Chapter 7: Problem Based Learning

Dejan Bokonjic, Mladen Mimica, Nurka Pranjic, Vanja Filipovic, Sladana Cosovic, Hans-Martin Bosse, Soeren Huwendiek, Michael Kirschfink, Silvia Skelin

1 Introduction

The story of problem-based learning (PBL) is as old as human life on earth. Our ancestors had to develop ways of tackling new threats of the environment they encountered, facing the need to define the problems and to seek new strategies if the available resources were insufficient.

In educational processes the implementation of PBL is more recent. It is not an invention in medical education. It originated from Maastricht University, Netherlands and McMaster University, Hamilton, Ontario, Canada. Many faculties all over the globe have now introduced PBL into their curriculum, and no other recent methodology has provoked such a controversial and emotional debate. The scientific outcome of this new-old methodology has been subject of extensive research and is discussed in this manual.

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.

2. Scientific background

Problem based learning (PBL) derives from a theory which suggests that for effective acquisition of knowledge, learners need to be stimulated to restructure information they already know within a realistic context, to gain new knowledge, and to then elaborate on the new information they have learned, for example by teaching it to peers or by discussing the material in a group setting.

PBL differs from more "traditional" approaches to teaching in that the participants are encouraged to use self directed learning skills, placing emphasis on a person’s ability to seek out and assimilate relevant information to tackle a problem at hand. The participants analyze a given clinical scenario, formulate and prioritize key learning objectives within that scenario, and then collect whatever additional information they consider relevant to address those objectives. Crucially, all this takes place within a group setting, so that each individual member of the group contributes to the learning process at every stage (c.f. 7-jump.

PBL is consistent with current philosophical views of human learning, particularly constructivism. Three primary constructivist principles, according to Savery and Duffy (1995) are that understanding comes from our interactions with our environment, cognitive conflict stimulates learning, and knowledge evolves through social negotiation and evaluation of the viability of individual understandings. The constructivist view of learning facilitates the adoption of PBL from pre-school to post-graduate training, and broadens its application far beyond medical training.

As a conclusion, PBL provides a more challenging, motivating and enjoyable approach to education. PBL graduates perform better in respect of interpersonal relationships, reliability and self-directed learning. As Albanese et al. (2000) conclude: If knowledge acquisition and clinical skills are not improved by PBL, the enhanced work environment for student and faculty that has been consistently found with PBL is a worthwhile goal. And finally, PBL induces an intensity winning hearts and minds.

3. Implementation of PBL

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

3.2.1 Organization of PBL sessions

A typical PBL tutorial consists of a group of students (usually six to ten) and a tutor, who facilitates the session. The length of time and number of sessions a group spends together may vary, but the time allocated should permit group dynamics to develop.

Students may elect a leader, time keeper and/or scretary for each PBL-session. The roles may rotate for each session. Flip charts, whiteboards or cards may be used during sessions to collect and structure items.
Generally, there are different ways of case-presentation: paper-cases, standardized patients, real cases (with the drawback of lack of standardization), multimedia cases (with the drawback of distracting from content). A standardized patient is person who presents certain medical problems based on specific standards and instructions. For standardized patients see the respective chapter in this manual. If the problem is dealing with a real patient in a ward, clinic, or surgery then a student may be asked to take a clinical history or identify an abnormal physical sign before the group moves to a tutorial room.

More information on case writing in chapter 3.3. case design.
More information about sequentially using non-medical problems and then medical problems in PBL.
More information on training of tutors see chapter 3.4 The role of the tutor.

3.2.2 The seven jump

PBL sessions are usually organized according to the Maastricht seven step procedure but may be modified. Generally, those seven steps are:

1. Clarifying terms

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Step 1. Identify and clarify unfamiliar terms presented in the scenario.
At the beginning of the session, the problem(s) should be presented to students. If you use paper cases one of the students reads it aloud to get the group talking from the beginning. The first activity of the group should be the clarification of problems, terms and concepts not understood at first moment.
The purpose of the first step is to agree on the meaning of the various words and terms and on the situation described in the problem. Use can be made of the knowledge possessed by the group members or retrieved from a dictionary.
Videoclips of this step: English, BiH-Languages, German

2. Defining the problem

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Step 2. Define the problem or problems to be discussed.
Definition of the problem is the main goal during this phase. The group should discuss and reach an agreement on the tricky events, which need explanation. Occasionally, a problem has been intentionally described on the way to test students’ ability to recognize certain symptoms.

Though they have some prior knowledge to recognize a problem, the prior knowledge doesn’t allow them to resolve the problem straight away. The aspects of how to generate good cases with problems the students will consider relevant is addressed in chapter 3.3.

Videoclips of this step: English, BiH-Languages, German

3. Brainstorming

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Step 3. Aspects on basis of prior knowledge are collected.
This should result in ideas to structure the problem.
Each individual may express his or her ideas free and without immediate discussion: it is important not to discuss and not to comment the ideas of others during this step, but to collect many ideas (prior knowledge). Together, students will compile ideas of the underlying circumstances of the problem (explanatory approach) and/or of implications arising from the problem (procedural approach).

