|Year : 2014 | Volume
| Issue : 2 | Page : 243-246
Problem-based learning in health professions education: An overview
Department of Oral Pathology, Penang International Dental College, Butterworth, Malaysia
|Date of Web Publication||11-Nov-2014|
Department of Oral Pathology, Penang International Dental College, 1200, Butterworth
Source of Support: None, Conflict of Interest: None
Problem-based learning (PBL) has been discussed and deliberated at various levels in health professions education in the last few decades. It has been accepted as a student-centered pedagogy that helps learners understand the core concepts, as well as helping them develop adult learning skills, communication skills, team working skills among other skills, which are considered as essential soft skills for future professional practice and employment. This article presents a description of the origin of PBL, the principles of learning that it is based on and a detailed description of the type of PBL process that can be used to introduce PBL. The research evidence in favor of PBL from the perspective of the faculty and the students has also been discussed with suggestions for future research based on literature.
Keywords: Problem based learning, PBL, health profession education
|How to cite this article:|
Telang A. Problem-based learning in health professions education: An overview
. Arch Med Health Sci 2014;2:243-6
| Introduction|| |
Problem-based learning (PBL) is a student-centered approach to active learning in which students learn through the experience of resolving meaningful problems. In contrast to the traditional lectures, PBL is conducted with small groups of students working together to achieve understanding. The main objective of PBL has been to develop adult learning skills through self-direction, collaborative problem-solving, nurturing clinical reasoning and communication skills. These skill sets promote lifelong learning and better prepare students for their professional careers. 
| Historical Background|| |
Problem based learning was popularized by Barrows and Tamblyn following their research into the reasoning abilities of medical students at McMasters University in the 1960's. They found that students perceived the vast amount of material presented through the traditional medical curriculum as having little relevance to the clinical practice of medicine. In order to stimulate and motivate the learners in seeing the relevance of learning for future roles and maintaining a high level of motivation toward learning, PBL was developed. PBL was first implemented into health sciences education at McMaster University (Canada) in 1969, which was closely, followed by Newcastle University (Australia), Michigan State University (USA), Beer Sheva (Israel) and Maastricht University (Netherlands). It has since been implemented globally in many health professional courses including medicine, dentistry, nursing, and pharmacy. ,, Some universities such as Maastricht have adopted a pure PBL curriculum with few post-PBL lectures; some like McMaster University developed a PBL curriculum with few lectures,  whereas some others like Harvard Medical School implemented a hybrid PBL curriculum that provides more structured didactic learning supported by PBL sessions.  In some schools, there is a PBL approach running at the whole curriculum level such as the faculty of odontology in Malmo (Sweden) and the faculty of dentistry at the University of Hong Kong (SAR) whereas in others, PBL is presented at a single course level within a lecture-based curriculum.
The four key learning principles on which PBL is based are constructive, collaborative, contextual and self-directed learning.  The constructive principle emphasizes that learning is an active process in which students actively construct or reconstruct knowledge networks. In other words, learners in a PBL tutorial are actively involved in the process and the elaboration of facts and ideas during their interactions helps in stimulating prior knowledge. This helps learners to relate new information to existing knowledge and thus achieve deeper and richer learning experience. 
The collaborative principle of learning is based on social structure in which two or more individuals interact during certain circumstances that have a positive effect. The interactions in the tutorial group include elaboration, co-construction, mutual support; constructive criticism and social interaction that have a positive effect on learning. Collaborative learning in PBL takes place when participants have the same goal, share responsibilities, are mutually dependent and need to reach an agreement through open interaction.  The principle of contextual learning states that all learning is situated that is, always learning takes place in the context. The situation in which knowledge is acquired determines the use of this knowledge.  In the case of PBL, learners are exposed to authentic, complex problems or cases which are professionally relevant and developed in the context of future clinical practice. This facilitates the transfer of knowledge by anchoring learning in meaningful contexts.  Self-directed learning implies that learners play an active role in planning monitoring and evaluating the learning process.  The emphasis on self-directed learning is an important distinguishing feature of PBL.  In a PBL process, learners discuss and plan approaches to tackle their gaps in knowledge, while reflecting on their progress, as well as the progress of their group. This makes them aware of their prior knowledge and motivates them to take charge of their learning process, which is an important skill to become a lifelong learner.
