Problem/Case Based learning

[hemeonc88]

Hi everyone,

The PBL method of learning has always made me wonder how students can become good doctors without having the basic knowledge.

From what I know students are given various problems or diseases on which they have to do a lot of research on. For example, Multiple myeloma. A student has to learn the pathophysiology, the treatments, the prognosis and everything that is related to this disease.

This method of learning is completely different to the traditional way where you study anatomy, physiology, neuroscience and then in the senior years...do courses like pathology and clinical skills.
I wonder how students can learn from a disease perspective rather than covering the basics first and then building on top of that?

It will be nice to hear some comments from those who have experienced PBL/CBL.

Cheers

[thinker001]

Is the Australian system strictly PBL? what about the US? i'm new at this so please excuse my ignorance.

[Lyndal PN]

There are educational adantages and disadvantages to both. Am happy to give dsome detaila s this is my area of expertise...currently busy will post a proper answer later tonight :)

L

[dadoc]

The University I currently attend has PBL. I think its a slight disadvantage, but I Lyndal can probably shed more light on it than I can

[WendyMBBS]

Aussie schools are not 100 percent PBL, its a mixture of both lecture and PBL sessions. I have a friend who goes to USyd, where students complete a mixture of both, in the first few weeks its lecture, then a mix of PBL and lectures.

[Lyndal PN]

Problem based learning (PBL) has been adopted in various forms in higher education, and particularly medical education, worldwide. The research evidence supporting the positive learning approaches facilitated by problem based learning is strong (Albanese, 1993, Barrows and Tamblyn, 1980, Bligh, 2000, Vernon and Blake, 1993) and the pedagogical benefits are explained by Bouhujis as such:

Literature suggests that adopting a deep cognitive approach to study, engaging a concrete problem prior to exploration of relevant principles and learning in a context that approximates the future situation where the knowledge will be applied, all favour comprehension and eventual successful application i.e. transfer of the learned material (Bouhuijs et al., 1993 pp127)

Although “PBL” is sometimes used to refer to an isolated instructional method, it is fundamentally a conception of knowledge, understanding and education profoundly different from the traditional discipline based medical education model. It is a system of constructing and delivering curricula using clinical problems as the focus of student activity (Barrows, 1994). These problems then provide an intellectual starting point and form a puzzle to motivate the learner to solve: they are not merely case examples to demonstrate known facts (Boud and Feletti, 1997) . PBL does not equate to the addition of problem solving activities to an otherwise discipline centred curriculum, but refers to a course that starts and ends with reallife clinical problems rather than an exposition of disciplinary knowledge. Facilitated small groups explore these problems and the students are stimulated to undertake self-directed learning, with feedback (but specifically not didactic teaching) provided by their tutor (Barrows and Tamblyn, 1980, Boud and Feletti, 1997).

There are key features that are common to PBL approaches to learning. According to Dolmans et al, problem based learning is based on insights into learning, emphasising that learning should be constructive, self-directed, collaborative and contextual in its undertaking (Dolmans et al., 2005). The fundamental learning principles in PBL can be summarised as:

Learning as a constructive process - Students actively construct or reconstruct their learning networks. The principle of constructivism thus espouses that learning in a process of creating meaning and building personal interpretations of the world based on personal experience and relationships with people and events. Learners should be actively involved in the process and encouraged to utilise construction and elaboration to stimulate a deeper and richer understanding of material (Dolmans et al., 2005, Ertmer and Newby, 1993, Glaser, 1991).

Learning as a self-directed process - There is an implication that self directed learning ensures students take an active role in planning, monitoring and evaluating their learning process. For ideal self-directed learning, learners should be stimulated to recognise their prior knowledge and direct their learning processes from a motivational and cognitive perspective. This will assist the acquisition of new knowledge and promote lifelong learning (Boekarts, 1997, Dolmans et al., 2005, Pintrich, 1999).

Learning as a collaborative process - Collaboration is a social and interactive process – not a matter of learners dividing tasks, but mutual interaction and a shared understanding of problems. For collaborative learning to occur, learners need to share common goals and responsibilities, be mutually dependent and reach agreement through interaction. Verbalisations, co-constructions, mutual support and criticism all support collaborative learning (Coles, 1985, Dolmans et al., 2005, van der Linden et al., 2000).

Learning as a contextual process - Learning should take place in a context relevant to its ultimate application. If learning only ever occurs in a classroom environment, transferring those skills to a clinical setting may be challenging. (Billet, 1996, Dolmans et al., 2005, Ertmer and Newby, 1993).

