PBL: students' roles

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Problem Based Learning
Dr Reg Dennick Assistant Director of Medical
Education The University of Nottingham
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What do you already know/not know about PBL?

• Discuss with a partner.

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Learning Objectives

• Explain the educational rationale for PBL
• Describe the seven-step PBL process
• Participate/Observe in a partial PBL session
• Critically evaluate the evidence for the
  effectiveness of PBL

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?
Traditional PBL
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ANCIENT MEDICAL THEORY
LATIN GREEK
HIPPOCRATES ARISTOTLE GALEN
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GRAMMAR, PUBLIC SCHOOLS UNIVERSITIES Dominated
by Latin Greek Ancient history and
philosophy Theology MEDICINE Entry needed Latin
(Greek) All anatomical nomenclature in
Latin/Greek
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• Entry into medicine had a language and theory
  barrier going back to an ancient view of
  education. (Higher education was for an elite
  class using a secret language?)
• Even with rise of scientific medicine in 19th C
  the traditional medical curriculum had a
  Theory/Practice split and the requirement for
  Latin was not dropped till 1950s in UK

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Theory Practice

• In education there has been a historical split
  between theory and practice
• Theory has to be learned first before dealing
  with practice.
• PBL turns this split on its head.
• Problems deriving from practice are used as
  triggers to acquire theoretical knowledge

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PBL definition

• The learning which results from the process of
  working towards the understanding of, or
  resolution of, a problem
• (Barrow Tamblyn 1980)

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The most powerful learning occurs when the
student is dealing with uncertainty. John Dewey
Cognitive dissonance (Festinger)
Problems
Dis-equilibration (Piaget)
Paradigm shifts (Kuhn)
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Problem Based Learning

• A strategy for learning where small groups of six
  to eight students work in a series of tutorials
  discussing problems provided by the Faculty
  related to their course.

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PBL is a type of Small Group Teaching activity

• Content
• The Scenario
• The Problem
• The Context
• The Knowledge
• The Skills
• The Attitudes

• Process
• Talking
• Dialogue
• Questioning
• Hypothesising
• Collaboration
• Activity
• Communication skills
• Interpersonal skills

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PBL

• students engage in a collaborative activity
  that
• makes them think
• makes them ask questions
• activates prior knowledge
• tests their understanding
• elaborates new knowledge
• reinforces their understanding by speaking
• provides motivation for learning
• makes them practise a logical, analytical
  approach to unfamiliar situations
• Involves
• learning in context
• integrated learning
• collaboration

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PBL fulfils the conditions for effective adult
learning

• Relevant context
• Adults are self-motivated
• Adults learn best in groups
• Adults prefer doing to being told
• Active learning through posing own questions and
  finding own answers therefore student centred
• Integrated learning learning in a variety of
  disciplines simultaneously
• Deep learning for understanding metacognition
  reflection appropriate feedback opportunities
  for practice

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Where does it come from?

• Celstin Freinet (1896-1966)
• McMaster Medical School (Hamilton, Ontario) 1969
• University of Maastricht (1974)
• Manchester (1995)
• Liverpool etc (1997)
• Nottingham (Derby) 2003

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How does it work?

• Scenario
• Small group
• Generate questions
• Research questions
• Answer questions
• Communicate answers

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The Maastricht Seven Step PBL process

• Step 1 Clarify terms and concepts
• Step 2 Define the problem(s)
• Step 3 Analyse the problem(s) - Brainstorm
• Step 4 List of the analysis and possible
  solutions
• Step 5 Formulate Learning Objectives
• Step 6 Collect additional information focussed
  on Learning Objectives
• Step 7 Synthesise and present new information

