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EDITORIALS: Diana F Wood Problem based learning BMJ 2008; 336: 971 [Full text]

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Problem Based Learning: Pros and Cons?

Urban J.A. D'Souza   (2 May 2008)

Problem-based learning and the death of the hyphen

Roger K.A. . Allen   (4 May 2008)

A Response from Koh et al

Gerald C H Koh, Khoo HE, Wong ML, Koh D   (4 May 2008)

A hybrid curriculum would be a more suitable format for developing countries

Alberto E D'Ottavio, Larisa I Carrera and Tomás E Tellez   (4 May 2008)

Re: The death of the hyphen

Neville W Goodman   (5 May 2008)

Re: A hybrid curriculum would be a more suitable format for developing countries

James L Acree   (6 May 2008)

PBL: an undergraduate experience

Faisal Siddiqui   (7 May 2008)

Medicine is about communicating with people.

Wouter Havinga   (7 May 2008)

PBL type teaching approaches: Rigorous evidence still required

Mark J Newman   (7 May 2008)

Evdience 'for' or 'against' will always be difficult

Jean McKendree   (22 May 2008)

The Problem with Problem Based Learning

Muhammed R S Siddiqui   (11 September 2008)

Problem Based Learning: Pros and Cons? 2 May 2008
Urban J.A. D'Souza, Associate Professor School of Medicine, University Malaysia Sabah, 88999 Kota Kinabalu, Sabah, Malaysia Send response to journal: Re: Problem Based Learning: Pros and Cons?	Problem based learning – Why it is still a controversial topic? The reason may be as medical educators look at the product than the process. In terms of products, student, teachers, parents and society look at the grades obtained by a medical doctor in his/her degree. In most of the traditional schools, as mentioned by Diana Wood, lecture base and didactic clinical teaching may enable a good student (with good memory etc.) to score good grades in the examination and definitely on an outlook his results are best. In problem based learning, the process of learning shall help the student to gain better cognitive, communication skills and also may help to gain better knowledge even for a moderate student. Since both preclinical and clinical knowledge is amalgamated in PBL teaching, better application of medical knowledge in understanding the concepts is better as medical practice requires a holistic approach. But Universities applying only a PBL based curriculum may need a relook/focus as initial years in medical studies, a student may be lost due to early entry of clinical science before getting accustomed with basic body parts and functions. It is always better if the first year medical studies involving basic sciences be in traditional system with little exposure to PBL at a later stage(second semester). Since year 1 is the basic foundation year where a medical student need to know the normal body parts, functions and metabolism; more lectures, practical and demonstrations may help in a better way to understand as many students are the adolescents and of younger age group, PBL base which was developed on adult learning theory may be too early especially in the developing world. Most the of the Asian University entry level students join after their high school levels and from their mother tongue language schoolings. Sudden transition from native language to English is also is an added burden. Secondly adolescent age group student entry into these universities also is a practice and student may not be able to adapt immediately to the theory of adult learning practice of PBL. It is better to adopt a hybrid curriculum with both traditional and PBL base especially in developing and Asian universities as both traditional and PBL learning methods have their own pros and cons in the learning process. Competing interests: None declared
Problem-based learning and the death of the hyphen 4 May 2008
Roger K.A. . Allen, Senior Consultant Thoracic and Sleep Physician Wesley Medical Centre, Auchenflower, Brisbane, Australia Send response to journal: Re: Problem-based learning and the death of the hyphen	I observe that both the editor of the BMJ and the author of this article appear oblivious of the use of the hyphen; that near-extinct coupling of carriages viz “nouns” in the English language. This is not a "typo". Such examples include that favourite, "evidence-based medicine", and my favourite, "angiotensin-converting enzyme". It is ironic that a suntanned "colonial" bumpkin from Oz (alas, the cultural cringe) sees the emperor's new clothes. Without the hyphen, the noun and verbal noun (in Latin, the "gerund"), and participles (past and present) hang loose and unattached to the adjacent noun like shags on a rock. As an aside, the correct use of the gerund leads to the extinct use of “my going" and not "me going". There will be those of you who think such attacks on the phrase “sans hyphen” are petty and pedantic. But as Luther