AMEE

Education Guide

15
no. Problem-based
Learning: a
practical guide

M H Davis & R M Harden

AMEE Secretariat
Association for Medical
Education in Europe (AMEE)
Tay Park House
484 Perth Road
Dundee DD2 1LR
Not for reproduction Scotland, UK
Further copies may be purchased from AMEE Tel: +44 (0)1382 631953
Fax: +44 (0)1382 645748
E-mail: amee@dundee.ac.uk
An International Association for Medical Education Web: www.amee.org
ISBN: 1-903934-16-8
 Problem-based learning: a practical guide

Problem-based learning: a practical guide

AMEE Medical Education Guide No 15

This AMEE Education Guide was first published in Medical Teacher.

Davis MH and Harden RM (1998). AMEE Medical Education Guide No.15: Problem-based learning: a practical
guide. Medical Teacher 21(2): 130-140.
Harden RM and Davis MH (1999). The continuum of problem-based learning. Medical Teacher 20(2): 317-322.

The Authors
M H Davis is a doctor specialising in medical education, and Senior Lecturer in Medical Education, Centre for
Medical Education, University of Dundee, Dundee, UK
R M Harden is Director of the Centre for Medical Education and Teaching Dean in the Faculty of Medicine,
Dentistry and Nursing at the University of Dundee. He is also Director of the Education Development Unit (Scottish
Council for Postgraduate Medical & Dental Education), Dundee, UK

The Medicine Wheel

With many facts and theories we are all faced

But the best kind of learning is problem-based.
Of true medical solutions to be the inventor
Students should take a problem as the wheels centre.
This approach is easier and much more real
Each discipline being like the spokes of the wheel.
Working outwards we learn all the necessary skills
Like Anatomy, Surgery and giving out pills.
This system should always get the vote
Over learning exhausting details by rote.
For beyond the memorising of so many a fact
The useful person is one who can act.
Judge

Guide Series Editor: Pat Lilley

Production and Desktop Publishing: Molly Gunn and Lynn Bell

AMEE 1999

Copies of this guide are available from:

AMEE, Centre for Medical Education, University of Dundee, 484 Perth Road, Dundee DD2 1LR,
Scotland, UK.
Tel: +44 (0)1382 631967 Fax: +44 (0)1382 645748 E-mail: p.m.lilley@dundee.ac.uk

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 Problem-based learning: a practical guide

Contents
Page

Summary .. .. .. .. .. .. .. 3

Introduction .. .. .. .. .. .. .. 3

What is Problem-based Learning (PBL)? .. .. .. .. 4

An approach to learning and curriculum design with a number of specified features .. 5
A specific educational approach based on rules and examples .. .. .. 6
A range of approaches .. .. .. .. .. .. 6

Why should you be interested in PBL? .. .. .. .. 7

Some advantages of PBL .. .. .. .. .. .. 7
Some disadvantages of PBL .. .. .. .. .. .. 7

What approach to PBL should you adopt? .. .. .. .. 8

The PBL process .. .. .. .. .. .. .. 9

The problem and its presentation .. .. .. .. .. 10

What makes a good problem scenario? .. .. .. .. .. 10
Considerations in the choice of medium .. .. .. .. .. 11

Facilitating PBL .. .. .. .. .. .. .. 12
The extent to which facilitation is necessary .. .. .. .. .. 12
The process of facilitation .. .. .. .. .. .. 12
Staff development .. .. .. .. .. .. .. 13
Role of study guides .. .. .. .. .. .. 13

