PROBLEM-BASED PROBLEM-BASED LEARNING LEARNING

In In Medical EducationMedical Education

Presented by:Presented by:

Dr. Soha Rashed Aref MostafaDr. Soha Rashed Aref MostafaProf. of Community Medicine Prof. of Community Medicine

Member of Medical Education DepartmentMember of Medical Education DepartmentFaculty of MedicineFaculty of Medicine

Alexandria UniversityAlexandria UniversityEgyptEgypt

Teacher-centeredStudent-centered

New-Innovative Curricula

Traditional Medical Curricula

Information gatheringProblem-based

Discipline-basedIntegrated

Hospital basedCommunity-based

StandardElective

Apprenticeship-basedSystematic

Continuum

S

P

I

C

E

S

SPICES

what is it?what is it?

Definition of PBLDefinition of PBL

An An instructional student-centered approach which which uses uses carefully constructed clinical problemscarefully constructed clinical problems as as a context for students to: a context for students to: define their learning define their learning needsneeds, , conduct self-directed enquiry, integrate theory and practice, and apply knowledge and skills to develop a solution to a defined problem.

The case serves as a The case serves as a stimulus for learningstimulus for learning

WHAT IS PROBLEM-BASED WHAT IS PROBLEM-BASED LEARNING, AND HOW LEARNING, AND HOW DOES IT DIFFER FROM DOES IT DIFFER FROM PROBLEM SOLVING? PROBLEM SOLVING?

Problem-solving Problem-solving vs. vs. problem-problem-based learningbased learning

- different but inter-related -- different but inter-related -

Problem-solving:Problem-solving: arriving at decisions arriving at decisions based on prior knowledge and based on prior knowledge and reasoningreasoning

Problem-based learning:Problem-based learning: the process of the process of acquiring new knowledge based on acquiring new knowledge based on recognition of a need to learnrecognition of a need to learn

PROBLEM SOLVINGPROBLEM SOLVING PROBLEM-BASED PROBLEM-BASED LEARNINGLEARNING

Educational strategyEducational strategy Traditional discipline-basedTraditional discipline-based Integrated systems-basedIntegrated systems-based

Main characteristicsMain characteristics - The focus is on - The focus is on preparatory learning preparatory learning prior to exposure to the prior to exposure to the problem. problem.

- The - The staff set the staff set the problems (problems (case history case history problems in a primarily problems in a primarily lecture- based formatlecture- based format), ), and and students attempt to students attempt to resolve them using resolve them using previously taught previously taught curricular content. curricular content.

- The problem comes first - The problem comes first without advance readings, without advance readings, lectures, or preparation.lectures, or preparation.

- The problem serves as a - The problem serves as a stimulus for the need to know.stimulus for the need to know.

- Based on their own prior - Based on their own prior knowledge and the knowledge and the identified gaps in that identified gaps in that knowledge, students knowledge, students determine the learning determine the learning issues within their own issues within their own group. They then identify group. They then identify and use a variety of and use a variety of learning resources to learning resources to study these issues and study these issues and return to the group to return to the group to discuss and share what discuss and share what they have learned.they have learned.

PROBLEM SOLVINGPROBLEM SOLVING PROBLEM-BASED PROBLEM-BASED LEARNINGLEARNING

Role of the teacherRole of the teacher Content expertContent expert Tutor/FacilitatorTutor/Facilitator

Learning environmentLearning environment Passive, teacher-centered Passive, teacher-centered Learning becomes Learning becomes dependent upon the self-dependent upon the self-directed efforts of the small directed efforts of the small group. This method creates group. This method creates a a more active, student-more active, student-centeredcentered learning learning environment environment

Who is responsible for Who is responsible for directing the learning directing the learning activitiesactivities

Teacher The student decides what he/she needs to learn

Rationale for introducing PBL Rationale for introducing PBL into the undergraduate into the undergraduate curriculacurricula

The rationale for PBL lies in its The rationale for PBL lies in its comparability with modern comparability with modern educational principles. Its educational principles. Its approach is based on principles approach is based on principles of of adult education and self-adult education and self-directed learning.directed learning.

