Review Articles

Problem-based learning
A critical review of its educational objectives and the
rationale for its use

Samy A. Azer, PhD, FACG.

ABSTRACT

Over the past 30 years there has been an increasing interest in curriculum innovation in medical schools in North America,
the United Kingdom, Netherlands, and Australia. Since the introduction of problem-based learning at McMaster
University in Canada in 1969, several medical schools throughout the world have adopted problem-based learning as the
educational and philosophical basis of their curricula. Several studies have shown that problem-based learning is an
important educational strategy for integrating the curriculum, motivating the students and helping them to identify their
learning issues and set their own learning goals. However, there is a great deal of concern regarding what problem-based
learning means and the advantages of problem-based learning over traditional curriculum have not been clearly addressed.
In this review, a broad range of the definitions of problem-based learning have been addressed and the rationale for
problem-based learning and its educational objectives are discussed.
Keywords: Problem based learning, medical curriculum, self-directed learning, small group.

Neurosciences 2001; Vol. 6 (2): 83-89

primary goal of problem-based learning (PBL) is States, Europe, the Middle East, Africa and Asian/
A to foster clinical reasoning or problem-solving
skills in students. Problem-based learning is an
1
Pacific nations and other universities in Australia
(the Flinders University of South Australia, the
approach to professional education that has been University of Sydney, the University of Melbourne).
based on research into how adults learn most Problem-based learning is an approach to learning
effectively.2 This approach was first introduced into that uses a problem to drive the learning13,14 rather
medicine at McMaster University in Canada in 1969. than a lecture with subject matter, which is taught.15
A few years later, 2 universities adapted the PBL In PBL programs, a set of problems is used to engage
approach to medical education, the University of the students in learning in small groups. A
Limber at Maastricht, the Netherlands in 1974 and framework for PBL curriculum is usually designed
the University of Newcastle in Australia in 1976. 3-9 by an executive group, which sets the scope and
Since then the use of PBL in medical education has major theme for each semester. Students then
been endorsed by the World Health Organization,10 identify the salient features of the problem, the areas
the Association of American Medical Colleges and in which they lack information needed to understand
the World Federation of Medical Education.11-12 the problem and how best it can be approached and
Problem-based learning is now an entrenched dealt with. These problems are presented to students
component of medical school programs in the United to solve prior to teaching them basic science or any

From the Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia.

Published simultaneously with special permission from Saudi Medical Journal.

Address correspondence and reprint request to: Dr. S. Azer, Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine,
Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria 3010, Australia. Tel. +61 (3) 83448035. Fax. +61 (3) 83440188.
E-mail: [email protected]

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 Problem based learning ... Azer