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A PBL scenario
Ranjit Singh, 46, has just returned from the
Indian sub-continent where he visited his brother
and family for a period of one month. He lives
with his wife, their four children and his
parents in a three bedroom terraced house in the
Peartree district of Derby. He works as a waiter
in a local Indian restaurant. Recently he has
started coughing a lot, has little energy, is
losing weight and has developed a fever. He
visited his GP after he coughed up some blood and
developed chest pains. His GP suspects TB and has
sent a sputum sample for analysis and Mr Singh
for a chest X-ray.
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Learning Objectives for the PBL scenario

• Basic and clinical sciences
• Describe mechanisms and common causes of cough.
• Describe types of clinical investigations
  available for patients with cough. Interpretation
  of CXR.
• Outline the microbiology of mycobacterium
  tuberculosis.
• Describe the immune response to TB, its use in
  diagnosis and the tuberculin test.
• Describe clinical and pathological manifestations
  of TB.
• Outline the drug regimes for treating TB, their
  mode of action, side effects and the problem of
  drug resistance.

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Learning Objectives for the PBL scenario

• Community and population
• Describe the epidemiology of TB, the impact of
  socio-economic factors and its relation to HIV.
• Discuss the social and family issues associated
  with TB in the community.

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Learning Objectives for the PBL scenario

• Patient and Doctor
• Describe how communication problems can be dealt
  with in ethnic minorities.
• Awareness of perception of TB in Asian
  communities and problems of stigmatisation.
• Dealing with issues of confidentiality versus
  compulsory notification patient autonomy.
• Describe how to ensure compliance with complex
  and long-term drug regimes.
• Persuade family members to be immunised.

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Learning Objectives for the PBL scenario
Personal and Professional Development Doctor as
patient awareness of personal immune status.
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PBL students roles

• Work in a group of six to eight
• Meet for about an hour and a half two or three
  times a week
• Analyse, discuss and generate questions and
  learning tasks from the scenario
• Engage in self-directed learning
• Communicate results back to group

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PBL role of the facilitator

• The facilitator must let the students be
  responsible for their learning.
• The facilitator must let the students do the
  work.
• The facilitator has the role of monitoring and
  evaluating the discussion. Guidance is given in
  the form of suggestions.
• The facilitator has background information
  concerning the case under discussion.
• The facilitator may intervene if the students are
  not working or if the activity is starting to go
  in the wrong direction.
• The students may ask the facilitator for advice
  which can be given according to his or her
  judgement.

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Small group Facilitator styles Kurt Lewin

• Autocratic
• facilitator basically controls all the
  objectives and activities of the group and keeps
  intervening to ensure they are carried out.
• Laissez-faire
• allows the group to decide what its objectives
  are, what activities it is engaged in and has
  minimal input into the session.
• Democratic
• collaborates with the group, helping them to
  agree on a set of objectives and activities and
  only intervening to keep the group dynamic
  orientated in a positive direction.

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Facilitator StylesJohn Heron Six dimensions of
facilitation

• Facilitators need to be aware of basic issues
  which can influence the learning process
• Planning
• Meaning
• Confronting
• Feeling
• Structuring
• Valuing.
• These are independent processes that weave
  through each SGT session.

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Herons 18 facilitation styles
Facilitators can move between all these styles
during a small group teaching session.
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Heron the most effective facilitator

• should value autonomy, co-operation and
  hierarchy in that order as this recognizes the
  personal autonomy of group members to
  self-actualize collaboratively, with the
  facilitator taking responsibility to achieve
  group goals.

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Students engage in a wide variety of learning
experiences of which PBL tutorials are of central
importance.
lecture/plenary
topic tutorials
library skills
PBL tutorial
practicals
clinical work
personal study
demonstrations
computer assisted learning
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A PBL week
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BREAK!!!
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A taste of PBL
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Problem Based Learning Scenario(Environmental
Studies)

• Rolls Royce have revealed that they have a small
  nuclear reprocessing plant on their premises in a
  heavily populated area of Derby. It is similar to
  a plant in Japan where there was a recent
  accident.

