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Problem-based learning: description, advantages, disadvantages, scenarios and facilitation.

SUMMARY

Problem-based learning arose out of educational initiatives in the 1960s and is often one of the most contentious issues within medical education. McMaster University in Canada was the first to implement problem-based learning on a large scale within medicine and this was soon followed by universities in Europe and Australia. In modern times, few western medical schools do not include at least some aspect of problem-based learning within their instructional itinerary, and many build their entire curriculum and instructional procedures around problem-based learning. This article provides an overview of problem-based learning within medical education, pertinent background, describes the characteristics of problem-based learning, its advantages and disadvantages, problem-based learning scenarios and facilitation.

Key Words: problem-based learning, facilitation, scenarios, medical education

Problem-based learning (PBL) arose out of educational initiatives in the 1960s that were primarily based on theoretical advances in behavioural psychology. Several researchers (1-3) successfully argued that learners who commenced learning by focusing on problems before attempting to understand underlying principles had equal or greater success than learners using a traditional approach whereby underlying principles are presented first and then applied to a specific problem.

PBL was initially developed and applied in a medical education context at McMaster University in Canada by Howard Barrows (4-6). Shortly thereafter, problem-based learning curricula were established in both Europe and Australia at Maastricht University and the University of newcastle (7). over the past 30 years numerous other medical schools within Australia and overseas have designed new medical courses, or redesigned existing medical courses, using the PBL approach. And, whereas PBL may not form the foundation of every medical course within the western world, almost all courses include at least some component of PBL. Individual specialists of anaesthesia and intensive care may have their own questions about PBL, what it is, its advantages and disadvantages, choosing PBL scenarios and the facilitation of PBL. This article seeks to provide an overall summary of these questions for those involved in the education of anaesthetists and intensive care specialists.

Much misunderstanding and confusion exists about PBL, largely because it is a broad term used to convey numerous concepts with different meanings. PBL has been defined as "active learning stimulated by, and focused round a clinical, community or scientific problem" (8). The key notion is that learning commences as a problem, query or question that the learner seeks to solve (9). PBL goes beyond merely providing an opportunity to problem solve to make problem solving the main reason for learning. In this regard, learners specifically identify and seek out the knowledge they themselves require to solve the problem (8). Herein lies the power of PBL because the learner is required to solve a specific problem whilst acquiring knowledge on how to solve similar problems. It is argued that it is this latter knowledge which becomes of greatest benefit in professional life as a practising anaesthetist or intensive care specialist. of the numerous definitions of PBL, most have four common elements:

1. learning objectives are translated into a problem,

2. successful solutions require an explanation, with a possible diagnosis and treatment options,

3. learners use small group discussions to analyse and understand the problem and potential solutions,

4. questions or issues that are not answered within small group discussion form the basis for further learning outside the group.

In 1987 international experts in the area of PBL from within and outside medical education gathered at a symposium at the Centre for Medical Education, the University of Dundee. one of the results of the symposium was an acronym identifying eight key features of PBL (10). The acronym was appropriately spelt "PROBLEMS".

Problems:

The key units for studying relevant learning are problems.

Resources:

Provision of adequate resources (e.g, instruction, peers, library, internet and other members of the health care team) allows self-learning to take place.

objectives:

Learning objectives are planned by teachers but may have trainee input.

Behaviour:

As a trainee's knowledge increases so their behaviour progressively evolves to become more like an expert.

Learning:

Learning is active, trainee-directed and sometimes monitored by peers and facilitators.

Examples:

Peers and facilitators facilitate use of higher order cognitive skills through the use of examples.

Motivation:

The PBL approach should be designed to stimulate interest in a topic and motivate learning.

Self-directed learning and self assessment:

Trainees are equipped with the tools to undertake self-directed learning and self-assessment once they graduate formal education to become lifelong learners. This is thought to be a potentially useful skill for anaesthesia and intensive care specialists whose clinical practice often occurs in isolation from their peers.

ADVANTAGES OF PBL

The popularity of PBL and its rapid widespread adoption by the medical community has arisen from several powerful advantages. These include (8):

1. Making curriculum content relevant by building learning around clinical, community or scientific problems.

2. Focusing learning on core information relevant to real scenarios and reducing information overload.

3. Fostering the development of valuable transferable skills useful throughout lifelong learning. These include leadership, teamwork and communication as well as problem solving.

4. Facilitating trainees becoming responsible for their own learning. This is an essential skill for medical specialists actively engaged in their own continuing professional development throughout their professional lives.

5. Increased motivation of trainees to learn by focusing the learning on 'real-life' scenarios.

6. Encouraging a deep rather than surface approach to learning by forcing trainees to interact with information on multiple levels and to a greater depth than traditional teaching approaches.