information needed to solve the problem.16 Hence, without preparing them. A series of images, a 2-3
PBL acknowledges the possibility of prior minute video or a cartoon may accompany the trigger
knowledge (whether from secondary school text. The following example of a trigger text has
education, previous PBL cases or other forms of been used in one of the problems we have developed
learning within the science, medical or psycho-social for the new medical curriculum at the Faculty of
schools).17 Further knowledge is acquired on a "need Medicine, Dentistry and Health Sciences.
to know" basis, enabling the learner to identify their "Mr. Bill Smith, a 48 year old invalid pensioner, is
own learning needs. Knowledge gained is fed back brought to the Emergency Department of a
into the problem.18 In this way PBL allows the Melbourne hospital by ambulance one evening. He
learner to identify learning topics and discipline is pale, drowsy and is holding an emesis bowl filled
related to the problem. One advantage of this with fresh blood. The ambulance officer tells you
approach is increased motivation.14 that Mr. Smith’s neighbor had called for the
What does PBL mean? Problem-based learning ambulance. She had heard a loud crash and had
may be best thought of as a syndrome comprising of gone into Mr. Smith’s flat to check if he was alright.
a number of components.12 The term "case-based She found him lying on the bathroom floor. He was
learning" is sometimes used rather than PBL. The conscious but drowsy. There was a large amount of
latter term, despite its international currency, is not fresh blood in the toilet and some blood in his beard.
ideal; not all cases are problems, and solving these Mr. Smith is able to answer your questions and tells
"problems" is not the primary purpose of the you that he hasn’t been feeling too well for the last
exercise.12,18 According to Barrows (1986), the term few weeks. His belly has felt uncomfortable and has
PBL can have many different meanings depending gradually become so swollen that he can’t do up his
on the design of the educational method employed trousers. This morning he vomited some material
and the skills of the teacher.19 Barrows (1986) states that looked like coffee grounds and tonight he
that there is no single version of PBL and he has vomited blood. The next things he can remember is
attempted to classify forms of PBL using a his neighbor finding him on the bathroom floor."
taxonomy.19 Other authors agree that there are The trigger text is followed by instructions. The
varying forms of PBL and changes may be tutor should facilitate the discussion of these
implemented in the format and models of problems questions as needed. Students are asked to list key
to enable students to go into more depth.14,20 Table 1 information regarding the patient, identify major
summarizes available definitions of PBL in the problems and for each problem, make a list of how it
medical education literature. Although these may be caused (provide their hypotheses). Then they
definitions seem to address a common ground, they are asked to develop a mechanism to explain each
raise several issues for dispute over what constitutes hypothesis they have proposed and discuss factors
PBL. For instance, the notion that PBL enhances the that could contribute to the problem. This part is
process of acquisition of problem-solving skills has approximately 60 minutes and is completed by
been disputed.24,25 Recently, the issue of whether asking students about further information that might
PBL should fulfill the items included in these be obtained from history questions to help them to
definitions has been raised.26 It is also of interest to refine their hypothesis. Students should also explain
note that several variations or models of PBL have their reasoning.
been developed, and there is ongoing argument What is the rationale for using PBL? The PBL
regarding which models are legitimate applications approach is based on cognitive psychology and the
of the principles and which are sufficiently distinct to broad principles of adult education. This approach
be outside the legitimate field of PBL. 26,27 This differs fundamentally from the traditional approach
diversity in the definition of PBL is due to the fact in which students acquire background knowledge of
that PBL is still an emerging concept. Differences in the basic sciences in the early years of the course and
the perception and beliefs held regarding PBL by its apply this knowledge to the diagnosis and
practitioners have also contributed to this diversity. management of clinical problems in the later years of
Lloyd-Jones et al and Folly et al found numerous their program. The traditional approach has been
articles that described PBL programs in criticized for a number of reasons.16,30,31 The major
undergraduate, graduate and continuing medical areas of criticism are: the traditional approach creates
education, but only a handful met the criteria an artificial division between basic sciences and
outlined in Barrows’ taxonomy of PBL.19,28,29 These clinical practice, academic institutions focus on
authors concluded that the inappropriate utilization scientific research rather than on the competencies
of the term has now become a serious problem of needed in practice, time is wasted in acquiring
PBL programs. Regardless of these differences, a knowledge that is subsequently forgotten or found to
number of clinical stages or steps are usually be irrelevant in the future, application of knowledge
considered in the PBL process (Table 2). The acquired from basic sciences can be difficult and the
problem usually begins with a trigger text or a acquisition and long-term retention of information
scenario, which is often presented to the students that has no apparent relevance can be boring and of

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Table 1 - Available definitions of problem based learning.

(1) “The learning that results from the process of working toward the understanding or resolution of a problem. The problem is encountered first in
the learning process and serves as a focus or stimulus for the application of problem solving or reasoning skills, as well as for the search for a
study of information or knowledge needed to understand the mechanisms responsible for the problem and how it might be solved.”1

(2) “The term applies to any method that achieves 4 important objectives in medical education: the structuring of knowledge for use in the clinical
contexts, the development of an effective clinical reasoning process, the development of self-directed learning skills and increasing motivation
for learning”.19
(3) “It is crucial that the problem 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 faculty members”.21

(4) “An nonstructural method characterized 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”.22

(5) “An approach to learning and instruction in which students tackle problems in small groups under the supervision of a tutor”.17

(6) “A method of learning or teaching that emphasises the study of clinical cases, either real or hypothetical; small discussion groups; collaborative
independent study; hypothetical-deductive reasoning and a style of faculty direction that concentrates on group process rather than imparting
information”.23

Table 2 - Clinical reasoning: steps in problem based learning process.

Tutorial 1:

* Students working in small groups (8-10 students), clarify the cues in the trigger text. The trigger may also be a series of images, 2-3 minute video
or a cartoon.

* Students define problems in the trigger (Problem formulation) and retrieve own knowledge relating to the identified problems.

* Students generate a list of hypotheses for each problem.

* Students develop methcanisms to explain each of their hypotheses. They then develop an enquiry strategy based on their hypotheses.

* Students read further information provided with the problem of the week (eg. medical history).

* Students use the new information to support or exclude each of their hypotheses.

* Students identify areas of gaps in existing knowledge. They may negotiate, delegate, and refine their learning issues throughout tutorial 1.

Between tutorial 1 and 2:

* Students work independently and look for information/answers to each of the learning issues identified by the group in tutorial 1. Students may
use resources such as textbooks, journal articles, web sites, computer aided programs (CAL) in this process.