The problem-based learning tutorial process
Essential components of a PBL tutorial is a small group of students approximately 8-10 in number and a facilitator. The students elect a chairman who will lead the discussion and a scribe or clerk who will help the group in charting the progress. The learning cycle in PBL begins in the first tutorial [Figure 1] by presenting minimal information about a complex problem and ends with student reflection.  While working with the problem in the first tutorial, students use white boards to record their evolving ideas. The whiteboard serves as a focus for interaction and as a forum for the group to co-construct knowledge. It also helps externalize and provide a systematic approach to problem solving.  The board is divided into three records keeping columns by the scribe to facilitate problem solving [Figure 2]. The facts column holds information that students gather from the problem statement such as what the problem is and where did it occur. The ideas column keeps track of the brainstorming/analyzing process for the facts identified. This is followed by elaboration and clustering of ideas to identify knowledge gaps. The knowledge gaps identified are placed in the learning issues column. Thereafter, each member of the group is encouraged to work self-directed on all the learning issues identified. The time for SDL is predetermined based on the depth and difficulty of the problem that could be between 3 and 7 days. In the second tutorial, the group re-discusses the problem, shares and applies the new knowledge to integrate and solve the problem. The tutorial ends with an evaluation process wherein each member is encouraged to reflect on their performance and the group's performance. This helps students to identify gaps in their thinking and transfer their problem-solving strategies, self-directed learning strategies and knowledge. Critical reflection can give students a basis for improvement. 
The role of the problem
Research and experience with PBL suggest that to foster meaningful learning the problems should be complex, ill-structured and open-ended, that is, have no one "right" answer.  They must be realistic and resonate with the student's experience. Designing effective problems is not an easy task. If the problems are too well structured, close ended and too simple it will not challenge students to construct knowledge actively.  If the problems are not realistic it will not stimulate the students towards constructive and contextual learning. In other words, good problems are contextual and should often require a multidisciplinary solution.
The role of chairman
The chairman should be well prepared to conduct the tutorial systematically. He/she should involve all members in the discussion by summarizing, asking questions, re formulating/paraphrasing statements to help understanding. Drawing meaningful conclusions to the group discussion and conducting a meeting in a democratic way will help the students to develop managerial skills in this role.
The role of scribe
The scribe or clerk is selected by the group with the main responsibility of clerking the group discussion in a systematic manner using the white board. The scribe should coordinate well with the chairman, while actively contributing in the discussion and putting up points on the white board only upon consensus in the group.
| The Role of the Facilitator|| |
In PBL, the tutor/facilitator has a transformed role from that of a "sage on the stage" to that of a "guide by the side."  Aim of facilitation is to ensure that students work on the tasks with sufficient depth. Facilitators should ask open-ended questions at the right time to stimulate discussion and provide sequential information by gauging the level of the group discussion. He/she should show active listening behavior, communicate formally and informally and provide feedback to all members. Thus, the role of a facilitator is that of an expert learner, able to model strategies for learning and thinking, rather than an expert in content.  The best tutor/facilitator knows when and how to intervene and has the students learning as his top priority. 
Problem-based learning research
Research on PBL in various settings have shown that students in a PBL curriculum have better knowledge application and clinical reasoning skills  and they consistently outperformed traditional students on long-term retention assessments. , It is also reported that PBL students have superior ability to synthesize basic knowledge and clinical experience in addition to applying and transferring the knowledge and skills into the workplace.  Studies on PBL graduates provide strong evidence for positive long-term effect on students self-directed and lifelong learning skills and attitude, as well as developing higher order thinking skills.  Student perception studies have also suggested an overall positive attitude, as students consider PBL to be effective in promoting their learning in dealing with complex problems,  enriching their learning of basic science information,  developing thinking and problem-solving skills,  improving interpersonal and professional skills,  as well as advancing self-directed learning, higher level thinking, and enhancement of information management skills.  However, the most interesting debate in PBL research has been its comparison with conventional curriculums. Systematic review of the literature suggests a large number of studies in favor of PBL with an equally large number of studies suggesting no difference between the curriculums. , Strobel and van Barneveld  in their meta-synthesis of meta-analyses comparing PBL with learning in conventional classrooms conclude that traditional learning approaches tend to produce better outcomes on assessments of basic science knowledge, but don't always do so, and PBL approaches tend to produce better outcomes in terms of clinical knowledge and skills. This view has been supported by many studies conducted thereafter. However, an argument among researchers remains that studies that compare and measure the outcome or effects of PBL do not focus on the theoretical claims behind PBL, which results in unreliable insights.  Norman and Schmidt  argue that the trails of curriculum level interventions are a waste of time and resources because there is no such thing as a blinded intervention or an uniform intervention in educational research. What is needed is research that bridges theory and practice and extends knowledge about developing and improving PBL in practice. Dolmans and Gijbels  in a recent dialogue on PBL suggest that the research in PBL needs to go beyond measuring the outcomes of PBL in terms of student achievement. They also suggest that a micro-analytic approach to investigating the process of PBL is more necessary and sensible than the question of which learning environment is better. Thus, future research in PBL should be focused on the micro-components of PBL such as self-directed learning, group interactions, quality of feedback, use of real patient compared with paper-based scenarios and effects of cultural backgrounds on the tutorial group interactions.
