Education Guide for Faculty Members

Problem Based Learning (PBL)

School of Medical Sciences University Science Malaysia Department of Medical Education

Dr. Hafiza Arzuman

First Publication: February 2010 Dr. Hafiza Arzuman

All rights reserved. No part of this publication may be reproduced stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of author/s or publisher.

ISBN: 978-967-5547-04-1

Edited by Dr. Hafiza Arzuman Medical Education Department, School of Medical Sciences, USM, Kubang Kerian, 16150 Kota Bharu Kelantan, Malaysia

Published by:

KKMED Publications Medical Education Department, School of Medical Sciences, USM, Kubang Kerian, 16150 Kota Bharu Kelantan, Malaysia Published in Malaysia

Preface
I strongly believe in Joseph Jouberts quote To teach is to learn twice. There was a time when the world acted on books; now books act on the world also from his quotation. The idea to come up with this book started to rumbling in my mind, as I have been assigned by the department to coordinate the faculty development programme on PBL tutor skills development. I felt that there should be some supplementary resource guide along with the hands-on exercise in the workshop. So I came up with this book and encouraged to published it with the encouraging words from Dr John Dent*(The guide could be a useful one for new faculty members). A Chinese Proverb quotes Tell me and I'll forget; show me and I may remember; involve me and I'll understand. Problem -based learning is basically involving students in their learning process and helps them to understand the concept. Problem based learning is used in many medical schools and by many different teachers. To achieve the full potentiality, PBL needs to be well designed and the tutors need to have intensive preparation through hands-on educational experiences. This book is designed for tutors as a supplementary resource, who wants to learn how to implement PBL and understand the different phases of how PBL is conducted. The content of this book has been selected from the work of experts in the field of medical education that have been considered of value. To keep this book user friendly an example of a week PBL (USM replication) has been included at section 3 Thanks to Dr. Muhamad Saiful Bahri Yusoff, for his help in managing the publication procedure of this guide. I hope together, all of us can make the PBL session more exciting and effective for the students. I am thankful to almighty ALLAH for his blessings in my life. Hafiza Arzuman Medical Education Department School of Medical Sciences Universiti Sains Malaysia January, 2010

* Dr John Dents interests are in developing clinical teaching initiatives in ambulatory care and rural community settings. Together with Professor Ronald Harden he has edited the multi author text A Practical Guide for Medical Teachers as a resource book for Medical Education

Dedication
My father Late A. K. M. Habibur Rahman you were my mentor for personal development and the best human being I have ever seen in my life

My best friend Late Dr. Jawwad Ahmad Khan. I will be missing you and your comforting support for the rest of my life

My children -Saquib Ahmad Khan, Aquif Jawwad Khan and Rafid Jawwad Khan. I am sorry for depriving all of you from mothers care and I do respect your sacrifice

Lastly
My professional mentor Professor. Dr. Muzaherul Haq. You put me in this field and I must act on it.

Contents
Aim of the guide Objectives of the guide The guide i i i 1 1-2

Section 1
1.1. Importance of small group teaching method

Section 2
2.1. Problem Based Learning (PBL) 2.2. The meaning of the term PBL 2.3. The steps of PBL process 2.4. The process of Problem Based Learning 2.5. Diagrammatic flow chart of PBL process: 1 2.6. Diagrammatic Flow chart of PBL process: 2 2.7. PBL triggers (problem scenario) 2.7.1. Guidelines for development of PBL trigger 2.7.2. Criteria to create effective PBL trigger 2.8. Sitting arrangement in PBL session 2.9 Tutors role in PBL process 2.10. Students role in PBL process 2.11. Diagrammatic presentation of participants role in PBL process 2.12. Assessment and Evaluation in PBL

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Section 3
Example A week PBL

Reference list

Aim of the guide

To teach in small group is an art and it needs special competencies by the teacher. It is the most satisfying experience for both teachers and students if both engage properly in the process. Problem Based learning process is one of the small group teaching methods. This aim of developing the guide is to help the novice tutors to understand the importance of small group teaching and the process of Problem Based Learning (PBL). The Department of Medical Education, School of Medical Sciences is organised faculty development programme on PBL each year to familiarise the new tutors with the PBL process. It is hoped that this guide will be a supplementary resource material for the tutors to become more familiar with PBL process.