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• Step 1 Clarify terms and concepts
• Step 2 Define the problem(s)
• Step 3 Analyse the problem(s) - Brainstorm
• Step 4 List of the analysis and possible
  solutions
• Step 5 Formulate Learning Objectives
• Step 6 Collect additional information focussed
  on Learning Objectives
• Step 7 Synthesise and present new information

Rolls Royce have revealed that they have a
nuclear reprocessing plant on their premises in a
heavily populated area of Derby. It is similar to
a plant in Japan where there was a recent
accident.
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Evidence for effectiveness

• We need to know what it is.
• What do we mean by effectiveness?
• What outcome measures should we use?

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The Evidence

• Can you define/describe it?
• What sort of an educational process is it?
• How does it relate to mainstream educational
  theories?
• What is the educational rationale?
• Is it Constructivist, Student Centred, Rogerian,
  Kolbian, Dewian, Post-modern, Confucian?
• Is there a common underlying process?
• Is it really Question Based Learning? Problem
  solving? Situation based Learning?
• How many variants of PBL are there? How are they
  related?

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Evidence

• How effective is it?
• What do we mean by effective in this context?
• Can we measure its effectiveness?
• How do we measure its effectiveness?
• Quantitative or Qualitative or both?
• Can you control all the variables?

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Evidence

• What outcomes can be used to measure
  effectiveness?
• Exam results?
• Personal satisfaction? Academic achievement?
  Clinical competence? Patient satisfaction?
• Knowledge, Skills, Attitudes?
• Communication and interpersonal skills?
• Life-long learning skills?
• Participation in CPD?
• Must there be a control or comparative group?
• Randomization?
• Is the RCT the gold standard for educational
  research?
• Is process more important than outcomes?

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Summary of evidence

• Academic achievement
• little significant difference
• Clinical achievement
• PBL students have superior clinical skills and
  communication skills
• Approaches to learning
• PBL students more likely to use deep rather than
  surface and more likely to engage in
  self-directed learning

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Summary of Evidence

• Graduates of PBL
• More likely to engage in CPD
• Teacher Student satisfaction
• Greater for PBL
• Costs
• More expensive with gt100 students

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• Problems with PBL
• Perceptions
• Training
• Dual tracking
• Coverage holes in knowledge
• Expert v. non-expert tutors
• Resource-intensive
• Significant start-up and maintenance costs
• Demanding of staff time
• Can be stressful for students and staff
• Need strong commitment of faculty

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My views

• It needs to be well defined, organized and
  integrated into the curriculum.
• Students need to understand what it is they need
  to learn about learning.
• For most students its a great way to learn and
  they love its collaborative and interactive
  nature.
• Students talk to each other for three hours a
  week about the subject.
• For students and facilitators its very
  stimulating and enjoyable its fun!
• Graduate PBL students achieve the same knowledge
  scores in clinical exams and communicate well in
  the clinical environment

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A student view
My overall experience of PBL has been a positive
one and I would argue that PBL has a lot to offer
medical students. PBL not only provided me with
a knowledge of the fundamental areas of medicine
but also made me aware of my responsibility for
my own learning, a crucial element in
itself.Working in a group allowed me to develop
my interpersonal skills as well as providing a
stimulating work environment, which is not always
achieved if spent in lectures all day.
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References

• Foundations of Problem-based Learning (2004).
  Maggi Savin-Baden Claire Howell Major. Open
  University Press.
• The challenge of Problem Based Learning (1997).
  Eds David Boud and Grahame Feletti. Kogan Page.
• A pilot systematic review and meta-analysis on
  the effectiveness of Problem Based Learning.
  (2003) Mark Newman. LTSN-01 report.
• (http//www.medev.ac.uk/docs/pbl_report.pdf)

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• Any final questions?

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Learning Objectives

• Explain the educational rationale for PBL
• Describe the seven-step PBL process
• Participate/Observe in a partial PBL session
• Critically evaluate the evidence for the
  effectiveness of PBL