said, “Here I stand”. I believe it is a symptom (or perhaps a sign) of the general decline and malaise in the use of our mother tongue. “Good” English is so necessary for the precise communication of scientific and medical concepts. Education in Australia is being reduced to a mediocre, common denominator (everyone passes here) and the same has happened in our medical course at the University of Nameless (UN) in this state where students are taught problem based (sic) medicine from day one without the rigour of the more stratified method that we had e.g. anatomy, physiology, biochemistry etc and then clinical medicine. It is like teaching Latin experientially without teaching a single declension or conjugation. Give me the old method and not the “Lady Bird” version dreamt up by "brave new world" educationalists. Despite the polyglot in Australia from the influx of people from all over the globe, few Australian graduates study a foreign language for matriculation and an appalling number of Australians born here are not even fluent in English let alone another tongue. I suspect the editorial staff at the BMJ is the same. At our universities, lecturers complain of the plethora of students who can’t write clear, concise English. The study of foreign languages leads to a more analytical knowledge of the mother tongue, and should result in more precise and learned expression. When my daughter started Latin at this year at UN, they spent the first week being told about the difference between a noun, adjective and verb, and even more mind-blowing (note the hyphen, BMJ staff), about the "subject" (nominative) and "object" (accusative) cases. The mind boggles. Precise English with hyphens is essential in medicolegal reports and for the writing of scientific papers. In the former, the loss of a hyphen, a comma, a semicolon (also almost extinct) can dramatically change the meaning of a sentence. So it’s over to you editors and boffins to get this sort of stuff right. You are the final custodians of educated English. The war for good English on radio, televison and our daily rags (thanks, Rupert) has long been since been lost and if you go down the drain, I fear the war is over. Why not totally debase this problematic language of the bard, gut it, stuff it and put it on the spit and make it a "problem baist (sic) learning”? Competing interests: None declared
A Response from Koh et al 4 May 2008
Gerald C H Koh, Assistant Professor Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Khoo HE, Wong ML, Koh D Send response to journal: Re: A Response from Koh et al	We would like to thank BMJ and Dr Diane Wood for her editorial on our systematic review on the effects of problem based learning (PBL) during medical school on physician competency. (1,2) We agree with Dr Wood that medical education needs to focus more on outcomes than processes, with PBL being no exception. It was precisely the intense debate among educators in our institution on whether the resources channeled into PBL were justified by the production of better doctors that drove us to perform our systematic review. As Dr Wood rightly pointed out, "PBL" in medical school curricula around the world has evolved to hybrid models which adopt the key features of PBL: small group teaching instead of didactic lectures, and timely and constructive feedback. The names of such new models range from 'team based learning' to 'peer assisted learning'. Based on our personal experience as medical educators, we agree with Dr Wood that the key to the success of PBL lies in these principles, rather than on strict adherence to traditional PBL pedagogical methodologies. Nevertheless, PBL remains as one of the many teaching modalities available, and each has its inherent strengths and weaknesses. Moreover, some teaching methodologies are more suited to students of certain personality types than others.(3) We believe that a good medical school curriculum should have a variety of teaching methodologies to meet the needs of a heterogeneous student population and to leverage on the strengths of each pedagogical modality. We also agree with Dr Wood that evaluating education programmes in the real world is challenging because of major confounding factors such as heterogeneity in experience and teaching style of the tutors involved. The process is made even more difficult if outcomes such as physician competency are measured years after the pedagogical intervention. How can one be certain that improved communication skills are a result of PBL per se and not due to other immeasurable factors such as availability of more skillful tutors or increasing patient expectations for better communication? As with clinical research, not everything can be measured but still we should continue to look for causal relationships between effective interventions and outcomes that matter. Outcome based medical education research is no exception and we concur with Dr Wood that further research is needed to explain why graduates from some medical schools perform better than those from other medical schools. Such research should not be about fault-finding but about finding out what better medical schools are doing right, so that ultimately patients benefit. Gerald CH Koh, Khoo HE, Wong ML, Koh D References 1. Koh GCH, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178:34-41. 