Cases may be used in many educational designs. The features that differentiate PBL from other models are:

• Problems are the driving force behind student learning, driving contextual, constructive and flexible learning
• Stimulus materials are used to guide students through problem discussion
• Problems are presented as close to a “real life” situation to gain the students attention and foster their curiosity
• Critical thinking is necessarily applied, with the assistance of resources to help students learn from their problem solving attempts
• Supportive, cooperative, small group work with a tutor facilitates the process (although the tutor is not necessarily a subject specialist)
• Tutors task is to probe knowledge, ensure engagement and monitor progress of students
• Small groups are collaborative, interactive and motivational
• Students identify their own learning needs, their own strategies and use of learning resources as appropriate
• Students then reapply this knowledge to the original problem and evaluate their learning processes (Boud and Feletti, 1997, Dolmans et al., 2005)

[Lyndal PN]

Evidence for a Problem Based Approach
Initially, the PBL course at McMaster was developed in an attempt to increase student motivation and enjoyment; however the design is also based in sound educational theory. Mårtenson, an educator at the Karolinska Institute states that:

“The characteristics of problem based learning and the focus of the teachers involved are in accordance with research findings in learning psychology” (Mårtenson, in Barrows and Tamblyn, 1980).

There have since been numerous studies to investigate and document the efficacy of a PBL approach. Much discourse exists, comparing assessed knowledge, clinical competence, student and staff satisfaction, tutor qualifications and problem solving ability (Bland, 2004, Musal et al., 2004, Schmidt, 1998, , Tavakol and Reicherter, 2003). Consistent research evidence regarding the outcomes of PBL can be
difficult to obtain and the conclusions are, at best, tentative. This is partly due to the lack of a definitive “gold standard” for measuring outcomes.. Early research relied on weak study designs with, small and highly specific studies from single centres and the wide range of educational processes included as problem based (Albanese , 1993, Berkson, 1993, Bligh, 2000, Finucane et al., 1998).

Notwithstanding these research limitations, evidence supporting positive learning outcomes facilitated by PBL is strong.



Meta-analyses by Albanese (1993) and Vernon and Blake (1993) found student satisfaction and clinical performance favour problem based learning. Many authorshave reported that the students and faculty enjoyed their experience of PBL more than their traditional classes and students showed a greater motivation to attend (Albanese andMitchell, 1993, Barrows and Tamblyn, 1980, Berkson, 1993, Bligh, 2000, Boud and Feletti,1997, Finucane et al., 1998, Vernon and Blake, 1993)



Some authors have directly compared the learning approaches of students from PBL and traditional schools (Coles, 1985, Newble and Entwistle, 1986, Newble and Gordon, 1985). In Newble and Clarke’s research, students from the University of Newcastle’s PBL curriculum scored very highly on scales of deep approaches to learning– more so than groups tested previously in other institutions, including the UK students assessed by Coles. Both studies found the PBL students were more likely to study for meaning and less likely to study for reproduction (Coles, 1985, ).



Solving patient problems and making defensible decisions has been described as the heart of undergraduate medical thinking (van Puymbroeck et al., 2003). The terms for this process – “clinical reasoning”, “clinical decision making” and “diagnostic reasoning” are often used interchangeably in the literature (Round, 2001) and form a fundamental skill for many health professions, yet are often not addressed adequately in medical curricula.
The traditional medical school structure of pre-clinical years separated from clinical years has been criticised by authors such as Normal and Schmidt (1990) as creating an artificial division of knowledge. For this reason, integrated problem based learning has been identified as a process that encourages reasoning as well as deep learning (Sefton et al., 2000). Clinical reasoning does not develop in isolation, but in association with increasingly refined and elaborated medical knowledge (Schmidt et al., 1990). Evidence suggests that the reasoning abilities of students in a PBL environment is enhanced, however this can be at the cost of factual knowledge in areas such as basic sciences (Patel et al., 1993). This scientific learning needs to be integrated and contextualised, however, so that useful knowledge linkages can occur as an aid to reasoning.

Limitations of PBL
While these positive features of PBL are well described, the process also has its critics (such as Berkson) whose published research challenges previous findings by clearly defining the limitations so far. As some authors have published reports that students from PBL courses have superior clinical skills, Berkson has proposed that the research findings have been biased by the nature of students selected for PBL courses and by the study selection methods themselves (Berkson, 1993). Their apparent clinical superiority, as reported by Patel et al and others (Neufield et al., 1981, Patel et al., 1991, Saunders et al., 1990) may have been confounded by the stronger community focus and greater clinical exposure at early stages of the course; rather than the PBL methodology per se
(Berkson, 1993, Schmidt, 1998)

It has been argued by some authors that students learn basic sciences more thoroughly by traditional methods than by PBL and this seems to be an accepted truism in medical education (Tavakol and Reicherter, 2003). The meta-analyses of Albanese (1993) and Vernon and Blake (1993) concluded that students in PBL courses reported a decreased comprehension and confidence in their knowledge of the basic sciences. Difference in tested knowledge however, was not statistically
significant. It appears that the differences may be in self- belief, rather than examination performance.

