Problem-Based Learning

One of the new trends in medical education, particularly in the US, is Problem-Based Learning or PBL. PBL posits that letting students explore topics openly, with goals and guidance rather than tasks and obligations, will lead to greater investment in learning by students, as well as overall better retention of knowledge. Extending on this idea, PBL often involves students working in teams - Team-Based Learning or TBL - to allow students to share knowledge more freely and to work collaboratively towards a solution.

In theory, PBL addresses a lot of the objections I have to the current "standard" approach in medical education, particularly in pre-clerkship. I find the lecture-heavy, test-based format I went through to be rather inefficient and puts students in a fine position to burn out or put in a token effort. Yet, I'm very skeptical of PBL, particularly TBL, in the way many schools seem to want to use it.

Central to my concerns with PBL is that to solve a problem, you first need the tools and knowledge to do so. Giving students the freedom to choose an approach, or putting them in groups to work together, does little to overcome any gaps in necessary knowledge students inevitably have when training to become a physician. PBL proponents will argue that having students explore to find that background knowledge helps retention - and undoubtedly it does - but it's also very inefficient unless students know exactly where to look for that information. For example, it's very important for students to know the first-line treatment for simple UTIs. It's basic knowledge anyone who's finished clerkship should be able to pass along. Yet, if you were to search for that information, you'll quickly get about a half-dozen different answers, all of which are partially correct, but picking out the standard conventional answer is impossible without being given some actual instruction by a knowledgeable person. A naive learner simply won't have the context necessary to discriminate between imprecise recommendations available. The freedom to explore an answer - or the benefit of collective thought - simply doesn't contribute in the way guided instruction would.

Once all the necessary background information has been learned or provided, PBL works great at putting it all together. Moreover, putting all that knowledge together can help with retention of those facts. TBL can further enhance this by letting students fill in each others gaps in knowledge, since no student gets everything right 100% of the time - even the best students forget something.

Unfortunately, the goal of pre-clerkship is largely to give students that background information. Putting it together is left for clerkship, which essentially functions like a natural form of PBL. Clerkship has the additional advantage of authenticity, an often-overlooked trait when trying to motivate students to work. For all its promise of enhanced student engagement, PBL suffers from much the same drawback as traditional instruction - goals are set by the program, not by the student. PBL becomes just a different hurdle to jump over to move onto the next step. The motivation to do well remains extrinsic, even as engagement increases. In clerkship, the presence of an actual patient to empathize with - and the fear of disappointing preceptors invested in their patients well-being - provides some intrinsic motivation.

PBL and TBL can have an important role in education, particularly medical education, but their use needs to be tailored to their strengths. These techniques should be used to solidify knowledge already learned, not to teach new information. Most importantly - and proponents of PBL are quick to advocate this - instructors should be readily available to provide context and direction, as both PBL and TBL can quickly become troublesome if students' thoughts veer away from the correct path. As much as possible, PBL should be used where students already have motivation to learn, should be evaluated in a formative manner, and ideally the topic should involve some choice from students. PBL is a great tool, but it's not a panacea - it should be used where it's appropriate, and discarded where not. My experiences with PBL and TBL thus far have made me worried that educators might not understand where these tools are best employed.