Effects and Efficiency of PBL

[BrCo]

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So I was reading this article about the effects of PBL on physician competency:

http://www.cmaj.ca/content/178/1/34.full.pdf+html

In the interpretation of their meta-analysis they found:
1) slight evidence that PBL had negative effects on knowledge possession
2) strong evidence that PBL had positive effects on knowledge application
3) graduates of PBL curriculum believed themselves to possess less knowledge, but supervisors generally found little difference between PBL group and control group (they chalked this off to increased knowledge application effects)

So after reading this article I was left wondering a couple things:

Is there really that much of a difference between knowledge possession and application? Ie: Doesn't possession lead to application? How should physician competency really be defined?

How do med students view PBL? How about practicing physicians? Is it worthwhile? Or is it just a newfound trend? If you had the same amount of time given, would you chose to study independently or do a PBL case? What helps more on exams? On boards?

Especially with respect to secondaries, I'd like to be able to comment on my personal preferences for curriculum, but I feel unable to form a preference without actually being a med student. Thanks everyone.

 

[allantois]

It appears that most schools that do PBL add them on top of traditional lectures. You will certainly do independent studying on your own.

Many schools also utilize Standardized Patients for "knowledge application".

 

[Ismet]

I freaking hated PBL. But it wasn't a huge part of the pre-clinical curriculum (it was also mostly only in 1st year) so I sucked it up and got through.

I do know some people who really liked PBL. It depends on the person and how they learn. I didn't learn much from PBL, can't recall anything I specifically learned in a PBL that helped for exams or much less boards. I much rather study on my own.

Many schools also utilize Standardized Patients for "knowledge application".

We use SP's for practicing H&Ps, motivational interviewing, etc. Not sure if that's what you mean by knowledge application, but it's not related to what we do in PBL.

 

[Cyberdyne 101]

I freaking hated PBL. But it wasn't a huge part of the pre-clinical curriculum (it was also mostly only in 1st year) so I sucked it up and got through.

I do know some people who really liked PBL. It depends on the person and how they learn. I didn't learn much from PBL, can't recall anything I specifically learned in a PBL that helped for exams or much less boards. I much rather study on my own.



We use SP's for practicing H&Ps, motivational interviewing, etc. Not sure if that's what you mean by knowledge application, but it's not related to what we do in PBL.

Is it possible to know beforehand if PBL is for you? I realize that there are different degrees of PBL, but I'm wondering if someone can have an idea about this before med school.

 

[Ismet]

Is it possible to know beforehand if PBL is for you? I realize that there are different degrees of PBL, but I'm wondering if someone can have an idea about this before med school.

Do you like mandatory group work? I sure don't. I'm not antisocial in the slightest, but I like to learn efficiently and in my own way, not by being forced to sit in a small group room for 4 hours.

I'm sure different schools do PBL differently, but the way it was set up in my 1st year was 2 hours at the beginning of the week where you'd go through a case with your group. It's supposed to be student-led with the faculty facilitator helping out if necessary, but often times the faculty member ran the group. Being 1st years, we knew relatively nothing clinical whatsoever. So we would go through the case with the facilitator and pick out things we didn't know. That could be things like lab tests or organisms or a clinical finding. After going through the case, we would come up with 8-9 learning objectives (one for each member of the group). The assignment for that week was then for each person to research their learning objective and present it to the rest of the group (usually with a powerpoint) when we met for another 2 hours later in the week, plus usually a follow-up case or something.

I don't mean to overly bash PBL, as some people really truly like PBL and prefer it over lectures or self study.

In 2nd year we had "workshops," which were MUCH more useful. Still small groups, but we would work through several cases with a faculty member and work through questions. We had a couple EKG workshops during cardio that were absolutely essential for me for learning how to read EKGs. Plus no presentations. Plus we actually had a better idea of what was going on clinically, at least in the course we were in. That's the kind of group work I didn't mind and thought was helpful.

