Problem Based Learning In The United Kingdom Education Essay

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Problem-based learning (PBL) has been widely adopted in medical curricula for several years. PBL follows a clearly defined process, which I shall describe in the next section. More recently, we have seen the development of clinical PBL (CPBL), which is designed to complement ward-based clinical teaching.

When I was a medical student, PBL was relatively new and only comprised a very small proportion of the curriculum. Since then, PBL has been increasingly used in the UK and some medical schools now offer courses which almost solely involve PBL as the learning method. This has stimulated me to think about the theory underlying PBL and how it compares to traditional lecture-based undergraduate medical education. I was interested as to whether the increasing use of PBL has affected outcomes, such as examination results and the quality of doctors produced.

I am asked to facilitate PBL and CPBL on a regular basis. Consequently, I selected this teaching experience as the topic of this assignment, in order to allow an opportunity to consider the role of these tutorials within undergraduate medical education and how to maximise the learning experience for the students.

The experience of facilitating a set of CPBL tutorials

I facilitate CPBL tutorials for penultimate year St. George's University of London (SGUL) medical students undertaking their five-week clinical attachment in psychiatry. I shall be describing my most recent experience of facilitating a series of five weekly CPBL tutorials with a group of seven students on the four-year MBBS (MBBS 4) course.

SGUL runs three separate undergraduate courses. One of these is the traditional five-year course, which accepts both school leavers and graduates. In this assignment, I shall refer to this course as MBBS 5. The other course that is relevant to this assignment is the four-year course, which is only open to graduates. I shall refer to this course as MBBS 4.

In advance of the tutorials starting, I received a list of students in my tutorial group, one of whom had been allocated as the lead student. It was my responsibility to set a time and venue for the tutorials and communicate this information to the lead student at the beginning of the first week of their placement. The lead student was expected to disseminate the information to the rest of the group and to prepare a case for the first tutorial.

When setting the time of the tutorials, I took into account considerations about my work commitments and the students' placement timetables. I chose to hold the tutorials after the academic programme at Tolworth Hospital each week because the students and I were expected to attend the academic programme, so we would already be together. I was also aware that the consultants have a regular meeting slot immediately after the academic programme. Therefore, it was unlikely that the students would have been timetabled to attend clinical teaching at that time.

At the first tutorial, we discussed the purpose of the tutorials and set ground rules for behaviour within the group. The medical school provides guidance on how CPBL tutorials should run and the students were very familiar with such tutorials. I was clear that the purpose of the tutorials was to support the learning of the students and that they should set the topics to be discussed. The students were aware of the importance of confidentiality when discussing patients and we agreed to behave respectfully to each other during the tutorials.

One student normally acts as a scribe in each session, taking notes on a flip chart. During the first session, the students discussed this and decided that they would prefer not to have a scribe, as the scribe misses out on the opportunity to make their own notes.

At each tutorial, a student or pair of students presented a patient that they had taken a history from during their placement. The students who were to present were selected at the previous tutorial, except in the case of the first tutorial, when the lead student presented a case.

Once the case had been presented, the other students asked questions, facilitating a discussion about diagnosis, management plan and any other issues that the case generated. The students identified topics that they would like to read more about and set learning objectives accordingly. They then researched these learning objectives for discussion at the next tutorial.

Once the students felt they had exhausted the discussion about the case, we moved on to discussing the learning objectives set the previous week. Topics included mental state examination, risk assessment, history taking and psychopharmacology. The students shared the information they had gathered, again facilitating the discussion. It was at this point in the tutorial that I acted more as an expert, clarifying any points that had not been clear from their reading.

Each tutorial lasted between sixty and ninety minutes, with the first tutorial being the shortest, as there were no learning objectives to discuss. Attendance by the students was generally very good, although two students left for an elective in Australia before the end of the placement.

Critical reflection on the experience

I often feel anxious prior to teaching sessions. My specific anxieties around PBL tutorials include motivating the students, as I have found it difficult in previous tutorials to encourage MBBS5 students to initiate a discussion; remaining within the boundaries of my role as a facilitator, rather than providing a didactic teaching session; and a fear that the students will ask questions that I am unable to answer.

I thoroughly enjoyed facilitating this set of tutorials. This was my first experience of tutorials with the MBBS 4 students. I found them to be much more engaged with the tutorials than their peers on the MBBS 5 course. They were able to generate excellent discussions without prompting from me. I felt that I was much more able to remain within my role as a facilitator, rather than providing active teaching.

