Issue 28 / 4 August 2014

ALMOST 40 years after problem-based learning turned medical education on its head, a group of Australian doctors argue there’s little high-quality evidence to show it beats a lecturer in front of a chalkboard.

In a ‘Perspectives’ article in the MJA this week, Professor Les Bokey and colleagues from the University of Western Sydney, said it was “striking” that although problem-based learning (PBL) emerged at the same time as evidence-based medicine, there was still “very little high-quality evidence for its effectiveness compared with TLL [teacher-led learning]”. (1)

The authors concluded that the model, which involves students working together to solve real-world problems, was no better or worse than other teaching methods used in undergraduate medicine, including TLL, case-based learning, large group lectures, small group tutorials, bedside teaching, dissection or simulations.

“None of these is universally accepted as optimal in all circumstances, and all can contribute to effective and efficient education of future health care professionals”, they wrote.
    
Professor Bokey, a colorectal surgeon at Liverpool Hospital, Sydney, and his coauthors reiterated long-standing criticism that anatomy training had suffered in the era of PBL, arguing that “this deficiency would be best served by establishing a national core curriculum”.

They noted that the volume of anatomy training at the University of Sydney’s medical school fell from 253 hours in the first 2 years of the old undergraduate course in 1996 to 50 hours in the new graduate program in 1997.

“As a result, students now question whether their knowledge of gross anatomy is adequate for safe medical practice and argue for a return to cadaver dissection”, they wrote.

The authors also argued that PBL had disenfranchised many clinician teachers, who found themselves replaced by non-specialist “facilitators”. As a result, student contact with practising physicians was “diluted” and “expert bedside clinical teaching suffered”.

Professor Bokey told MJA InSight his intention was not to criticise PBL or the generations of doctors it had produced.

He said medical interns today were “much more empathetic and compassionate towards patients” than their forebears, and could “hold their heads up high” compared with interns around the world.

Emeritus Professor John Hamilton, previously dean of medicine at the University of Newcastle where PBL was first introduced in Australia and chair of the curriculum committee at Canada’s McMaster Medical School where PBL was first developed, told MJA InSight he had identified some of the hazards of the model in a critique he wrote in 1976. (2)

One significant problem was the way the method was sometimes deployed by inactive tutors who left students too unguided in their exploration of the sciences, he said.

“It is one of the more difficult tasks of a tutor to judge the scientific rigour of a discussion”, he wrote in the critique.

However, Professor Hamilton told MJA InSight that when PBL was deployed well, it could be an “energising experience for students … inculcating in them a habit of continued learning”.

He warned that “newer forms of competency-based medical education and learning through simulation have to be used very carefully”.

“It must not be forgotten that underneath all the competencies of practical action there must be the fundamental competency to apply and to understand the scientific foundation not just of ‘what’ to do, but ‘why’,” Professor Hamilton said.

“Without the ‘why’ there will be no scientific framework within which to cope with the unexpected or to engage with the new in clinical disease and scientific discovery.”

Medical Deans Australia and New Zealand agreed that PBL was “just one of a large range of educational methods available in contemporary medical education and all come with advantages and disadvantages”.

A spokesperson told MJA InSight the concern about clinician educators feeling disenfranchised was valid. “We need to have our valuable clinical educators and supervisors engaged to assist in training the next generation of doctors.”

 

1. MJA 2014; 201: 134-136
2. BMJ 1976; 1: 1191


Poll

Do you think problem-based learning has produced better doctors?
  • No - they lack basic knowledge (70%, 85 Votes)
  • Don't know - it hasn't been measured (20%, 24 Votes)
  • Yes - they are more well rounded (11%, 13 Votes)

Total Voters: 122

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17 thoughts on “Learning lacks evidence

  1. Dr Merle Wigeson says:

    The problem with PBL is that if a particular condition does not come up with a particular group of students, they know nothing about it, and have to start from scratch as qualified physicians if a patient presents with this condition. PBL may teach a lot about a small number of conditions, but does not replace a good core curriculum that covers all aspects of what a good doctor needs to know.  It is becoming obvious that graduates are coming out lacking core skills, not through their own deficiencies, but because of glaring gaps in the PBL system.  Post graduate courses that attempt to teach medicne in four years are also a concern, as basic anatomy and physiology courses are truncated.

