MBBS5 and MBBS4, respectively.
The experience of facilitating CPBL tutorials
My most recent experience of CPBL involved facilitating a series of five weekly CPBL tutorials with a group of seven students in the penultimate year of the MBBS4 course. This was a very positive experience for me as I was working with a group of students who were familiar with the PBL process and used the tutorials as a valuable learning encounter. I have chosen to focus on the second tutorial in the series, as I felt that this was a particularly successful learning experience.
The tutorial was largely student-led and started with one of the students presenting a patient that they had examined. After the case had been presented, the other students asked questions, facilitating a discussion about the diagnosis, the management plan and other issues that the case generated. The students identified topics that they would like to read more about and set learning objectives to research before the next tutorial.
Once the students had exhausted the discussion about the case, they moved on to discussing the learning objectives set the previous week, which included how to perform a mental state examination (MSE). The students discussed each area of the MSE, with particular focus on what questions to ask to elicit symptoms from a patient.
When discussing auditory hallucinations, the students decided that they should be categorised under 'Thought' in the MSE. As an expert in the subject matter, I was in the position to question this incorrect assumption and following further discussion, the students revised their previous position.
The students were given an opportunity to practice performing a MSE through the use of role play, during which I acted as a patient. I also shared my methodology for examining a patient's mental state. The students reached the conclusion that there was no single correct way to ask the questions and that they needed to develop a style that they felt comfortable with. The students reported that they found the role play extremely useful, by improving their confidence to perform the examination on a real patient.
Critical reflection on the experience
I often feel anxious prior to teaching sessions. My specific anxieties around CPBL tutorials include motivating the students, as I have found it difficult in previous tutorials to encourage quiet students to engage in discussion; remaining within the boundaries of my role as a facilitator; and a fear that the students will ask questions that I am unable to answer. I struggle to tolerate periods of silence and tend to find myself filling these gaps by providing didactic teaching.
I thoroughly enjoyed facilitating this set of tutorials, which was my first experience of CPBL with the MBBS4 students. The students discussed complicated psychological concepts at a high level, which I found particularly stimulating. This highlighted the depth of knowledge that can be gained from others and reminded me how important it is for doctors to draw upon this knowledge as they progress through their careers, rather than discounting their juniors as educators.
The students were keen to share the knowledge that they had reaped from self-directed learning (SDL) and support all group members to attain the same level of understanding, thereby demonstrating cooperative learning (1, 2). I felt that the students were better able to identify the sources of misunderstanding if a fellow student was struggling to understand a concept than I was as facilitator.
I did not experience anxiety during this set of tutorials. We successfully created a safe, relaxed environment by setting ground rules at the first tutorial. The students seemed to feel comfortable asking questions and discussing difficult feelings that they had experienced.
Comparison with previous experience
In the past, I have found myself teaching rather than facilitating in CPBL. However, during this set of tutorials, I found it easier to remain within my role as a facilitator and to prompt the students to think about the correct answers, rather than telling them the answer. I felt that this was what the students wanted, whereas in my previous experiences with MBBS5 student groups, the students often seemed keen to be 'spoon-fed' the answers, rather than using discussion to obtain knowledge from their peers.
Previously, I have managed difficulties in group dynamics by taking a lead role in the tutorials. However, in this set of tutorials, the students functioned well as a group, encouraging each other and resolving conflict amongst themselves. They took responsibility for each other and when a group member was absent the other group members were aware of this in advance and the reason why.
There are many possible reasons for the differences between the MBBS4 and MBBS5 students, including previous degree, age, previous experience and confidence. Furthermore, from the start of the MBBS4 course PBL is used as the main learning method, so the MBBS4 students are more familiar with the format and expect to learn by SDL and sharing of knowledge. On the contrary, the MBBS5 students have a lot more traditional lectures and are accustomed to being taught in this manner.
Until now the MBBS5 course has had a much larger cohort than the MBBS4 course.
However, the numbers accepted onto the MBBS4 course are increasing, which leads me to speculate about the impact on the group dynamics in MBBS4 CPBL tutorials in the future.
ii. Areas for improvement
Despite how well the students led the tutorials and generated discussion, I still found myself struggling to tolerate silences and fighting the temptation to directly correct any misperceptions, rather than using a Socratic method of directing the students to the correct answer. I believe that this is because I was educated under a traditional teacher-led medical curriculum and I have less familiarity with a student-centred approach.
