Does problem‐based learning work? And whose fault is it if it doesn't? A response to the article by R. H. Glew

The Learning & Teaching Support Network (LTSN) for Bioscience is a national, government-funded organization whose remit is to form a network of teachers in bioscience departments to harvest and share good practice in learning, teaching, and assessment (bio.ltsn.ac.uk). Glew [1] presents a dismal picture of problem-based learning (PBL)1 as applied in some medical schools, but an equally grim picture could be presented of some more conventionally presented medical courses: hours spent memorizing minor details, little ability to make use of the information memorized, material presented with no clinical context, assessment only of regurgitated material, discipline-based material presented in isolation with no concept of the big or integrated picture, students without communication skills and with little appreciation of critical analysis or how to tackle new areas of knowledge for themselves, ineffective and disorganized science-based lecturers with poor teaching skills, and clinical teachers who fail to turn up for classes. Neither extreme serves our students well. Proponents of both extremes, traditional or PBL, need to remember that the recent changes in medical education have been in large part a response to pressures on medical education from a variety of sources [2]. In fact, for over 100 years various eminent medics and scientists have pointed to the (over)load of information. Thomas Huxley in 1876 referred to the tendency to an “overloading of the curriculum of education” and the wish to find a means “to give the student a larger amount of time for self-education” (quoted in Ref. 2). The Flexner report (1910) had expressed dissatisfaction with medical education [3], and in 1913 Osler [4] wrote about the problems of students' capability of memorizing a growing number of items of knowledge. The GPEP Report [5] referred to “an overemphasis on memorization of facts in basic science courses.” When a few years ago the British Biochemical Society ran a discussion meeting with the title “How much biochemistry should a good doctor know?” [6], an old American friend with a lot of experience in teaching medical students in the United States, who happened to be visiting Leeds at the time, said that the answer to this question was: “A damn lot!”. The same may be said of anyone working in the biological and medical areas generally; but at the present time, the amount of knowledge in these areas is increasing exponentially. It is a fact that no one person can keep up with anything more than a small part, and this applies as much to students as to anyone else. Our tradition of filling students up with knowledge and at graduation pushing them out into the world as our products, complete (the so-called “bottle theory” of education, Fig. 1), will no longer do. This has been apparent to bioscientists and medics for some time now. The knowledge the graduated student contains may not be the right knowledge for use in solving problems to be encountered in the next 30–40 years of working life, and indeed the knowledge required may not have been discovered at the time of graduation. Hence the only way of proceeding is to develop skills appropriate for life long learning and for finding and being able to use information when there is a problem to be solved. In addition to these “pedagogical” issues, there are now economic and technological issues too: more students, less staff, different expectation from patients, fewer resources, less time, more emphasis on research output, new methods and technologies to aid teaching and learning, and greater diversity among students apart from the greatly increased discipline knowledge. Maintaining the status quo was not a realistic option. Medical courses evolved to their previous state over many years, and it is unsurprising that a short period of radical and wholesale change should now deliver a product that is different from its predecessor. Medicine practiced by today's graduate over the next 40 years will be very different from that practiced by the graduates of the 1960s. If we are to review the products of medical education let us be sure it is against the requirements for tomorrow's doctors and not against the requirements for yesterday's. There can hardly be much that is controversial here: the question is how to do it, in other words, how to find some other way than filling students up with knowledge that has a limited shelf life that may or may not be of use in the future, of producing graduates that are skilled at finding and using information to solve problems rather than being able to remember a great deal. One of the solutions to this particular problem was to introduce PBL, and many medical schools in North America took up the idea enthusiastically. This has been reasonably successful, although one may argue about whether the medics that are produced are any worse or any better than those produced by the traditional route or whether they are just “different.” Other arguments are that such individuals possess much less (i.e. “insufficient” according to some) basic knowledge and that the M.D. sitting in his office with an ill patient cannot say: “This problem is very interesting, now we need to go and find the information necessary to solve it before I can treat you: come back in 3 day's time” (honest though this response might be). PBL was not the only change that has occurred in medical education. Integrated courses, clinical material throughout the course, use of technology and computer-based learning, core curricula and options, group working, and continuous assessment have all been introduced into medical education at a time when student expectations, abilities, and attitudes (e.g. to assessment driven participation) were also changing. Institutional missions have become more focused and explicit, and this reflects in staff attitudes. Not in every institution is teaching the top priority. It needs to be explained that the situation in the United Kingdom is somewhat different from that in the United States. First of all, most of the medical courses in the United Kingdom are undergraduate with the majority of students entering from high school at age about 18. (This is changing with the formation of some graduate schools, but this is only just happening. One might imagine that medical students who are already graduates would be more mature and more prepared to be responsible for their own learning and are therefore better equipped to respond to and profit from a PBL setting. At least some of the new graduate courses will be PBL ones.) Perhaps because of the young age of the majority of entrants, the majority of the 40 or so United Kingdom medical schools have taken the decision not to go via the PBL route: in fact only three have become almost completely problem-based: Manchester, Liverpool, and Glasgow. However, the non-PBL schools have changed their curricula significantly following the precepts of the document Tomorrow's Doctors produced in 1993 by the General Medical Council, the controlling body for United Kingdom medical education [2]. This document said that it was recognized that there was too much information and that medical students were being asked to remember too much of it rather then develop other skills and attitudes that would be appropriate for the future medical practitioners. The curriculum, it suggested, should be pared down to an essential “core,” and there should be opportunities for students to choose from