| Conclusion|| |
As a student-centered method of pedagogy built on the principles of learning, PBL has been implemented in many schools in different formats. Research evidence on its effects or its comparison with the traditional curriculum is not entirely conclusive but is strongly suggestive of positive perception among learners and positive impact on overall understanding and clinical reasoning skills as well.  As health professions education enters the next millennium with young learners who are all digital natives,  it will be interesting to see this method of pedagogy evolve to achieve its aim of improving overall understanding and improving clinical reasoning through the integration of basic sciences and clinical sciences.
| References|| |
|1.||Bassir SH, Sadr-Eshkevari P, Amirikhorheh S, Karimbux NY. Problem-based learning in dental education : a0 systematic review of the literature. J Dent Educ 2014;78:98-109. |
|2.||Hillen H, Scherpbier A, Wijnen W. History of problem-based learning in medical education. In: van Berkel HJM, Scherpbier A, Hillen H, and van Vleuten C, editors. Lessons from problem-based learning. Oxford; New York: Oxford University Press; 2010. p.5-13. |
|3.||Johnson SM, Finucane PM. The emergence of problem-based learning in medical education. J Eval Clin Pract 2000;6:281-91. |
|4.||Polyzois I, Claffey N, Mattheos N. Problem-based learning in academic health education. A systematic literature review. Eur J Dent Educ 2010;14:55-64. |
|5.||Dolmans DH, De Grave W, Wolfhagen IH, van der Vleuten CP. Problem-based learning : f0 uture challenges for educational practice and research. Med Educ 2005;39:732-41. |
|6.||Billet S. Situated learning : b0 ridging sociocultural and cognitive theorizing. Learn Instr 1996;6:263-80. |
|7.||Hmelo-Silver CE. Problem-based learning : W0 hat and how do students learn? Educ Psychol Rev 2004;16:235-66. |
|8.||Dolmans D, Balendong HS. Problem construction: A series on Problem Based Medical Education. Maastricht; Datawyse Universitaire Pers Maastricht; 2012. |
|9.||King A. From sage on the stage to guide on the side. Coll Teach 1993;41:30-5. |
|10.||Maudsley G. Making sense of trying not to teach : a0 n interview study of tutors ideas of problem based leanring. Acad Med 2002;77:162-72. |
|11.||Hung W, David HJ, Rude L. "Problem-based learning." In: Spector JM, Merril MD, Merrinboer JV, Driscoll MP, editors. Handbook of research on educational communications and technology. 3 rd ed. New York; London: Taylor & Francis; 2008. p.485-506. |
|12.||Dochy F, Segers M, Van den BP, Gijbels D. Effects of problem-based learning : A0 meta-analysis. Learn Instr 2003;13:533-68. |
|13.||Norman GR, Schmidt HG. The psychological basis of problem-based learning : a0 review of the evidence. Acad Med 1992;67:557-65. |
|14.||Patel VL, Groen GJ, Norman GR. Effects of conventional and problem-based medical curricula on problem solving. Acad Med 1991;66:380-9. |
|15.||Mennin SP, Kalishman S, Friedman M, Pathak D, Snyder J. A survey of graduates in practice from the University of New Mexico's conventional and community-oriented, problem-based tracks. Acad Med 1996;71:1079-89. |
|16.||Martin KJ, Chrispeels JH, D'eidio-Caston M. Exploring the use of problem-based learning for developing collaborative leadership skills. J Sch Leadersh 1998;8:470-500. |
|17.||Caplow JA, Donaldson JF, Kardash C, Hosokawa M. Learning in a problem-based medical curriculum : s0 tudents' conceptions. Med Educ 1997;31:440-7. |
|18.||Lieux EM. A skeptic's look at PBL. In : D0 uch B, Groh SE, Allen DE, editors. The Power of Problem-Based Learning : A0 Practical 'How To' for Teaching Undergraduate Courses in Any Discipline. Sterling, VA : S0 tylus Publishing; 2001. p. 223-35. |
|19.||Schmidt HG, Vermeulen L, van der Molen HT. Longterm effects of problem-based learning : a0 comparison of competencies acquired by graduates of a problem-based and a conventional medical school. Med Educ 2006;40:562-7. |
|20.||Kaufman DM, Mann KV. Students' perceptions about their courses in problem-based-learning and conventional curricula. Acad Med 1996;71:S52-4. |
|21.||Strobel J, van Barneveld A. When is PBL more effective? A meta-synthesis of meta-analyses comparing PBL to conventional classrooms. Interdiscip J Probl Based Learn 2009;3:44-58. |
|22.||Norman GR, Schmidt HG. Effectiveness of problem-based learning curricula : t0 heory, practice and paper darts. Med Educ 2000;34:721-8. |
|23.||Dolmans D, Gijbels D. Research on problem-based learning : f0 uture challenges. Med Educ 2013;47:214-8. |
|24.||Prensky M. Digital natives, digital immigrants part 1. Horizon 2001;9:1-6. |
[Figure 1], [Figure 2]