 

[CherryRedDracul]

How do med students view PBL? Largely depends on how it is implemented and on a student's learning style. For me, it was a good time to go on Facebook, Youtube, etc. I'm a solo studying kind of guy.
Is it worthwhile? Or is it just a newfound trend? If you suck at problem solving, maybe it might be worthwhile. But I went through engineering school, so problem solving is my forte. Innovative strategies for learning is trendy and is great for generating data for education PhDs to churn papers out the wazoo.
If you had the same amount of time given, would you chose to study independently or do a PBL case? Independent study.
What helps more on exams? On boards? Independent study.

With that said, I didn't find PBL to be a complete waste of time because groups were physician-led. But you know what worked much better for me? Hitting the floors during preceptorship, gathering a history & doing a physical on an actual patient, presenting my findings and my assessment and plan to the attending, and getting feedback for it. I barely remember PBL sessions, but I remember things that happened with my patients much more vividly.

 

[BillrothI]

Most med students and former med students I know were not big fans of PBL. The description from @Ismet is pretty similar to what I have heard from others. However, I am curious about how schools like Vanderbilt implement PBL and would be interested in hearing from students who are attending schools that use a PBL-based curriculum.

-Bill

 

[Cyberdyne 101]

Do you like mandatory group work? I sure don't. I'm not antisocial in the slightest, but I like to learn efficiently and in my own way, not by being forced to sit in a small group room for 4 hours.

I'm sure different schools do PBL differently, but the way it was set up in my 1st year was 2 hours at the beginning of the week where you'd go through a case with your group. It's supposed to be student-led with the faculty facilitator helping out if necessary, but often times the faculty member ran the group. Being 1st years, we knew relatively nothing clinical whatsoever. So we would go through the case with the facilitator and pick out things we didn't know. That could be things like lab tests or organisms or a clinical finding. After going through the case, we would come up with 8-9 learning objectives (one for each member of the group). The assignment for that week was then for each person to research their learning objective and present it to the rest of the group (usually with a powerpoint) when we met for another 2 hours later in the week, plus usually a follow-up case or something.

I don't mean to overly bash PBL, as some people really truly like PBL and prefer it over lectures or self study.

In 2nd year we had "workshops," which were MUCH more useful. Still small groups, but we would work through several cases with a faculty member and work through questions. We had a couple EKG workshops during cardio that were absolutely essential for me for learning how to read EKGs. Plus no presentations. Plus we actually had a better idea of what was going on clinically, at least in the course we were in. That's the kind of group work I didn't mind and thought was helpful.

I like group work when it's productive. I guess the biggest drawback of undergrad group work is the possible lack of peer cooperation (ie you end up doing more work yourself due to slackers). I imagine that's less of an issue in med school.

So you're essentially saying that your 1st year PBL wasn't really appropriate for the material you had learned up to that point. On the other hand, group work in med school can be productive if it's used in the right context. I'm wondering if schools are actually open to student feedback about this sort of stuff. I'm guessing like almost everything, it depends on the school.

Thanks for the feedback!

 

[Ismet]

I like group work when it's productive. I guess the biggest drawback of undergrad group work is the possible lack of peer cooperation (ie you end up doing more work yourself due to slackers). I imagine that's less of an issue in med school.

So you're essentially saying that your 1st year PBL wasn't really appropriate for the material you had learned up to that point. On the other hand, group work in med school can be productive if it's used in the right context. I'm wondering if schools are actually open to student feedback about this sort of stuff. I'm guessing like almost everything, it depends on the school.

Thanks for the feedback!

There's really no need for cooperation. It's actually fairly independent "group" work, i.e. you each do your research independently and then "teach" it to the rest of the group. Few people slacked on presentations, but usually there was nothing exclusive to PBL that was tested, so no one really cared if someone slacked.

