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2013; 35: 95–100

TWELVE TIPS

Twelve tips on how to survive PBL as a medical


student
E. BATE & D.C.M. TAYLOR
The University of Liverpool School of Medicine, UK

Abstract
Background: Starting medical school can be both exciting and daunting. This is particularly the case when the style of learning is
different from that which has been experienced previously. For many students, their first experience of learning through a
problem-based learning (PBL) approach is when they commence their medical student programme.
Aim: This article provides 12 tips on how to survive PBL as a medical student.
Methods: The tips have been based on the authors’ experience of PBL and the current literature evidence base. A chronological
order was used for the tips to guide the reader, whether student or PBL facilitator, through tips for the various stages of the PBL
process.
Results: These 12 tips provide students and PBL facilitators with 12 practical tips to help them to realise the learning process and
rationale for PBL. The tips commence with surviving the initial PBL sessions and continue through the process, finishing with the
use of PBL in the clinical setting where the written scenarios are replaced by patient case histories.
Conclusion: Using a PBL approach facilitates the learning of clinical and science knowledge in context through clinical scenarios,
whilst working and learning together as a group. It is envisaged that these tips will be beneficial for PBL facilitators working with
students that are new to PBL, and for the PBL students themselves.

Introduction Although learning through PBL can be challenging,


especially initially, it is good preparation for the continuous
Problem-based learning (PBL) is incorporated, to a greater or self-motivated life-long learning, required for a career in
lesser extent, within the curriculum of many medical schools medicine, and it is hoped that these 12 tips will help both PBL
world-wide (Taylor & Miflin 2008). The original theory facilitators working with new students and students them-
formulated by Barrows, was implemented in McMaster selves, to learn to learn through PBL.
University medical school in 1969 (Spaulding 1969). The
‘McMaster philosophy’ fostered the PBL approach whereby
students work in small groups on a health problem, identifying Tip 1
their own educational needs and being responsible for the
acquisition of the knowledge required to understand the Firstly, try not to panic about PBL
scenario (Neufeld & Barrows 1974).
As mentioned above, the transition to PBL may be a daunting
The rationale for the use of PBL and andragogy in medical
prospect, particularly if previous study has taken the form of
education has been extensively studied, and is grounded in
predominantly didactic, lecture-based teaching. Some students
cognitive psychology (Schmidt 1993). The use of clinical
(and tutors) find this transition stressful; with PBL becoming a
scenarios, promotes active learning, building on epistemic
‘threshold concept’ or an area of ‘troublesome knowledge’ that
curiosity (Maudsley 1999). Activating the prior knowledge,
13

prevents commitment to PBL (Savin-Baden 2006; Kamei et al.


drawing on previous experiences, helps understand the
2012). To help overcome this, it is important to (Land et al. 2005):
20

scenario, and aids the integration of future learning within


this prior knowledge scaffold (Dewey 1938). This facilitates (a) Understand the rationale for PBL.
deep learning in context (situated learning) (Durning & (b) Tolerate the initial uncertainty and persevere, engaging
Artino 2011), which is associated with subsequent improved with the PBL process.
application and recall of the knowledge (Harris & Alexander (c) Have confidence in the system; PBL has been used since
1998). PBL is a form of collaborative learning whereby PBL 1969, with increasing evidence demonstrating that
groups work together throughout the whole process. students graduating from PBL curricula are more pre-
Collaborative learning has been shown to promote student pared for work as a doctor (Schmidt et al. 2006;
motivation to learn, reasoning skills, elaboration and deep Watmough et al. 2006).
learning (see Bossert 1988, for an overview; also Dolmans (d) Be patient and realise that different members of the PBL
et al. 2005). group will experience PBL as a threshold concept to a

Correspondence: Dr. Emily Bate, School of Medicine, The University of Liverpool, Liverpool, L69 3GE, UK. Tel: 0151 794 8747; fax: 0151 795 4369;
email: e.bate@liv.ac.uk
ISSN 0142–159X print/ISSN 1466–187X online/13/020095–6 ß 2013 Informa UK Ltd. 95
DOI: 10.3109/0142159X.2013.759198
E. Bate & D. C. M. Taylor

