01 January 2001

problem-based learning - a detailed description


The Problem-Based Learning (PBL) emphasizes student-centered, self-directed learning. Groups of eight students meet with a faculty facilitator two to three times per week. Faculty members do not "teach" in the traditional sense. Instead, they serve as facilitators.

A series of cases focus on learning the basic sciences required to understand patient problems. Students then work independently and in small groups on learning issues before the next meeting, at which time the new information is discussed and refined in the context of the case.

The Problem-Based Learning Pathway is ideal for students who:

* Are self-directed;
* Are comfortable with flexibility in their learning goals;
* Learn best through reading and small group discussion; and
* Want a strong clinical context for their learning.

Problem-Based Learning Curriculum Program Description and Objectives

In the Problem-Based Learning Pathway, the passive delivery of information is completely eliminated. Students are placed in small groups of eight students each, and each group is assigned one faculty member whose function it is to facilitate discussion in the group. Because the faculty members who serve as group facilitators are not necessarily authorities on the material being discussed, the students learn to not rely upon him/her to teach. A series of cases serve as a basis for learning the basic science required to understand the clinical scenario. The object is not to diagnose the case, but to identify what are called learning issues, topics for further independent and/or group study. Students then work independently and in small groups on their learning issues before the next meeting, at which time the new information is discussed and refined in the context of the case. If necessary, further learning issues are then identified and studied.

This program provides an environment in which the learning of the basic sciences will be approached with considerably more enthusiasm than under the lecture system. With a problem-based approach to the basic sciences it is also hoped that the students will feel more comfortable and confident in dealing with uncertainties, and with the challenge of solving clinical problems. If so, then the students should be better prepared to enter into their clinical clerkships, which commence with the third year of medical school.

With this approach, the memorization of isolated facts, taken out of context, is de-emphasized. Those skills which are of value in helping students develop into self-directed, independent learners are used repeatedly throughout the students' education. It is the process of learning rather than the factual information itself which is stressed. The small group setting also fosters the development of a sense of community among students, who learn to work together in a problem-solving capacity. They learn both trust and responsibility as active members of the group. They become comfortable both receiving and giving criticism, with having their position questioned without taking it personally, and questioning without fear of threatening others. The small group process also provides valuable practice in sharpening students' clinical reasoning skills, which have been suggested to constitute the scientific method of clinical medicine.

The main objective of the course is to foster the educational and personal development of medical students who will:

* Take personal responsibility for learning, both during and following medical training;
* Command a relevant knowledge base characterized by depth, breadth and flexibility;
* Be skilled in the critical evaluation and acquisition of new knowledge, with a commitment to life-long learning;
* Be proficient at clinical reasoning;
* Have good interpersonal skills and enjoy working with other students.
* Be better prepared for entry into clinical clerkships.

The mechanism of achieving this objective will be an approach which will:

Shift the emphasis of the program from teaching to learning, by requiring students to be active, independent and self-directed learners and problem solvers, rather than passive recipients of information;

Emphasize the development of attitudes and skills which stress the acquisition of new knowledge rather than the memorization of existing knowledge, by limiting the amount of factual information that students are expected to memorize;

Provide a small group environment, within which the students can work cooperatively to solve common problems in an analytical way, with faculty who are facilitators of the discussion rather than teachers.

The Tutorial Process in Problem-Based Learning

The heart of a Problem-Based Learning Pathway is the tutorial group (8 students plus one faculty facilitator). Each member of the group has responsibilities which are important if the process is to succeed (See Roles of Participants). Members must feel free to challenge one another in a constructive manner and feel comfortable with being challenged, but without feeling personally threatened or insulted. In the early stages of group dynamics, this is difficult because members are uncomfortable with this behavior, but with familiarity, it becomes an enjoyable exercise which serves to help the group and its members focus on those areas where their knowledge must be extended.

The PBL cases are based on actual patients. The Progressive Disclosure Model is used. Initially, only the name, age, gender and chief complaint are made available. Following discussion, the group will request additional information, such as the results of a history and physical. Additional discussion follows and the students begin to form an initial differential diagnosis. After this discussion, the group will request new data, such as the results of an EKG or an MRI, and again, discussion follows. During the process, the students raise "learning issues", topics that they need to know more about. Following completion of a case, the students submit their final learning issues to the PBL office. The final learning issues serve as the basis for examination questions.