I wouldn't say the PBL material wasn't appropriate for the class. I'm saying that as a 1st year med student in a biochem class, when you're given a full H&P writeup with labs and everything, you have no idea what you're looking at. The PBL in general was about a biochem topic, and there were certain biochem learning objectives in there, but a lot of the time was spent with the facilitator walking us through the case and what things meant, or picking out things we didn't know as learning objectives. Like if we would ask the facilitator what X is, he wouldn't give us an answer, he would just say "that's a learning objective." I guess my main point is that it's an inefficient way to learn. For me.

 

[Cyberdyne 101]

There's really no need for cooperation. It's actually fairly independent "group" work, i.e. you each do your research independently and then "teach" it to the rest of the group. Few people slacked on presentations, but usually there was nothing exclusive to PBL that was tested, so no one really cared if someone slacked.

I wouldn't say the PBL material wasn't appropriate for the class. I'm saying that as a 1st year med student in a biochem class, when you're given a full H&P writeup with labs and everything, you have no idea what you're looking at. The PBL in general was about a biochem topic, and there were certain biochem learning objectives in there, but a lot of the time was spent with the facilitator walking us through the case and what things meant, or picking out things we didn't know as learning objectives. Like if we would ask the facilitator what X is, he wouldn't give us an answer, he would just say "that's a learning objective." I guess my main point is that it's an inefficient way to learn. For me.

So then you had to research and/or follow up on the learning objective, correct?

Thanks for elaborating!

 

[Ismet]

So then you had to research and/or follow up on the learning objective, correct?

Thanks for elaborating!

Yep. Usually it just entailed a Wikipedia search (or UpToDate if you really wanted to impress) and ~5 slides/5 min. Like I did a presentation on myoglobinuria for a biochem PBL. And a presentation on eye anatomy for an immunology PBL (because that makes sense? i think we were grasping for straws there haha)

 

[Law2Doc]

It appears that most schools that do PBL add them on top of traditional lectures. You will certainly do independent studying on your own..".

Right. It's not an either or. Most PBL is relatively painless and sometimes it forces you to focus on topics you otherwise would have just glossed over. preparing a topic for presentation and working well in a group are valuable things that early med students rarely get good enough at but often yield immeasurable dividends later in med school. Most med students don't like PBL because their comfort zone for learning is holing up in the library by themselves, but that's really not an approach that carries over once the clinical years start -- you really need to break down those premed skillsets and PBL is just one little way of doing so.the big problem isn't that PBL is a bad idea but it's that med schools often implement it poorly and early med students still have a premed mindset and think of it as time away from things that will prepare them on USMLE. So the buy in isn't there and that kind of dooms it to failure.

 

[NickNaylor]

I like group work when it's productive. I guess the biggest drawback of undergrad group work is the possible lack of peer cooperation (ie you end up doing more work yourself due to slackers). I imagine that's less of an issue in med school.

So you're essentially saying that your 1st year PBL wasn't really appropriate for the material you had learned up to that point. On the other hand, group work in med school can be productive if it's used in the right context. I'm wondering if schools are actually open to student feedback about this sort of stuff. I'm guessing like almost everything, it depends on the school.

Thanks for the feedback!

This is the whole problem with PBL. If you have an excellent facilitator and excellent group mates, PBL can be extremely effective, fun, and just as informative as a typical lecture. The problem is that didn't happen in my experience, and most of the time was spent addressing a list of questions in minimal detail to say we talked about them. I imagine the quality would be higher at an institution that does all of its teaching using the PBL method, but there's no guarantee of that.

IMO PBL is a stunt meant to pretend to be innovative without really doing anything of value. The truth of medical school is this: you will do 90% of the learning on your own. If you don't do it during the pre-clinical years, then you'll definitely do it on the wards (which is the knowledge that actually matters). That statement is true regardless of the curriculum you use. There is simply too much information to reasonably cover in a lecture format while retaining all of that information.

 

[hushcom]

How do med students view PBL? How about practicing physicians? Is it worthwhile? Or is it just a newfound trend? If you had the same amount of time given, would you chose to study independently or do a PBL case? What helps more on exams? On boards?