Principles of adult learning

Adults are motivated by learning that:

• Is perceived as relevant• Is based on, and builds on, their previous experiences• Is participatory and actively involves them• Is focused on problems• Is designed so that they can take responsibility for their own learning• Can be immediately applied in practice• Involves cycles of action and reflection• Is based on mutual trust and respect

It differs fundamentally from our It differs fundamentally from our traditional curricula, in which traditional curricula, in which

students:students:

Preclinical phase (years 1-Preclinical phase (years 1-3)3)

acquire "background" acquire "background" knowledge of the basic knowledge of the basic

sciencessciences

Clinical phase (years 4-6)Clinical phase (years 4-6) apply this knowledge to the apply this knowledge to the diagnosis and management diagnosis and management

of clinical problemsof clinical problems

This traditional approach has This traditional approach has been criticised for a number of been criticised for a number of reasons:reasons:

Many existing curricula fail to meet the needs of Many existing curricula fail to meet the needs of current and future doctorscurrent and future doctors

It creates an artificial divide between the basic and It creates an artificial divide between the basic and clinical sciencesclinical sciences

Time is wasted in acquiring knowledge that is Time is wasted in acquiring knowledge that is subsequently forgotten or found to be irrelevant (The subsequently forgotten or found to be irrelevant (The acquisition and retention of information that has no acquisition and retention of information that has no apparent relevance can be boring and even apparent relevance can be boring and even demoralising for students)demoralising for students)

Application of the acquired knowledge can be difficultApplication of the acquired knowledge can be difficult

The educational objectives of PBL The educational objectives of PBL address many of the perceived problems address many of the perceived problems in traditional medical curriculain traditional medical curricula

Its possible advantages over traditional Its possible advantages over traditional approaches include: its greater approaches include: its greater relevance relevance to the practice of medicineto the practice of medicine, its ability to , its ability to promote retention and application of promote retention and application of knowledgeknowledge, and its encouragement of , and its encouragement of self-directed life-long learning self-directed life-long learning

Course material is usually Course material is usually systems- basedsystems- based Integration of basic and Integration of basic and clinical sciencesclinical sciences

Integrated Systems-based Curriculum Map

ExampleExample

When studying PBL cases relating to CVS, When studying PBL cases relating to CVS, students learn about:students learn about:

Normal bodily structure and functionNormal bodily structure and function

The clinical features, diagnosis and The clinical features, diagnosis and management of common CVDsmanagement of common CVDs

Furthermore, they learn to take a relevant Furthermore, they learn to take a relevant clinical history and to physically examine the clinical history and to physically examine the CVS CVS

Knowledge is acquired in contextKnowledge is acquired in context and and builds builds on what is already knownon what is already known

These facets aid These facets aid knowledge retentionknowledge retention, add , add interestinterest and increase and increase motivationmotivation to learn to learn

Students continually explore their Students continually explore their knowledge, identify both their personal knowledge, identify both their personal learning needs and strategies required to learning needs and strategies required to address them. This process helps to develop address them. This process helps to develop skills for life-long learningskills for life-long learning

Efficacy and advantages of PBLEfficacy and advantages of PBL

PBL: the claims and the evidence

Although efficacy of PBL is Although efficacy of PBL is difficult to evaluate, the current difficult to evaluate, the current enthusiasm for PBL seems enthusiasm for PBL seems justified and its use is likely to justified and its use is likely to increase further.increase further.

The place of PBL in the The place of PBL in the curriculumcurriculum

Teacher-centeredStudent-centered

New-Innovative Curricula

Traditional Medical Curricula

Information gatheringProblem-based

Discipline-basedIntegrated

Hospital basedCommunity-based

StandardElective

Apprenticeship-basedSystematic

Continuum

S

P

I

C

E

S

SPICES

Emphasis on PBL ranges

Dominance of the curriculum Minor supporting role

Problem-based learning

Clinical Clinical Apprenticeship ModelApprenticeship Model

Time in the curriculum

Preclinical phase

Clinical phase

A PBL-based curriculum is typically organized into a number of units based on body systems. Each unit is based on a number of PBL Cases (case=hypothetical patient whose problem requires analysis and resolution).

Hybrid curriculaHybrid curricula

In preclinical phase, PBL can be In preclinical phase, PBL can be designed and timetabled so as to designed and timetabled so as to complementcomplement other teaching other teaching methods such as:methods such as:– LecturesLectures– Practicals, other laboratory workPracticals, other laboratory work– Computer-assisted learningComputer-assisted learning

ExampleExample

While learning about CVS in PBL While learning about CVS in PBL tutorials, students tutorials, students dissect the dissect the heart inheart in anatomy practicalsanatomy practicals, and , and have have lectureslectures on the on the radiological radiological featuresfeatures of heart disease. of heart disease.

