Problem-based learning: its rationale and efficacy

Paul M Finucane, Steve M Johnson and David J Prideaux

Problem-based learning (PBL) in medical education uses clinical cases as the context for
students to study basic and clinical sciences. Its possible advantages over traditional
approaches include its greater relevance to the practice of medicine, its ability to promote
retention and application of knowledge, and its encouragement of self-directed life-long
learning. Possible disadvantages include higher costs, both in resources and staff time.
Although its efficacy is difficult to evaluate, the current enthusiasm for PBL seems justified
and its use is likely to increase further. (MJA 1998; 168: 445-448)

Introduction - What is PBL? - Rationale for using PBL - Is PBL effective? - Advantages of PBL - Disadvantages
of PBL - Future directions in PBL - Acknowledgements - References - Authors' details
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Introduction Medical schools [which fail to implement educational reform] will

continue to graduate doctors who are, on the whole, largely adequate,
but who could be so much more. Max Kamien1

After much criticism and calls for reform in medical education,2-4

several Australian medical schools have made fundamental changes in
student selection processes, curricula, teaching strategies and assessment
methods. The Karmel Report in 19735 -- which concluded that
Australian medical school curricula were too science- oriented, not
innovative and neglected primary care -- stimulated changes in existing
medical schools. It also led to the establishment of a new medical school
in Newcastle, in 1978, with a mandate for innovative approaches to
medical education.6 Among its many innovations, the Faculty of
Medicine at Newcastle emphasised learning through the study of clinical
problems (ie, problem-based learning [PBL]).7,8

Although new to Australia, PBL was by then well established at

overseas institutions, most notably McMaster University in Canada,
where PBL was introduced in the medical curriculum in 1969.9,10 The
PBL "experiment" has been endorsed as an educational strategy by the
World Federation of Medical Education11 and the World Health
Organization.12 By 1991, some 100 medical schools in the United States
had embraced PBL to varying extents,13 and PBL is now an entrenched
component of medical school programs in Canada, the United Kingdom,
the Middle East and Asia.14 PBL is widely accepted in Australia, and the
three medical schools with recently developed graduate entry programs
(Flinders University of South Australia, the University of Sydney and
the University of Queensland) have based their new curricula on PBL.15
Other Australian medical schools are also adopting PBL. By the year
2000, more than 50% of Australia's doctors will have graduated from
schools with PBL-based curricula. While PBL has been developed
primarily for the early years of medical education programs, there is
increasing interest in PBL in the clinical years.16-18
What is PBL? Definitions of PBL vary, but a comprehensive example would be "an
educational method characterised by the use of patient problems as a
context for students to learn problem-solving skills and acquire
knowledge about the basic and clinical sciences".19 Students usually
meet in small groups two or three times a week for PBL tutorials. They
are presented with a clinical problem (eg, a patient with chest pain), and,
in a series of steps, they discuss possible mechanisms and causes,
develop hypotheses and strategies to test the hypotheses, are presented
with further information, and use this new information to refine their
hypotheses, finally reaching a conclusion. A tutor usually acts as a
facilitator, guiding students in this group-learning process.

In the course of this exercise, students identify both their existing levels
and gaps in their knowledge. These gaps form the basis for independent
learning outside the PBL tutorials. The identification and pursuit of
these so-called "learning goals" is a key element of the PBL process.
Rationale for using The PBL approach is based on principles of adult education20 and
PBL cognitive psychology.21 It differs fundamentally from traditional
curricula, in which students acquire "background" knowledge of the
basic sciences in the early years of the course and in the later years
apply this knowledge to the diagnosis and management of clinical
problems. This traditional approach has been criticised for a number of
reasons:4,22,23

• It creates an artificial divide between the basic and clinical

sciences;
• Time is wasted in acquiring knowledge that is subsequently
forgotten or found to be irrelevant;
• Application of the acquired knowledge can be difficult;
• The acquisition and retention of information that has no apparent
relevance can be boring and even demoralising for students.