  2. Department of Health Victoria Clinicians Health Channel says:

    as a full timer in the public hospital system, I can definitely say that the new fangled PBL teaching method has NOT produced better interns.  in fact at times quite the opposite.  the level of knowledge of some areas is quite appalling.

  3. Don Cameron says:

    As a practicing clinician and medical teacher (at all levels) for almost 30 years, I would make 2 points: Firstly, I strongly agree that the success of any curriculum (PBL or otherwise) depends on how it’s been implemented – PBL curriculae in Australia have been done both really well and really poorly. There is probably no such thing as “standard PBL”. And most importantly, without ongoing review and maintenance, even good curriculae can fall into disrepair! Secondly, the argument over the optimal amount of anatomy teaching in the medical course was raging long before the introduction of PBL as dissection time started to feel the squeeze from other sections of the curriculum. The argument over the balance of subject areas in a curriculum is an important one and independent of the way the curriculum is delivered. As a footnote, I went through a PBL-based curriculum that actually included gross dissection!

  4. Thomas walker says:

    Without good knowledge of anatomy, they are unable to answer the first question in the diagnostic cascade-WHERE is the lesion?

    WHAT is the lesion  or pathophysiological process seems to be addressed too early by these graduates.

    So what tests to order still depends on the WHERE .

    Relying implicitly on the tests ignores the inherent order of inaccuracy.

    As the article says, it is not their fault; they have not been taught the core basics thoroughly. So the deductive process starts in the middle not at the begining.

    Some of the problems seem to be teaching by non clinicians. eg I read recently in a teaching manual, instructions on using the tonometer to measure intraocular pressure. The steps do not work;  Was it written after reading the specifications??and not testing in the clinic?

    Is the post graduate course better? seems like a good idea to have mature persons committing to medicine.

    BUT after speaking with clinician teachers there are problems. Their personalities are crystallised so that they want to learn THEIR way not the teacher’s. Some have financial and family commitments so they spend as little time as possible in clinical work and keep part time jobs to pay the mortgage; and so on.

    PBL should NOT be the ONLY teaching technique.

  5. q402681@amamember says:

    As a currently practicing pathologist and an ex-GP who graduated decades ago and have been a Senior Associate Lecturer at a University, a College Examiner and a mentor for medical students through the AMA, I feel quite confident in presenting my real world observations about PBL. There are no differences in intelligence, commitment or innate ability in students over the last five decades. Unfortunately, PBL trainiing was instituted (mainly) from the USA in the 80s & 90s for Universities to assuage the dual problems of inflationary cost rises and Government financial restraints. These costs lead directly to poorly competitive clinical teaching salaries. Proof of concept was never a consideration. That there are extensive and variable basic knowledge gaps in recent graduates is so obvious as to be not worth debating. In a very real sense they have been given a “Readers Digest” approach to medical education (Here is Joe’s liver go figure!) and are often guided by non-medical people who simply don’t know what they don’t know.  Without a core national undegraduate curruiclum, students in our country will continue have no clear signposts indcating what is really important for safe practice. They are left scrambling to catch up retrospectively in the wards. In my current practice I now spend far more of my time on the phone answering basic physiology, biochemistry and disturbingly, pathology questions than I did 20 years ago. It is a personal tribute to these young doctos that they do succeed,

     

  6. Clem Boughton says:

     As a 1950 medical graduate Sydney Uni, I appreciated the value of having done 3 plus years of the basic clinical sciences, before ever encountering a sick patient. The knowledge already acquired, especially pathology and path. physiology, made understanding disease processes reasonably straightforward. This was augmented by bedside tutorials from practicing clinicians. One of my sons did the new Newcastle course instituted by David Maddison, and found it hard to decide how much of the relevant disciplines to study for each chosen clinical problem. The impression was that the students were not given enough guidance. Undoubtedly this has since been corrected. However the impression I had, was that a course based on PBL, could result in very patchy knowledge of the      very important basic underlying sciences. Despite this, he is a very competent doctor .  I would certainly not like to study Medicine in that way.