variable extent, possibly dependent on their previous articulate prior knowledge aids the processing of new
exposures or pre-conceived understanding ( pre-liminal information, and the subsequent retention and recall of
variation) (Meyer & Land 2005). the information being learnt (Norman & Schmidt 1992).
For example, when working on the scenario about reproduc-
Once the initial stage of liminality associated with PBL has
tion, take the time to discuss and draw the processes of
been left, learning through PBL should be an exciting journey,
meiosis and mitosis recalled from an earlier educational
whereby clinical scenarios are used to prompt the identifica-
experience. This demonstrates how much is already known
tion of knowledge gaps and to guide learning in context.
by the group and enables the identification of the learning
objectives required, such as; how meiosis occurs in gamete
Tip 2 formation and how this differs between males and females.
If prior knowledge is not activated most groups form large
Work with your PBL group non-specific learning objectives (which are difficult for the
PBL group sessions are a core component of a PBL course and individuals to interpret), and the recall of any new information
typically a group will work together for an extended period of learnt may be jeopardised (Norman & Schmidt 1992).
time. Take the trouble to get to know the group; perhaps
consider organising a group meal or event. This helps the Tip 4
group to move into the ‘performing’ stage of group develop-
ment (Tuckman & Jensen 1977). Recognise that there is no syllabus per se
The PBL group should not just be a study group, but should
develop into a ‘community of practice’ within which the group Even though there may be a formal syllabus, this is only part of
members work together to achieve and learn the necessary the story. The syllabus is what is needed to be known to
information required to understand the clinical scenarios as a perform as a competent foundation year doctor. Remember
group of medical students, and eventually, progress to become though, that everything cannot be learnt at once, and that you
junior doctors (Lave & Wenger 1991). will be continuing to learn throughout your medical career, as
As mentioned earlier, collaborative learning is an important treatments develop and understanding of pathology changes.
component of PBL because understanding and meaning are This was acknowledged in the General Medical Council’s
socially constructed through collaboration and discussion with (GMC’s) Tomorrow’s Doctors 2009, which encourages the
others (Michaelsen et al. 2002). development of competent foundation doctors with the
Within the PBL sessions, ensure that concepts and learning ability to continue learning and remain up-to-date throughout
are discussed, elaborating on ideas as a group. The importance their postgraduate career (Margetson 1999; General Medical
of social interaction for learning has long been established; Council 2009).
Piaget described the effect of social environment on intellec- Nevertheless, at the start of each PBL module there will
tual development through the stimulation of learning, and seem to be a large body of new information that needs to be
Vygotsky described the zone of proximal development as the studied. This can be quite daunting. First, it is important to
difference between an individual’s knowledge level and the activate the groups’ prior knowledge (see Tip 3), and then, use
development level realised through interaction with others this prior knowledge to form SMART (Specific, Measurable,
(Vygotsky 1978; Palincsar 1998; Piaget 2001). Visschers-Pleijers Attainable, Relevant and Time-bound) learning objectives
and colleagues analysed the group interactions during the PBL (Garbutt 1996).
sessions, aiming to learn more about the collaborative learning
processes occurring (2006). This study demonstrated that 63% Tip 5
of the group time was spent on cumulative reasoning, whilst
only 10% was spent on asking explanatory questions of each Work to an appropriate depth for you
other, and 7% on handling conflict about the knowledge
(Visschers-Pleijers et al. 2006). It is at the points of cognitive What depth should I be studying to? How do I know that I am
conflict or discourse that learning is thought to be occurring. working to the correct level? What if my PBL group is not
Consequently, it is important to try to ask ‘critical questions’ of studying topics in sufficient detail to enable us to pass the
each other and to counter statements or theories to optimise exams?
collaborative learning within the PBL sessions (Visschers- These are common concerns that are raised by students
Pleijers et al. 2006). when learning through PBL. It is important to work as a group.
In the feedback sessions, share learning with the group –
collaborate. This can help to demonstrate the varying depths
Tip 3 different group members have gone to, which should guide
the learning process, along with prompts from the facilitator.
Ensure that the group activates prior knowledge
Remember though, the depth that a student needs to study to
before forming the learning objectives
within each area will be individual (as each student will bring
This is easily (and, in our experience, frequently) omitted, but to the group a unique ‘prior knowledge’). Each student will
it is an essential step. Prior knowledge forms the foundation have their own individual learning needs and plan at the end
for the construction and transformation of new knowledge of the PBL session, stemming from the groups’ shared
(Duffy & Cunningham 1996). Taking the time to actually objectives.
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Surviving PBL as a medical student

