PROBLEM BASED LEARNING WITH INEXPERIENCED MEDICAL

STUDENTS

Problem-based learning (PBL) has become accepted in most medical schools around the
world. It provides medical students with an opportunity to learn with and from each other
in a more informal setting. First-year medical students however, may find PBL a
completely new way of learning which is in addition to the fact that they are under
tremendous pressure to adjust to medical school. To assess the experiences of the new
learner and the challenges faced by their tutors, one has to first understand the diversity
of students in medical school. Medical school is no longer the sole domain of Caucasian
males from upper class homes.

PBL has its origins in the Canadian medical system. McMaster University, located in
Hamilton, Ontario was the first school to employ PBL education successfully (Camp
1996). The primary element of PBL is the small group learning which facilitates students
getting to know each other and benefit from a diversity of perspectives and backgrounds.
Mclean, Van Wyk, Peters-Futre and Higgins-Opitz studied first year PBL students in
South Africa. Their research revealed that students benefited from the small-group
tutorials and felt that this specific setting made the transition to medical school far more
comfortable for them. Their research revealed that the small groups made learning more
conducive, helped to facilitate the adaptation to a new and challenging pedagogy, fostered
student integration and promoted personal development (2006). DeLeng et al (2006) note
that PBL has a great deal in common with evidence-based medicine in that they both seek
to identify key information and then organize the learning process around it.

One of the key skills that medical students must learn is critical thinking. It is imperative
that they develop the ability to analyze difficult situations and come up with quick,
resourceful answers. In another research study, Tiwari, Lai, So and Yuen (2006)
concluded that PBL provides medical students with a specific advantage in that they have
a statistically higher probability of developing critical thinking over students who learn in
the pure lecture-based format.

1
Another key role in PBL is that of the tutor. The tutor’s primary responsibility is not to
teach but to facilitate learning. In that respect, they endeavour to empower the students
within their groups to develop the skills and knowledge required of a medical doctor. For
inexperienced students however, this could prove to be an enormous challenge as they
face setting their own goals and in a very practical way teaching themselves and each
other for the very first time in their formal education. A team of researchers in Bahrain
studied the perceptions of the students and the tutors to try and determine the type of tutor
that would be most effective for new learners in the PBL system.

“These findings support the previous research on tutoring that both social congruence
(interpersonal qualities) and cognitive congruence (sensitivity of the tutor concerning the
difficulties experienced by students), are important factors stimulating student
learning…” (Kassab, Al-Shboul, Abu-Hijleh and Hamdy 2006, p. 463).

Researchers identified another possible area that could be problematic for new learners in
PBL which is that of goal setting. It is clearly the case that not all students enter first year
medical school with the same skill set. In addition to other skills they must have, PBL
challenges students to develop individual problem-solving skills. Hendry, Lyon, Prosser
and Sze (2006) identified the fact that not all new medical students fully understand PBL
or what is expected of them. This presents a problem with respect to understanding their
responsibilities as opposed to those of the tutor and developing the ability to set
reasonable goals for themselves. They concluded that most of the students understood
PBL as a system of working together with their fellow students (within their groups) to
try and solve/resolve problems. This meant they placed far less emphasis on their own
individual responsibilities and goal-setting abilities. This is clearly an area where the
tutors can take the initiative to ensure that all the students understand what is expected of
them under the PBL system.

The tutors are of course evaluated for their abilities. A study conducted in the Netherlands
revealed that even inexperienced students (that is, first year students) are able to

2
differentiate between effective and ineffective tutors. The major implication of this Dutch
study is that medical faculties must pay close attention to training tutors with particular
emphasis on providing students with appropriate and constructive feedback (Dolmans,
Janssen-Noordman and Wolfhagen 2006).

Even with some of its issues, PBL continues to dominate with over 70% of American
medical schools using this system. However, changes to the PBL system are already on
the horizon in order to provide the most effective medical education possible. One of
these new systems is the hybrid system. In this system, the school blends PBL learning
with traditional lectures. One of the schools to adopt this new system is the University of
New Mexico. They did so because of concerns that the tutorial format created specific
problems such as; a lack of preparation from some students, lack of meaningful self-
assessment within some groups, a perception of a lack of in-depth learning for some
students, and a need to provide more laboratory time and direct lectures (Espey et al.
2007). There has also been a concern that the use of PBL is not interpreted in the same
way at all medical schools. This hybrid system which provides a more structured format
includes a need for students to engage in far more advanced preparation, presentations of
original research and the ability to make presentations and summaries (Espey e al. 2007).

Another innovation of PBL is to introduce patient contact early on in the process.

Research has demonstrated that students benefit from real experience rather than focus on
solely on case studies and research. However, those researchers who have studied the use
of real patient encounters for students in the pre-clinical stage emphasize that it is not
easy to match patient situations with course outcomes and integrating these patient
contacts must be done very carefully. The reason for introducing this into the learning
process is because of problems associated with PBL learning. One of the specific
problems that PBL-based learning has produced is a reported difficulty with the
application of theoretical knowledge. This has been especially so when students are
transitioning from preclinical and theoretical courses to their clinical training (Diemers, et
al. 2007).

3
The introduction of the patient encounters early on in PBL provided medical students an
opportunity to work in pairs and take real case histories. The Dutch study proved that this
is a worthy change to the original development of PBL. A significantly high number of
students who participated in this new aspect of the program reported a sense of
satisfaction with the “patient encounter” part of the program. They expressed the ability
to learn a great deal from direct contact with patients and felt that this truly enhanced
their learning experience. This is indicative that patient encounters introduced early on in
PBL education has a positive benefit (Diemers et al. 2007).