I was asked to be a small group facilitator for the coming academic year, and the format is closer to PBL than anything else, so I will give my preliminary impression before ever having done it.

For one, PBL is not new. It originated in Canada and was first adopted in the US in 1979 by the University of New Mexico. Over the years it has been adopted and adapted by many institutions, although few rely on it as the primary means of learning.

Also, I have come to find out that the LCME is really opposed to medical school curricula that involve >50% lecture. Schools therefore have to find non-lecture ways to teach, and PBL serves that purpose. It also fulfills requirements for active and self-directed learning.

I have been warned by others with more experience that a vocal minority will hate it, but that most students will either enjoy it or be indifferent to it. Obviously if it is poorly implemented it will be poorly received. I can appreciate the strong desire of the medical student to be "spoon fed" and left alone, but to echo Law2Doc it does present the opportunity to push students out of their comfort zones before they hit the wards, which is not a bad thing. I don't think that a student can ever have too much practice reviewing a patient history, extracting the relevant information, and deciding what to do next, even if the exercise is somewhat contrived.

 

[nemo123]

Most med students and former med students I know were not big fans of PBL. The description from @Ismet is pretty similar to what I have heard from others. However, I am curious about how schools like Vanderbilt implement PBL and would be interested in hearing from students who are attending schools that use a PBL-based curriculum.

-Bill

Vandy doesn't use PBL... They use small group sessions instead, and apparently the reasoning there is that the administration believes that PBL is too low yield for the amount of time you invest into it.

 

[Planes2Doc]

It sucked for commuter students like me. I live 40 minutes from campus, and it's not fun driving all the way out for a mandatory session, and then go all the way home twice a week. Luckily, we had one hour sessions, and in Biochem we usually managed to get out early. I agree with @Ismet 's sentiments... It's tough having to go through the information when you have no clinical basis. I'll admit that it was a fine way to learn to read lab values, but this also could've beendone in the confort of my own home on my own time.

 

[Caesar]

Yep. Usually it just entailed a Wikipedia search (or UpToDate if you really wanted to impress) and ~5 slides/5 min. Like I did a presentation on myoglobinuria for a biochem PBL. And a presentation on eye anatomy for an immunology PBL (because that makes sense? i think we were grasping for straws there haha)

Your school does PBL the wrong way.

 

[DermViser]

Most med students and former med students I know were not big fans of PBL. The description from @Ismet is pretty similar to what I have heard from others. However, I am curious about how schools like Vanderbilt implement PBL and would be interested in hearing from students who are attending schools that use a PBL-based curriculum.

-Bill

I believe they just recently implemented it with their "Curriculum 2.0" ridiculousness.

 

[DermViser]

Vandy doesn't use PBL... They use small group sessions instead, and apparently the reasoning there is that the administration believes that PBL is too low yield for the amount of time you invest into it.

In that case it would be called TBL (team based learning) which is pretty analogous to PBL.

 

[DermViser]

This is the whole problem with PBL. If you have an excellent facilitator and excellent group mates, PBL can be extremely effective, fun, and just as informative as a typical lecture. The problem is that didn't happen in my experience, and most of the time was spent addressing a list of questions in minimal detail to say we talked about them. I imagine the quality would be higher at an institution that does all of its teaching using the PBL method, but there's no guarantee of that.

IMO PBL is a stunt meant to pretend to be innovative without really doing anything of value. The truth of medical school is this: you will do 90% of the learning on your own. If you don't do it during the pre-clinical years, then you'll definitely do it on the wards (which is the knowledge that actually matters). That statement is true regardless of the curriculum you use. There is simply too much information to reasonably cover in a lecture format while retaining all of that information.

The Problem with Problem-based Medical Education
http://onlinelibrary.wiley.com/doi/10.1002/bmb.2003.494031010158/pdf

• "Around 1990 the craze for student-centered, problem-based learning began sweeping through United States medical schools like wild fire through a parched Colorado forest. Its promoters and advocates thought they had reinvented medical education. Like most plans, on paper it looked great. But, in my judgment, twixt the cup and the lip, between the design and the implementation, there have been many a slip."