  7. Ulf Steinvorth says:

    Agree with most of what has been said above and teaching PBL/CBL myself found two additional aspects of  concern: 1. the sometimes astonishingly different levels of knowledge, learning and dedication in different groups for which there does not seem to be a clear solution and which seems to be random allocation to higher or lower outcome groups 2. the concept of pre-reading being accepted as ‘work being done and topics having been learnt’ on arrival.

    PBL is much more costly than lecture learning yet with increasing group-size and increasing emphasis on students learning the contents themselves prior to the PBL tutorials the line between what is being taught and what is expected to be self-taught becomes ever more blurred. A further concern for the ones who want to get or deliver a world-class medical education and potentially also for the increasing number of overseas fee-paying students who simply do not get what they pay for anymore.

     

     

     

  8. Dr Louis Fenelon says:

    In 1978 I entered the foundation year of the University of Newcastle Medical School; one of those new fangled PBL doctors. Nothing compares to the course we did. Senior staff were not at all upset about isolating their talents from the students, because that was what it was all about. We were thrown to the dogs with zero formal teaching in anatomy, physiology, biochemistry, etc. We were examined on all of it at every exam though; all of it. Turn back a page and you were disqualified. No core teaching but 100% accountability was wrong and cruel. You cannot problem solve anatomy, physiology, etc and witholding teaching is misguided or manipulative. It was not misguided in Newcastle, just punitive.

    Before the end of week 1 in year 1, I was observing surgery, doing patient rounds and performing my first breast examination. Clinical work provided a balance to the lack of teaching. We had lots of great clinicians helping us throughout the course. 

    It is unfair to disclaim PBL, just as it was totally wrong of our teachers to exclude TLL. We had a feel for medicine at graduation because we had been part of the system for 5 years and good at learning when needed. We were also really good at unnecessary anxiety and it discouraged a lot of us from specialist training.

    Doctors working with current graduates are the key to their learning and capabilities and our profession rests its reputation on you. Fact is that we learn from our profession, not just in our undergraduate course.  Perhaps recognising what is missing in your interns and other junior staff allows you to be the mentor they (we) all need.

     

  9. Ian Robertson says:

    Hard to disagree with the valid and conclusive comments made above. All of my (final year , graduate PBL based course) students agree that their learning has been patchy , and dependent on problems encountered . Their knowledge of anatomy is scant, and their understanding of normal biological function is lacking. Perhaps an anecdote will serve to demonstrate the point . Not so long ago I tore my quadriceps in a fall ; not one of my group of four final year students knew where the quadriceps was ! 

    And we wonder why our patients go to chiropractors !

  10. Lucy van Baalen says:

    I studied at Newcastle University.  I had the best anatomy Professor (Nik Bogduk) who taught us how to problem solve anatomy.   I still use his notes and teach his dance of the dermatomes and myotomes. Prof Bogduk made us design joints and work out what structures need to be there to carry out the function of the joint.  I am a 3rd year PBL tutor at Newcastle University, and I expect the students to correlate the clinical findings to the anatomy and physiology.  For neuro problems, the students are expected to give the diagnosis in terms of “where is the lesion” (anatomy) and “what is the lesion” – “stroke” is not good enough – they are expected to identify the location & pathology (e.g. left MCA affecting right UL/ face motor cortex and Broca’s and Wernicke’s area due to thromboembolism).

    As a GP acupuncturist, I have been able to teach myself musculoskeletal anatomy and biomechanics by using the skills I learnt at Newcastle Uni – asking the right questions from physios, orthopods, clinicians, patients and written information, and being able to integrate this in a way that dry isolated anatomy lessons never could. 