2. Wood DF. Problem based learning – Time to stop arguing about the process and examine the outcomes. BMJ 2008; 336:971. 3. Luh SP, Yu MN, Lin YR, Chou MJ, Chou MC, Chen JY. A study on the personal traits and knowledge base of Taiwanese medical students following problem-based learning instructions. Ann Acad Med Singapore. 2007;36:743- 50. Competing interests: None declared
A hybrid curriculum would be a more suitable format for developing countries 4 May 2008
Alberto E D'Ottavio, Medical Professor and Researcher Medical School and Research Council, Rosario National University, 2000 Rosario, Argentina, Larisa I Carrera and Tomás E Tellez Send response to journal: Re: A hybrid curriculum would be a more suitable format for developing countries	When during 2002 our public medical school at Rosario, Argentina, began to implement a pure problem-based learning (PBL) curriculum, other medical schools (9 public and 16 private) were taking into account this possibility as well. By that time, the basic requirements for successful implementation of that format and the difficulties that such curriculum could face were published and a hybrid format proposed (1). The curriculum planners’ decision was to go on with the program assuming that potential impediments for PBL curriculum implementation could be overcome. During 2007, a comparison was performed between the aforesaid basic requirements and the scenario faced by the curriculum from 2002 to 2007. Simultaneously, 19 medical teachers of both sexes (50 ± 15 years old) selected from a population of 195 teachers were interviewed about their perceptions on eventual problems related with the development of the format along that period. Both studies clearly revealed that the implementation offered difficulties that only a hybrid format, as opportunely suggested by us and also by Urban J.A. D'Souza, could save. In conclusion, the hybrid curriculum would be a more suitable format for developing countries as ours. Reference 1.Carrera LI, Tellez TE, D’Ottavio AE. Implementing a Problem-Based Learning Curriculum in an Argentinean Medical School: Implications for Developing Countries. Acad. Med. 2003; 78: 798-801 Competing interests: None declared
Re: The death of the hyphen 5 May 2008
Neville W Goodman, Retired Anaesthetist Bristol, BS9 3LW, UK Send response to journal: Re: Re: The death of the hyphen	Dr Allen may be being unfair on the author of the article: the BMJ has - for ever as far as I know - expunged almost every hyphen from its articles. I think the BMJ believes hyphens are messy, and make the text look somehow unattractive. That's as may be but, as Dr Allen so correctly writes, hyphens make for easier reading. It is, however, important that they are not used lazily in strings of noun modifiers. An article (not in the BMJ) included the phrase "fixed duration constant rate infusions". The meaning is made clearer by two hyphens, but is better written as "infusions of constant rate and fixed duration". The BMJ also dislikes capital letters. While there is no need for Consultants and Surgeons, simply altering all capitals to lower case may be wrong: an article in the BMJ many years ago dealt with "conservative social commentators", who may have been conservative, but the correct sense was Conservative. Competing interests: None declared
Re: A hybrid curriculum would be a more suitable format for developing countries 6 May 2008
James L Acree, Senior Consultant Aviation Training Consulting, LLC Send response to journal: Re: Re: A hybrid curriculum would be a more suitable format for developing countries	As curriculum designers for high-risk, rapidly changing occupations like aviation, we have been investigating the application of the "systems approach" to training clinicians of all description. For aviation training, the hybrid model has been the norm since the early 1940s, and it was driven by economic necessity as the natural outcome of what is now called the systems approach to training. It is the number one reason that flying is now statistically safer than driving any appreciable distance. I've also conducted research into the use of surgical simulation for PBL, with positive results (currently under peer review for publication), all based on the systems approach. I recommend that clinical educators consider the systems approach to training in pursuing reliable human performance in the rapidly changing field of clinical education. Competing interests: None declared