Student assessment and PBL .. .. .. .. .. 14

Relationship of PBL to other educational strategies and

curriculum developments .. .. .. .. .. .. 14

Conclusions .. .. .. .. .. .. .. 15

References .. .. .. .. .. .. .. 16

Appendix: The continuum of problem-based learning .. .. .. 18

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 Problem-based learning: a practical guide
Summary
This practical guide for health professions teachers
provides a perspective of one of the most important
educational developments in the past 30 years. Problem-
based learning (PBL) is a continuum of approaches
rather than one immutable process. It is a teaching
method that can be included in the teachers tool-kit
along with other teaching methods rather than used as
the sole educational strategy.
PBL reverses the traditional approach to teaching and
learning. It starts with individual examples or problem
scenarios which stimulate student learning. In so doing,
students arrive at general principles and concepts which
they then generalise to other situations.
PBL has many advantages. It facilitates the acquisition
of generic competencies, encourages a deep approach
to learning and prepares students for the adult learning
approach they need for a life-time of learning in the
health care professions. It is also fun. PBL helps in
curriculum planning by defining core, ensuring relevance
of content, integrating student learning and providing
prototype cases.
There are also drawbacks associated with PBL.
Students may fail to develop an organised framework
for their knowledge. The PBL process may inhibit good
teachers sharing their enthusiasm for their topic with
students and student identification with good teachers.
Teachers may not have the skills to facilitate PBL.
Introduction
PBL is one of the most important developments in health
professions education in the latter part of the twentieth
century. Some argue suggested Boud and Feletti
(1991) that it is the most important development since
the move of professional training into educational
institutions. Since it was first developed by Howard
Barrows at McMaster (Barrows and Tamblyn 1976),
new medical schools throughout the world have adopted
PBL as the educational and philosophical basis of their
curricula and traditional schools have included it within
their portfolio of teaching methods or have converted
their undergraduate programmes to PBL.
In the United Kingdom, the General Medical Council
(GMC) has advocated a problem-oriented approach in
its recommendations for basic medical education (GMC
1993). Medical schools are well aware of the merits
of the learner-centred and problem-orientated
approaches and are striving towards their adoption,
moves which are strongly encouraged.
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The problem scenario is of crucial significance. It should
engage the students interest and be skilfully written.
While the medium selected for presentation of the
scenario is usually print, other media may be used. The
clinical tasks carried out by the student may replace the
problem scenario as the focus for learning.
Students are supported during the PBL process by tutors
and/or study guides. The amount of support required is
inversely related to the students prior learning and
understanding of the PBL process. A range of additional
learning resources and opportunities may be made
available to the students, including text books, videotapes,
computer-based material, lectures and clinical sessions.
Tutors require group facilitation skills, an understanding
of the PBL process and knowledge of the course and
of the curriculum in general. They need special personal
qualities and it is preferable if they have expertise in the
content area.
While special assessment processes have been
developed to assess students learning by the PBL
method, the general principles of assessment apply to
PBL courses and a mixed menu of assessment methods
needs to be employed.
Curriculum design involves a skilful blend of educational
strategies designed to help students achieve the
curriculum outcomes. PBL may make a valuable
contribution to this blend but attention needs to be paid
to how it is implemented.
However, PBL is also a matter of some controversy. Is
it a significant development or a passing fad? Is PBL
appropriate only in new medical schools or has it
relevance in traditional schools? Indeed, what is PBL?
Can PBL be introduced in any part of the curriculum?
One difficulty in discussions about PBL is that there is a
great deal of confusion about what is meant by the term.
Indeed, the term is often misused and misapplied in
practice. There is also doubt or lack of clarity about the
educational underpinnings of PBL. The role of the
teacher in PBL is very different from the role of the
teacher in the traditional curriculum and this role change
may seem threatening to some teachers in the health
professions. It is often thought that PBL is difficult to
organise and expensive to implement in terms of time
and resources.
 Problem-based learning: a practical guide
The aim of this booklet is not to produce a critical review
of the research evidence for and against PBL and its
role in the undergraduate medical curriculum. A number
of reviews have been published with this as their
objective (Albanese and Mitchell 1993, Vernon and Blake
1993). Rather it is presented as a practical guide on
PBL for teachers in the healthcare professions. It
provides the educational background necessary for
teachers to understand the approach and hints on the
application of PBL to the readers own course or
curriculum.
The questions for individual teachers is not whether to
implement a PBL curriculum or not, but rather the extent
to which they should introduce PBL into their own
teaching (Harden et al 1984). Where should their course
be on the continuum between problem-based at one end
of the spectrum and an information-gathering approach
at the other?
What is PBL?
Some Definitions
Confusion and misunderstanding often exist about what
is PBL. The term PBL is employed to convey different
concepts and with different meanings.
It is helpful to think of PBL as active learning stimulated
by, and focused round a clinical, community or scientific
problem. The principal idea behind problem-based
learning is.. that the starting point for learning should
be a problem, a query or a puzzle that the learner wishes
to solve (Boud 1985). It is not simply the opportunity
to solve problems, but rather learning opportunities where
solving problems is the focus or starting point for
students learning. Student work on the problem
suggested Ross (1991) is explicitly used to get students
themselves to identify and search for, the knowledge
that they need to obtain in order to approach the
problem. Students on presentation of the problem have
two objectives: solution of the problem and learning
related to the problem.
Presentation
of problem
Solution Learning related
of problem to problem
+
This relationship between the problem and the
knowledge gained is emphasised by Boud & Feletti
(1991). This (PBL) turns the normal approach to
problem solving found in university and college