I think it would have been helpful if I had researched the learning objectives each week. I was surprised by the depth and breadth of reading by the students. At times, they discussed very complex subjects and I was not always able to answer all their questions. For me, this highlighted the attrition of my knowledge since completing my postgraduate examinations two years ago and encouraged me to undertake more professional reading and revision. This is also led me to consider the value of having a facilitator who is an expert in the field, which I will address in the key points.
On a positive note, I think the students found it helpful to see that I was able to function competently as a senior doctor despite being unable to recall everything I have learnt. Students can feel overwhelmed by how much they have to learn and retain. I felt that I was able to reassure them that it is acceptable to refer to text books and colleagues.
What is the evidence for the effectiveness of PBL in medical curricula?
Does having an expert facilitating PBL impact on student learning?
What difficulties may arise with PBL group functioning and what are the solutions?
My literature search revealed very minimal literature on CPBL. Therefore, I have decided to expand my key points and literature review to the broader topic of PBL. I acknowledge that not all the literature around PBL will be generalisable to CPBL, which differs from PBL by specifically addressing the students' clinical encounters (Appendix 2).
The evidence for the effectiveness of PBL
In the early 1990s, four separate systematic reviews of the outcomes and implementation issues of PBL were published (3-6). Overall, these reviews suggested that PBL is more nurturing and enjoyable than traditional courses and that, in terms of clinical functioning, PBL students performed better than traditional students (4, 5).
However, they also showed that PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in (4). Furthermore, there was no significant difference between the two groups on measures of clinical knowledge (5).
In 2000, Colliver (7) reviewed the medical education literature from 1992 to 1998, including the four main reviews of PBL from the early 1990s, and produced a critical overview of PBL, its effectiveness for knowledge acquisition and clinical performance, and the underlying educational theory.
Originally, PBL was based on the theory of contextual learning, which states that when material is learnt in the context of how it will be used, it supports learning and capacity to use the information. PBL uses this principle by providing a case in the real-life context of a patient visiting a doctor.
Colliver (7) concluded that the contextual learning argument was based on a weak research finding and that there was "no convincing evidence that PBL improves knowledge base and clinical performance, at least not of the magnitude that would be expected given the resources required for a PBL curriculum". Unlike previous reviews, Colliver's review challenged thinking about the educational effectiveness of PBL.
Later in 2000, Norman and Schmidt (8) responded to Colliver's paper with their own interpretation of the research evidence. They did not think its was sufficient to rely on randomised controlled trials (RCTs) and argued for the use of a broad range of research designs and variables.
Albanese (2) also produced a paper as a retort to the review by Colliver (6), which concluded that the positive effect that PBL has on the learning environment is "a worthwhile gain in, and of, itself", despite the absence of a thorough understanding of its effect on knowledge.
Albanese (2) concurred with Colliver's (7) criticism of contextual learning theory as an argument for PBL and proposed four new theories for understanding how and why PBL works; information-processing theory, cooperative learning, self-determination theory and control theory.
Since 2000, PBL has been used increasingly in undergraduate medical education in the UK. During this time the educational theory behind PBL has continued to develop and several new reviews and studies have been published.
A number of studies have shown that PBL graduates are better prepared with respect to several competencies (9-12). Dolmans et al (13) commented on how PBL stimulates cognitive effects which are believed to positively contribute to how students apply knowledge. De Grave et al (14) found that PBL helps to restructure a student's knowledge base by inducing conflict within students.
In keeping with self-determination theory, PBL is thought to increase motivation because students decide what is relevant to their learning and define their own learning objectives (13).
In 2009, Macallan et al (15) conducted the only study to date specifically evaluating CPBL. This study showed that students found CPBL a "positive learning experience" and verified the idea that CPBL is "a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching".
Expert versus non-expert tutor
There is much controversy in the literature as to whether an expert PBL facilitator promotes learning or not. Barrows (16) suggested that non-directive facilitation was more important than subject-matter expertise.
Silver and Wilkerson (17) demonstrated that expert tutors impede student-to student discussion by taking a more directive role in the tutorials, speaking more often, providing direct answers to students' questions and suggesting more items for discussion.
However, other studies have found the opposite effect. A study by Eagle et al (18) found that in tutorials facilitated by an expert tutor, students generated twice as many learning issues and spent almost twice the amount of time on SDL than students attending tutorials facilitated by non-experts.
As a result of these contradictory findings, some researchers began to investigate the relationship between tutor characteristics and differential contextual circumstances (19). These studies were based on the notion that "PBL is a complex learning environment in which different variables influence each other mutually" (20).