Tutorial 2:

* Students group reconvenes, about 3 days after tutorial 1, to discuss their own learning issues. They discuss knowledge acquired and link the new
information to issues raised in the problem.

* Students discuss laboratory investigations that might help them to confirm their final hypothesis.

* They may discuss any other issues in the problem (eg. cultural issues, psychosocial problems or ethical issues).

* Students synthesise and summarise evidence collected from the trigger, medical history, and physical examination and investigation results to
support their final clinical impression.

* Students discuss with their tutor, group performance and feed back on group dynamics and suggestions to improve group performance.

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limited value. In addition to these limitations in needs of each students, and (6) to encourage
traditional approach, a number of factors have independent critical thinking skills.
influenced the increased adoption of PBL:- a need The major objectives of PBL are discussed in the
for professionals to be more able to fulfill the needs next section. I have also included currently available
of the community; 32 information explosion in many evidence regarding the extent to which PBL
areas of professional knowledge and the introduction promotes these objectives when compared with more
of informatics in medical education;25,33 a need for conventional approaches in education.
professionals to be able to adopt challenges in Achieving integration. Problem-based learning
biology as well as social origins of health and embodies critical thinking in education. In doing so
disease. 34 The need to foster the development of it opens the curriculum, not by assuming that a move
practical skills needed by professionals and life long must be made from disciplinary to interdisciplinary,
learning.2,14,19 The need for multi-professional but by considering whatever is needed in tracking
education and effective communication in health care problems.16,43 Problem-based learning programs seek
systems. 35 The growing interest in learning and understanding of appropriate depth in response to the
teaching at the tertiary level and the fact that problem in question. In the case of education this is
professional practice is constantly changing and likely to involve not only philosophical and
involves complexity, uncertainty, instability and sociologic issues but also psychological, historical
values conflicts has further influenced the and economic considerations in an interactive way.15
dissemination of PBL in medical education.36 Many Schmidt and Boshuizen found that without
international meetings and conferences have integration of basic science knowledge, the basic
recommended new guidelines for medical science knowledge cannot be applied flexibly in
education. 37-39 These meetings raised the issue that clinical settings.44 Recently, it has been shown that
learning should be as similar as possible to students trained within the context of a PBL
professional activities and the need for the curriculum displayed better diagnostic performance
introduction of integrated, problem-based learning or than students trained within a conventional
problem-solving, and multi-professional.37-40 The curriculum.45 The integration of basic and clinical
rapid development of science and the changes in the sciences proposed to cause this effect.
health care systems requires new tasks and Achieving cognitive objectives. Several studies
innovations in professional health that meets have demonstrated that PBL students are more likely
community health needs, promotion of health, socio- to use the hypothesis-driven reasoning strategies on a
cultural differences, ability to solve problems and to novel problem than the non-PBL students. In
work in teams and use managerial skills. Problem- addition, the PBL students were more able to provide
based learning and multi-professional training coherent explanations to problems compared to non-
provides an ideal strategy to close the gap between PBL students and were more likely to include
education and practice. They focus on learning scientific concepts in their reasoning.46-47 These 2
instead of teaching and are able to create an attitude studies focused on a cognitive prospective drawn
that will facilitate the process of learning throughout from research on PBL students and provided some
life.6,41 evidence that PBL at least contributes to the making
What are the educational objectives of PBL? The of better doctors. Recently, students in full-time
need for change to improve medical education raises PBL, elective PBL and full-time traditional curricula
several key features regarding the acquisition of at 2 schools were compared on a series of patho-
knowledge, use and application of knowledge, physiological explanation tasks over the course of
interpretation of data and development of lifelong the first year of medical school. 48 The students’
learning skills. According to Barrows, the ability to solve problems was considered from
educational objectives of PBL fulfill these key several viewpoints such as accuracy, coherence and
features. 42 The educational objectives of PBL can be comprehensiveness of explanation, reasoning
summarized as follows: (1) to acquire a knowledge strategies and use of science concepts. The data
base that should be better retained, useable in clinical from this study clearly shows that PBL students
context, extended by future self-directed study and generate explanations that are more accurate,
integrated from the many disciplines relevant to coherent and comprehensive than non-PBL students.
medicine; (2) to develop clinical reasoning (problem They were able to transfer the reasoning strategies
solving) skills characteristic of the expert clinician; that they are taught and are more likely to use
(3) to develop self-directed learning skills; (4) to science concepts in their explanations. This effect
encourage sensitivity to all patients’ needs both was stronger for the full-time PBL students. The
medical and psycho-social; (5) to provide a student- authors concluded that by promoting the use of
centered learning method that is motivating for the hypothesis-driven reasoning strategies, PBL might
students, perceived as relevant to a career in accelerate this development as students engage
medicine, capable of being individualized to the knowledge that will eventually become encapsulated