That being said the problem is when you enter the wards - education is not didactic to where everything you learn is taught to you with lecturer directing a classroon. I think the PBL structure is trying to get you acclimated to this type of learning that happens on the wards. That being said if your facilitator sucks, or your group sucks, then you would have been much better off learning on your own.

 

[Caesar]

In that case it would be called TBL (team based learning) which is pretty analogous to PBL.

Not at all. PBL when it is done the way it's supposed to be is about giving a problem to a group that they have to use a fund of knowledge to solve, its not supposed to be a time for the actual acquisition of knowledge, just application. It's not about one person coming in and presenting a powerpoint about learning issue #17 and another student doing a different one. I went through a PBL curriculum, and have been a leader for second years. My approach has been that every student is using the exact same books to study and learning the same things so when we show up to group we talk about application of that knowledge. Usually we do some group board style questions that are related to the material everyone should have read and can talk about approaches to the questions (because you can learn from all the answer choices not just knowing the right one) and then we will present different situations and give actual problems that need to be worked out. This nonsense where schools add "PBL" and its just a group of kids presenting topics is complete hogwash and if I had to do it would 100% agree it was a waste of time.

 

[DermViser]

Not at all. PBL when it is done the way it's supposed to be is about giving a problem to a group that they have to use a fund of knowledge to solve, its not supposed to be a time for the actual acquisition of knowledge, just application. It's not about one person coming in and presenting a powerpoint about learning issue #17 and another student doing a different one. I went through a PBL curriculum, and have been a leader for second years. My approach has been that every student is using the exact same books to study and learning the same things so when we show up to group we talk about application of that knowledge. Usually we do some group board style questions that are related to the material everyone should have read and can talk about approaches to the questions (because you can learn from all the answer choices not just knowing the right one) and then we will present different situations and give actual problems that need to be worked out. This nonsense where schools add "PBL" and its just a group of kids presenting topics is complete hogwash and if I had to do it would 100% agree it was a waste of time.

Actually no. It's not supposed to be where everyone has a set fund of knowledge already in place but more that you're supposed to be able to find that knowledge effectively to answer a problem, demonstrating the principles of that topic. The reason is that in real medicine, your answers don't all come from one textbook or one source.

 

[Caesar]

Actually no. It's not supposed to be where everyone has a set fund of knowledge already in place but more that you're supposed to be able to find that knowledge effectively to answer a problem, demonstrating the principles of that topic. The reason is that in real medicine, your answers don't all come from one textbook or one source.

sigh, I didn't want a long post.
Day 1 you open case no one knows anything, you decide whats important and rely on what you know already to develop what you need to know. There isn't much actual teaching that goes on the first day, its about recognition of knowledge gaps and identification of problems.
Day 2 you come to close out the case and discuss gaps in knowledge and apply the info you should have got from the previous problem (case) to others.
You should not be doing power points or formal peer teaching. Maybe someone comes across something different and shares that. In my experience thats less than 5% of the time. M1s and M2s don't go to the literature. They go to Robbens or Pathoma or similar and that's entirely appropriate.

 

[Ismet]

Your school does PBL the wrong way.

I agree. I've always assumed that this is not the way PBL-centered curriculums are run, as I know people who go to such schools and love it. I'm sure it's much more effective there.

 

[Ismet]

In that case it would be called TBL (team based learning) which is pretty analogous to PBL.

I think different schools define TBL differently, but TBL at my school is nothing like PBL and it is so so so much worse. While there are definitely people in my class who like and prefer PBL, I'm pretty sure TBL is mostly regarded with distaste or at best indifference. We only have a handful per year so it's no biggie.