Objectives of the guide

After going through the guide the tutors will be able to 1. know the importance of PBL as a small group teaching method. 2. understand the basic concept of PBL process 3. know the different steps in PBL process 4. know his/her role as a tutor in the PBL process 5. know the students role in the PBL process 6. know the basic principles of developing triggers/ problem scenario 7. facilitate a PBL session successfully

The Guide
The guide is divided in to sections. The first section provides you with the information about the importance of small group teaching and the rationale of adopting different small group teaching methods specially PBL by the School of Medical Sciences. The following sections are focused on the process of Problem Based Learning. This guide also provides you with a replicated example of a week PBL (consists of two sessions) designed for Respiratory Block of phase 2 MD programme to give the tutors a genuine sense of PBL format using by the medical school of USM. The evaluation grading check list is not a true replication of the schools format. This is intentional; with a hope in future the school will adopt a more objective checklist for grading the students in PBL session.

Section 1
1.1 Importance of Small Group Teaching (SGT)
Current understanding of educational strategies supports the use of small group as an effective method of teaching and learning. At present the medical students needed to be an activated one, equipped for independent life long learning and team work and also with the recent educational innovation in the field of small group teaching like problem based learning (Walton & Matthens, 1989). Small group teaching (SGT) is a teaching method for generating free communication between teacher and his/her students and among students themselves. (Westberg & Jason, 1996). Small group teaching encourages students active participation, helps to explore subject matter, stimulates students critical thinking, promotes students problem solving ability, promotes group skills and communication skills and encourages for self directed learning.

It also provides an important opportunity for social contact with peers and teacher. This social contact helps students to resolve a range of issues indirectly associated with teaching and also helps them to resolve any social problem. Small groups teaching are not ideal for disseminating information, but they are helpful for students to develop understanding of concepts and to improve strategies and approaches to problems. In PBL to achieve these higher-order thinking and learning activities promoted by small group work, it is important for the student to engage in meaningful communication directed towards a goal or set of goals. These higher-order thinking skills (e.g., application of concepts and principles, problem-solving, etc.) are the primary objective of PBL small group sessions. (Crosby J, 2006)

The criteria of effective teaching and learning are all fostered in small group interactions especially in problem based learning. The literature is equivocal on the number of students that constitutes an effective small group. Eight to twelve is accepted as the optimum number but maximum may be up to twenty. Ideally it should allow a number of students in a group which would help in success-full implementation of those features in a session. To some one the effective group may be less than ten participants. Again some group may work effectively with a larger number of participants. Small group teaching depends more on the features displayed by that group rather than the number in it. Therefore, in short we can say that the aim of a small group session should be to encourage students to adopt deep approach towards learning and to be a self directed active learner. (Walton H, 1999) Small group method also offers experience of working in a group. Group Skill is crucial in medical profession where working in a group or team is an important aspect of holistic health care. Group Skills also include the ability to communicate effectively, to prioritise the tasks, to manage the time and to exercise interpersonal skills. There are many small group teaching methods; the most recent and effective adapted method is PBL by many medical schools world wide The School of Medical Sciences of Universiti Sains Malaysia also adopted PBL as one of its teaching learning strategy for phase 2 undergraduate medical programme. It is one of the main small group teaching methods for Para-clinical teaching for phase II students.

Section 2
2.1. Problem Based Learning (PBL)
The Problem Based Learning is relatively a new method of teaching in medical schools. It is one of the small group teaching method which helps student to be a critical thinker and a problem solver. It also helps students to be a self directed learner there by a life long learner. PBL is an effective way of delivering medical education in a coherent, integrated programme and offers several advantages over traditional teaching methods. PBL is based on principles of adult learning theory, including motivating the students, encouraging them to set their own learning goals, and giving them a role in decisions that affect their own learning. So it is important to make sure that all the tutors are familiar with the process of PBL and also efficient in handling a PBL session.

2. 2. The meaning of the term PBL

PBL is an approach in learning and instruction in which students tackle problems in small group under the supervision of a tutor (Schmidt H. G., 1983). PBL is an educational strategy whereby a practical problem constitutes the basis for the learning of relevant information. Study is centered on a problem and is triggered by recognition of the fact that certain items of information are necessary and must be acquired in order to understand the problem and or make the decision The principal idea behind PBL is that the starting point for learning should be a problem, a query that the learner wishes to solve (Bound 1985). PBL is not only to solve the problem, but rather learning opportunities where solving problem is the focus or starting point for student learning. Students work on the problem to identify and search for the knowledge that they need to obtain in order to approach the problem. (Davis M.H. & Harden R. M., 1999).