One systematic review of the literature concluded the tutor should have expertise in the subject matter and in PBL facilitation (19). Schmidt (21) found that when the structure of a course is low and/or students lack prior knowledge, the tutor's expertise has a greater impact on student performance.
Difficulties in group functioning
Group learning is thought to be superior to individual learning because of activation of prior knowledge and elaboration of newly acquired knowledge, consistent with information processing theory (22).
However, difficulties can arise in group functioning for a number of reasons. Hendry et al (23) used anonymous surveys to investigate PBL group problems in a graduate-entry medical programme and reported three most common group problems as rated by tutors and students. These were quiet students, dominant students and tardiness or absenteeism. The quality of this study was limited by a low response rate to the surveys, which affects the generalisability of the results.
A recent study by Kindler et al (24) categorised problems into "individual student" and "group dynamics". "Group dynamics" were further sub-divided into "tutor-associated problems", such as "tutorial domination" and "lack of proper knowledge regarding PBL approach", and "student-associated problems", such as "negative attitude towards each other" and "unresolved personal conflict".
The main "individual student" problems were "quiet" and "chronically tardy or absent" students (24). Quiet students are one the main problems that I have encountered. Consideration needs to be given to why some students are particularly quiet, including a lack commitment (23) or "feelings of inferiority" (25).
In accordance with Honey and Mumford (26) quiet students may have a reflector-diverger learning style, which is characterised by taking time to consider experiences, postponing reaching definitive conclusions and enjoying observing other people in action. Tiberius (25) encouraged tutors and the group to accept and cooperate with these students and to utilise their unique strengths.
Van den Hurk et al (27) highlighted that it can be problematic when students do not study the learning objectives in depth. This is something that I have observed, whereby students simply read aloud from their notes and are unable to apply their knowledge to the case under discussion. Consequently, I find myself explaining the material, as if giving a lecture, thereby inhibiting the key learning mechanisms of PBL, activation of prior knowledge and elaboration of newly acquired knowledge (22).
When some members of the group are not doing any work, the motivation of all group members is affected and students who were initially motivated begin to contribute less to the group (28). There is little social cohesion and these groups do not develop the team spirit that encourages the members to care about the group. Slavin (29) described the consequent group atmosphere as "social loafing".
De Grave et al (30) identified another problem as being all the students reading the same material from the same book during the SDL phase. This limits the material and viewpoints for discussion, resulting in a lack of elaboration.
Dolmans et al (13) hypothesised that when tutors are faced with a difficult group, they revert to the teaching style they feel comfortable with, namely a teacher-centred approach, which is in contradiction with the ethos of the student-centred approach of PBL.
Analysis of literature and discussion
What is the evidence for the effectiveness of PBL in medical curricula?
In the early 1990s, four systematic reviews of undergraduate medical education cautiously supported the short-term and long-term outcomes of PBL compared with traditional learning (3-6).
There were limitations to the quality of the reviews, including absence of blinding; insufficient information about controls; a limited research base, with studies of PBL curricula coming from only a handful of medical schools; and diversity in what different individuals called PBL. There was a risk of confounding, as it would have been very difficult to randomly assign students to different teaching methods for large segments of their training.
Furthermore, these studies were conducted at a time when PBL was a relatively new and innovative style of medical education. Therefore, reports of negative experiences may not have been submitted or accepted for publication. These limitations lessen the confidence one can give to conclusions drawn from the literature regarding the outcomes of PBL at that time.
On the whole, recent research largely supports the findings of the earlier reviews, which suggested that graduates of PBL curricula were better able to apply knowledge and function clinically. Nonetheless, the literature does not demonstrate differences in the knowledge base of graduates from PBL and traditional curricula (31).
There is a wealth of evidence to support the claim that PBL results in greater participant enjoyment and enthusiasm for learning than traditional medical education. For example, Colliver (7) found that students value the interpersonal skills that PBL encourages and that are also key to effective clinical practice.
Antepohl et al (32) found that graduates of a PBL curriculum showed "a high degree of satisfaction with their undergraduate education and how it prepared them for medical practice".
Research into this field continues to be problematic. A lot of the recent studies have used questionnaires to compare the outcomes of different curricula, which introduces recall and response bias.
Macallan et al (15), who considered CPBL from the students' viewpoint, acknowledged that this is a common limitation of PBL research, as "students may not correctly perceive those factors that truly enhance their learning". However, I agree with their comment that more objective measures are difficult to apply in this context.