Another guide can be the resources provided by the question each other’s ideas and concepts, aiming to resolve any
university. These can range from the plenary sessions, to confusion or queries together. To facilitate this, listen to each
anatomy dissection or demonstration classes. It is important to other, maintain confidentiality and share experiences. You are
identify the resources that are meaningful to you; there is little not competing in the PBL setting and the more you actually put
point forcing yourself to read a book or resource that you do into the session the more you get out of it.
not understand. Instead, start with a resource at your level of Try to engage the entire group through the use of open
understanding and progress to the more in-depth resources. questions, such as ‘what does everyone else think?’ Another
Try not to simply rote learn the information needed just to ‘tick method is to ensure that every person in the group writes on the
off the objective’. Aim to understand the principles, for board/flipchart at least once in each session. Setting ground
example, the physiology, so that the pathology then makes rules as you begin to work with every new PBL group has been
sense to you. This will enable you to identify why, for identified as a method to help groups to function successfully
example, the symptoms described in the scenario may be (Hitchcock & Anderson 1997). This set of agreed ground rules
occurring. can subsequently be referred to in order to help the group work
effectively together. As a group, it is the responsibility of
everyone, including the tutor, to address any issues that could
Tip 6 lead to the group being dysfunctional as soon as possible,
otherwise student learning can be jeopardised.
Use PBL to help develop a learning approach that is The ability to lead and promote good teamwork within a
best for you and study using different resources group is not only essential as a PBL student, but also when
Have the confidence to learn from different resources, not only working in a multi-disciplinary team as doctors (General
textbooks and lectures, but journal articles, the Internet, Medical Council 2009).
patients, experience and each other. Appraise your sources
critically and cross-reference them. Some sources may explain
ideas more clearly than others and may be more up-to-date.
Tip 8
In addition to utilising a variety of resources, it is important
to develop learning techniques that are best for you, e.g. Respect differing viewpoints expressed by other
highlighting information, drawing quick mind-maps, writing members of the group
notes or practising questions on the topic, remembering that Pooling of resources and information learnt facilitates discus-
the time is finite and that the most efficient and effective way of sion enabling the investigation of different views. Remember
learning for you is the best way. A warning though, the way that there may be no correct answer. Medicine is rarely certain
that works best for you for examinations which only test recall and there are often many valid possible answers. Some
may not serve you well as a medical student. members of the group will find this easier to accept than
Students on a PBL course often have a more flexible others, which was expressed by Perry in his scheme for
timetable. Ensure that you do not leave your PBL learning until intellectual and ethical development (Kloss 1994; Perry 1999).
the night before the next session. Try to work steadily on the In this scheme, students progress through four main categories
objectives throughout the week, gradually building on your of knowledge:
understanding, using a variety of resources. Entwistle
(Entwistle et al. 1979) described three approaches to learning; (1) Dualism – there is one right solution to a problem, and
deep, strategic and superficial. Revising facts the night before that is what is learnt from the teacher.
the PBL sessions to recite would be considered superficial (2) Multiplicity – there is an appreciation that there are
learning, whilst deep learning is where a thorough in-depth many different solutions to a problem and that views of
understanding of the topic and its processes is achieved. peers are acceptable, but the teacher is still correct.
Strategic learning, meanwhile, is learning what is perceived to (3) Relativism – the merits of the different opinions can be
be necessary to pass the exams. weighed up and information from peers and teachers is
Although it is acknowledged that a strategic approach to accepted and compared.
learning is sometimes required, especially during the one- (4) Commitment – the knowledge learnt from multiple
week run up to the final examinations, the PBL process aims to sources can be appraised and amalgamated, alongside
foster deep learning approaches whereby knowledge is personal experience, which can then be applied to
understood and learned in context, and is therefore retained everyday problems.
and easily retrievable. This can be related to within the PBL group setting, as
gradually a greater range of resources are used by the group,
as opposed to the one ‘correct’ textbook. Different members of
Tip 7
the group may find it easier than others to reflect critically on
the different views expressed and appreciate the lack of one
Encourage equal participation from all group mem-
‘correct answer’. It is important to discuss differences of
bers and ask questions of each other
opinion thoroughly within the group as it is this ‘discourse’ that
Ensure that the group utilises the PBL sessions, to share their stimulates deeper reflection on ideas and subsequent learning
learning, but also to learn from each other within the group. across Vygotsky’s ‘zone of proximal development’ (Vygotsky
These sessions provide a safe learning environment in which to 1978; Palincsar 1998).
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E. Bate & D. C. M. Taylor