Theoretically, PBL, with its educational objectives24 (Box 1), can avoid
many of these problems.25 Various disciplines, particularly the basic and
clinical sciences, are integrated throughout the curriculum. As students
attempt to understand and solve clinical problems, they learn about
normal bodily structure and function, and apply this knowledge to their
search for a solution. Learning occurs in context and builds on what
students already know. In theory, this process can aid retention,10,21,26,27
add interest14,19,21 and increase motivation to learn.21 Students (with
initial help from tutors) determine both their own learning needs and the
strategies they need for learning (eg, the efficient accessing of library
resources or the formation of study groups).
Is PBL effective? The efficacy of PBL is difficult to evaluate,28 as it is generally
introduced together with other changes in the curriculum and along with
changes in student selection, staff development, and assessment
procedures. With so many confounding variables, it is hard to determine
the extent to which PBL contributes to any detected change in outcomes.
Many of the early claims for its effectiveness were based on the
anecdotal evidence of enthusiasts. Empirical research often consisted of
small and highly specific studies from single centres, and the ability to
generalise from such findings is uncertain. Pooling information to gain
an overview of the advantages of PBL is difficult and may be
misleading. For example, there are considerable differences in what
individual medical schools even consider to be PBL.29

Conclusions about the effectiveness of PBL are thus tentative, and the
methodological and logistical problems which constrain educational
research make it very difficult to conduct randomised controlled trials.
Indeed, few such trials have been, or are ever likely to be, undertaken.
Advantages of PBL The justification for PBL lies in its compatibility with modern theories
of adult learning, together with evidence of efficacy in some areas.
Recent reviews highlight the aspects of PBL generally agreed to be
effective and those aspects whose efficacy is controversial19,21,28,30 (Box
2).

Most students enjoy the active participation which PBL fosters and
consider the process to be relevant, stimulating and even fun,19,31 while
teachers tend to enjoy the increased student contact.19 Students and
teachers report that the learning environment created by PBL is more
convivial as traditional barriers between students and faculty are
lowered.14
 There is convincing evidence that PBL fosters self-directed learning
skills10,21,26,27,32 and this may help medical school graduates to be life-
long learners.32-34 PBL activities also bring together faculty from
different disciplines, initially in planning and developing the curriculum
and later in teaching and assessing students -- promoting interaction
between basic scientists and clinicians. This can have important spin-
offs in fostering collaborative research, improving the delivery of
clinical services and enhancing the work environment.

In other areas, however, PBL seems not to have lived up to expectations.

There is no evidence that PBL curricula are any better than traditional
curricula in achieving one of their prime aims -- the fostering of clinical
reasoning and problem-solving skills. Also, while there is both
theoretical support and anecdotal evidence that PBL enhances
motivation and helps in the development of interpersonal skills, these
effects have never been proven.30
Disadvantages of The criticism most often voiced is that PBL is costly, in demands of
PBL staff time and teaching materials and other physical resources (Box 3).
Both initial and on-going costs should be considered -- considerable
energy and resources are needed over several years to develop the
curriculum and to train tutors and students in the PBL process. Most
schools need to import expertise to help initiate, develop and sustain
PBL.
Once up and running, a PBL curriculum can be demanding of staff time;
Des Marchais estimated that the introduction of PBL at Canada's
University of Sherbrooke increased the teaching load by 30%.31
However, at the University of New Mexico, PBL increased the contact
time between students and staff without increasing the overall teaching
load.35 The demand on teaching staff is largely determined by class size.
Compared with the costs of lecture-based curricula, the relative costs of
PBL-based curricula increase with increasing class size. The "break-
even" point (ie, the point where the costs of PBL and conventional
curricula are the same) appears to be with annual student intakes of
about 4030 or 50.33

Other necessary resources for PBL include properly furnished and

equipped tutorial rooms. For successful PBL, ready access to first-class
library and computer facilities is a necessity rather than a luxury.
Accordingly, PBL may not be economically viable for medical schools
whose annual student intake exceeds 100.19 However, some large
medical schools have recently introduced PBL-based courses. For
example, the University of Queensland, with a medical student intake of
240, introduced a PBL-based graduate entry medical program in 1997
(D Price, Senior Lecturer in Medical Education, personal
communication). It is probable that technological advances, particularly
in computing and telecommunications, have enhanced the ability of
large medical schools to deliver PBL-based curricula.