Problem Based Learning is

Presentation of problem (Play with problem)

Solution of problem (Learn and grow together in a group)

Learning related to problem (Learn with problem)

2.3. The steps of Problem Based Learning (PBL)

Problem Based Learning (PBL) follows a simple cycle. The facilitatory role of the tutor varies with each stage of cycle. The teacher must ensure that all group members know the stages of the Problem-based learning. Although the steps are listed in a straight for ward fashion, there is often some overlap, rethinking as the group proceeds. The steps are 1. Identify the problem 2. Explore the pre-existing knowledge 3. Generate hypothesis and possible mechanisms 4. Identify learning issues 5. Self study 6. Re-evaluation and application of new knowledge to the problem 7. Assessment and reflection of learning (Walsh A , 2005)

2.4. The process of Problem Based Learning

Retrieved from www.renomodelpto.com/images/PBL%20Process.ren..on 8th June, 09

The details of how PBL process is implemented differ from institution to institution. How ever the general principles remain the same Students are presented with a problem (case, video tape or problem scenario for example). Students (in groups) organise their ideas and previous knowledge related to the problem, and attempt to define the broad nature of the problem. Throughout discussion, students pose questions, called "learning issues," on aspects of the problem that they do not understand. These learning issues are recorded by the group. Students are continually encouraged to define what they know - and more importantly - what they don't know. Students rank, in order of importance, the learning issues generated in the session. They decide which questions will be followed up by the whole group, and which issues can be assigned to individuals, who later teach the rest of the group.

Students and instructor also discuss what resources will be needed in order to research the learning issues, and where they could be found.

When students reconvene, they explore the previous learning issues, integrating their new knowledge into the context of the problem.

Students are also encouraged to summarise their knowledge and connect new concepts to old ones. They continue to define new learning issues as they progress through the problem.

Students soon see that learning is an ongoing process, and that there will always be (even for the teacher) learning issues to be explored.

2.5 Diagrammatic Flow chart of PBL process: 1

Meet the problem

List known facts

List unknown

Research unknown

Create possible solutions

Choose most viable solution

Report solution

Adapted from: http://www.ncsu.edu/pbl/design.html

retrieved on 17th June, 08

2.6 Diagrammatic Flow chart of PBL process: 2

Problem

Small group discussion

Self study

Exchange of Exchange Information of

Informatio
A description of phenomena Prepared by a team of teachers Directs learning activities

What do we already know about the problem? (Activation of prior knowledge) What do we still need to know about the problem? (Learning goals)

Did we acquire a better understanding of the process involve in the problem?

Learning resources Integration of knowledge from different disciplines

Structure of simple written material

Title: does not pertain to a diagnosis but written as a problem Trigger material: a story, a description of a phenomena or event Instruction: To provide explanation for and or to indicate which action is to be taken

2.7. PBL triggers (problem scenario) and its presentation

The selection or to develop a problem scenario for use in PBL has some criteria and it is also a matter of importance. The problem should raise compelling issues for new learning and that students have an opportunity to become actively involved in the discussion of these issues with appropriate feedback and corrective assistance from the tutor (Wilkerson and Feletti , 1989).

2.7.1 Guidelines for development of PBL trigger

Each problem should revolve around a common clinical scenario- history of present illness, relevant past history, family history , social circumstances, system review and initial physical findings The problem format should be sequential interdependent Each problem should be address over 2-3 sessions period/week accordingly additional information are provided as a second sheet Each problem should contain a tutor guide and is not given to students Problem should ideally provoke discussion and emphasise aspects of basic sciences to clinical sciences If appropriate associated visual materials may accompany the problem ( photography, lab reports, X-ray, a research problem, a video, an article, area or simulated patient and so on ) Adapted from: PBL - Queens university at Kingston, Canada, Faculty of Medicine Retrieved from: http://meds.queensu.ca/pbl/pbl_in_practice/writing_pbl_cases on 7th January, 09

2.7.2 Criteria to create effective PBL triggers

Develop clear and detailed learning objectives Learning objectives likely to be defined by the students after studying the scenario should be consistent with the faculty learning objectives Problems should be appropriate to the stage of the curriculum and the level of the students' understanding
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Scenarios should have sufficient intrinsic interest for the students or relevance to future practice

Basic science should be presented in the context of a clinical scenario to encourage integration of knowledge

Scenarios should contain cues to stimulate discussion and encourage students to seek explanations for the issues presented

The problem should be sufficiently open, so that discussion is not curtailed too early in the process

Scenarios should promote participation by the students in seeking information from various learning resources (Diana F. W., 2003)