Tip 9 Tip 11

Ensure that all curriculum themes (e.g. anatomy, Reflect and evaluate yourself and each other giving
physiology, pathology, public health, psychology and constructive feedback to your peers and tutor at the
ethics) identified by the scenario are studied and end of each session
applied
In doing this, the group’s PBL process improves session by
The PBL scenarios are based on clinical situations. session. An increasing evidence base demonstrates that PBL’s
When considering the learning objectives required to under- andragogical processes are not sufficient alone to promote
stand the scenario, ensure that all aspects of the ‘patient’ deep learning, but need to occur with concurrent peer, and
are considered, for example, in a scenario about a diabetic self-evaluation, and formative assessment (Rushton 2005;
patient: Papinczak et al. 2008).
Dolmans et al. described two of the main problems
Think about the structure and function of the
occurring within PBL as; dysfunctional tutorial groups and
pancreas. What is diabetes and what is the aetiology
tutors being too directive (2005). Problems occurring within
of diabetes? How do you manage and treat it, and
PBL groups leading to them being dysfunctional can range
how is diabetes managed by different health profes-
from; groups that are cynical about the PBL process causing
sionals? What are the implications socially and
the lack of engagement and adherence to the PBL steps, to,
psychologically for patients diagnosed with, and
group members not preparing sufficiently for the sessions
living with diabetes? What could be the impact on
(Dolmans et al. 2005). One of the main methods for addressing
family and social life of being diagnosed with
these issues is through the group evaluation at the end of every
diabetes? Is it an important public health issue, and
PBL session, where all members are encouraged to participate.
how has its prevalence varied over the past 10 years?
Questions to consider during the evaluation include: What
The list continues.
went well/not so well in the session? Did the group work
Similarly, when discussing the learning outcomes in the together with everyone participating? Was time well managed?
feedback sessions, try to integrate the different themes. Did the learning objectives formed help the group to under-
Integrating the information learnt in this way, helps the stand the scenario? How could the group improve on any of
formation of an organised knowledge network that can be the above issues for further sessions? (Holen 2000).
easily retrieved and activated by future similar situations. In addition to this, reflection on your own learning and
This ‘situated learning’ with the formation of ‘schemas’ knowledge is vital as part of the learning process. As identified
or ‘illness scripts’ (Collard et al. 2009) has been shown earlier, Dewey described the importance of recognition of
to significantly improve the amount of structured prior experience in the formation of new learning (1938),
knowledge learnt by 38–40% compared to the students which was later expanded by Kolb in his experiential learning
using non-schema-based learning approaches (Blissett cycle. In this cycle (Kolb, 1984), prior knowledge or experi-
et al. 2012). ence (concrete experience) is reflected upon through self-
evaluation and peer feedback (reflective observation), from
which theoretical studies are undertaken (abstract conceptua-
lisation) followed by the implementation of what has been
Tip 10
learnt (active experimental isolation), which then forms the
new concrete experience to recommence the cycle (Maudsley
Do not use notes during the PBL sessions, but do
& Strivens 2000).
use the board/flipchart to help explain concepts in
The ability to provide and respond to peer feedback, in
your own words
addition to reflecting on your own learning, are essential
The ability to recall knowledge and express it coherently is components for the development of the self-directed, life-long
good preparation for the challenges to be faced as a doctor learning and self-efficacy required for a professional career
since questions will be posed not only by other healthcare (Papinczak et al. 2007a, b).
professionals, but also by patients. This is not always easy, but
explaining complex ideas and concepts to your peers reaffirms
and challenges your own knowledge and is good preparation
for your future career.
Tip 12
Working without notes also demonstrates and tests the
Apply the skills that you learn within PBL to other
level of understanding attained, as opposed to reading ability.
situations
By using the board to explain diagrams and concepts, this
focuses the group’s attention, and facilitates the discussion PBL is not just a process to be used purely during the set PBL
(Taylor & Miflin 2008). This also negates the need for notes, as sessions; remember to use and apply the skills that you learn
different members of the group can help the person writing on from PBL. The process of recognising knowledge gaps,
the board. Through conversation and debate group members revisiting current understanding and identifying new learning
fill in each other’s knowledge gaps, without having to read the objectives are important skills for continued professional
information from personal notes. development.
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Surviving PBL as a medical student

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