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 MBBS 4 students come from a vast variety of backgrounds, so each was able to bring a different set of skills and knowledge to the tutorials. For example, one of the students had a background in catering and she was able to raise important issues about a patient's nutritional status that I would not have considered.

I often find it hard to take a back seat during tutorials and not end up teaching rather than facilitating. During this set of tutorials, I found that I was better at asking questions to prompt the students to think about the correct answers, rather than telling them the answer. I felt that this was also what the students wanted, whereas in my previous experiences with MBBS 5 student groups, the students often seem keen to be 'spoon fed' the answers rather than using discussion to obtain knowledge from their peers. This may be because the MBBS 4 course uses PBL as its main learning method from the start of the course, so the MBBS 4 students are more familiar with the format and expect to learn by self-directed learning and sharing of knowledge. On the other hand, the MBBS 5 students have a lot more traditional lectures and are accustomed to being taught in this manner.

I find teaching an anxiety-provoking situation. However, I felt very comfortable facilitating this set of tutorials. We successfully created a safe, relaxed environment and the students seemed to feel comfortable asking questions and discussing difficult feelings that they had experienced. This may have been because all the students in the group knew each other and were used to working with each in PBL settings. Again this is different to facilitating tutorials with MBBS 5 students, who often are not well-acquainted with the other members of the group.

The MBBS 4 course had accepted much smaller numbers of students than the MBBS 5 course. Therefore, the MBBS 4 students tended to know each other a lot better than those students on a larger course. However, the numbers accepted onto the MBBS 4 course are increasing and I wondered whether this will impact on the group dynamics in MBBS 4 PBL tutorials.

In terms of areas for improvement, I think it would have been helpful if I had also 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 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.

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 not to be able to recall everything you have learnt and that you can refer to text books.

I received positive feedback through verbal comments from the students and written feedback to the course organisers. The students seemed to enjoy the tutorials and found them of educational value. As well as discussing the cases and learning objectives, we discussed a career in psychiatry, as a number of the students expressed an interest in this field. I think I was able to give the students a realistic and enthusiastic insight into my profession. My hope is that, even if the students do not pursue a career in psychiatry, they will have a positive view of mental health professionals, helping to lessen stigmatisation of the profession.

Key points

How do the outcomes of PBL-based curricula compare to those of traditional curricula, involving large group lectures?

Does previous undergraduate experience affect how students learn?

Does having an expert facilitating PBL impact on student learning?

Literature review

The theoretical basis of PBL

Originally, PBL was based on the theory of contextual learning. The basic principle is 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 (2000) undertook a review of the literature and concluded that the contextual learning argument was based on a weak research finding.

Albanese (2000) concurred with Colliver's 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.

Schmidt (1983) claimed that information-processing theory underpinned PBL. This theory involves three major elements, namely prior knowledge activation, encoding specificity and elaboration of knowledge. Prior knowledge activation is the process of students using previously-gained knowledge to understand and organise new information. Encoding specificity is similar to contextual learning theory, i.e. learning is promoted when the environment in which something is learned resembles the environment in which it will be applied. Elaboration of knowledge describes how information will be better understood and easier to recall when there is an opportunity for elaboration in the form of discussion, answering questions, and so forth.

From my experience of facilitating PBL, I have observed all three of these elements commonly occurring in PBL. This theory incorporates contextual learning theory but a more comprehensive theory for understanding PBL.

I will now briefly discuss each of the other three learning theories of PBL proposed by Albanese and reflect on my experience of facilitating PBL with respect to these theories. Firstly, cooperative learning refers to an individual's perception that they can only fulfil their goals if the other group members also do so.

Qin et al (1995) conducted a meta-analysis of studies assessing the effect of cooperative versus competitive learning on problem solving. They defined cooperation as the presence of joint goals, mutual rewards, shared resources, and complementary roles among members of a group. In competitive learning situations individuals perceived that they could only reach their goals if the other group members could not. They defined four types of problem solving, situations which required participants to form a cognitive representation of a task, plan a procedure for solving it, execute the procedure and check the results. They found that members of cooperative teams outperformed individuals competing with each other on four types of problem solving. These results held for individuals of all ages and for studies of high, medium, and low quality. The superiority of cooperation, however, was greater on non-linguistic than on linguistic problems.

I observed cooperative learning in action during the set of CPBL tutorials that I have described in this assignment. The students were keen to share the knowledge that they had reaped from self-directed learning and support all group members to attain the same level of understanding. 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 an expert facilitator.

