1.1 What is so special about PBL?

With this method we accept self-directed learning and the fact that students themselves structure and define the relevance of the medical knowledge. This method enhances the development of skills like literature retrieval, critical appraisal of available information and the seeking of opinions and aims at empowering students to learn to be life-long learners, making it enjoyable and motivating.

PBL appreciates medical knowledge as tool to understand and to deal with problems. Together, students will compile ideas concerning the underlying circumstances of the problem (explanatory approach) and/or the implications arising from the problem (procedural approach).

1.2 What is the idea behind problem-based learning?

PBL is an approach for structuring curriculum content, facing students with problems from practice, which provides a stimulus for self-directed learning of students following defined steps. Problem-based learning (PBL) is a method that challenges students for working cooperatively. It prepares students to think critically and analytically, and to find and use appropriate learning resources.

Problem-based learning means cooperative learning starting off with a problem. The problem is in the centre of the focus should foster a process among the students of assessing and discussing the issues of the problem. The goal is to activate prior knowledge of the students and to help them to start a learning process by reconstructing their knowledge and making new sense of it.

The seven steps are:

1. Clarifying terms
2. Defining the problem
3. Brainstorming
4. Structuring and hypothesis
5. Learning objectives
6. Searching for Information
7. Synthesis

At the end of each session: Feedback

In the sessions, a case can unfold as a PBL-spiral:

Problem-based learning is problem-based learning not problem-based teaching. The focus is on the student’s reflection and reasoning, aiming at students constructing their own knowledge. The role of the tutor in PBL is shifted to a facilitator, providing a creative environment for the students’ activities to flourish. With PBL the curriculum shifts from a faculty-centered approach to a student-centered, interdisciplinary process. This has implications for the learning environment in a faculty as a whole.

1.3 Going back in history

William Osler in 1899 recommended abolishing lectures and allowing students more time for self-study. He underlined the role of teacher in helping students to develop their skills in observation and reasoning. As Woolsley (1997) defines a teacher as someone who fosters the learning process and thereby modifies behavior and patterns of thinking for a lifetime, and not one who only presents facts.

McMaster University is a world-class leader in problem-based learning, pioneered by its Medical School. They developed a curriculum which is based on problem-based learning.

Harvard Medical School derived its use of PBL from earlier work at Case Western Reserve University. Today, most US medical schools and many more in most countries of the world are implementing (or are planning to implement) PBL in their curricula to a greater or lesser extent.

1.4 Elements of PBL

Core or basic elements of PBL are students and group work as stimulus for interaction, starting from a problem as a stimulus for learning, and with a tutor as facilitator.

Henk Schmidt describes the relation of different factors and key elements of PBL as a Path model of PBL:

The extent of prior knowledge, the quality of the problems and the tutor’s performance are the key elements determining group functioning and outcome of the tutorials.

1.5 Preparing a faculty for PBL and change a curriculum

To establish a PBL in a curriculum is not an easy task. Generally, tutoring problem-based learning requires more contact hours between teachers and student and more time for preparing the session and leading the small group. Changing the curricula has associated costs. PBL-tutorials in a curriculum require numerous small rooms equipped for teaching and adequate resources for the students to perform research. One first approach can be to establish a PBL parallel track for a limited number of students. An unavoidable drawback of this approach of a parallel track is the temporary co-existence of an "old" and a "new" curriculum. Students in the old curriculum may feel neglected by staff which is absorbed with implementation of the new curriculum.

Several schools have recently demonstrated the feasibility of changing from a traditional to a PBL curriculum (DesMarchais, 2001; van Rossum, 2000; Schwartz, Mennin, Webb, 2001). Most commonly, some years are needed to reach an agreement among the staff to plan, develop, and begin the implementation of the PBL curriculum.

3.1 General considerations

Before implementing PBL in the medical education of an institution there are several main questions necessary to be answered:

• What are the instructional goals?
  For more information see chapter 1.1: What is so special about PBL?
• How should PBL be incorporated into the curriculum?
  For more information see chapter 1.6: Preparing a faculty for PBL
• What problems should be used and how should they be structured and presented?
  For more information see chapter 1.5: Elements of PBL, 3.3: PBL case design, and 3.2.2: Seven jump
• How should small groups be formed?
  A balance between good and weak students as well as of male and female students should be maintained. A group size of seven or eight students is ideal. A size of less than five or more than ten is not feasible. Students should ideally be randomly assigned to their groups to prevent more than the coincidental number of groups with very high or poor performance, due to prior selection.
  For more information see chapter 1.5: Elements of PBL and 3.5: The Role of students
• How to evaluate the program and the students?
  One major point is to establish a continuous evaluation process by introducing a feedback round at the end of each single PBL-session.
  For more information see chapter 1.5: Elements of PBL, 3.2.2: Seven jump and 3.7: Examining with PBL
• What resources should be available?
  See chapter 3.2.1: Organization of PBL sessions

3.2 Structuring PBL

3.3 PBL case design

PBL sessions will only be as good as the individual cases designed are. Designing interesting and effective PBL cases can be difficult at first, but case designers quickly get better at it with practice.
Without appropriate cases evoking interest and fascination among the students, students will not reach the intended goals of a PBL-session. It may lead to confusion, frustration or loosing interest if the cases unfold to complex or complicated on one hand or too simple or trivial on the other.

