Professor Kwan has practised PBL in medical education at McMaster University for nearly two decades and is a PBL consultant in many medical schools in the Asia Pacific region.

So, What is PBL?

PBL is becoming an increasingly popular pedagogic jargon. “What does PBL stand for?” your students may ask. Whether PBL stands for Problem-Based Learning, or Partnership and Bonding in Learning (cited from the ‘PBL Student User’s Guide’ by the PBL committee of NUS’s Faculty of Medicine), it makes no difference to some students who do not care as long as this is not a question in the examination. There are those who care and are curious; they want to know not only what PBL stands for, but also how PBL works. I am sure that this holds true for teachers as well.

According to the citation used in the PBL student User’s Guide of the Faculty of Medicine here: “Problem-based learning (PBL) is grounded in the belief that learning is most effective when students are actively involved and learn in the context in which knowledge is to be used”. This was indeed the philosophy that McMaster University based upon in the inception of its medical education more than 30 years ago. Therefore, PBL is active learning with particular relevance to the learning objectives (as opposed to the traditional passive spoon-feeding rote learning based on teacher-designed didactic lectures and instructions). ‘Active’ implies dynamic interactions among the learners and ‘learning’ signifies the focus on the process used by the learners rather than the process imposed by the teachers. Life is too short and knowledge is too broad. Learning must be relevant to learners’ objectives in order to be effective and efficient. In medical education, the learners’ knowledge and skills will ultimately be applied within the context of biomedicine and healthcare. Then their learning would be most effective using scenarios of clinical situations as the triggers for learning. The scenarios then become the trigger problems in PBL (which are often referred to as ‘Health Care Problems’ or ‘HCPs’ in medicine) as a means to trigger the learning process. The primary aim is not to solve the clinical problems. Therefore, PBL should not be mixed up with problem solving, although problem-solving skills usually result as a benefit of PBL. This is also distinctly different from the traditional clinical case study, either in tutorial format (sometimes called ‘small-group conference teaching’) or the bedside format during the clinical years of the students. In both conventional tutorials and bedside teaching, the teacher remains as the centre of students’ learning, and problem solving is usually the bottom line.

From the above, you may realise that PBL is not a monopoly for medical education, it applies widely to learning in most professional schools and disciplines, including Nursing, Dentistry, Art, Music, Architecture, Archaeology, Engineering, Law, etc. In fact, PBL was first applied in business schools.

In PBL, students learn using carefully designed scenarios from which the issues are identified and the objectives developed. Students learn whatever relevant to their learning objectives. They learn what they needed and when they have to know.

PBL: Magic or Myth?

In the traditional curriculum, preclinical disciplines, such as anatomy, biochemistry, physiology and pharmacology are prerequisite for proceeding to paraclinical subjects and clinical specialties. They are mainly knowledge-based and usually taught didactically by experts in given disciplinary areas, often as large group classes in lecture theatres. In contrast, in the PBL curriculum, HCPs are designed as a guide for learning from an integrative perspective. Knowledge in anatomy, physiology, pharmacology, microbiology, biochemistry, community medicine, etc. will all come into place as long as they are of significant relevance to achieving the learning objectives of a given HCP as defined by the students. Students usually manage the learning pace and strategy in PBL with maximal flexibility within the boundaries clearly defined as the study road map listed in the students’ handbook. This is called ‘self-directed learning’, a distinct characteristic of PBL. One should not mix it up with ‘self-indulgent study’ or ‘self-willed learning’ in the traditional system where students were left alone to cram for the examinations. Teachers serving as tutors are not knowledge-providers as in the case of spoon-feeding; they serve to facilitate the learning process. Instructions are carried out via discussions among students in small-group tutorial format, where all members (including tutors) know each other by the first names. This small-group learning should not be mistaken as small-group teaching as in conventional tutorials and bedside teaching noted above.

In traditional education, teaching is generally overdone and learning is underserved. Students have little or no time to digest, comprehend and intergrate the imposed materials.

The traditional curriculum still entails the education principles based on didactic teaching generally practised in the secondary schools, while the PBL curriculum represents scenarios analogous to adult learning imprinted with maturity and professionalism. Therefore, PBL represents a learning behaviour, which differentiates tertiary/higher education from the secondary school education. Most teachers carry the mentality that medical students must be well equipped with as much basic science knowledge as possible in case they need to apply it in clinical years 2–3 years down the road. This is the so-called ‘in case’ approach in teaching. In PBL, students learn as the issues are identified and developed, be it basic science or clinical skills, anatomy or physiology. They learn whatever is relevant to their learning objectives as identified in the HCP. They learn what they need, when they need to know it. This is called an ‘in time’ approach to learning.

PBL: A Change of Mindset

To increase the competitive edge, politically or academically, an increasing number of traditional professional and educational institutions are adapting PBL as an operating strategy with variable degrees of understanding of the underlying philosophy and the readiness for implementation. I have encountered places and situations where PBL was superficially treated as a teaching methodology or a course (i.e. PBL was claimed to be in practice, but with little evidence of PBL spirit). It is also not uncommon to observe that traditional didactic lectures are used to complement or enhance learning in PBL in a so-called ‘hybrid system’. This system may have a chance to succeed if the lectures are kept to a minimum and remain interactive as well as integrative. Theoretically, it would be very unusual to come across a hybrid system where PBL is used as a complementary strategy to enhance the effect of the traditional didactic lectures. This is like using the slide-rule to aid computer calculation. However, the reason for the appearance of various forms of PBL is simple: there are major differences in the mindset as a result of the historical burden chronically carried by an established traditional institution. For instance, your builders will tell you that it is much easier and cheaper to build a new house than to renovate an old house; and your car mechanic will also advise you to put in a new engine rather than to repair an old functionally defective one.

Students are young and flexible enough to learn to be tolerant and adaptable to new ways of learning. It is a common observation that persistent resistance, despite the evidence of many successful examples, comes largely from teachers. The sentiment of resistance generally reflects ignorance, insecurity and fear. In the traditional system, teachers are used to being in full control of the learning activities (because they are knowledge-providers); in PBL, they may no longer enjoy such power in the group. In the traditional system, teachers are perceived as experts on the subject they teach; in PBL, they become non-expert tutors and feel so insecure and frustrated about being unable to answer questions that are not within their expertise area. Besides, handling the group dynamics amongst students is new and uncomfortable for the traditional teachers, who have never received training in this area. The fear of the unknown and the unfamiliar causes high anxiety in teachers. High anxiety leads to avoidance, and therefore, resistance and rejection. Furthermore, teachers favour didactic teaching in the traditional system because they need to justify being paid to lecture as teachers. It is natural and more comfortable for these teachers to follow the same way their teachers taught them. So, the vicious cycle perpetuates and the mindset reinforces itself and becomes too deep-rooted to accept revolutionary alternatives. At best, they may accept some evolutionary changes by decorating their teaching with some PBL-like activities. This is indeed how various forms of PBL get cloned and confuses many newcomers.

The resistance against PBL is usually not due to the mindset of students, but the mindset of teachers.

So, how should the mindset of the teachers be changed to put PBL in the proper perspective? The anxiety and fear in teachers should be removed by leading them to understand the true spirit of PBL, by training them to be effective facilitators (as tutors) and teachers (as resource persons), by providing feedback and guidance to their performance in facilitating learning and handling group dynamics, and by giving them attractive incentives and rewards. This topic is a broad but also very important subject of PBL in its own right. It may deserve a separate future discussion involving administrative strategies.