a selection of optional courses in subjects that interested them (“special study modules,” SSMs) and that should take up about 30% of the curriculum time. The other major change that Tomorrow's Doctors suggested, and which the majority of medical schools took up in various ways, was to reorganize the curriculum so as to be integrated both horizontally and vertically. “Horizontally” meant doing away with the subject boundaries, especially in the preclinical or basic science areas, so that there were no Anatomy, Biochemistry, Physiology, and Pharmacology courses as such. Most of the medical schools have in fact put in place some variant of a “systems-based curriculum” in which all of the subject areas are mixed up in the various courses, for example, “The Cardiovascular System” or “The Musculo-skeletal System.” “Vertically” means that that preclinical-clinical divide should be fuzzed such that even in their 1st year students should start to get some clinical exposure and experience by, for example, visiting clinics, spending time with a general practitioner, or shadowing a nurse. This may not be seen as all that relevant to the discussion of the failure of PBL described by Glew. However, it may be said that the fuzzing of the boundaries, albeit not without pain and resistance by faculty as one may imagine, has put medical schools on the right road to more medically relevant basic science teaching in which medical problems are considered as such. In this scenario it is not so difficult to bring in PBL, and in fact many of the “non-PBL” medical schools do in fact run some classes as PBL sessions, in other words they do partial PBL. In our own medical school some laboratory practical classes have been replaced by PBL sessions. This has not been totally plain sailing, but the gentle introduction of PBL has allowed us to proceed cautiously without the trauma of a “big bang” approach. It certainly means that the students have a varied diet of some lectures, some labs, some small group tutorials, and some PBL sessions plus opportunities to go out on visits and to take SSMs. What of the United Kingdom medical schools that embraced PBL fully? There is no doubt that some of them have been very successful, especially those where there has been full commitment of all of the faculty. In others the transition has not been so smooth possibly because there has not been full commitment. In all, some lectures are given at least in the early part of the course partly because the high school experience of the incoming undergraduates is heterogeneous. (Whereas it is conceivable to start from an almost zero knowledge base when faced with a problem posed in a PBL session and to find information and teach yourself, it can be a rather slow way to do things.) Anecdotal evidence from the Manchester University Medical School [7] is that the medics turned out at the end are no worse than medics produced by the traditional route (although they probably do have a lower level of basic knowledge) but tend to be different in character, perhaps more open-minded and enquiring. However, the other thing that has been noticed is that this starts before entering the medical school. Some students still prefer the traditional route of medical education, while others specifically opt for PBL courses, so perhaps it is not so much the courses themselves but the character of the individuals entering and emerging from them. What Glew [1] is saying in his article is that, although the theory is good, the implementation in many American medical schools has been less than good. The basic scientists never really embraced the basic philosophy of PBL and have felt disempowered by the clinicians, no longer being seen as knowledge experts (albeit in a rather small knowledge area) but rather as facilitators. The clinicians had little regard for the amount of basic science knowledge alleged to be needed by the practicing physician (“You will never need to know this when you get to practice … ”), thus weakening the basic scientists' case, but have also been less than committed in turning up to run tutorials and small group sessions, etc. One can understand the arguments of the basic scientists who receive credit for doing research and getting grants but get little actual credit for teaching medical students, and those of the clinical staff who have a heavy load of clinics and patients to deal with as well as emergencies. But all of this conspires to confound worthy attempts to change the basic way in which we teach—away from teaching facts to encouraging students to learn in ways in which their learning is contextualized so that they develop their own knowledge structures. As has been said many times before, if you are going to change over to PBL you need a strong Dean who is committed and will provide resources and who will endeavor to achieve wholesale commitment from the teaching staff [8]. One cannot help but agree with the majority of what Glew says in his article, namely “theory OK, implementation (in some cases) not so good,” for the reasons he enunciates. Recognizing the different situations in the United States and the United Kingdom (while well understanding them), what should one do? The conclusion might be that conversion to PBL does not have to be 100%: a little-by-little approach can work and give one the opportunity to try things out and also demonstrate how it works to one's skeptical colleagues before proceeding further. Moreover, if this is done in the context of curriculum change in the direction of an integrated curriculum, then it is more likely to be successful. This does not get away from the fact that commitment and belief in the philosophy of PBL are absolutely vital nor does it get away from the fact that the small group teaching required by PBL is more “uneconomic” in terms of faculty time and that there is inevitably pain to be experienced by faculty in changing from subject experts to facilitators. Alvin Newman, Director of Curriculum Development, University of Toronto Medical School, wrote in 1993 [9]: “The Faculty of Medicine of the University of Toronto has undertaken a dramatic renewal of its undergraduate curriculum. We recognized the need for change and forged a consensus among our students and faculty that change was important, urgent and worthwhile.” It is important to note that this was recognized as a major change and that it was vital that “everyone was on board.” Even at the time that he was writing (after the course had been running for about 1 year) he foresaw that there could be problems (students fixated on the exams, methods of assessment not changing at the same rate as the curriculum, and student preferring “spoon feeding” to thinking), but this did not alter his conviction that this change was the right thing to do. The bottle theory of education: a naïve view. The student is a vessel to be filled up with information. When the bottle is filled the student is ready to graduate and be sent out into the world. Unfortunately not all of the information is captured by the bottle. Moreover the information contained within the bottle may not be the right information the student needs to solve future problems (there is no way of putting it all in), and indeed the information required may not even have been discovered at the time of graduation. Consequently, to function successfully in one's career, life long learning is vital. Furthermore the skills of finding and using information are just as important as being able to remember facts.

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