2.8 Sitting arrangement in PBL session

Tutor

Student

Adapted from: School of Medical Sciences, Universiti Sains Malaysia http://medic.usm.my/ Queen's University School of Medicine, Kingston, Canada http://meds.queensu.ca/pbl/assets/prossqueenspblsli des.ppt

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2.9. Tutors role in PBL process

To switch from disseminator of information to facilitator of learning can be challenging for new tutors. Those unfamiliar with the PBL process are uncertain about the function of tutor in PBL. It is important for the tutor to understand the PBL process. The tutor should keep appropriate balance between dominating discussion in one hand and detaching themselves from students learning on the other hand. There are no hard and fast rules for PBL tutoring. The considered tasks of the tutor in PBL include Climate setting - create an environment that is conducive for self directed learning Treat the students as adult learners Foster cooperation rather than competition in group work Clarifying learning needs and help students to frame learning objectives and set goals Designing a learning plan help students with learning plans and strategies Engaging in learning activities to ensure that the students are in the right tract stimulate elaboration of information and ideas, direct the learning process, stimulates integration of knowledge, stimulate students interaction and individual accountability and facilitate information location. Evaluating learning outcomes which include formative and summative evaluation The teachers skills of modeling and facilitating PBL sessions help students to become problem-solvers and they can take on the responsibility of using the skills on their own.

2.10. Students role in PBL process

Treat all members of the group with respect Be punctual in attending all sessions Openly express his/her thoughts and ideas Clarify and question his/her thoughts and contributions Offers feedback to group members and tutors Complete assignments thoroughly and on time Be sensitive to learning needs of other group members Interact with group members Take responsibility for the learning process

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2.10 All participants role in PBL process

Source: Diana F. W., (2003). ABC of learning and teaching in medicine: PBL, BMJ, 32:328 -33

2.11

Assessment and Evaluation in PBL

PBL process includes regular opportunity for feedback to all group members. Formative feedback should occur at the end of each tutorial. Assessment of PBL needs to focus on the objectives that PBL fosters in conjunction with the educational course objectives. To assess students performances in PBL sessions mainly includes Tutor assessment of students, Self assessment and Peer assessment. The main tool is checklist contains criteria that contain: knowledge application, critical thinking, self directed learning and group work. The use of formative assessments to provide regular, informative and detailed feedback to students on their progress and performance at various stages during a given course is an essential component of the PBL educational strategy. Such assessments will enable students, whenever necessary, to undertake effective and timely remedial action that is either self-initiated or upon the advise of the tutor.

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Section 3
Example of a week PBL for Respiratory block
This guide provides you with a replicated example of a week PBL session developed for the Respiratory block of year 2 phase II MD programme. It will help you to understand the authentic picture of PBL session conducted by the medical school of Universiti Sains Malaysia. The Respiratory block consists of four weeks and each week has a problem with its own objective for the PBL session. Each week has two to three PBL sessions based on the problem and the learning objectives. The duration of each session is of 1 hours to 2 hours.

Respiratory Block (Example of a week PBL session consists of two sessions of 2 hours duration each) This one week PBL course is designed from the respiratory block for year 2 students of phase 2 MD programme of the School of Medical Sciences, University Science Malaysia.

Time schedule: There will be two sessions in the week. Each session will be of 2 hours and each group will consists of 12 students of year 2. In session 1 there will be 15 minutes break in between the distribution of Trigger 1A and 1B

The PBL Pack: As a tutor you will receive the PBL pack the week before your PBL session from academic office. In the pack you will receive i. ii. iii. iv. v. The problem of the week with the specific objectives of the week Trigger materials (Trigger1A &1B for session1 and Trigger 2 for session 2) Discussion points sheet for each trigger Tutor guide Students grading/ evaluation sheet

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School of Medical Sciences Universiti Sains Malaysia

PHASE II YEAR 2 (2010/2011)

RESPIRATORY BLOCK
WEEK - 3

Problem: Difficulty in Breathing

Specific objectives for the week 1. Recall the development of tracheo-bronchial tree and lungs. 2. Recall the cough reflex mechanism 3. Define the terms wheezing, sputum and their causes and discuss their pathogenesis 4. Describe the pathogenesis, pathology, pathophysiology and complications of bronchial asthma. Outline the investigations required and the principles of management (comprising preventive, curative, rehabilitative and psychosocial aspects). 5. List the groups of drugs used in treatment and prophylaxis of bronchial asthma and state their mechanisms of actions, methods of delivery and side effects. 6. Understand the importance of advice in relation to home management of a bronchial asthma patient

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School of Medical Sciences Universiti Sains Malaysia

PHASE II YEAR 2 (2010/2011)

RESPIRATORY BLOCK
WEEK - 3

Problem: Difficulty in Breathing Session 1 Trigger 1A (Duration: 1 hr) Total duration: 2 hours 30 minutes

A 7-year old boy with persistent cough for two months was referred to the pediatric out patient clinic of Hospital University Science Malaysia by his general practitioner.