    I also teach doctors acupuncture, as part of AMAC.  PBL and application reinforces the didactic teaching, and highlights the holes in the students’ knowledge.

    PBL teaches you how to find out the answer if you don’t know.  As doctors, you will can’t know everything about everything, so you need to have humility to acknowledge this, and a willingness to learn.

  11. Dr Rob Kielty says:

    In theory, I think PBL is a terrific idea. I was a disengaged medical student who felt overwhelmed by the medical curriculum when I trained in the mid to late 80s and had pretty much no idea what to do with this slew of text books and information that just kept coming. In short I was that generations equivalent to the PBL-trained caracature that many respondents ‘have highlighted. Pre PBL teaching is certainly no “golden era”.

    I have been a PBL tutor for several years and my observation is that there is not a need for more knowledge. We live in the 21st century and that information is out there and to hand if we need it. What is more important is the ability to understand and to apply. I note a comment that students are exposed to very few clinical conditions in the tutorials- that is because these cases are chosen as exemplars of particular areas. The expectation is that with some understanding and reading around, students will be equiped to think about other similar problems. Therefore the goal should be to teach students the core principles and then expose them to what that means v clinically- isnt that what the clinical teaching is for?

  12. Belinda Cochrane says:

    Lucy has hit the nail on the head. Most factual medical knowledge is accessible as long as you are aware of the available resources and know where to look. As for children learning literacy and numeracy, there is a certain amount of core knowledge without which they can’t proceed to practice. However, once that is acquired the important skills to progress medical ability are logical reasoning and investigative research. Personally, as 1994 graduate from the University of Tasmania our course had a heavy component of didactic (lecture style) teaching combined with some problem based learning, known at that time as the “4 column method”. I can tell you now, it was the lectures that I slept through! My point is that learning is very varied between individuals – different students may require different techniques. It is very important to use varied techniques to teach our students so all have the opportunity to discover their best means of learning. 

  13. Genevieve Freer says:

    My view of PBL is that it a useful tool in clinical years if preceded by core training in maths, physics, chemistry, biology, physiology, biochemistry, anatomy and pathology.

    Without these core skills, I now teach students whose maths is so poor that they cannot calculate a drug  dosage, nor fluid balance,whose anatomy is so poor that they cannot find normal pulses nor an apex beat, whose physics is so poor that they cannot interprete blood gases, nor oxygen flow rates, whose physiology is so poor that they do not know normal values for pulse rate, blood pressure, etc.

    I think it is unfair to expect that first year students are expected to know how to resuscitate a neonatal dummy, when they have not been taught normal values for pulse, respiratory rate, nor fluid maintenance in a neonate

    My view of PBL which is not preceded by core training in basics is that it is a cost-cutting measure which benefits the University , contracting a six year course into  four years, while placing a ridiculous load on medical students, who are expected to teach themselves these basics without the 2 years of time which it has taken in the past, and without the benefit of experienced lecturers and tutors, with the resulting epidemic o f” ADHD”  being diagnosed then prescribed stimulant medication in medical students.

     

  14. Dr David De Leacy says:

    Just to correct AceofSpades asssertion that PBL is a more expensive program of teaching: it most certainly is not. Indeed as I explained above it was introduced specifically as a stand alone method of education by university medical schools, primarily to reduce the costs (without proof of concept) of their new truncated four year post graduate courses. The initial two year GAMSAT selection bias for students with no scientific background combined with the compression of the historical three year preclinical course into a one year ‘almost’ stand alone PBL based one was a major disaster in many universities. Both of my children did medicine in this era and I ensured that they both did chemistry, biochemistry, physiology, immunology, microbiology, pharmacology and anatomy subjects in their pre-entry BSc course. Both flourished in the graduate degree course. Their colleagues however variably struggled depending on their scientific backgound to make sense of the PBL tasks set for them. Their common complaints were firstly, the lack of a cohertent and clearly presented basic medical curriculum so as to provide these mature age students a perspective for the information overload they experienced and secondly, the disproportionate amount of time required for social science topics that of necessity mitigated against time available for the basic science/medicine study. Too much in too short a time frame. I am not arguing against PBL per se. It is merely one teaching method with manifest strengths and weaknesses but should not be used as a  panacea for medial schools financial problems. 