Another of the weaknesses of the studies that I have encountered is that comparisons were often made between students or graduates from different medical schools. Consequently, it is difficult to know whether any differences observed were the result of curriculum design or the overall context of the school.
When appraising some PBL studies, I noticed that the studies were not based on any learning theory and, thus did not offer better understanding of why or why not PBL might work. A challenge for future research is to use learning theory to design PBL studies and use the data from studies to support theory.
Although RCTs have not been able to prove statistical effectiveness of PBL, there is considerable practical evidence, especially from the early 1990s reviews that students and faculty enjoy PBL more than traditional teaching methods (3-6).
It seems that more refined research methods and a wider range of research designs and variables are required to identify educational changes in this complex learning environment. There is opportunity for more UK-based studies following the introduction of PBL-based curricula at many UK medical schools over the past ten years. The literature regarding CPBL is very sparse, so this could be a key focus of future research.
However, Bligh (33) comments that "lack of hard `scientific' evidence for the effectiveness of PBL is not a reason for delaying implementation of PBL in curricula".
Does having an expert facilitating PBL impact on student learning?
The evidence from the literature regarding the use of expert PBL tutors is contradictory and the quality of the studies I reviewed was often limited by the use of small sample sizes.
Furthermore, most studies in this field used qualitative data, introducing difficulties with generalisability. Different schools use slightly different PBL formats, so study results from one school or course may not be generalisable to all medical schools.
Another problem with the literature is that there is no overall consensus as to what constitutes an 'expert'. However, all the studies I reviewed used the term to refer in some way to the facilitator's subject knowledge, rather than their ability to facilitate tutorials.
Unfortunately, I was only able to identify one paper that was specifically about CPBL (15). This study found that students "greatly appreciated it when expert clinicians demonstrated how clinical reasoning applied to the case". The authors suggested that the role of the expert was more important in the second tutorial, when the students were discussing the learning objectives from the previous session after SDL.
The study about CPBL involved students from the SGUL MBBS4 course, which has a PBL curriculum (15). Therefore, the results may not be representative of courses where the curriculum is not so firmly rooted in PBL. On a positive note, the authors reduced bias by using the well-validated Delphi consensus approach to report extensive qualitative feedback.
The research suggests that value of an expert facilitator is dependent on a number of factors, including course structure and the students' prior knowledge (21).
Dolmans et al (34) demonstrated that tutorial groups with relatively low levels of productivity require much more input from a tutor than highly productive groups, which is consistent with my experience. As discussed in my reflection, the MBBS4 students were highly productive and my role in the tutorials was minimal. On the other hand, my previous experience of PBL with MBBS5 students has been that the students did not engage in the process or generate sufficient discussion or learning objectives. In these tutorials, I found myself taking a much more central role.
Although there has been debate as to whether the facilitator needs to be an expert, the consensus view seems to be that expertise in group dynamics together with supportive enthusiasm is more valuable than deep subject knowledge (35, 19).
However, there is not sufficient literature to conclude whether this view is generalisable to CPBL. My experience would suggest that subject knowledge has a demonstrable value in CPBL.
I found that, for the most part in this series of tutorials, my role was solely as a facilitator. However, the students occasionally discussed complex clinical issues, which were not easy to understand from reading a textbook. As an expert in the subject matter, I was able to explain the concept in the clinical context.
From my experience, I appreciate that having an expert facilitator introduces a risk of the tutorial becoming didactic. Review of the background theory of PBL, especially self-determination theory (36), highlights the importance of the tutor, whether an expert or not, upholding a student-centred approach and encouraging students to accept more responsibility for their own learning.
What difficulties may arise with PBL group functioning and what are the solutions?
Whilst facilitating this set of CPBL tutorials, I observed a highly functional group, who were able to use the group setting to enhance their learning. However, my past experience of facilitating CPBL and PBL tutorials has not always been so positive.
The review of the literature revealed various difficulties that can arise within a PBL group, leaving me keen to understand how to remedy a dysfunctional group. The two main problems I have encountered have been students not engaging with the discussion process and students not undertaking the SDL.
Occasionally, when faced with a silent group of students who fail to engage in the discussion process, I find myself suggesting learning objectives. From review of the literature, I now realise that this leads to a further decline in motivation, as the students are not deciding what is relevant to their learning (13).
