Problem Based Learning

1. Problem Based Learning Dr Reg Dennick Assistant Director of Medical Education The University of Nottingham

2. Discuss with a partner. What do you already know/not know about PBL?

3. Learning Objectives • Explain the educational rationale for PBL • Describe the ‘seven-step’ PBL process • Participate/Observe in a partial PBL session • Critically evaluate the evidence for the effectiveness of PBL

4. ? Traditional PBL

5. ANCIENT MEDICAL ‘THEORY’ LATIN & GREEK HIPPOCRATES ARISTOTLE GALEN

6. GRAMMAR, PUBLIC SCHOOLS & UNIVERSITIES • Dominated by • Latin & Greek • Ancient history and philosophy • Theology • MEDICINE • Entry needed Latin (Greek) • All anatomical nomenclature in Latin/Greek

7. Entry into medicine had a language and theory barrier going back to an ancient view of education. (Higher education was for an elite class using a ‘secret’ language?) • Even with rise of ‘scientific medicine’ in 19th C the traditional medical curriculum had a Theory/Practice split and the requirement for Latin was not dropped till 1950s in UK

8. In education there has been a historical split between theory and practice Theory has to be learned first before dealing with practice. PBL turns this split on its head. Problems deriving from practice are used as triggers to acquire theoretical knowledge Theory & Practice

9. The learning which results from the process of working towards the understanding of, or resolution of, a problem (Barrow & Tamblyn 1980) PBL: definition

10. “The most powerful learning occurs when the student is dealing with uncertainty.” John Dewey Cognitive dissonance (Festinger) Problems Dis-equilibration (Piaget) Paradigm shifts (Kuhn)

11. A strategy for learning where small groups of six to eight students work in a series of tutorials discussing problems provided by the Faculty related to their course. Problem Based Learning

12. Content The Scenario The Problem The Context The Knowledge The Skills The Attitudes Process Talking Dialogue Questioning Hypothesising Collaboration Activity Communication skills Interpersonal skills PBL is a type of Small Group Teaching activity

13. students engage in a collaborative activity that: makes them think makes them ask questions activates prior knowledge tests their understanding elaborates new knowledge reinforces their understanding by speaking provides motivation for learning makes them practise a logical, analytical approach to unfamiliar situations Involves learning in context integrated learning collaboration PBL

14. Relevant context Adults are self-motivated Adults learn best in groups Adults prefer ‘doing’ to being told Active learning through posing own questions and finding own answers: therefore student centred Integrated learning: learning in a variety of disciplines simultaneously Deep learning for understanding; metacognition; reflection; appropriate feedback; opportunities for practice PBL fulfils the conditions for effective adult learning

15. Celstin Freinet (1896-1966) McMaster Medical School (Hamilton, Ontario) 1969 University of Maastricht (1974) Manchester (1995) Liverpool etc (1997) Nottingham (Derby) 2003 Where does it come from?

16. Scenario Small group Generate questions Research questions Answer questions Communicate answers How does it work?

17. The Maastricht ‘Seven Step’ PBL process • Step 1: Clarify terms and concepts • Step 2: Define the problem(s) • Step 3: Analyse the problem(s) - ”Brainstorm” • Step 4: List of the analysis and possible solutions • Step 5: Formulate Learning Objectives • Step 6: Collect additional information focussed on Learning Objectives • Step 7: Synthesise and present new information

18. A PBL scenario Ranjit Singh, 46, has just returned from the Indian sub-continent where he visited his brother and family for a period of one month. He lives with his wife, their four children and his parents in a three bedroom terraced house in the Peartree district of Derby. He works as a waiter in a local Indian restaurant. Recently he has started coughing a lot, has little energy, is losing weight and has developed a fever. He visited his GP after he coughed up some blood and developed chest pains. His GP suspects TB and has sent a sputum sample for analysis and Mr Singh for a chest X-ray.

19. Learning Objectives for the PBL scenario • Basic and clinical sciences • Describe mechanisms and common causes of cough. • Describe types of clinical investigations available for patients with cough. Interpretation of CXR. • Outline the microbiology of mycobacterium tuberculosis. • Describe the immune response to TB, its use in diagnosis and the tuberculin test. • Describe clinical and pathological manifestations of TB. • Outline the drug regimes for treating TB, their mode of action, side effects and the problem of drug resistance.

20. Learning Objectives for the PBL scenario • Community and population • Describe the epidemiology of TB, the impact of socio-economic factors and its relation to HIV. • Discuss the social and family issues associated with TB in the community.

21. Learning Objectives for the PBL scenario • Patient and Doctor • Describe how communication problems can be dealt with in ethnic minorities. • Awareness of perception of TB in Asian communities and problems of stigmatisation. • Dealing with issues of confidentiality versus compulsory notification: patient autonomy. • Describe how to ensure compliance with complex and long-term drug regimes. • Persuade family members to be immunised.

22. Learning Objectives for the PBL scenario Personal and Professional Development Doctor as patient: awareness of personal immune status.

