Problem-based learning: its rationale and efficacy

Paul M Finucane, Steve M Johnson and David J Prideaux

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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)  

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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 PBL	The PBL approach is based on principles of adult education20 and 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 PBL	The criticism most often voiced is that PBL is costly, in demands of 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 in PBL	The pendulum of educational reform is swinging away from traditional 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.
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Authors' details

Reprints will not be available from the authors.
Correspondence: Professor Paul M Finucane, Department of Rehabilitation and Aged Care, School of Medicine, Flinders University of South Australia, Bedford Park, SA 5042.
E-mail: sfinupmATrgh.sa.gov.au