Another possible disadvantage of PBL is its relative inefficiency -- some

research suggests that PBL curricula cover about 80% of what might be
accomplished in a conventional curriculum in the same period.19 There
are particular concerns about students' grounding in the basic sciences,
with some evidence (although confounded by uncontrolled variables,
including the effects of admission policies) that students from PBL-
based schools do less well than those from traditional schools in the
basic science component of the US National Board Examinations.28
However, it is argued that, as much of the basic science content in
traditional curricula lacks relevance and is quickly forgotten,22 it matters
little that PBL students fail to learn or remember such material.

PBL can also be stressful for both students and staff, at least until they
become familiar with the process.30 Most students come to PBL from
educational backgrounds where teachers direct learning. By contrast,
PBL does not limit what students may choose to learn, and the process
 may provide little guidance on the best ways of achieving learning
goals. Students may be concerned that their learning strategies are
misdirected or inefficient. These concerns should be anticipated and
addressed within PBL tutorials where students develop and refine the
necessary skills.Yet one study which compared levels of student stress
in a traditional and a PBL curriculum found that PBL was less
stressful.36 Some teachers find that PBL is unduly demanding of their
time and some are uncomfortable in small-group situations and with
their role as facilitators. Tutor training is needed to address these issues.

Finally, as accounts of PBL have come mainly from medical schools

where it was implemented in the context of major curricular reform,
with much enthusiasm and investment in the process, the "Hawthorne
effect" -- where enthusiasm per se influences the outcome -- may have
been operating, and it may be difficult to differentiate enthusiasm for the
new curriculum from real gains in student learning. The introduction
and maintenance of PBL in less fertile educational environments may be
more problematic.
Future directions The pendulum of educational reform is swinging away from traditional
in PBL approaches and towards PBL with such momentum that further
emphasis on PBL seems inevitable. Yet PBL and traditional curricula
are far from incompatible, and Berkson argues that the two will
gradually merge.30 As commitment to the principles of adult learning
and the creation of a more stimulating and supportive learning
environment become more common goals for both students and
teachers, traditional curricula will face pressure to become more
integrated and interactive. Resource limitations and other constraints
may force some medical schools with PBL-based curricula to revert to
traditional learning methods. Yet advances in educational technology
(eg, teleconferencing, computer-assisted learning) may well lessen the
resource demands of PBL and make it more attractive to larger
institutions.

