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Problem- and case-based learning

Problem-based learning (PBL) was first implemented at McMaster University in Hamilton, Canada, in the late 1960s. It can also be argued that PBL is the formalisation of a process that has underpinned clinical teaching for many years. PBL is now to be found in undergraduate medical curricula throughout the world, and its introduction in the UK was encouraged by the General Medical Council’s recommendations on undergraduate medical education, Tomorrow’s Doctors (1993, 2003).

What is problem-based learning?

As Davis and Harden (1999) have indicated, there is still some confusion about what PBL really is. It is best thought of as an educational approach where students are encouraged to take an active role in their learning by discussing a problem (or scenario) centred on a clinical situation, community problem or current scientific debate. In the clinical context, this might be a description of events when a patient attends a GP surgery or A&E department. The history, presenting complaint, signs and symptoms, ethical issues, investigations needed (and their outcomes) can all be woven into the case, as required. The problem has to be written so that the students can identify the areas that they need to explore in order to be able to resolve satisfactorily gaps in their knowledge and understanding that become apparent during group discussion.

A key point in understanding the nature of PBL is to differentiate it from problem solving. In problem solving exercises the basic assumption is that the students have the knowledge and skills required to arrive at a solution (albeit that the application to a specific problem may further stretch them). In PBL the problem is the starting point that enables students to identify for themselves new areas for their learning.

For PBL to be effective, it is important that participants work together in a structured way. Initially, a problem designed by the faculty staff is reviewed by a group of students. Ideally, there should be no more than 10 members in the group, and they should select for themselves a student chair and scribe for the session. (The scribe will record the ideas generated by the group on a whiteboard or flipchart.) It is the task of the staff facilitator to ensure that the group works through the problem in a methodical way. A series of steps can be identified – that below is based on the Maastricht ‘seven jump’ model.

  1. The group starts by identifying any terms with which they are unfamiliar. Some members of the group may have some prior knowledge that will help the group.
  2. The students openly discuss the scenario and define the problem.
  3. The group brainstorms possible explanations or hypotheses which fit with the events/problems they identified.
  4. Some provisional explanations/conclusions are reached that would reasonably explain the essence of the case.
  5. The students formulate their learning objectives – those aspects which the group have determined need further study.
  6. Working independently (or in pairs) the students use the resources available to them to achieve the learning objectives.
  7. The group meets again a few days later to pool the information they have gained from private study and discuss the case in the light of this new knowledge.

Ideally, the students and facilitator should then evaluate the case and its suitability for PBL. Schmidt (1983) provides a fuller description of the process.

For more about PBL, see 'Facilitating learning: small group teaching methods' in Explore around this topic. Please note this will be available soon.

You may want to explore different approaches from the ‘classic’ PBL approach to encourage and develop learners’ problem-solving skills or clinical decision-making skills. Such approaches might include clinical case-based learning and cilnical scenarios.

Clinical case-based learning

Developing a ‘bank’ of interesting clinical cases that illustrate various aspects of clinical learning. These might include:

  • case notes/extracts from a case history
  • investigations carried out and the results, X-rays, etc.
  • reports written by other health professionals
  • examples of letters (referral, discharge, follow-up)
  • video or audio tapes of patient encounters
  • extracts from relevant articles about the clinical condition, treatment options, etc.

These cases can be used as stimulus material to encourage students or trainees to learn about a specific clinical condition. This can be helpful, for example if the condition is a common one, but the patients the learners have had the opportunity to see have not been typical or did not stay in hospital long enough. Because the material is based on real patients and real resources, it is seen as interesting and relevant by learners and allows the teacher to pre-select material which illustrates specific learning points.

Remember to seek appropriate permissions when copying and using such material. Websites such as the Patient Voices site are useful sources of case-based multimedia resources.

Clinical scenarios

You may find it useful to write or think about some typical clinical scenarios to use as a stimulus for discussion or to encourage learners to seek out more information about a topic. These may cover wider issues than just clinical conditions. The advantage of writing these yourself is that you can tailor them to include the issues you want learners to discuss or find out more about. These might include legal or ethical issues, public health issues, resource allocation issues, etc. Such clinical scenarios might include:

  • newspaper cuttings about clinical cases
  • articles from, for example, the Lancet or British Medical Journal
  • reports or recommendations from public bodies or agencies
  • statistical reports showing trends or disease patterns
  • a stimulus piece you have written which points learners in the right direction or which asks some key questions.

Other types of clinical scenario could be written more like anecdotes about situations in which you or colleagues have been involved. These may be used to stimulate discussion about doctor–patient relationships, dealing with carers or relatives, communicating with colleagues, dealing with complaints, etc.

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