THE PBL TUTORIAL THE PBL TUTORIAL PROCESSPROCESS

The PBL process is tightly structured and The PBL process is tightly structured and contains a number of key stepscontains a number of key steps

The PBL tutorial:The PBL tutorial: Typically consists of a small number of Typically consists of a small number of

students (ideally between 6-10)students (ideally between 6-10)

Is facilitated by one or more faculty Is facilitated by one or more faculty tutors who guide the process without tutors who guide the process without contributing directly to the solution of contributing directly to the solution of the problem or being the primary source the problem or being the primary source of information of information

Meeting two times a week for two or Meeting two times a week for two or three hours per sessionthree hours per session

Completing a case in two or three Completing a case in two or three sessionssessions

Key steps in the PBL tutorial process

1. Case presentation2. Identifying key

information3. Generating and

ranking hypotheses4. Generating an

enquiry strategy5. Defining learning

objectives6. Reporting back7. Integrating new

knowledge

How does problem-based learning work?

What instructors do:- Develop real-world, complex and open-ended problems such

as might be faced in the workplace or daily life.- Act as facilitators, making sure students are staying on track

and finding the resources they need.- Raise questions to student groups that deepen the

connections they make among concepts.- Strike a balance between providing direct guidance and

encouraging self-directed learning.

What students do:- Address the problem, identifying what they need to learn in

order to develop a solution and where to look for appropriate learning resources.

- Collaborate to gather resources, share and synthesize their findings, and pose questions to guide further learning tasks for the group.

e.g., 6-week Cardiovascular e.g., 6-week Cardiovascular UnitUnit

Students might deal with Students might deal with 6 cases6 cases in in 18 PBL tutorials18 PBL tutorials

Each case is designed and written by experts Each case is designed and written by experts with with specific learning objectives in mindspecific learning objectives in mind

e.g., one of the LO of a case dealing with e.g., one of the LO of a case dealing with asthma asthma might be to might be to stimulate students to learn about the stimulate students to learn about the structure and function structure and function of the respiratory system.of the respiratory system.

Cases are written so as to Cases are written so as to encourage students themselves to encourage students themselves to identify their own specific learning objectives.identify their own specific learning objectives.

Learning process is Learning process is student-directedstudent-directed, and the tutor functions , and the tutor functions more as a more as a facilitatorfacilitator, not a didactic teacher., not a didactic teacher.

Case presentation

How does a case serve as a How does a case serve as a

stimulus for learningstimulus for learning? ?

Example: Example: PBL tutorial processPBL tutorial process

1. Case presentation: 1. Case presentation: The tutor provides the group The tutor provides the group with some introductory clinical information about a with some introductory clinical information about a hypothetical patient.hypothetical patient.

Mary Smith, a 28-year-old office worker and part-time swimming instructor, comes to see her GP because of pain in her chest and shortness of breath. This has been a recurring problem in recent months and seems to be gradually worse. On the previous evening, while participating in a swimming gala, she became so short of breath that she found it difficult to walk.difficult to walk.

2.2. Identifying key informationIdentifying key information

3.3. Generating and ranking Generating and ranking hypotheses:hypotheses:

e.g., Infection, cardiac problem, e.g., Infection, cardiac problem, allergy, asthma, broken rib.allergy, asthma, broken rib.

Allergy Allergy ˃ cardiac problem˃ cardiac problem

4.4. Generate an enquiry strategy:Generate an enquiry strategy: What additional information is What additional information is

required?required? e.g., Previous medical problems e.g., Previous medical problems

and relevant drug, family & and relevant drug, family & psychosocial histories, physical psychosocial histories, physical exam, lab. tests. exam, lab. tests.

Additional informationAdditional information

Further discussion with her GP reveals that Ms Smith’s chest pain and shortness of breath come on following exercise, particularly in a cold environment. When she becomes particularly short of breath, she starts to wheeze. She sometimes has a dry cough and has never had haemoptysis. There is no recent history of physical trauma and no personal or family history of heart disease. She had eczema in childhood but has never had asthma. She has smoked for the past 5 years and increased her smoking to 40 cigarettes a day since she broke up with her intimate friend 3 months ago. She takes an oral contraceptive pill but no other medication.