23. Work in a group of six to eight Meet for about an hour and a half two or three times a week Analyse, discuss and generate questions and learning tasks from the scenario Engage in self-directed learning Communicate results back to group PBL: students’ roles

24. The facilitator must let the students be responsible for their learning. The facilitator must let the students do the work. The facilitator has the role of monitoring and evaluating the discussion. Guidance is given in the form of suggestions. The facilitator has background information concerning the case under discussion. The facilitator may intervene if the students are not working or if the activity is starting to go in the wrong direction. The students may ask the facilitator for advice which can be given according to his or her judgement. PBL: role of the facilitator

25. Autocratic: facilitator basically controls all the objectives and activities of the group and keeps intervening to ensure they are carried out. Laissez-faire: allows the group to decide what its objectives are, what activities it is engaged in and has minimal input into the session. Democratic: collaborates with the group, helping them to agree on a set of objectives and activities and only intervening to keep the group dynamic orientated in a positive direction. Small group Facilitator stylesKurt Lewin:

26. Facilitators need to be aware of basic issues which can influence the learning process: Planning Meaning Confronting Feeling Structuring Valuing. These are independent processes that weave through each SGT session. Facilitator StylesJohn Heron: ‘Six dimensions of facilitation’

27. Heron’s 18 facilitation styles Facilitators can move between all these styles during a small group teaching session.

28. ……should value autonomy, co-operation and hierarchy in that order as this recognizes the personal autonomy of group members to self-actualize collaboratively, with the facilitator taking responsibility to achieve group goals. Heron: the most effective facilitator……

30. Students engage in a wide variety of learning experiences of which PBL tutorials are of central importance. lecture/plenary topic tutorials library skills PBL tutorial clinical work practicals personal study demonstrations computer assisted learning

31. A PBL week

32. BREAK!!!

33. A taste of PBL

34. Rolls Royce have revealed that they have a small nuclear reprocessing plant on their premises in a heavily populated area of Derby. It is similar to a plant in Japan where there was a recent accident. Problem Based Learning Scenario(Environmental Studies)

35. Step 1: Clarify terms and concepts • Step 2: Define the problem(s) • Step 3: Analyse the problem(s) - ”Brainstorm” • Step 4: List of the analysis and possible solutions • Step 5: Formulate Learning Objectives • Step 6: Collect additional information focussed on Learning Objectives • Step 7: Synthesise and present new information Rolls Royce have revealed that they have a nuclear reprocessing plant on their premises in a heavily populated area of Derby. It is similar to a plant in Japan where there was a recent accident.

36. We need to know what it is. What do we mean by effectiveness? What outcome measures should we use? Evidence for effectiveness

37. Can you define/describe it? What sort of an educational process is it? How does it relate to mainstream educational theories? What is the educational rationale? Is it Constructivist, Student Centred, Rogerian, Kolbian, Dewian, Post-modern, Confucian? Is there a common underlying process? Is it really Question Based Learning? Problem solving? Situation based Learning? How many variants of PBL are there? How are they related? The Evidence

38. How effective is it? What do we mean by effective in this context? Can we measure its effectiveness? How do we measure its effectiveness? Quantitative or Qualitative or both? Can you control all the variables? Evidence

39. What outcomes can be used to ‘measure’ effectiveness? Exam results? Personal satisfaction? Academic achievement? Clinical competence? Patient satisfaction? Knowledge, Skills, Attitudes? Communication and interpersonal skills? Life-long learning skills? Participation in CPD? Must there be a control or comparative group? Randomization? Is the RCT the ‘gold standard’ for educational research? Is process more important than outcomes? Evidence

40. Academic achievement: little significant difference Clinical achievement: PBL students have superior clinical skills and communication skills Approaches to learning: PBL students more likely to use deep rather than surface and more likely to engage in self-directed learning Summary of evidence

41. Graduates of PBL More likely to engage in CPD Teacher & Student satisfaction Greater for PBL Costs More expensive with >100 students Summary of Evidence

42. Problems with PBL • Perceptions • Training • Dual tracking • Coverage & ‘holes’ in knowledge • Expert v. non-expert tutors • Resource-intensive • Significant start-up and maintenance costs • Demanding of staff time • Can be stressful for students and staff • Need strong commitment of faculty

43. It needs to be well defined, organized and integrated into the curriculum. Students need to understand what it is; they need to learn about learning. For most students it’s a great way to learn and they love its collaborative and interactive nature. Students talk to each other for three hours a week about the subject. For students and facilitators its very stimulating and enjoyable: it’s fun! Graduate PBL students achieve the same knowledge scores in clinical exams and communicate well in the clinical environment My views

44. A student view “My overall experience of PBL has been a positive one and I would argue that PBL has a lot to offer medical students. PBL not only provided me with a knowledge of the fundamental areas of medicine but also made me aware of my responsibility for my own learning, a crucial element in itself….Working in a group allowed me to develop my interpersonal skills as well as providing a stimulating work environment, which is not always achieved if spent in lectures all day.”

45. Foundations of Problem-based Learning (2004). Maggi Savin-Baden & Claire Howell Major. Open University Press. The challenge of Problem Based Learning (1997). Eds: David Boud and Grahame Feletti. Kogan Page. A pilot systematic review and meta-analysis on the effectiveness of Problem Based Learning. (2003) Mark Newman. LTSN-01 report. (http://www.medev.ac.uk/docs/pbl_report.pdf) References

46. Any final questions?

47. Learning Objectives • Explain the educational rationale for PBL • Describe the ‘seven-step’ PBL process • Participate/Observe in a partial PBL session • Critically evaluate the evidence for the effectiveness of PBL