As with all curricular innovations, PBL must be understood as a ‘moving system’ and
therefore not a static one. This implies that PBL must be constantly studied and
challenged to ensure that it does indeed provide medical students with the education and
training they need to proceed into clinical training. According to one researcher who is
also a member of the faculty of medicine at the University of Calgary, there is an ongoing
concern as to whether or not students in the PBL system are learning the entire
curriculum. She summarized her concerns as follows:

“In conclusion, it is apparent that despite similarity in student study time between
groups, significant variability in content of learning issues and resources accessed was
apparent. The trend toward increased use of electronic resources is important and may
require adjustment in type of resources recommended to students” (Veale 2007, p.381).

Students in any professional training program must not only learn the technical
information and skills but they must also learn to be the professional they are expected to
be. There is perhaps no professional we expect more of than our physician. We take our
greatest fears and expectations into the examining room with us and they are the ones
who must examine and reassure us in a calm yet professional manner. According to van
Mook et al (2007) very little is actually known about the ways in which the skills of
professionalism are taught within the tutorial groups that are endemic to PBL. A Dutch
study was the first to investigate this particular subject. They concluded that there is a
need for students to learn how to assess their professional behaviour. Implicit in this

4
conclusion is that there is also a need for first-year students in PBL education to be
informed about the importance of professionalism, what that entails and subsequently
how to evaluate both themselves and others.

As noted earlier in this paper, the development of innovations to the PBL system is an
ongoing process. One of these innovations is Patient Centered Learning (PCL). A joint
American-UK research paper addresses the importance of this change in medical
education. The difference with PCL is that it is learning which is organized around real
patients. These may be standardized patients, in other words, in-person patient visits, or
they could also be a ‘virtual patient’. While this may sound like PBL, there are significant
differences between the two. (Smith, Cookson, McEndree & Harden 2007).

To a degree, this is similar to the innovation represented by the hybrid system described
earlier in this paper. PCL provides medical students with real patient interactions and
simulates the daily work of a medical practitioner. The primary difference between PCL
and PBL is that the latter focuses on case histories and theoretical scenarios. The former
focuses on real patient-doctor interactions and thus, real casework experience. Some
schools such as Hull York Medical School and UC San Francisco Medical School have
altered medical education by focusing the curricula around the real-life cases and not the
other way around which has been the traditional focus of PBL. This provides a real-life
learning experience for inexperienced students and exposure to the very nature of medical
practice itself. The change in focus also provides a means for instructors to impart the
benefit of their own practices in the training exercises. It becomes very real and very
pertinent.

PBL is certainly an innovative form of education. Researchers from South Africa note
that PBL has been a highly successful system for their country. One of the reasons that
PBL has been deemed so successful is that it represents a proactive, non-threatening
setting. All of the students who are inexperienced feel unsure of themselves, but within
the small groups, and under the tutelage of a compassionate, experienced tutor, they
slowly become exposed to the important information. This setting has proven to be

5
important especially among a diverse student group (Maclean, Van Wyk, Peters-Futre &
Higgins-Opitz, 2006).

As with all systems, PBL should continue to be evaluated and updated to meet the needs
of medicine and its students. To date, however, it has proven to be a highly successful
system for medical education even the first-year inexperienced students.

REFERENCES

6
Camp, G. (1996). Problem-Based Learning: A Paradigm Shift or a Passing Fad? Medical
Education Online, 1(2), p. 1-6. https://www.msu.edu/~dsolomon/f0000003.pdf [accessed
23 November 2008].

De Leng, B. A., et al. (2006). Student Perceptions Of A Virtual Learning Environment

For A Problem-Based Learning Undergraduate Medical Curriculum. Medical Education,
40, p. 568-575.

Diemers, A. D., et al. (2007). Students’ Perceptions Of Early Patient Encounters In A

PBL Curriculum: A First Evaluation Of The Maastricht Experience. Medical Teacher, 29,
p. 135-142.

Dolmans, D.H.J.M., Janssen-Noordman, A. & Wolfhagen, H.A.P. (2006) Can Students

Differentiate Between PBL Tutors With Different Tutoring Deficiencies? Medical
Teacher, 28(6), p. e156-e161.

Espey, E., et al. Revitalizing Problem Based Learning: Student And Tutor Attitudes
Towards A Structured Tutorial, Medical Teacher, 29, p. 143-149.

Graham, D., et al. (2006). Conceptions Of Problem-Based Learning: The Perspectives Of

Students Entering A Problem-Based Medical Program. Medical Teacher, 28(6), p. 573-
575.

Kassab, S., Al-Shboul, Q., Abu-Hijleh, M. & Hamdy, H. Teaching Styles Of Tutors In A
Problem-Based Curriculum: Students’ And Tutors’ Perception. Medical Teacher, 28(5), p.
460-464.

MacLean, M. (2006). The Small Group In Problem-Based Learning: More Than A

Cognitive ‘Learning’ Experience For First-Year Medical Students In A Diverse
Population. Medical Education, 28(4), p. e94-e103.

7
Smith, S.R., Cookson, J., Mckendree, J. and Harden, R.M. (2007). Patient-Centered
Learning - Back to the Future. Medical Teacher, 29, p. 33-37.

Tiwari, A., Lai, P., So, M., & Yuen, K. (2006). A Comparison Of The Effects Of Problem-
Based Learning And Lecturing On The Development Of Students’ Critical Thinking.
Medical Education, 40, p. 547-554.

van Mook, W.N.K.A., et al.. (2007). Factors Inhibiting Assessment Of Students’

Professional Behaviour In The Tutorial Group During Problem-Based Learning. Medical
Education, 41, p. 849-856.

Veale, P. (2007). Prospective Comparison Of Student-Generated Learning Issues And

Resources Accessed In A Problem-Based Learning Course. Medical Teacher, 29, p. 377-
382.