New informationNew information

Revising their hypothesesRevising their hypotheses

Discard / Re-rank / Other Discard / Re-rank / Other hypotheses hypotheses

• Anxiety attacks with hyperventilation

• Possible thromboembolic disease due to oral contraceptive use

• Asthma

• Cardiac problem

• Broken rib

5. Defining learning objectives5. Defining learning objectives

Once the students have decided on a preferred hypothesis Once the students have decided on a preferred hypothesis (e.g., allergy), they must explain the (e.g., allergy), they must explain the biomedical science biomedical science mechanismsmechanisms that link their hypothesis to the presenting that link their hypothesis to the presenting problems.problems.

What students What students know?know? What they What they do not know?do not know? What they What they need to know?need to know?

to further their understanding of the underlying mechanisms, to further their understanding of the underlying mechanisms, and their ability to solve the clinical problem. and their ability to solve the clinical problem.

e.g., Students may e.g., Students may identify gaps in their knowledgeidentify gaps in their knowledge of the of the mechanics of breathing, anatomy of airways, mechanisms of mechanics of breathing, anatomy of airways, mechanisms of oxygen delivery to tissues, or mechanisms of pain oxygen delivery to tissues, or mechanisms of pain perception.perception.

5. Defining5. Defining learning objectives learning objectives (cont.)(cont.)

The identification of gaps in knowledge helps The identification of gaps in knowledge helps students to students to define their learning objectivesdefine their learning objectives and these become the and these become the focus of self-directed focus of self-directed studystudy in the interval between tutorials. in the interval between tutorials.

Learning objectives should be clear and Learning objectives should be clear and specific and of appropriate scopespecific and of appropriate scope to be to be addressed in the time available between addressed in the time available between tutorials (typically 2-3 days). tutorials (typically 2-3 days).

At each tutorial, the group might identify At each tutorial, the group might identify three to five major learning objectives and three to five major learning objectives and perhaps an equal number of lesser objectives.perhaps an equal number of lesser objectives.

5. Defining5. Defining learning objectives learning objectives (cont.)(cont.)

Although the PBL tutorial is student-centered, Although the PBL tutorial is student-centered, major learning objectives are identified in major learning objectives are identified in advance by the case writers as part of the advance by the case writers as part of the overall curriculum design.overall curriculum design. Tutors may need Tutors may need to provide prompts to ensure that major to provide prompts to ensure that major objectives are identified and pursue d.objectives are identified and pursue d.

In PBL, as In PBL, as knowledge is acquired in the knowledge is acquired in the context of a specific clinical problemcontext of a specific clinical problem (the (the problem is encountered before the student problem is encountered before the student has the knowledge to understand it), it is has the knowledge to understand it), it is likely to be likely to be better focused and retained.better focused and retained.

6. Reporting back6. Reporting back

In the follow-up tutorial, students In the follow-up tutorial, students reconvene to report on their self-directed reconvene to report on their self-directed study and share and integrate new study and share and integrate new knowledge. knowledge.

All students should contribute to the report-All students should contribute to the report-back and their unique perspectives are back and their unique perspectives are incorporated into the process of knowledge incorporated into the process of knowledge building. The exchange and debate of ideas building. The exchange and debate of ideas promotes the consolidation and elaboration promotes the consolidation and elaboration of new knowledge and understanding of new knowledge and understanding

7. Integrating new 7. Integrating new knowledgeknowledge

• Based on the principle that knowledge is consolidated more readily in context, students, guided by the tutor/facilitator, should relate new biomedical knowledge to the patient's problem.

• Students are required also to extend their discussion beyond the biomedical and clinical sciences and consider the public health, socioeconomic, ethical and legal aspects of the case.

How do I get started with PBL?

Develop problems that:- Capture students’ interest by relating to real-world

issues.- Draw on students’ previous learning and experience.- Integrate content objectives with problem-solving skills.- Require a cooperative, multi-staged method to solve.- Necessitate that students do some independent research

to gather all information relevant to the problem.

Design assessment tools that:- Account for process (e.g. research, collaboration) as well

as content skills.- Are closely tied to course learning objectives.- Balance individual and group performance.