  15. karen price says:

    Interesting comments and yet “Good Qualtiy Medical Education and Methods” are hard to quantify as an outcome.  Have there been any studies around this? 🙂
    I have been perturbed by anatomy ignorance.  When giving a lateral thigh simple IM injection to a patient I casually asked my 4th Year Medical student what structures I might be going through and got a blank stare. I don’t know who was more horrified the patient, the medical student or me!
    Problem based learning seems to focus on just that “problem” so students would know the median nerve and the sciatic nerve as these have obvious problems that would warrant a tutorial. However “normal” structures may be missed. So how is a Dr to operate from first principles when faced with a “new” or “novel” problem in the rough and tumble world of clinical practice? Can we predict what problems today’ students might encounter tomorrow? Also of interest is Prof Hamilton discussing the merits of PBL and the caveat “when it is done well” and again this comes down to educational principles. So much of the outcome depends on the competency of the teacher rather than the method. I’m sure all of us can remember attending simply terrible lectures in the traditional chalk and talk method with lecturers whose interpersonal skills resembled an inanimate object. There was very little knowledge translation. Rather than throw the PBL baby out with the bath water, I think making medical education a priority and a skill set for experienced practitioners as well as those University Based Researchers would enhance medical undergraduate training quite significantly. However a return to first pinciples on Anatomy would seem an additional improvment.

  16. Ian Hargreaves says:

    Every year our patients spend millions of dollars on vitamins which are useless to anyone who is not malnourished, on dietary supplements like glucosamine which cannot grow cartilage in an adult, on moisturising skin creams with transcutaneous collagen, on chiropractic manipulation for their children’s asthma, and so on. Unless we, as doctors, have a knowledge of the basics of anatomy and physiology and biochemistry, we and our patients will always be at the mercy of the sellers of snake oil.

    I recently watched my registrars nodding in approval as the sales rep produced graphic slides of how his product was superior because it was “low profile”. I could not resist the temptation to inform the rep (and my trainees) there was an engineering term for the low profile plate he was marketing, which was “thinner and weaker” then the other company’s hardware that he was disparaging.

    The real world is too busy for a group to workshop every clinical situation as it arrives, but a knowledge of first principles of basic science is a wonderful tool. When my patient asks me if the shampoo with a pro vitamin will help her, I can inform her that a pro vitamin is not something better than an amateur vitamin, but simply an inactive precursor.

  17. Sophie Cohen says:

    Finally the critiques of PBL are coming to the fore instead of it being touted as the new and best model for adult learners in medical school.

    I entered medical school in 2007 and was disappointed by the PBL-focus from my first week onwards. Despite being a naive student with no sense of what to expect at medical school, I found PBLs were an inefficient and  ineffective way to teach core content (4 hours per week plus hours of preparation). A facilitator who is not a doctor is ‘guiding’ the students through clinical scenarios with the students teaching each other using their lecture notes and research. 

    I think the PBL method made my clinical years and internship harder rather than easier because the method of reasoning  and the differential diagnostic process is different in the real world. PBL leaves students insecure about what key points to cover and often the learning objectives, that are only released at the end, have not been adequately covered initially because of the ‘not knowing what you don’t know’ situation of most students. The differential diagnoses are run through in a textbook manner rather than with clinical reasoning from an expert to explain how to rule in or out certain differentials. 

    I wish my medical school days had included less PBL.  I hope the debate the MJA articles have prompted will ensure the efficacy of PBLs will be rigorously assessed and that the opinions of students subjected to this teaching method is at least taken into account. Unfortunately it is my generation of doctors who will likely prove how inadequate PBLs are as the main vehicle for teaching the majority of medicine, even if our bedside manner is appealing.

     

     

     

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