PBL: an undergraduate experience 7 May 2008
Faisal Siddiqui, Foundation programme doctor Severn deanery, BS16 1LE Send response to journal: Re: PBL: an undergraduate experience	As a newly qualified foundation year 1 doctor from a problem based learning (PBL) medical course and now working at a hospital where medical students are taught a traditional curriculum, I feel that I can give a different insight on the subjective outcomes of PBL. As Dr Wood described, and has been widely researched, PBL has a number of advantages in comparison to a more traditional curriculum, most recently by Koh et al, showing beneficial aspects in psycho-social developments aspects to training(1). Dr Wood also feels that can also be achieved by tutorial based teaching in small groups, with constructive feedback, as used at Cambridge University. Dr Wood also highlighted a study showing variance in the performance in postgraduate examinations of graduates of different medical schools, by McManus et al(2); claiming that some of this variance was due to undergraduate teaching programme. Although this study did claim that performance may be due medical school training, it is interestingly explained by the quality in training rather than delivery of the curriculum. The authors of the study felt that the strongest factor was felt to be the actual qualifications at point of entry to medical school. Having now taught medical undergraduates who are training in a more traditional based course than mine own, I can see some obvious benefits. The students appear to have a better base of knowledge that I feel is missing when taught from PBL teaching. However I also feel that these students may have more problems when relating their pre-clinical studies to actual real patients. Whilst at medical school, during my preclinical years I had regular PBL sessions supplicated by lectures. PBL was at the core of the curriculum and self directed learning was the force de jour. Unfortunately self directed learning at such an early stage in your medical education can be counter productive. Often PBL facilitators or tutors would vary in their experience on the subject matter, and therefore their expertise in the PBL topic would be dictated by their reading of a set of tutor notes (a short background on the topic). As the student this can be difficult as there are no immediate solutions to the complex PBL topics. Your depth of knowledge can therefore be governed by your reading of the recommended text book; an almost DIY experience. Students of a traditional curriculum appear to enjoy the diversity offered by the PBL experience, from my teaching sessions with them. Small groups based tutorials can often turn into mini-lectures but by retaining the main structure of PBL teaching can be hugely beneficial to both student and teacher. I would therefore suggest that hybrid curriculums, as suggested by Carrera et al(3), would not only be suitable to developing countries but in the UK as well. By introducing PBL slowly and making it a more central component during the clinical years it may successfully combine advantages of both systems. During the clinical years the student are in contact with far larger patient numbers and PBL scenarios become immediately more relevant to the student. PBL facilitators are more likely to be active clinicians, as the students are based in the hospital environment, rather than researchers. Indeed I enjoyed my PBL teaching much more during my later years at medical school. Dr Wood encourages us to stop debating on process of teaching but rather focus on ensuring diversity in education in giving better defined graduate outcomes and graduates with the required competencies. However I believe that only once the process has been refined can we start to compare the outcomes fairly. Perhaps a national curriculum with a more hybrid make-up and national exit exam would not only be fairer to student and teacher, but to the patient also, in our quest to make better doctors. References: 1) Koh GC-H, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178:34-41 2) McManus IC, Elder AT, de Champlain A, Dacre JE, Mollon J, Chis L. Graduates of different UK medical schools show substantial differences in performance on MRCP(UK) part 1, part 2 and PACES examinations. BMC Med 2008;6:5. 3) Carrera LI, Tellez TE, D’Ottavio AE. Implementing a Problem- Based Learning Curriculum in an Argentinean Medical School: Implications for Developing Countries. Acad. Med. 2003; 78: 798-801 Competing interests: None declared
Medicine is about communicating with people. 7 May 2008