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under their hypotheses. Furthermore, PBL context that this difference was amplified in the clerkship (40
appears to incorporate all the conditions that for students from the problem-based curriculum
facilitate deep learning49-52 whereas the experience of versus 11 for those on the conventional track).60 Shin
conventional professional education seems to et al have shown a higher score on a written test on
encourage a superficial level of learning. 53,54 hypertension for graduates of a problem-based
Promoting small-group learning. The small- program 10 years after graduation; however, this data
group format of PBL is invaluable in the was not corrected for possible base-line differences
development of negotiation, communication and in knowledge or for differential retention of
collaborative skills.14,55 Small-group work is better knowledge.61 Norman and Schmidt reviewed the
than a lecture for higher order activities, e.g., experimental evidence supporting differences in
analysis, evaluation and synthesis. This may reflect student’s learning that can be attributed to PBL.62
increased motivation in small-groups. Active They found that PBL enhances intrinsic interest in
preparation, with face-to-face contact may ensure the content to be mastered, and it appears to enhance
that a member seeks to understand at a deeper level. and maintain self-directed learning skills.
Group discussion activates previously acquired Promoting teamwork. Working in groups
understanding, helping identify any deficits and provides mutual support, laying the foundations for
facilitating new comprehensions.1,3 Other benefits of future behavior and strategies adopted with
small-group learning include, promotion of an adult professional members of the team.8 Transferable
style of learning and development of collaborative skills (e.g., leadership, teamwork, organizations,
learning and other transferable skills.56 According to giving support, prioritizing and setting tasks,
Hare, the key attitudes which aid group functioning problem solving, motivating climate and managing
are positive attitudes to the group, positive attitudes time) are seen as important attributes in health
towards interaction, readiness to be creative and professionals. Such competencies are best fostered
readiness to be critical at the right time and in the not by direct teaching to transmit information but by
right way. 57 This view regarding developing positive teaching to encourage specific kinds of cognitive
attitudes to facilitate co-operative PBL team work activities. Students can observe the effect they have
has been recently supported.58 Among the important on other members of the group. These experiences
positive attitudes towards the group are: join the may influence future behavior and strategies adopted
group without deciding ahead of time that the with professional members of a team. Multi-
experience will be unpleasant, be committed to the professional aspects of health care require team
group process and consensus and have a feeling of working and PBL allows students to work effectively
responsibility to expend time and energy for the in small groups and develop teamwork,
group.58 communicating skills and collaborative learning.56 In
Promoting self-directed learning. Self-directed PBL programs which emphasize the importance of
learning is an adult learning strategy. It is early contact with patients and clinicians, students
information seeking behavior in response to practiced communication skills from the first week
identified learning needs. This leads to targeted use of year one and were more able to explore the
by the learner of a variety of learning resources to importance of role models in clinical education and
overcome deficiencies in knowledge, skills or the significance of teamwork in health care
professional development. Effective self-directed systems. 63
learning requires the development of self-assessment In conclusion, PBL presents the most promising
skills, critical appraisal skills and effective time prospects for better medical education. Qualities
management. Studies have shown that PBL students ensured by PBL such as self directed learning,
have different study patterns than those of enhancement of cognitive learning and integration,
conventional curriculum students.59 Vernon and teamwork, cooperative peer learning, development of
Black conducted 5 separate meta-analyses on 35 reflective attitudes, critical evaluation and
studies representing 19 institutions.23 They found assessment, suggest a potential value of its
that the PBL students used more journal articles, implementation in medical education. However,
electronic searches, books, and self-selected some of these qualities still need full investigation to
resources and felt more competent in information- ensure the validity and long-term effectiveness of
seeking skills. Newble and Clarke found 3rd and 4th PBL to produce competent doctors for the new
year PBL students were more likely to study for millennium.
meaning than conventional students.50 Blumberg and
Michael used a variety of measures, including library Acknowledgment. I would like to thank Professor Richard
circulation data, to show that students in a problem- Larkins, Dean of the Faculty of Medicine, Dentistry and Health
Sciences, and Associate Professor Susan Elliott, Director of the
based track borrowed more material during the FEU, Faculty of Medicine, Dentistry and Health Sciences, the
course than did students from the conventional University of Melbourne, Victoria, Australia for their valuable
curriculum (67 books/student/year versus 43) and comments and input during the preparation of the manuscript.

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