 

[NickNaylor]

The Problem with Problem-based Medical Education
http://onlinelibrary.wiley.com/doi/10.1002/bmb.2003.494031010158/pdf

• "Around 1990 the craze for student-centered, problem-based learning began sweeping through United States medical schools like wild fire through a parched Colorado forest. Its promoters and advocates thought they had reinvented medical education. Like most plans, on paper it looked great. But, in my judgment, twixt the cup and the lip, between the design and the implementation, there have been many a slip."

That being said the problem is when you enter the wards - education is not didactic to where everything you learn is taught to you with lecturer directing a classroon. I think the PBL structure is trying to get you acclimated to this type of learning that happens on the wards. That being said if your facilitator sucks, or your group sucks, then you would have been much better off learning on your own.

While I agree that didactic learning doesn't happen too much on the wards, in my experience the "let's sit and have a pow-wow and talk about topic X" also didn't happen. I can see the value of PBL if the goal is to be able to take a question or unknown piece of information and go through the exercise of finding quality sources and possibly primary research articles in order to answer that question. That certainly happens on the wards and is a critical skill to learn. The typical roundtable-type discussion that PBL follows, though, seems to be strictly limited to discussion cases that happen in conferences. Those are interesting in some sense, but I never found them particularly informative. And that wasn't really the format we used on rounds or any other on-the-wards teaching, which was more just pimping Jeopardy with quick points about important findings.

 

[DermViser]

While I agree that didactic learning doesn't happen too much on the wards, in my experience the "let's sit and have a pow-wow and talk about topic X" also didn't happen. I can see the value of PBL if the goal is to be able to take a question or unknown piece of information and go through the exercise of finding quality sources and possibly primary research articles in order to answer that question. That certainly happens on the wards and is a critical skill to learn. The typical roundtable-type discussion that PBL follows, though, seems to be strictly limited to discussion cases that happen in conferences. Those are interesting in some sense, but I never found them particularly informative. And that wasn't really the format we used on rounds or any other on-the-wards teaching, which was more just pimping Jeopardy with quick points about important findings.

I guess I was more relating it to the learning. Often times in a lecture-based didactic format, it often comes down to committing lines of text off of powerpoints to memory and being able to regurgitate them well enough to answer questions on a multiple choice exam. Learning, assessment, and evaluation are relatively isolationist.

It's then more a shock when you enter MS-3 where real medicine isn't at all like that, where patients don't have question stems and A), B), C), D) and E) written on their chests and you're forced to work in teams and groups. The history taking, physical exam, differential diagnosis, assessment and plan process is nothing like the thinking done for a multiple choice exam. I'll admit though that in MS-3 a lot of the "hidden curriculum" comes into play which complicates things even more.

That being said the reason I liked lecture-didactic type learning in the first 2 years is bc it was relatively controlled, the expectations were clear, etc. and I felt like I learned what I needed to, and how I needed to. For most schools, PBL/TBL is a circle jerk for medical school administration to show how "innovative" they are which they can brag about in their next journal article to Academic Medicine.

 

[BrCo]

Is there anyway to distinguish schools that have informative PBL sessions from those that do not? What questions should I be asking on the interview trail? @DermViser @NickNaylor @Ismet

 

[NickNaylor]

Is there anyway to distinguish schools that have informative PBL sessions from those that do not? What questions should I be asking on the interview trail? @DermViser @NickNaylor @Ismet

This is the difficulty with PBL - it is hard to execute well, thus the quality depends on the people you're going to work with. I'm not sure if there are any questions you could ask would specifically help you in this regard. Try and talk to current students (ideally ones not involved with admissions) and see what they think. That's probably your best bet at figuring out whether a school's curriculum is doing a good job or not.

 

[DermViser]

Is there anyway to distinguish schools that have informative PBL sessions from those that do not? What questions should I be asking on the interview trail? @DermViser @NickNaylor @Ismet

I think that's very hard to distinguish as to which ones have "great" PBL and which ones don't. I would try to find someone who DOESN'T volunteer to do med school admission tours and get the lowdown on implementation. That's really the best you can do.