Wouter Havinga, locum GP GL6 6JL Send response to journal: Re: Medicine is about communicating with people.	Indeed in medical school the physical processes need to be learned and a problem (analytical) approach is appropriate. However in the school of life, the doctor needs to be equipped with solution focused abilities. Particularly in general practice, the problem focused approach can maintain illness and results in stress in doctors. Imagine a GP who is going to ask a patient the list of questions to pin down the diagnosis of depression. Are you low? How is your appetite and sleep, etc? And when all the questions start to confirm the doctor's suspicion, s/he can finish with the question; and do you feel like stepping out of it all, taking your own life? You can imagine that not only the patient but also the doctor will become hopeless with this kind of problem approach. Giving advice or pills is not the only way forward. People need to be empowered to develop their own physical and mental health. What the family doctor is presented with in the surgery is in general the result of stress. A problem focused approach might encourage people to become dependent and continue to visit the surgery. Solution focused brief therapy techniques, motivational interviewing techniques, building self-esteem and life coaching principles, on the other hand, can help patients to mobilise their own resources and make the patient independent of the doctor. Solution focused skills can inspire both patients and doctors. I like to believe that the doctor can broaden the patient’s awareness and turn the consultation room into a temple of healing, rather than a work space where only problem focused templates are followed. Competing interests: Wouter Havinga provides seminars on the above
PBL type teaching approaches: Rigorous evidence still required 7 May 2008
Mark J Newman, Senior Research Officer Institute of Education, University of London Send response to journal: Re: PBL type teaching approaches: Rigorous evidence still required	The review of PBL by Koh and colleagues(1) is exactly the type of effort that we requested after systematically reviewing previous 'reviews' of effectiveness of PBL some years ago(2) and the authors should be applauded for such an excellent piece of work. However I think the authors conclusions are rather stronger than the evidence they included can support given the many limitations of the individual studies (3). Unfortunately what the review reveals most clearly shows is that we still do not have very much rigorous research on the comparative effectiveness of PBL compared to other teaching and learning approaches to hep us make decisions about how to design curricula or teach. I think one of the other problems also highlighted by the review is a lack of clarity about exactly is being 'delivered' and called PBL. Diana Wood (4) is correct in highlighting the lack of control group descriptions as a problem, but her claim that PBL is being used all over the world belies another. That is that people are doing something and calling it PBL but that these things may vary quite a lot (5). As I think Howard Barrows has said before there is no longer PBL but a rather a variety of hybrids. I think it might be fruitful to start viewing PBL as a term used to denote a family of teaching approaches that share some common principles and to encourage descriptions of each individual approach on a series of consistent common dimensions(6). Only once we know what it being practised will be able to untangle the more detailed questions about the impact of the variations that are obviously there in practice. There are no shortage of existing frameworks and I would urge people researching in this field to use them 8-10. 1. Koh GC-H, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178:34-41. 2. Newman M (2003) A pilot systematic review and meta-analysis on the effectiveness of Problem Based Learning. Newcastle. Learning & Teaching Subject Network Centre for Medicine, Dentistry and Veterinary Medicine. ISBN 0 7017 01587. http://www.medev.ac.uk/docs/pbl_report.pdf 3. Newman M (2006) Fitness for purpose evaluation in Problem Based Learning should consider the requirements for establishing descriptive causation. Advances in Health Sciences Education 11:391-402 4. Wood DF. Problem based learning – Time to stop arguing about the process and examine the outcomes. BMJ 2008; 336:971. 5. Margetson D. 'What counts as Problem-based Learning', Education for Health, 11, 2, (1998). pp 193-201 6. Newman M (2005) Problem Based Learning: An introduction and overview of the key features of the approach. Journal of Veterinary Medical Education 32(1) 12-20 7.Barrows, H. S. (1986). A Taxonomy of Problem-based Learning Methods. Medical Education, 20, 481-486. 8.Charlin, B., Mann, K., & Hansen, P. (1998). The many faces of problem-based learning: a framework for understanding and comparison. Medical Teacher, 20, 323-330. 9.Harden, R. & Davis, M. (1998). The continuum of problem-based learning. Medical Teacher, 20, 317-322. 10.Savin-Baden, M. (2000). Problem-based learning in Higher Education: Untold Stories. Buckingham: Society for Research in Higher Education and Open University Press. Competing interests: None declared
