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
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
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
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.