Self-determination theory may underlie matters of motivation and behaviour relevant to PBL. Williams et al (1999) argue that self-determination theory, a theory which has been effective in treatments for patients who smoke or who have hypertension or coronary artery disease, has the potential to significantly improve education. The theory differentiates between two types of motivating conditions, controlled and autonomous. Controlled motivators are thought to be maladaptive and include external demands as well as "introjected regulation", which are internalized beliefs about what one "should" do. These are all associated with either explicit or implicit rewards or punishments. Under controlled forms of motivation, individuals act with a sense of pressure and anxiety. In educational terms, this refers to short-lived, rote learning, which students do not integrate into their long-term values and skills. Albanese inferred that traditional curricula tended to involve controlled forms of motivation.

Albanese described autonomous motivators as "those which are personally endorsed by the learner and reflect what the individual finds interesting and important". In comparison to the external rewards and punishments associated with controlled motivating conditions, autonomous motivation allows the individual to behave with a sense of volition, agency, and choice.

PBL promotes autonomous motivators by considering the perspectives of the students and encouraging students to accept more responsibility for their own learning. I felt that I was able to support this by asking the students what they wanted to achieve from the tutorials, facilitating their discussions by asking prompting questions and seeking the opinions and feelings of students in a non-judgemental manner. As I discussed in my reflection, we were able to create a safe, relaxed environment, which minimised pressure and control and encouraged a high level of performance and collaborative learning. It seems that autonomous motivators fit better with PBL than a traditional curriculum.

The final theory of PBL proposed by Albanese was control theory. This theory was first introduced by Glasser (1986), who conjectured that all behaviour, including learning is intended to satisfy one or more of the following five internal needs:

1) To survive.

2) To belong and be loved by others.

3) To have power and importance.

4) To have freedom and independence.

5) To have fun.

Albanese felt that PBL satisfies all five needs. It allows freedom because the students are able to structure their time and choose what to discuss. It satisfies the need for power, as students have the power to set their own learning objectives. PBL promotes love and belonging because it allows students and facilitators to become more personally involved with one another than in lectures. The 1993 reviews highlighted how both students and faculty enjoy PBL, thereby satisfying the need for fun. PBL promotes survival through students helping students. These claims by Albanese are in concordance with what I experienced as the facilitator of the CPBL tutorials.

To conclude, although Colliver (2000) found the theoretical development of PBL to have been weak, there is an array of theory that can be applied to PBL. I have described four theories but there may be others. Further research is required to investigate how theory can be transformed into effective PBL.

Andragogy

Upon reflection, I noted significant differences in the way in which the MBBS 4 students interacted in the CPBL tutorials and their ability to use these tutorials as a learning tool compared to students on the MBBS 5 course. I wondered whether this may reflect how learning styles change as we become adults and mature.

In the 1950s, Malcolm Knowles developed the theory of andragogical learning, contrasting the learning methods of adults with those of children, pedagogical learning. Knowles claimed that one of the main differences between these two forms of learning was that the role of the educator was minimised in adult learning.

Andragogy is based on the following five assumptions about how adults learn and their attitude towards and motivation for learning (Kaufman, 2003):

Adults are independent and self directing;

They have accumulated a great deal of experience, which is a rich resource for learning ;

They value learning that integrates with the demands of their everyday life;

They are more interested in immediate, problem centred approaches than in subject centred ones; and

They are more motivated to learn by internal drives than by external ones.

Learner-centeredness is described in the literature as a distinguishing characteristic of adult education. Traditional medical curricula reflect inform students as to what they should learn and what kinds of knowledge are considered important (Sheared & Sissel, 2001) (Titmus, 1999). In contrast, PBL places learners at the centre of their learning experience and promotes flexibility and individuation for self-directed, empowered adults (Manusco, 2000).

However, andragogy has been criticised, as adults do not automatically become self-directed upon achieving adulthood. They may not be psychologically equipped for it and may prefer or need direction from others (Beitler, 1997) (Titmus, 1999) (Courtney, Vasa, Luo, & Muggy, 1999).

Study of the literature reveals a lack of empirical evidence to support the differentiation between childhood and adult learning. Nonetheless, many education methods that are often used in higher education, including experiential learning, student autonomy and self-directed learning, stem from andragogy.

Outcomes of PBL-based curricula

In the early 1990s, four separate systematic reviews comparing PBL to traditional curricula were published. I shall summarise these reviews before moving on to discuss the more recent literature.