PBL is not a panacea for all the current ills in medical education.34 Of
the three major variables in learning -- students, teachers and curriculum
-- the latter is probably the least important.37 Nevertheless, the effect of a
well designed curriculum in facilitating learning should not be
underestimated. The current level of enthusiasm for PBL in Australia's
medical schools seems well justified.
Acknowledgements The authors acknowledge the staff and students of the School of
Medicine at Flinders University of South Australia for providing the
context for the writing of this paper.
References 1. Kamien M. The reform of medical education. Med J Aust 1993;
158: 226-227.
2. World Health Organization (1973). Training and preparation of
teachers for schools of medicine and of allied health sciences.
Geneva: World Health Organization Technical Report Series, No.
521.
3. Muller S. Physicians for the twenty-first century: report of the
project panel on the general and professional education of the
 physician and college preparation for medicine. J Med Educ 1984;
59: 1-208.
4. Lowry S. What's wrong with medical education in Britain? BMJ
1992; 305: 1277-1280.
5. Expansion of medical education: Report of the Committee on
Medical Schools to the Australian Universities Commission.
Canberra: AGPS, 1973.
6. Clarke R. The new medical school at Newcastle, New South Wales.
Lancet 1978; I: 434-435.
7. Maddison D. A medical school for the future: the Newcastle
experiment. World Health Forum 1980; 1: 133-138.
8. Leeder SR. An Australian approach to medical education -- The
Newcastle experiment. Med J Aust 1984; 140: 158-162.
9. Neufeld VR, Barrows HS. The "McMaster Philosophy": an
approach to medical education. J Med Educ 1974; 49: 1040-1050.
10. Barrows H, Tamblyn R. Problem-based learning: an approach to
medical education. New York: Springer, 1980.
11. Walton HJ, Matthews MB. Essentials of problem-based learning.
Med Educ 1989; 23: 542-558.
12. Fulop T. Setting the stage: Problem-based learning in the mirror of
the great social target -- health for all. In: Schmidt HG, deVolder
ML, editors. Tutorials in problem-based learning: a new direction.
Assen, The Netherlands: van Gorcum, 1984: 1-5.
13. Jonas HS, Etzel SI, Barzansky B. Educational programs in US
medical schools. JAMA 1991; 266: 913-920.
14. Blight J. Problem based, small group learning: an idea whose time
has come. BMJ 1995; 311: 342-343.
15. Geffen LB. The case for graduate schools of medicine in Australia.
Med J Aust 1991; 155: 737-740.
16. van der Vleuten C, Wijnen W. Problem-based learning:
perspectives for the Maastricht experience. Amsterdam: Thesis
Publishers, 1990.
17. Tosteson D. New pathways in general medical education. N Engl J
Med 1990; 322: 234-238.
18. Barrington D, Wing L, Latimer K, et al. Evaluation of a change
from traditional case studies to patient-based, problem-based
learning: a case study. Med Teach 1997; 19: 104-107.
19. Albanese MA, Mitchell S. Problem-based learning: a review of
literature on its outcomes and implementation issues. Acad Med
1993; 68: 52-81.
20. Knowles M. The adult learner: a neglected species. Houston: Gulf
Publishing Company, 1990.
21. Norman GR, Schmidt HG. The psychological basis of problem-
based learning: a review of the evidence. Acad Med 1992; 67: 557-
565.
22. Schmidt HG. Problem-based learning: rationale and description.
Med Educ 1983; 17: 11-16.
23. Des Marchais JE, Bureau MA, Dumais B, Pigeon G. From
traditional to problem-based learning: a case report of complete
curriculum reform. Med Educ 1992; 26: 190-199.
24. Barrows HS. Problem-based, self-directed learning. JAMA 1983;
 250: 3077-3080.
25. Schmidt HG. Foundations of problem-based learning: some
explanatory notes. Med Educ 1993; 27: 422-432.
26. Blumberg P, Michael J. Development of self-directed learning
behaviours in a partially teacher-directed problem-based learning
curriculum. Teach Learn Med 1992; 4: 3-8.
27. Dolmans DHJM, Schmidt HG. What drives the student in problem-
based learning? Med Educ 1994; 28: 372-380.
28. Vernon DT, Blake RL. Does problem-based learning work? A
meta-analysis of evaluative research. Acad Med 1993; 68: 550-563.
29. Wolf FM. Problem-based learning and meta-analysis: can we see
the forest through the trees? Acad Med 1993; 68: 542-544.
30. Berkson L. Problem-based learning: Have the expectations been
met? Acad Med 1993; 68: S79-S88.
31. Des Marchais JE. A student-centred, problem-based curriculum: 5
years' experience. Can Med Assoc J 1993; 148: 1567-1572.
32. Shin JH, Haynes RB, Johnson ME. The effect of problem-based,
self-directed undergraduate education on lifelong learning. Can
Med Assoc J 1993; 148: 969-976.
33. Donner RS, Bickley H. Problem-based learning in American
medical education: an overview. Bull Med Libr Assoc 1993; 81:
294-298.
34. Headrick L, Kaufman A, Stillman P, et al. Teaching and learning
methods for new generalist physicians. J Gen Intern Med 1994; 9:
S42-S49.
35. Mennin SP, Martinez-Burrola N. The cost of problem-based vs
traditional medical education. Med Educ 1986; 20: 187-194.
36. Moore-West M, Harrington DL, Mennin SP, et al. Distress and
attitudes toward the learning environment: effects of a curricular
innovation. Teach Learn Med 1989; 1: 151-157.
37. Sinclair D. Basic medical education. London: Oxford University
Press, 1972: 1-19.
38. Finucane P, Allery LA, Hayes TM. Comparison of teachers at a
"traditional" and an "innovative" medical school. Med Educ 1995;
29: 104-109.
39. Vernon DTA. Attitudes and opinions of faculty tutors about
problem-based learning. Acad Med 1995; 70: 216-223.
40. Dolmans D, Schmidt H. The advantages of problem-based
curricula. Postgrad Med J 1996; 72: 535-538.
41. Newble DI, Clarke RM. The approaches to learning of students in a
traditional and in an innovative problem-based medical school. Med
Educ 1986; 20: 267-273.
42. Engel CE. Problem-based learning. Br J Hosp Med 1992; 48: 325-
329.
(Received 10 Jan, accepted 4 Sep, 1997)