Evdience 'for' or 'against' will always be difficult 22 May 2008
Jean McKendree, Senior Lecturer in Medical Education Hullk York Medical School, YO10 5DD Send response to journal: Re: Evdience 'for' or 'against' will always be difficult	I must agree with Mark Newman that a major challenge in attempting to definitively compare ‘PBL’ and ‘traditional’ curriulae is defining them in the first place. There are so many flavours of each that comparisons are fraught with confounds and qualifications. I think, personally, that asking for overall comparisons may be too simplistic a question, given the multiple factors that go into any curriculum change. However, there is certainly evidence that active learning results in better retention than passive learning, that placing responsibility on students for directing their own learning is more effective (and more enjoyable) than goose- stepping everyone down a single path, and that integrating knowledge with application is better than teaching isolated facts. I think an example of a good, informative review is found in a 2005 article in Review of Educational Research that looked at performance on different types of assessments by students from PBL and traditional courses (however they defined them). Briefly, they distinguish three aspects of knowledge targeted by assessment: 1) Concepts, 2) Principles (ie. rules or relationships between concepts that can be used to interpret, explain, predict, etc), and 3) Linking of concepts and principles to conditions for application. Most (all but one) of the included studies were from medical education. Results indicated that aside from the usual appeal for more and better studies, the first type of knowledge (Concepts) showed a slight negative effect for PBL - the much-reported fact that PBL students do slightly worse on tests of factual knowledge such as the NBME Part I. However, the second and third types of knowledge showed a positive effect for PBL, particularly the Principles aspect. I personally think that turning out students who are better at applying concepts and principles is perhaps more desirable than focusing on graduates who perform well in written tests, such as reported in the McManus et al paper comparing medical school performance. As with all educational research, however, it is not straightforward to compare whole ‘programmes’ of learning and the effort may in the end be moot because of the move toward more integrated, self-directed courses anyway, as mentioned by others above. D Gijbels, F Dochy, P van den Bossche, and M Segers (2005) Effects of Problem-Based Learning: A Meta-Analysis from the Angle of Assessment, Review of Educational Research, Vol 75, No 1, pp. 27-61. Competing interests: None declared
The Problem with Problem Based Learning 11 September 2008
Muhammed R S Siddiqui, Research Registrar Worthing BN11 2NE Send response to journal: Re: The Problem with Problem Based Learning	I am a graduate from a university that implemented PBL as its core teaching style. The issue of whether debate on the style itself being important or not is in my mind not very helpful. All debate is important because it allows us to revisit the failings and successes of systems. The reality is that on one side you have a very rigid side saying that there are no problems with PBL and another saying that it is useless. The other question is what exactly is PBL, how do you define it and how is that definition implemented. Questions that are never really answered are issues such as should midwives, nurse and lay people be leading PBL tutorials because that is what happens! Surely debate and discussion is the only constructive way of dealing with this. I agree that a national exam is a good idea but will that mean the lowest common denominator is used in the sense of examinations being dumbed down. The other issue is that we seem to be comparing 'PBL doctors' to 'conventional ones' as if they are the Gold standard. And finally is medicine a vocational subject, you have academic achievers at school, they wanted to be doctors but they wanted to apply scientific thinking and reasoning to their career. Some people love the study of knowledge per se. Do we deny this group of medics the chance to persue that if we try and streamline people towards simply becoming doctors? Medicine studied at university is a subject and whilst most people become doctors one should not forget that as a subject it should be acknowledged as such and not merely as a route to becoming a doctor because in that way it limits freedoms and choice that every medical student deserves to have. Competing interests: None declared