How to create effective PBL How to create effective PBL scenariosscenarios

Learning objectives likely to be defined by the students after studying the Learning objectives likely to be defined by the students after studying the scenario should be consistent with the faculty learning objectivesscenario should be consistent with the faculty learning objectives

Problems should be appropriate to the stage of the curriculum and the level of the Problems should be appropriate to the stage of the curriculum and the level of the students' understandingstudents' understanding

Scenarios should have sufficient intrinsic interest for the students or relevance to Scenarios should have sufficient intrinsic interest for the students or relevance to future practicefuture practice

Basic science should be presented in the context of a clinical scenario to Basic science should be presented in the context of a clinical scenario to encourage integration of knowledgeencourage integration of knowledge

Scenarios should contain cues to stimulate discussion and encourage students to Scenarios should contain cues to stimulate discussion and encourage students to seek explanations for the issues presentedseek explanations for the issues presented

The problem should be sufficiently open, so that discussion is not curtailed too The problem should be sufficiently open, so that discussion is not curtailed too early in the processearly in the process

Scenarios should promote participation by the students in seeking information Scenarios should promote participation by the students in seeking information from various learning resourcesfrom various learning resources

CHECKLIST FOR CHECKLIST FOR PROBLEM PROBLEM CONSTRUCTIONCONSTRUCTION Is the content of the problem geared to students' prior knowledge?Is the content of the problem geared to students' prior knowledge? Is there a clear connection with one or more of the objectives of the block?Is there a clear connection with one or more of the objectives of the block? Is the problem sufficiently complex to offer cues for initial discussion and for Is the problem sufficiently complex to offer cues for initial discussion and for

generating learning issues?generating learning issues? Is the problem structured in such a way that it offers cues for discussion in Is the problem structured in such a way that it offers cues for discussion in

the group?the group? Has the problem been formulated clearly and, if possible, does it offer links Has the problem been formulated clearly and, if possible, does it offer links

with professional practice?with professional practice? Is the problem multidisciplinary and is clear to students?Is the problem multidisciplinary and is clear to students? Does the length of the problem enable inclusion of all the relevant information Does the length of the problem enable inclusion of all the relevant information

that is needed for identifying learning issues and does the problem not that is needed for identifying learning issues and does the problem not contain superfluous irrelevant information?contain superfluous irrelevant information?

Is the available time sufficient for studying the learning issues?Is the available time sufficient for studying the learning issues? Is there sufficient time available for reporting on all the learning issues?Is there sufficient time available for reporting on all the learning issues? Does the block offer sufficient variety in learning activities, i.e. does it include Does the block offer sufficient variety in learning activities, i.e. does it include

different types and formats of problems?different types and formats of problems? Is the number of problems geared to the number of group meetings in the Is the number of problems geared to the number of group meetings in the

block? Has a schedule been drawn up that specifies which problems are to be block? Has a schedule been drawn up that specifies which problems are to be discussed when?discussed when?

Which problems should be tackled in a specific sequence?Which problems should be tackled in a specific sequence?

HandoutsHandouts

HOW PBL PROBLEMS ARE CREATED: HOW PBL PROBLEMS ARE CREATED: General guidelines General guidelines & Tutor guide& Tutor guide

SAMPLE PBL TUTORIAL CASE: SAMPLE PBL TUTORIAL CASE: Tutor guide including Tutor guide including preset learning issues (Multidisciplinary)preset learning issues (Multidisciplinary)

KEY STEPS IN THE PBL TUTORIAL PROCESSKEY STEPS IN THE PBL TUTORIAL PROCESS

CONSTRUCTING PBL TUTORIAL CASES:CONSTRUCTING PBL TUTORIAL CASES: General concepts & core guidelinesGeneral concepts & core guidelines Initial questions for considerationInitial questions for consideration Planning the casePlanning the case Constructing & formatting the caseConstructing & formatting the case

GUIDE TO PBL TUTORIAL PROCESS AND SKILLSGUIDE TO PBL TUTORIAL PROCESS AND SKILLS

Handouts Handouts (cont.)(cont.)

ROLES OF THE TUTOR IN PBL TUTORIALSROLES OF THE TUTOR IN PBL TUTORIALS

GUIDES FOR ASSESSING STUDENT GUIDES FOR ASSESSING STUDENT PERFORMANCE: PERFORMANCE: Behavioral indicators for Behavioral indicators for each categoryeach category

PBL EVALUATION CHECKLISTS:PBL EVALUATION CHECKLISTS: Assessment of student participation in PBL by Assessment of student participation in PBL by

facilitatorsfacilitators Student assessment of the PBL facilitatorsStudent assessment of the PBL facilitators Self-assessment of participation in PBLSelf-assessment of participation in PBL Peer assessment of participation in PBLPeer assessment of participation in PBL