Dolmans et al (13) recommend that the tutor should use prompting questions to activate students' prior knowledge and to stimulate students to apply the newly acquired information to different situations (13). They also discuss how the tutor can play an important role in developing a team spirit by establishing a personal relationship with students in the group and suggest the use of "self- and peer evaluations by students, as a means of helping groups to evaluate on a regular basis and of developing self-reflection in students" (13). This student-centred approach to evaluation encourages learning by giving the students a high level of responsibility for their own learning (37).
Research has shown that the most effective interventions were those initiated by the group, thereby promoting a student-centred approach to resolving conflict (24, 35).
A common methodological limitation that affected the quality of the literature was the use of self-report data, which is susceptible to recall bias. In addition, Kindler et al (24) only used the opinions of tutors to decide whether interventions were successful or not and the tutors used in the study were very experienced and highly-rated. Consequently, this data cannot be applied to other PBL groups.
In order to create an environment in which the students feel able to intervene, ground rules about mutual respect, confidentiality and attendance need to be set, which is something that myself and the students did at the start of the first tutorial.
Tutors can also intervene by providing "effective feedback" (24), which has been described as a "necessity for learning" (38) and as "central to medical education" (39). However, delivering feedback in the group setting can heighten emotional responses, such as anxiety, which may help to explain why in-tutorial interventions fail to address a lot of group difficulties (24).
Papinczak et al (40) found that peer assessment strengthened "the sense of responsibility that group members have for one another", which is in keeping with the collaborative learning philosophy of PBL. However, a significant proportion of the students reported scepticism and feelings of discomfort with regards to peer assessment.
A number of researchers recommend that prior to the implementation of PBL, students be trained in consensual decision-making skills, dialogue and discussion skills, maintenance skills, conflict resolution skills, and team leadership skills (30, 41, 42).
Conflict arises when there are differences in thinking style and when there are misunderstandings in the group. Peterson (41) suggested the use of debriefing to allow students to address what went well, what they need to work on and what has been learned.
The literature discusses many difficulties that may affect group functioning, which can be divided into individual student, tutor and group problems (24). Suggested solutions include feedback, peer assessment, training for both students and facilitators and debriefing. Studies highlight the importance of students, rather than the facilitator maintaining responsibility for the group and its functioning.
My reflection highlights a number of differences between how undergraduate and postgraduate students interact in PBL, which are not addressed by the literature. There is a need for formal study of these differences. A large body of the research regarding group dynamics in PBL is from the Netherlands and it would be interesting to determine whether studies of UK PBL groups would yield similar results.
Proposals for future practice
This positive experience of working with a group of students who were well-engaged with the PBL process, has shown me how effective PBL can be as a learning experience and has prompted me think about the errors that I made when facilitating PBL groups in the past.
Through review of the theory and evidence behind PBL, I realise that, as PBL facilitator, I need to stop students at critical points and ask them to elaborate on what they are thinking; to clarify why specific questions were asked; to probe the students' understanding of principles and concepts, as suggested by Barrows and Tamblyn (43), rather than giving direct answers or a didactic teaching session.
I have also considered other changes I can make to my future practice, such as the use of a rotating chair to encourage student interaction. This was not necessary in this series of tutorials, as the students confidently led the tutorials. However, with less engaged groups I have tended to chair the tutorials. Self-determination theory highlights the importance of giving this responsibility to the students.
I need to tolerate silence when students are thinking and to encourage the students to reflect on silences and to develop their own solutions to difficulties in the group. This can be done through the use of peer feedback or debriefing.
The evidence for the use of peer feedback is contradictory but McCrorie (44) suggests the use of two-stage debriefing. In the first stage, the group as a whole is asked to rate itself against a set of criteria, such as attendance and punctuality, preparedness for the sessions, engagement in the sessions and behaviour towards one another. The second stage involves the individual students rating themselves against the group rating. The hope is to initiate a constructive, reflective discussion of the strengths and weaknesses of each group member. I plan to trial this method next time I facilitate PBL tutorials, as reflection and effective feedback are important skills for medical students to develop.
Other ways I can improve my facilitation of future PBL tutorials is through the use of Kindler et al's (24) list of suggested questions to help students resolve conflict and the use of ice breakers at the first tutorial to help relax the group and to initiate interaction (44).
In my reflection, I commented on my anxiety about not being able to answer student questions. Through review of the literature, I now understand that my role is not to answer questions but to help the students to answer them for themselves. However, I still feel that it would be beneficial if I research the learning objectives each week in order to be able to direct students towards appropriate sources and for my own professional development.
The key message that I take away from this experience is that adherence to the student-directed philosophy of PBL will result in an effective learning experience.