The first review was published in 1992 by Norman and Schmidt, who examined the psychological basis for PBL. They found no evidence that PBL brought about improvement in "general, content-free problem-solving skills". However, they felt that there was some preliminary evidence to suggest that PBL may "enhance both transfer of concepts to new problems and integration of basic science concepts into clinical problems". Their other conclusions were, "learning in a PBL format may initially reduce levels of learning but may foster, over periods up to several years, increased retention of knowledge"; "PBL enhances intrinsic interest in the subject matter"; and "PBL appears to enhance self-directed learning skills, and this enhancement may be maintained".

Albanese and Mitchell (1993) conducted a systematic review and meta-analysis of literature on the outcomes and implementation issues of PBL. They concluded from their findings that, compared with conventional medical education, PBL is more nurturing and enjoyable; PBL graduates perform as well, and sometimes better, on clinical examinations; and they are more likely to enter family medicine. However, they also found that PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in, and there appeared to be gaps in their cognitive knowledge base that could affect practice outcomes.

Vernon and Blake (1993) conducted a very similar meta-analysis of the literature. They concluded, "overall, the results of our meta-analysis support the superiority of the PBL approach over more traditional methods". They found that student attitudes, class attendance and mood were all consistently more positive for PBL than for traditional courses. In terms of clinical functioning, PBL students performed better than traditional students. However, there was no significant difference between the two groups on measures of clinical knowledge.

The conclusions of a literature review by Berkson (1993) were much less positive, stating, "the graduate of PBL is not distinguishable from his or her traditional counterpart. The experience of PBL can be stressful for student and faculty. And implementation of PBL may be unrealistically costly."

In 2000, Colliver 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. Colliver concluded, "the review of the literature revealed 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". Furthermore, this review found that links between PBL and underlying educational theory and research were weak, especially with respect to psychological and cognitive mechanisms. Unlike previous reviews, Colliver's review challenged thinking about the educational effectiveness of PBL. Colliver suggested that further research was required to clarify both theory and practice.

Later in 2000, Norman and Schmidt 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 and argued for the use of a broad range of research designs and variables.

Albanese (2000) also produced a paper as a retort to the review by Colliver. Albanese used results of students from differing curricula on the United States Medical Licensing Examination (USMLE) to suggest that PBL produced higher scores than traditional lectures. Albanese 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.

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 review was conducted by Newman et al (2003), which included only randomised controlled trials and quasi-experimental studies in which student performance or other outcomes were objectively measured. They identified ninety-one citations, but only fourteen studies met their inclusion criteria. Based on these fourteen studies they concluded that outcomes for students in the PBL groups were less favourable than those in the "control group". One weakness was the lack of consensus in the studies they reviewed on what constituted a control group.

Dochy et al (2003) were responsible for another recent meta-analysis of the effects of PBL, which showed that PBL had a positive effect on knowledge application of students. However, no effect on knowledge was found.

A number of studies including that be Prince et al have used self-report questionnaires to compare the opinions and competencies of graduates from PBL and non-PBL schools. The results suggest that PBL graduates are better prepared with respect to several of the competencies (Katinka J A H Prince, Boshuizen, van der Vleuten, & Scherpbier, 2005).

Antepohl et al (2003) conducted a questionnaire study of all graduates of the new PBL medical curriculum at the Faculty of Health Sciences, Linköping University, Sweden. They found that "graduates of the new medical curriculum showed a high degree of satisfaction with their undergraduate education and how it prepared them for medical practice". However, this study had some limitations. The use of postal questionnaires introduces response bias. They had a good response rate of 77% but it is possible that the 23% who did not respond may not had a positive view of their medical education.

This study raised questions regarding the degree to which graduates' subjective retrospective evaluation of their own undergraduate education can provide relevant information concerning the quality of the course. Schmidt and van der Molen (2001) overcame this issue when comparing PBL graduates to traditional graduates. They identified and corrected self-overestimation among PBL graduates by referring to self-ratings results in areas in which a difference between PBL and traditional students was not expected. If differences did occur, they were used to quantify self-overestimation and to correct for it.

Tiwari et al (2006) conducted a randomised controlled trial aimed at comparing the effects of PBL and lecturing approaches on the development of students' critical thinking. Their results revealed that PBL students had "significantly higher critical thinking disposition scores on completion of PBL compared with lecture students". "They also continued to have higher scores, albeit to a lesser degree, than the lecture students for two years afterwards." This study involved small numbers of students and relied upon self-report by students, which can introduce recall bias. Despite these limitations, this study highlights the need for further research to determine whether the differences in critical thinking are maintained in subsequent years.