Videoclips of this step: English, BiH-Languages, German

4. Structuring and hypothesis

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Step 4. Review steps 2 and 3 and arrange explanations into tentative solutions. During the fourth step, which forms the core of the analysis, the problem is explained on different ways. Ideas, which seem to be related, are worked out in relation to each other. Each group member is allowed to fully present ideas about matter. Group members can draw on all the prior knowledge they possess.

This prior knowledge may be based on information acquired in earlier education, facts and insights obtained by reading different articles or on another way. The other members of the group and the tutor are allowed to probe the students’ knowledge to the full, to introduce other explanations and question certain opinions. The process of brainstorming and discussion is a collaborative approach. It leads to more creativity and output than each member of the group could generate on his own.

Videoclips of this step: English, BiH-Languages, German

5. Learning objectives

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Step 5. Formulating learning objectives; group reaches consensus on the learning objectives; tutor ensures learning objectives are focused, achievable, comprehensive, and appropriate. The systematic approach and discussion may result in several outlines written down on the blackboard. These outlines are like possible explanations for particular problem.

However, since student prior knowledge is limited, questions will come up and dilemmas will arise. In this phase of the discussion, conflict between members of the tutorial group should arise.

The students will find out that certain aspects are not yet explained and resolved in the process of their discussion. PBL encourages students to define these aspects as learning goals putting them in charge of to learn. This state of cognitive dissonance between what I know and what I have to know to understand the outside world is an essential condition for PBL. Questions and dilemmas, which appeared during session, can be used as learning goals for individual self-directed learning. So, the main aim of this step is to formulate learning objectives on which group will concentrate their activities during phase six. In this stage it is possible to use conceptual map as a tool for research summary, making associations, integrating information and proceeding information and transferring it to long-term knowledge, but also a tool for defying new learning objectives.

Videoclips of this step: English, BiH-Languages, German

6. Searching for Information

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Step 6. Self-independent learning; during this phase students are going home and study. This phase is supposed to provide answers to the questions evoked in the problem-analysis phase and offer students possibility to acquire a more profound knowledge of theories at the root of the problem. The group members collect information individually with respect of defined learning objectives.

Information is collected from the literature but also from other sources (library, journals, internet etc.). PBL is also important because it gives possibility to students to find their own resources. Minimal time for their individual study is two days but could be longer. Students can learn individually but also in pairs or in groups. It is important to already decide in advance, how the results of the self-study period will be presented: by an individual, a small group or as discussion of all the groups. Students explore relevant sources of knowledge and then put the new information together, possibly resolving all the issues that were left open.

Videoclips of this step: English, BiH-Languages, German

7. Synthesis

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Step 7. Group shares results of private study. The tutor checks learning and may assess the group. So, the final step is synthesizing and testing the newly acquired information. Members of the group are sharing information gathered at home among each other. They also discussed whether they now acquired more proficient, accurate, detailed explanation and understanding about what is going on behind the problem.

If some of the students haven’t understood the issues well, task of other students is to try to explain them methodology of their work.

In this step it would be necessary for the certain types of the problems to check for students’ decision-making process and the algorithm behind their decisions.

8. Feedback

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Step 8: “Feedback” as described by Thoemen (1998, in German). We found it very helpful to institutionalise this step. It includes feedback of all students on the case, the process and the tutor, to improve the learning process. Also it is very important the students validate the course and give their comments on the quality of the problem as well as on the quality of the group process and the tutor’s performance.

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).

3.3.1 Sources of ideas for PBL cases

Probably the best way to get a sense of what a PBL case looks like is to look at some real medical cases, but then to work on them to structure them according to the didactic intention.
Useful sites for PBL cases are:

  • Department of Radiology, Brigham and Women's Hospital (Harvard Medical School)
  • University of Delaware Institute for Transforming Undergraduate Education (cases in Biology, Physics, Chemistry)
  • Examples of problems from McMaster University courses by P.K. Rangachari
  • National Center for Case Study Teaching in Science, Case Collection (scientific, partly medical cases)
  • THE TRIPSE: Undergraduate Problem-based Courses in Pharmacology

3.3.2 Case-writing

Writing is a complex process that requires a lot of practice. There are some steps which could help in PBL case design (dapted from: Active Learning Exchange (ALEx) of Schreyer Institute for Teaching Excellence. [15] )
The steps are:

Analyze Your Course [17ff]
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(what does this step mean?)
Choose a Problem Topic
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(what does this step mean?)
Brainstorm a Scenario
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(what does this step mean?)
Frame the Problem, Choose a Procedural and/or Explanatory approach
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(what does this step mean?)
Don’t Include All Information
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(what does this step mean?)
Review Your First Draft
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(what does this step mean?)
Develop an Instructional Plan (“Script”)
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(what does this step mean?)
Name Resources
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(what does this step mean?)

(adapted from Schreyer Institute for Teaching Excellence)

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:

3.5.1 Student leader

This student, chosen by the group, moderates the brainstorming and the following discussion to keep the team on track and is actively involved in group discussion. Each new session a new student leader may be chosen.

3.5.2 Time keeper

This student, also chosen by the group, will monitor time to make sure the progress through the steps and the case-content is balanced leaving sufficient time for a thorough discussion on one hand but being fast enough to complete the task.

3.5.3 Secretary

This student, also chosen by the group, takes notes of the team’s discussion and documents the learning goals assigned by the group members.

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.