The cough was prominent in the early morning and was sometimes associated with wheezing. It was mostly dry although on occasion there was scanty sputum, which was whitish and viscid. From afternoon onwards cough seemed to be less frequent. The cough seemed to get worse when he played outdoor games.

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Discussion Points (For tutors use only)

To guide the student in right direction Trigger 1A Cough Expectoration Wheezing Cough reflex, mechanism Common condition presenting with chronic cough Possible reasons why cough was worse in the morning and night Possible explanation for cough associated with exercise Examples of diseases where cough is associated with sputum and types of sputum in different conditions What does whitish and viscid sputum indicate? What is wheezing? How is wheezing generated? Common diseases with wheezing

Note : Break for 15 minutes before distribution of Trigger 1B

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School of Medical Sciences Universiti Sains Malaysia

PHASE II YEAR 2 (2010/2011)

RESPIRATORY BLOCK
WEEK - 3

Problem: Difficulty in Breathing Session 1 Trigger 1B (1 hour 15 minutes) There was no history of fever, chest pain and haemoptysis. He had a history of eczema of arms and legs, which was treated for nearly one year. There was no history of food allergy. His elder sister had a similar illness and his father had a history of allergic rhinitis. There was no contact history of tuberculosis. On examination, his pulse was 98/min, blood pressure 104/66 mmHg and respiratory rate 24/min. There was no cyanosis, clubbing or oedema. Examination of the chest revealed a prolonged expiratory phase with few scattered expiratory rhonchi in both lungs. A recording of the forced expiratory volumes performed at the clinic is provided. Total duration: 2 hours 30 minutes

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Discussion Points (For tutors use only)

To guide the student in right direction

Trigger 1B Symptoms of respiratory disease Associated symptoms/Family history Chest examination Relevance of fever, chest pain, haemoptysis in a patient presenting with cough Association between eczema, allergic rhinitis and wheezing normal breath sounds prolonged expiration and its pathogenesis rhonchi and mechanism of generation of ronchai types respiratory system abnormalities indicate by the chest examination findings name the parameter that should be determined by the investigation instructions to perform the test comment on the results other simple bedside investigation to obtain similar information other investigations that may have been helpful in this patient and reasons why they may be helpful

Expiratory flow rate Recording (vitellograph)

Other investigations

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School of Medical Sciences Universiti Sains Malaysia

PHASE II YEAR 2 (2010/2011)

RESPIRATORY BLOCK
WEEK - 3

Problem: Difficulty in Breathing Session 2 Total duration: 2 hours 30 minutes

Trigger 2 Other investigations, including full blood count and ESR, blood urea and electrolytes and chest X-ray were normal. A diagnosis of bronchial asthma was made and the boy was prescribed salbutamol and beclomethasone inhalers. The parents were asked to use a spacer device, which was also supplied, for administering the inhalers. Two months later the boy attended the follow-up clinic. He no longer complained of cough or wheezing. Forced expiratory volumes were recorded again It has improved and the tracing is provided. His parents were advised to continue using the beclomethasone inhaler regularly but to use salbutamol only before exertion or if he has a recurrence of the symptoms. The parents were given appropriate advice on the nature of the boys illness and their role in managing it at home.

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Discussion Points (For tutor only) To guide the student in right direction Trigger 2 Medication

Bronchial asthma

Diagnosis - all the features in this patient that diagnosis Definition Pathogenesis Other modes of presentation

supports the

Salbutamol and beclomethasone and their modes of action adverse effects the different advice for the two medications their uses in maintenance and acute attacks other medications useful in maintenance therapy

Medications as relievers and preventers of bronchospasm

Relievers beta 2 agonists ipratropium theophylline Preventers inhaled steroids sodium cromoglycate leukotriene antagonists Spacer devices - what they are, why they are used and advantages

Administration of medicaton Other advice (actual advice in detail not essential but the aspects to be considered should be mentioned)

Advice regarding compliance to medication regimen exercise natural history of disease avoiding acute exacerbations recognising exacerbations Compare the recording with the previous one and comment on the results.