Also in 2006, Schmidt et al conducted a large, robust study comparing professional competencies of PBL graduates to traditional graduates in the Netherlands. Participants were asked to complete a questionnaire, rating themselves on eighteen professional competencies derived from the literature. They concluded, "PBL not only affects the typical PBL-related competencies in the interpersonal and cognitive domains, but also the more general work-related skills that are deemed important for success in professional practice".

More recently, Koh and colleagues (2008) performed a systematic review of how PBL during medical school affected the competence of doctors after graduation. The authors only included publications that incorporated a control group of graduates from a "traditional" curriculum. They employed a thorough methodology, whereby doctors' self assessments of their competencies and assessments by independent observers were considered separately. Little correlation was seen between self-assessed and observer-assessed competency. Self-assessment showed a strong level of evidence against PBL for possession of medical knowledge, but this was not confirmed by independent observation. The authors concluded that PBL has positive effects on graduate competencies in important social and cognitive domains. Again, one of the problems with this review was the absence of a definition of the control "traditional" curriculum.

In 2009, Macallan et al evaluated which components of CPBL contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus method (Macallan et al, 2009). They showed that students found CPBL a "positive learning experience". They found that successful CPBL was supported by "the tutor's level of expertise and a non-threatening learning environment, conducive to student questioning". This study verified the idea that CPBL is "a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching".

Analysis and discussion

How do the outcomes of PBL-based curricula compare to those of traditional curricula, involving large group lectures?

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 (Albanese & Mitchell, 2003) (Vernon & Blake, 1993) (Berkson, 1993) (Norman & Schmidt, 1992).

There were limitations to the reviews, as highlighted by Albanese and Mitchell, including weaknesses in the criteria used to assess the outcomes of PBL; general weaknesses in study design; a limited research base, with studies of PBL curricula coming from only a handful of medical schools; and diversity in what different individuals call PBL.

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. There was also a risk of confounding, as it is very difficult to randomly assign students to different teaching methods for large segments of their training.

These limitations lessen the confidence one can give conclusions drawn from the literature regarding the outcomes of PBL at that time.

Although all four reviews had very similar results, most of the literature reviewed was from the United States when PBL was in the early stages of use. Therefore, I wanted to examine more up-to-date research from the UK.

The literature provides limited evidence for differences in outcomes between traditional and PBL courses. Jones et al (2002) (Jones, McArdle, & O'Neill, 2002) commented, "findings from published studies have varied from better `clinical functioning' by PBL students, better performance in knowledge tests by traditional course students, greater awareness of recent guidelines by PBL students, through to little or marginal benefits".

On the whole, recent research largely supports the findings of the earlier reviews, which suggested that graduates of PBL curricula are better able to apply knowledge and function clinically. However, the literature does not demonstrate differences in the knowledge base of graduates from the two different curricula.

Albanese (2000) (Albanese M. , 2000) argued that PBL improves clinical competence by making students more confident and self-aware as professional learners, thereby producing more efficient and enthusiastic doctors.

Nonetheless, not all the literature is consistent with this view. Rolfe et al (1995) (Rolfe, Andren, Pearson, Hensley, & Gordon, 1995) demonstrated that graduates from a traditional curriculum were rated higher for teaching, diagnostic skills and understanding of basic mechanisms compared to those from a PBL curriculum.

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 (2000) (Colliver, 2000) found that students value the interpersonal skills that PBL encourages and that are also key to effective clinical practice.

Research into this field continues to be problematic. A lot of the recent studies used questionnaires to compare the outcomes of different curricula, which introduced recall and response bias.

When appraising some PBL quantitative studies, I noticed that the studies were not based on any learning theory or were not testing predictions from a learning theory and, thus does not offer better understanding of why or why not PBL might work. A challenge for future research is to use learning theory to design quantitative PBL studies and use the data from studies to support theory.

Macallan et al (2009) considered CPBL from the students' viewpoint. They acknowledge 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. (Macallan, Kent, Holmes, Farmer, & McCrorie, 2009)

Another of the weaknesses of the studies that I have encountered is that comparisons are often made between students or graduates from different medical schools. Consequently, it is difficult to know whether any differences observed are the result of curriculum design or the overall context of the school.

Although randomised controlled trials have not been able to prove statistical effectiveness of PBL, there is considerable practical evidence from the 1993 reviews that students and faculty enjoy PBL more than traditional teaching methods.