7. Using a constructional approach to learning whereby trainees construct new learning around their existing understanding. numerous researchers argue for the benefits of PBL (11-13).

DISADVANTAGES OF PBL

Unfortunately no single education strategy is perfect for all educational situations and PBL has several significant disadvantages. These include (8):

1. The replacement of the traditional teacher role by the facilitator

which may make it difficult for trainees to emulate good teachers as role models.

2. Teaching faculty being required to facilitate learning rather than to directly impart their knowledge. This may be considered inefficient and, possibly, demotivating to faculty.

3. Knowledge acquired through PBL being less organized than knowledge acquired through traditional learning.

4. The difficulty of training facilitators and the scarcity of teaching faculty with the skills of facilitating rather than the skills of traditional teaching.

5. The time required of trainees to fully engage in PBL. This can be particularly problematic for time-poor faculty and trainees who are being asked to teach and learn within an increasingly crowded curriculum.

Additional disadvantages include the significant costs, resources and time required to train effective facilitators. PBL experts also point to concerns about the costs of implementing PBL programs, though note that other researchers argue that PBL is not necessarily more expensive than traditional educational approaches (14,15) and raise the issue of PBL not necessarily covering all areas within a medical topic (8).

The notable advantages and disadvantages described above make PBL a potentially useful strategy for the training of anaesthesia and intensive care specialists, but one which is unsuited to all situations or for the teaching of all relevant knowledge, skills and abilities. Additional comprehensive reviews of the research evidence for and against PBL have been published (16-18).

CHOOSING PBL SCENARIOS

Within medical education a scenario is typically used to provide an example from which a trainee may learn. Such a scenario may be related to a clinical, scientific or community problem (19). Part of the rationale for this approach arose from a contrast of the medical reasoning skills of novices and experts. Research has shown that experts compare a novel scenario to real scenarios with which they are familiar (20). Much of an expert's diagnostic and reasoning efforts are focused on the similarities and differences of a novel case with known cases. Thus PBL offers the opportunity to provide trainees with scenarios that will be of use throughout their professional life. In this regard the choice of PBL scenario is pivotal for the ultimate effectiveness of the PBL experience.

Carefully structured problems ensure trainees cover appropriate knowledge, skills and abilities. In this regard the scenario has been described as either a 'peg' or 'growing web' (21). The peg is viewed as a convenient hook upon which to arrange acquired knowledge whereas the growing web uses the problem as a focus for acquired practical understanding. The most effective problem scenarios exhibit several characteristics (22). The problem should:

1. Address one or more learning outcomes relevant to the trainee.

2. Facilitate trainees activating their prior learning and building upon existing knowledge.

3. Be consistent with the stage of learning at which a trainee is located at any given time.

4. Motivate trainees and, ideally, be relevant to the current or future practice of trainees as anaesthetists or intensive care specialists.

5. Provide an overall clinical context in which new knowledge is placed.

6. Stimulate trainee thought and discussion, provide guidance and encourage trainees to actively seek solutions.

7. Phrase an open-ended problem to facilitate discussion and explanation (i.e., closed problems with limited scope should be avoided).

8. Promote trainees to become actively involved in the pursuit of solutions using available resources including peers, instructors, members of the medical team, literature and the Internet.

Wherever possible, PBL scenarios should be based on real patients, or composites of real patients, in order to ensure trainees appreciate that they may encounter the same or similar problems in practice. Furthermore, the use of actual patients allows the designers of PBL scenarios to incorporate deidentified laboratory results, X-rays, scans and pathological materials (7). When choosing a scenario, designers should consider what topic area experts believe should be taught and the prevalence, severity, magnitude, treatability and intervention effectiveness (7,23).

FACILITATING PBL

Beyond the PBL scenario the single greatest factor that influences the success of a PBL program is the facilitatory skill, knowledge and ability of the teacher. Such is the importance of facilitation that, within PBL, the teacher is usually referred to as the 'facilitator'. The facilitator monitors and stimulates the PBL process by posing leading questions, challenging trainee thinking, and raising facts or issues relevant to the problem. In this regard, the facilitator is a guide who assists trainees develop the necessary skills in reasoning, hypothesis design and testing, study and self-evaluation (4). Facilitator competence must include (8) the facilitation of small group learning; a comprehensive understanding of the PBL program such that the facilitator can relate immediate and future learning opportunities to the PBL scenario and guide trainees to these opportunities; and a global understanding of the overall educational curriculum so that the facilitator can place discrete problems within the global educational experiences of the trainee. The abilities of facilitators to establish effective two-way communication with trainees, empathy and an open and trusting atmosphere have also been shown to be important (24).