The facilitator will monitor the direction of the group, and redirect them by asking appropriate questions for discussion if they digress too far, but this is done only if absolutely necessary. The students are given the latitude to pursue unproductive directions, and decide for themselves that a particular learning issue was not germane to understanding the patient's problems.

The Group Tutorial Process

Initially, a case requires several tutorial sessions to complete. The group tutorial process may be divided into three phases. In the first phase, one student reads the case while another serves as a "scribe" and writes information on a blackboard. The blackboard are divided into three areas, for facts, general ideas and learning issues. Facts are listed as they are read. The students then begin to discuss the facts, to decide as a group which facts are important and which are irrelevant, and to probe for scientific explanations and correlative information relating to the clinical picture presented. This is accomplished first using existing knowledge of the group members.

At this point, the students must challenge any information presented for accuracy and understanding. As they arise, ideas are listed which are eventually formulated into hypotheses to be tested. With each hypothesis, one or more learning issues (topics about which there is insufficient knowledge to understand the clinical picture or to pursue without additional research) are presented, as well as which resources the students should utilize in order to obtain the appropriate information.

During this process, the students must take particular care to not become preoccupied with making a diagnosis, but to adhere to their primary goal: that of understanding the basic mechanisms, not the diseases, responsible for the clinical symptoms and signs. The final activity of each session is for the group to evaluate its effort. The program objectives may be re-read at this time and recommendations made as to how to improve the group's performance.

During the second phase, the students engage in independent and small group study, addressing the learning issues adopted in the group session. Appropriate resources for acquiring this knowledge include textbooks, journals, microscope slides, X-rays and tomographic scans, audio-visual materials, and designated resource faculty, who may upon request provide information on a topic.

During the third phase, one student will present the patient using a format in which the known subjective and objective information is summarized and assessed, and a plan for continued management is proposed. This will initiate continued discussion, not only of the new knowledge and its use in evaluating their hypotheses, but also for the seeking of more information about the patient. In light of the new information they approach the case fresh, listing new ideas, formulating new hypotheses and learning issues, as new case information is provided and added to that which they already have. This is followed by another group self-evaluation, another period of independent study and another meeting. This process may be repeated several times during a single case, as additional learning issues are added until the group is satisfied that it has gained sufficient knowledge of basic scientific concepts to understand the basic mechanisms underlying the clinical picture presented in the case. At this time, a final self-evaluation occurs, and the group evaluates its activities and summarizes what it has learned.

Role of Participants

The facilitator is responsible for providing the case information at the appropriate times during the discussion. He/She also assures that each member of the group participates by prompting, if necessary, the more timid members. In addition, the facilitator monitors how accurately the group is addressing the desired objectives.

The facilitator will also evaluate the efforts of the group members in terms of the willingness to contribute and willingness to complete their independent study to the extent that they are able to contribute to the group effort.

The students have the responsibility to participate actively in the discussions of the group. They must be willing to both give and accept constructive criticism, be willing to admit to knowledge deficiencies where they exist and to conscientiously complete their independent study assignments so as to contribute effectively to the group effort. Students also have the responsibility to honestly evaluate the activities of each other, themselves, the facilitator and the group as a whole. Only in this way is improvement possible.

Content Examinations

Each exam includes board-type multiple choice questions, and may include practical questions about laboratory material such as interpretation of slides. The questions will be generated by the faculty and will be based upon the learning issues identified since the last examination. The exam process will be used to identify the students' strengths and weaknesses as well as contribute to their overall evaluation.

Faculty Evaluation of Student Performance

Students will be evaluated by each facilitator. In general, students performance in the small group will be evaluated in each of the following categories:

* Group participation and contributions;
* Preparation and learning skills;
* Interpersonal skills and professional behavior;
* Contributions to group progress.

General Overview

The core of the program is the series of problem-based learning cases which occupies much of the time in years 1 and 2. While Anatomical courses are taken, groups meet only once per week, thereafter groups meet three times per week for the remainder of the first year, and twice per week for the entire second year, up to approximately one month prior to the national administration of the NBOME COMLEX Level 1.