There are a variety of arguments for believing that it is too early to accept these negative findings of the literature. It seems that more refined research methods and a wider range of research designs and variables are required to identify educational changes in a complex, learning environment. Bligh (2000) stated, "lack of hard `scientific' evidence for the effectiveness of PBL is not a reason for delaying implementation of PBL in curricula".

Need more UK studies

Does previous undergraduate experience affect how students learn?

McCrorie (2002) described graduate-entry students as "highly motivated and committed" and "much more self-directed, challenging, demanding, questioning".

"Graduates have already learnt how to study and how to ration the other temptations of student life in order to keep up with their studies. This makes them better able to handle a self-directed learning approach" (Rushforth, 2004). Self-directed learning can be viewed as "a method of organising teaching and learning in which the learning tasks are largely within the learners' control" (Kaufman, 2003).

Kaufman (2003) suggested that graduates may also have some limitations to their learning, including fixed learning approaches, greater financial concerns and a limited scientific background at enrolment.

Taylor et al stated, "the major difference between adults and younger learners is the wealth of their experience" (Taylor, Marienau, & Fiddler, 2000, p.7). This is something that I reflected on following the CPBL tutorials, as the students in the group came from a variety of backgrounds. Each student was able to bring a different perspective and knowledge to the group, allowing for a richer learning environment.

On the other hand, students on the MBBS 5 course who have started their medical degree straight from school tend to have a similar educational background and experiences.

In the contrary to my observations, a study by Wilkinson et al (2004) concluded, "older age at entry may be more important than having a prior degree".

Does having an expert facilitating PBL impact on student learning?

Barrows (1985) suggested that non-directive facilitation was more important than subject-matter expertise when he described the role of PBL tutor as follows:

"Instead of giving students the information and facts they need through lectures and readings, they must learn to facilitate and indirectly guide student learning. They must allow students to determine on their own what they need to know and to learn through the study of varied resources. Instead of telling students exactly that they should learn and in what sequence they should learn it, the tutor must help students determine this for themselves." (Barrows, 1985)

There is much controversy in the literature as to whether an expert PBL facilitator promotes learning or not.

A study by Eagle et al (1992) 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 self-directed study than students attending tutorials facilitated by non-experts.

However, other studies have found the opposite effect. Silver and Wilkerson (Silver & Wilkerson, 1991) 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.

Macallan et al (2009) (Macallan, Kent, Holmes, Farmer, & McCrorie, 2009) found that students "greatly appreciated it when expert clinicians demonstrated how clinical reasoning applied to the case".

I found that, for the most part in the tutorials, my role was solely as a facilitator. However, the students occasionally discussed complex clinical issues, which were not easy to fully understand from reading a textbook. This was when I would step in to explain the concept in the clinical context.

Hendry et al (2003) claimed that some PBL tutors are too dominant (Hendry, Ryan, & Harris, 2003). They reported that "a dominant tutor causes tension and conflict in groups which leads to lack of commitment, cynicism or student absenteeism". However, it has also been shown that too little regulation by the facilitator also causes problems.

So far, there has been little mention of the "teacher" in problem based learning. PBL differs radically from traditional teaching styles in that it centres on "problem first" learning, rather than the more usual "subject first" way using scenarios to illustrate previously taught material. The leader of a PBL programme acts as a facilitator rather than a teacher, using their expertise not primarily to transmit facts, but to provide encouragement and guidance as the participants tackle the problems they have identified. The skill of PBL facilitation is that of knowing when to provide assistance to the group, be it suggesting useful resources they might like to consider or interjecting with thought provoking comments to guide the breadth and depth of learning, without necessarily imparting facts.4 There has been debate as to whether the facilitator needs to be an "expert in the field" regarding the subject matter being tackled, but the consensus view is that expertise in group dynamics together with supportive enthusiasm is more valuable than deep subject knowledge. The potential for "non-medical" facilitators to help with teaching in the emergency department is therefore significant. This has been a difficult idea for some "medical" teachers to grasp.5  ↵4Maudsley G . Roles and responsibilities of the problem-based learning tutor in the undergraduate medical curriculum. BMJ1999;318:657-61. ↵5Vernon DTA. Attitudes and opinions of faculty tutors about problem-based learning. Acad Med1995;70:216-23.

Conclusion

Helped to understand how PBL should run to be effective - try to use prompting questions rather than give direct answers

Use ice breakers at first tutorial to help with group dynamics

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