Problems encountered with PBL are often due to poor implementation (Das et al., 2002). The authors give examples relating to cases that are too simple (too structured and close ended to be challenging); tutors that are too directive (or too passive) and of dysfunctional tutorial groups. Das et al believe that these problems are closely related – groups are less likely to function well if they cannot relate to the case, and a passive or dominant tutor may not be able to address problems with group dynamics should they occur (Das et al., 2002, Dolmans et al., 2005). Many of these issues can be alleviated by adequate tutor training and evaluation and by retaining an overall focus on the educational philosophy underpinning problem based learning (Barrows and Tamblyn, 1980, Dolmans et al., 2001)

[Lyndal PN]

Many schools in Australia vary between traditional and purely PBL curricula. And many of the new schools (including Wollongong) adopt a hybrid approach.

Why a “hybrid” curriculum?
It has been demonstrated by many authors that students undertaking PBL based course are more likely to adopt a deep approach to learning, to have enhanced clinical reasoning and self regulated learning ability. Students in these courses are also more likely to be enthusiastic and motivated about their studies. There are noted limitations to PBL, however and these seem to be related to student confidence in medical science knowledge acquisition, student stress and greater faculty/resource costs.

Over the years there have been calls for revision of the McMaster PBL model to address these deficiencies and some have predicted that in time PBL and traditional curricula will eventually merge (Berkson, 1993). Hybrid curricula such as these have formed the basis of the University of Wollongong’s MBBS programme and aim to address the limitations of PBL while gaining some of the positive features of traditional curricula. Evidence is emerging that while self directed learning is an appropriate training ground for self-directed practice, the “hands off” approach adopted by some educators in PBL courses may be counterproductive, especially at the beginning of the course (Miflin et al., 2000).

Boekarts recommends that the addition of “scaffolding” can assist students while they gain expertise in initial skills of self regulation – and that support should be temporary and adaptive, like a set of “training wheels”. He goes on to say:

“Most students need practice to make their general cognitive strategies work in new domains. If they have not yet learned to regulate their learning in relation to a domain they may need initial external regulation to integrate and process cognitive information” (Boekarts, 1997).

At Wollongong, while our aim to continue the self-directed student centred, small group focus of the McMaster model; this teaching style is supplemented by workshops, tutorials, online material and lectures. These more structured educational activities are especially valuable in Phase 1 when students’ ability to problem solve is sometimes hampered by their lack of domain specific knowledge.

Hope that helps with the "what is PBL/CBL " question!! Phew! I bet you wished you hadn't asked !!! HA HA HA I believe PBL itself is advantageous, but not everyone is referring to the same thing when they describe PBL. Tacking cases onto a traditional curriculum is not, in my opinion, PBL. Neither is a model where students do not own their learning or take part in determining objectives. The cases need to DRIVE the learning, not just illustrate a point, for true educational integration to occur. (in my not-so humble opinion anyway!!!)

Now you have my views on it all, let me know if you have any specific comments / questions.

[hemeonc88]

That is a lot of information!
Thank you very much

[Lyndal PN]

That is a lot of information!
Thank you very much

ha ha and thats the short version of the answer!!

L

[hemeonc88]

Haha

I was wondering, do most of the Australian universities follow PBL like UOW?
And how much hospital/clinical experience do students get in the first two years?

I'm finishing my undergrad rite now (will be done in september) and am planning to apply the following summer to MANY universities including Australian.

[Lyndal PN]

Haha

I was wondering, do most of the Australian universities follow PBL like UOW?
And how much hospital/clinical experience do students get in the first two years?

I'm finishing my undergrad rite now (will be done in september) and am planning to apply the following summer to MANY universities including Australian.

Thats a difficult question as all Aussie medical schools are slightly different in their curriculum and educational philosophy. If you could generalise (and this is a big generalisation) most Australian medical schools use some form of cases in their early curriculum. Whether this follows the educational philosophy and therefore holds the benefits of true PBL is a matter for educational debate -- there are some instances in my personal opinion where the cases are not integral to the learning and therefore less advantageous. but thats just my opinion!!

Similarly the clinical experiences vary from school to school, although all schools by the end of 4 years (or 5 or 6 for undergrad) have a signifcant amount of time clinically. For Wollongong (which is of course the only school I can comment on with any authority) our students see patients from week 2 of the programme with clinical experiences increasing such that by 18 months the students are in hospitals 4 days/week and full time by the commencement of year 3.

Happy to provde more details if needed

Lyndal

[hemeonc88]

Thanks for the quick reply.

I was also wondering that in Australia to become a general physician do you have to do a residency after mbbs?
In US/Canada there is a 3 year residency for family medicine and only after that you are eligible to work as a family physician. One can go ahead and obtain a fellowship by getting trained in emergency medicine, gynecolegy, womens health etc.

I read that you are a FRACGP. Can you explain what you have to go through after mbbs to be a fellow in either GP or internal medicine (I'm interested in becoming a Hematology/oncologist)?

[dadoc]

Yes, my professor brought this up a couple of times, and even for a GP, they must complete their residency. Same with internal. Im not sure about Australia, but in the US, you can directly go into Hematology in your residency, or you can do internal and sub specialize.

Doing your residency in internal medicine and sub specializing is a better route in my opinion.