Vitellograph

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School of Medical Sciences Universiti Sains Malaysia

PHASE II YEAR 2 (2010/2011)

RESPIRATORY BLOCK
WEEK - 3

Problem: Difficulty in Breathing Tutors guide (For tutor only) The tutor guides for the week on problem Difficulty in Breathing gives a concise list of the aspects that this problem is intended to cover. Some of these aspects may also be delivered to students by other modes of teaching during the week e.g. lectures, FLMs and clinical teaching. However students are expected to discuss them at the PBL sessions too. The tutor will have the discussion point sheet. This is intentional, as the points should ideally be raised by the students. The students are expected to come up with the learning issues following each trigger .As a tutor your role is to facilitate them in the right direction and to identify the learning issues pertaining to the problem. However please ensure that the aspects mentioned in this discussion points are discussed by the students by directing them appropriately as and when necessary. This is best by guiding the students to the relevant aspects during discussion rather than repeating the question-form the areas mentioned It would be appreciated if you could supplement these with some reading of your own. URLs of some web sites with further information are given at the bottom of this page.

Distribution of triggers: PBL session 1 - distribute trigger 1A and discuss the issues arise. Break for 15 minutes and then distribute trigger IB and discuss PBL session 2 - discuss the learning issues and objectives from PBL 1B from previous session and then distribute trigger 2 and discuss

http://www2.qimr.edu.au/davidD/asthma1.html http://www2.qimr.edu.au/davidD/asthma2.html

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School of Medical Sciences Universiti Sains Malaysia Assessment/Grading form Total mark 4

PHASE II YEAR 2 (2010/2011)

Absent without valid reason 0

Characteristics demonstrated by student Total mark 1. Application of knowledge base ( 0.2 for each subcategory ) 1 shows evidence of through reading, breath and depth of knowledge shows ability to generate diagnostic hypothesis answers questions or shares his/her opinions without reading notes/books presents clear hypothesis/ facts and home work done asks relevant questions spontaneously 2. Clinical reasoning and decision making (0.2 for each subcategory ) 1 able to analyse hypothesis critically and suggests course of action when in difficulty discriminates important information of the problem from what it is not shows ability to generate diagnostic hypothesis shows ability to make decision about the therapeutic approach to the problem shows evidence of following a sequential management of the problem 3. Self directed learning ( self study) ( 0.2 for each subcategory ) 1 shows evidence to accomplishment of his/her own study shows evidence of reading diverse and bibliographic sources makes efforts to improve identifies his/her opportunity areas shows evidence to drive to the limits of his/her knowledge 4. Group work - ( 0.2 for each subcategory ) actively participates and follows discussion works towards the achievement of groups learning goal respects classmates opinion shows responsibility and commitment works as hard as the rest of the team-mates 5. Absent without valid reason

Tutor needs to give each student in the group an overall grading that reflects each students performance during two sessions for the week. For this purpose the tutor give grades for each session and derive an overall grade at the end of two sessions*

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Reference list
(References are good reading materials as well) 1. Bound D (1985), Problem based Learning in perspective in education for the professionals, Sydney, Higher education research and development of Australia 2. Crosby J (2006). Learning in Small Groups, AMEE Education guide No 8 reproduced under an agreement with the Association of Medical education, AMEE Education guide No 8 was first published in Medical teacher (1997) 19:189-202 3. Davis, M. H. & Harden, R., (2005). Problem Based Learning: A practical guide, AMEE Medical Education guides no 15, University of Dundee, Scotland, UK. 4. Diana F.W., (2003). ABC of learning and teaching in medicine : Problem Based Learning, British medical Journal , 326: 328 -33 5. Schmidt H. G., (1983). Problem Based Learning: Rationale and Description. Medical Education. 17:11-16 6. Walsh, A., ( 2005), The Tutor in Problem Based Learning: A novices guide, Mc Master university, Faculty of Health sciences 7. Walton H., (1999). Small group methods in Medical teaching. Medical Education booklet -1, Reproduced with the permission of ASME,12 Queen St, Edinburgh, EH2 1JE. 8. Walton H. J. & Matthews M.B., (1989). Essentials of problem based learning. Medical education 23:542-558 9. Westberg J. & & Jason H., (1996) Fostering learning in Small group. Sprinter Publishing company Inc , New York 10. Wilkerson, L., and Feletti, G., (1989). Problem-based learning: One approach to increasing student participation. In the departments, pg 53).

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