There is considerable debate about the importance of the facilitator being a content area expert. Some argue that a content area expert is more likely to give trainees answers or revert to a traditional teaching approach. Conversely a facilitator who is not a content area expert must rely solely on his or her facilitatory ability and is forced to behave in a way that sees trainees develop their own solutions. However, whereas the extent to which a facilitator is required to be a content expert is a matter of some debate within the literature, all PBL specialists agree that adequate training in the role of facilitator is essential for the success of a problem-based learning program. on balance, the best facilitator is probably a content area expert, who is fully familiar with the medical curriculum being taught, and has been appropriately trained in facilitation. Such a facilitator would be ideally placed to be able to limit the extent to which they provide solutions for trainees, in keeping with the underlying principle of PBL, yet able to provide the minimal level of clinical structure necessary for trainees to obtain optimal benefit from PBL (25,26). Certainly (and as mentioned above) few faculty are trained in the role of PBL facilitation and many are most comfortable with the more traditional role of information provider typified in traditional clinical teaching and lectures (8). However, adequate training in facilitation is essential for the success of PBL (7) and several successful approaches to faculty development have been documented specifically for PBL (27,28).

Accepted for publication on May 15, 2006.

REFERENCES

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(7.) Barrows HS. Problem-based learning applied to medical education. Southern Illinois University School of Medicine, Springfield Illinois 2000.

(8.) Davis MH, Harden RM. AMEE medical education guide no. 15: problem-based learning: a practical guide. Medical Teacher 1999; 21:130-140.

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(10.) Walton HJ, Matthews MB. Essentials of problem-based learning. Medical Education 1989; 23:539-558.

(11.) Schmidt HG, Machiels-Bongaerts M, Hermans H, tenCate TJ, Venekamp R, Boshuizen HP. The development of diagnostic competence: comparison of a problem-based, an integrated, and a conventional medical curriculum. Acad Med 1996; 71:658-664.

(12.) Shin JH, Haynes RN, Johnston ME. Effect of problem-based, self-directed undergraduate education on life-long learning. Can Med Edu J 1993; 148:969-976.

(13.) Westberg J, Jason H. Collaborative clinical education: the foundation of effective health care. Springer, new York 1993.

(14.) nieuwenhuijzen-Kruseman AC, Kolle LF, Scherpbier AJ. Problem-based learning at Maastricht: an assessment of cost and outcome. Education for Health 1997; 10:179-187.

(15.) Sefton AJ. From a traditional to a problem-based curriculum: estimating staff time and resources. Education for Health 1997; 10:165-178.

(16.) Albanese MA, Mitchell S. Problem-bases learning: a review of literature on its outcomes and implementation issues. Acad Med 1993; 68:52-81.

(17.) Berkson L. Problem-based learning: have the expectations been met? Acad Med 1993; 68:S79-S88.

(18.) Veron DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med 1993; 68:550563.

(19.) Harden RM, Davis MH. The continuum of problem-based learning. Medical Teacher 1998; 20:317-322.

(20.) Bordage G, Lemieux M. Semantic structures and diagnostic thinking of experts and novices. Acad Med 1991; 66:S70-S72.

(21.) Margetson D. What counts as problem-based learning? Education for Health 1998; 11:193-201.

(22.) Dolmans D, Snellen-Balendong H, Wolfhagen I, van der Vleuten C. Seven principles of effective case design for a problem-based curriculum. Medical Teacher 1997; 19:185-189.

(23.) MacDonald PJ. Selection of health problems for a problem-based curriculum. In D Boud and G Feletti. The challenge of problem-based learning. Kogan Page, London 1991.

(24.) Schmidt HG, Moust JH. What makes a tutor effective? A structural-equations modelling approach to learning in problem based curricula. Acad Med 1995; 70:708-714.

(25.) Davis WK, nairn R, Paine ME, Anderson RM, oh MS. Effects of expert and non-expert facilitators on the small group process and on student performance. Acad Med 1992; 67:470-474.

(26.) Schmidt HG. Resolving inconsistencies in tutor expertise research: does lack of structure cause students to seek tutor guidance? Acad Med 1994; 69:656-662.

(27.) Barrows HS. The tutorial process. Southern Illinois University School of Medicine, Springfield Illinois 1988.

(28.) Irby DM. Models of faculty development for problem-based learning. Advances in Health Sciences Education 1996; 1:6981.

R. W. JONES *

Australian and New Zealand College of Anaesthetists, Melbourne, Victoria, Australia

* B.Sc., Dip.Ed., B.Ed (Hons)., Ph.D., Director of Education.

Address for reprints: Dr R. W. Jones, Australian and new Zealand College of Anaesthetists, ANZCA House, 630 St Kilda Road, Melbourne, Vic. 3004.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Education and Training
Author:Jones, R.W.
Publication:Anaesthesia and Intensive Care
Date:Aug 1, 2006
Words:2687
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