Other Coursework

Students in Problem-Based Learning Pathway will participate in all other components of the lecture-based curriculum during the first and second years. These include the following:

* Human Clinical Gross Anatomy
* Medical Ethics
* Osteopathic Manipulative Medicine I - IV
* Healthcare Management
* Clinical Examination I - IV
* Public Health and Preventative Medicine
* Geriatric Medicine
* Basic Life Support / Advanced Cardiac Life Support
* Medical Jurisprudence
* Behavioral Medicine
* Human Sexuality

Within Anatomy Course:

* Histology
* Embryology

background: house of god

the house of god, an amazing novel by samuel shem, is a classic book describing life in medical school. if you haven't read it, i highly recommend it--particularly if you have any interest in going into medicine.

in the book, shem refers to harvard medical school as "man's best medical school," or "mbms" for short. in hommage to shem's work (and in jest of my own medical school), throughout this blog i will refer to my medical school as "man's worst medical school," or "mwms."

is my school really the worst? only time will tell.... enjoy!

case files

student dr. blaze

CC: “mwms is trying to kill me”
HOPI: onset July 2006. self-induced. many aggravating factors, few relieving factors.
PMH: too much school, too many illnesses.
SHX: social life? what social life?
FHX: complicated.
O: there’s no such thing....
A/P: self-induced torture. grit teeth, hold on tight, & try not to drown.


CC: “seattle is not boston
HOPI: onset July 2006. self-induced. many aggravating factors, relieving factor: mars hill. potential duration unknown.
PMH: lived in boston just long enough that nothing else compares.
O: trying to figure it all out.
A/P: seattle adjustment disorder. turn living room wall into mural of boston. find competent doctor.

mr. dr. do

CC: “pts have a hidden agenda”
HOPI: began in medical school; constant. aggravating factors: seeing the same pt sitting in the waiting room multiple times. alleviating factors: humor, solving a case.
PMH: medical school, residency, family practice.
FHX: mrs. dr. do & baby.
O: pcp in NAD. young enough to be student dr blaze’s sibling.
A/P: cynical, but kind. laugh more. hope that baby soon sleeps through the night.

mrs. dr. do

CC: “mwms treats adjunct faculty like crap”
HOPI: onset 2004 to 2006. aggravating factors: administration & medical students who can’t tell the difference between a bell and a diaphragm on a stethoscope. relieving factors: quitting.
PMH: medical school, residency, family practice, & lots of teaching.
FHX: mr. dr. do & baby.
O: strong woman, excellent teacher. young enough to be student dr. blaze’s sibling.
A/P: a woman & mom in family medicine, treated poorly by mwms. find another way to teach students, who desperately need & miss her.

dean honey

CC: “medical students are getting stupider”
HOPI: onset: many years ago. mwms. duration: extensive. aggravating factors: students. relieving factors: lounging in pool with a cold beer.
PMH: military service & a doctorate in anatomy.
O: couldn’t determine--was too busy hiding from him.
A: grouchy old man who refers to female students as “honey.”
P: retire.

super blaze

CC: none.
PMH: has jumped off a water tower in a single bound. runs, bikes, jogs, surfs, & performs other miraculous feats of a physical nature. takes incredible photos.
SHX: has fun.
FHX: has an awesome fiancee.
O: unable to observe. moving too fast.
A: super blaze.
P: keep going!

the godfather

CC: "you're thinking too much!"
HOPI: began last semester when he realized how detailed my outlines were. ;-)
PMH: has a DVM and a PhD in physiology. grew up in the sudan. possesses incredible generosity of spirit, hence why the pbl group named him the godfather.
FHX: with a wife and four daughters, he's always commenting on the unbelievable amount of estrogen in his house.
A/P: no problems. keeps reminding his students to take it easy.

a little disclaimer...

i'm a medical student. just a student. so please, don't take anything i say too seriously. remember that i was an english literature major as an undergrad, so there is much fiction to be found in these pages. do you think i'm telling a story about you or your illness? more likely, you're tapping into my sense of "everyman"--that is, your story resonates with what i write here because it's not so uncommon after all. need help? please, please go see your physician. <--i'm not her. yet. ;-)