Students should have enough – but not too much – prior knowledge to elaborate on the problem and the problem should evoke full attention and interest in dealing with it. Creating an appropriate problem for a problem based learning class is obviously a critical component that helps determine whether or not your session will be successful.
Figure 2 provides an overview of the PBL framework and underlines the importance of the good case design (Schmidt et al. 1995).

3.4 The role of the tutor

The faculty’s tutors (teaching staff, see chapter faculty development) play a central role as a facilitator in the PBL process, guiding and supporting the students as they "learn how to learn". The most important skill of a PBL-tutor is to know when to intervene, but more importantly when not to do so, in order to get the group working with their own resources. This requires a good training of the tutors.
For more information on see chapters 1.4 Elements of PBL and 3.2.2 The seven jump.

At the beginning of a session the tutor makes sure everyone is familiar with the method and backgrounds of PBL. He will help identify ground rules, make a contract and explain to all involved what is happening and why.
During sessions, students need support in analyzing problems and synthesizing relevant knowledge. They may misunderstand some aspects of the newly acquired information, use terms and concepts which are not truly understood, fail to recognize the coherence of the subject matter. In this case the tutor will facilitate clarification by the group members.
The role of the tutor is very different from the usual teacher's role. The tutor is a facilitator, responsible for guiding students to identify the key issues in each case. Students themselves have much more responsibility in PBL than in most traditional approaches to teaching process, the tutor is not just a passive observer: he or she must be active during the learning process and directive only when necessary to assure that the group stays motivated and on target and that all of them will pick up main learning goals.
The tutor has to check the understanding, ensure group achieves their learning goals, to encourage asking questions and explaining themselves, to introduce use of diagrams and drawings, to foster clinical reasoning and to provide feedback.

A good tutor must possess good knowledge, elaborate skills and attitudes.
- Knowledge
- Skills
- Attitudes

3.5 Role of students

In PBL, students need to take a more active part in the organizing of the teaching process. Students themselves may now lead sessions and learn how to work in their small team. This is a dramatic shift moving from a traditional lecture to a setting with a high amount of own responsibility for what is learnt and a multitude of roles and responsibilities for the students.
The group-learning facilitates not only the acquisition of knowledge but also several other desirable attributes concerning awareness, skills and attitudes, such as communication skills, teamwork, problem solving, independent responsibility for learning, sharing information, and respect for others. Students more or less become each other’s teachers. In this process all are involved, in taking defined roles in the sessions, such as student leader, time keeper or secretary.
Students are confronted with the critical evaluation of literature and data, and take responsibility for own learning success and creating hypothesis, order thoughts and reject false approaches/solutions. In this way students develop their self-directed learning skills.
Students acquire new knowledge, not as only a goal in itself, but primarily in order to pass an examination or to get a high grade. This is one major obstacle in education: How to motivate students to learn for life not just for grades? Great care has to be taken that the problems in the cased used have to be relevant to the students (see chapter case writing 3.3.2). [22]
Students have to complete assigned tasks, to present relevant information and identify irrelevant or excessive information. They should take initiative or otherwise help to maintain group dynamics to advance discussion by responding to or expanding on relevant issues. Students should address own difficulties in understanding, acknowledge own lack of appropriate knowledge and own discomfort in discussing or dealing with a particular issue and identify own strengths and weaknesses.

There are defined roles of students that can facilitate the group-process. These roles are taken by group members may help ensure the group functions effectively. These roles are:

3.6 Trouble-shooting in a PBL-tutorial

During PBL sessions a tutor will be confronted with numerous problematic situations and has to define when it is feasible to intervene and when not to intervene. In the following we present a selection of most common problematic situations a tutor can encounter:

• Lack of motivation - learning goals not achieved Videoclips: English
• Lack of preparation - learning goals not achieved
• Shyness, over-politeness- lack of group dynamics Videoclips: English
• Lack of guidance – students misunderstanding the method
• Personal problem – group dysfunction, Videoclips: English
• Size of the group – lack of group dynamics
• „Small groups within one group“– extraction of some students from learning process Videoclips: English
• the „know-it-all“– unsatisfactory student participation in work, wrong learning goals, Videoclips: English
• the „distractor“– learning goals not achieved, lack of group dynamics Videoclips: English
• Dominant tutor – tension and conflict , back to old teaching style Videoclips: English
• Passive or quiet tutor- learning goals not achieved, lack of group dynamics Videoclips: English
• Group suspicious about PBL – loss of motivation of students
• Ill-structured problem – students feel incompetent in solving a problem

3.7 Examining in a PBL curriculum

The differing techniques of assessing students in a PBL curriculum presents a challenge for those who wish to determine the best approach. As with all teaching, we should carefully design any assessment at the end of the courses to match the intentions, contents as well as the teaching and learning methods of the course. For an overview over examination methods see the respective chapter in this manual. For more information on examination tools in PBL see the elaborate publication of Nendaz and Tekianet [23].

MCQ examinations have been viewed to be of limited value for PBL courses for the following several reasons:
the use of MCQ in assessment will interfere with the students’ learning process and force them to focus on details in lectures and textbooks rather than the desired skills imbedded in PBL;
MCQ are of limited validity for measuring the application of knowledge;
MCQ lack to test cognitive skills or assess competence.
Key-feature questions will be of more value to reflect the procedural approach of a PBL session.
In an objective structured examination (OSCE) some practical aspects can be assessed, yet this method does not take into account that a PBL-session is meant to only simulate real life experiences.