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If you are not already committed to PBL, this booklet
will:
make you aware of the nature of PBL
highlight the advantages and limitations of PBL
help you to consider the range of approaches to PBL
and which approach may be most appropriate for
your own situation
provide you with hints for implementing PBL.
If you are already committed to PBL, the booklet will
provide you with a deeper understanding of PBL and
help you to place the approach you have adopted within
a broader framework of approaches to PBL.
programmes on its head. In the normal approach, it is
assumed that students have to have the knowledge
required to approach a problem before they can start
on the problem; here, the knowledge arises from work
on the problem.
Albanese and Mitchell (1993) suggest that PBL at its
most fundamental level is an instructional method
characterised by the use of patient problems as a context
for students to learn problem-solving skills and acquire
knowledge about the basic and clinical sciences.
Barrows explanation (1985 p 15) provides further
insights into the process. The basic outline of the PBL
process is: encountering the problem first, problem
solving with clinical skills and identifying learning needs
in an interactive process, self-study, applying newly
gained knowledge to the problem, and summarising what
has been learned.
Dolmans (1994) describes PBL as follows: Faculty
objectives are translated into a problem, usually
consisting of a set of phenomena in need of some kind
of explanation. Students analyse these problems,
attempting to understand the underlying principles or
processes through small-group discussion. During
discussion, questions which remain unanswered are
identified. These questions or learning issues serve as a
guide for independent and self directed learning.
PBL may be though of as:
an approach to learning and to curriculum design with
a number of specified features; Walton and Matthews
(1989), for example, describe it as a syndrome with
 Problem-based learning: a practical guide
eight features. Charlin et al (1998) have identified
seven educational principles as to how students learn
in PBL.
a specific educational approach based on the
relationship between concepts or principles and
examples or problems.
a range of approaches a genus with different
species (Barrows 1986) or a continuum (Harden and
Davis 1998).
an umbrella term which involves any learning
experiences in which problems are solved. Many
would disagree with this definition however and
would wish to see some of the features, for example
those described by Walton and Matthews (1989) or
by Charlin et al (1998), included before calling the
approach PBL.
An approach to learning and curriculum
design with a number of specified features
Some authorities recognise the complex nature of the
learning process which occurs in PBL and have found
it helpful to regard PBL as a syndrome. Some essential
ingredients were identified at a symposium on the topic
attended by some of the world experts in PBL (Walton
and Matthews 1989). The acronym PROBLEM,
identified the key features of PBL:
Problems
Problems provide the key units for structuring
relevant learning.
Since Shoemaker developed learning in a functional
context with radio technicians in 1960, educationists have
appreciated the benefits of learning in a real or simulated
task environment. Shoemakers students more rapidly
became effective and efficient radio technicians when
trained by exploring radios which were broken than by
traditional methods.
Resources
Information for self-learning
Students are given access to a range of resources
teachers, other health professionals, their peers, the
library, basic science and clinical departments and so
on and are helped to discover the proper use of these
information sources.
Objectives
The learning objectives are planned by teachers,
but with student input
The problem scenarios together with the curriculum
documents, are a statement of faculty aims and
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objectives. Through identification of learning issues by
students in the PBL process these aims and objectives
are refined and expanded by students, facilitated by a
tutor.
Behaviour
Students behaviour progressively mirrors
that of the doctors
In PBL students are confronted with clinical situations
and are engaged in critical reasoning and decision
making. They do this as members of a small group or
team. Since most health care professionals work in
teams, and often in multiprofessional or interdisciplinary
teams, these skills should prove useful after graduation
or post basic training.
Learning
Active and student-directed; peer- and
tutor-monitored
In an experiment by Godden and Baddeley (1975),
marine divers were asked to memorise information on
shore and underwater. When tested, they remembered
the information significantly better in the environment
in which they learned it. Learning in context as in PBL,
assists students to organise their long-term memory for
ready retrieval (Kriel et al 1986).
Examples
Establish rules and lead to higher concepts
Students are prompted by appropriate examples towards
higher order thinking.
Motivation
The excitement of discovery
Students start, in PBL, with a problem which is designed
not only as a focus for their teaching but also to arouse
their interest in the topic. Whitehead (1932) describes
the rhythm of education and identifies three stages in
education: romance, precision and generalisation. The
romance of learning, the excitement of discovery, is
provided by the problem scenario.
Self-directed learning and self-assessment
Developing the learning habit
Learning does not end with basic training in the health
professions, but continues for life. By developing self-
directed learning skills, PBL facilitates the production
of lifelong learners. PBL aids the development of
students assessment and criticism of themselves. In
the process of PBL students have to identify what they
need to learn. This promotes the habit of self-assessment
 Problem-based learning: a practical guide
essential for self-directed learning where there is no
tutor, teacher or end-of-term assessment to inform
students of their progress.
Charlin et al (1998) defined seven criteria for student
learning in PBL based on educational principles. The
core principles are:
the problem acts as a stimulus for learning
it is an educational approach, not an isolated
instructional technique
it is a student-centred approach.
The student learning must involve:
active processing of information
activation of prior knowledge
meaningful context
opportunities for elaboration/organisation of
knowledge.
A specific educational approach based on
rules and examples
In the traditional approach to education, rules and
principles are presented first. Students then apply these
to clinical problems or examples of the rules and
principles in action. In a problem-based approach the
order is reversed. Students tackle problems or examples
first and in doing so discover the rules and principles for
themselves.
PBL is not a new concept, but has its origins in
programmed learning, a form of learning package
popular in the 1960s. Programmed learning was based
on behavioural psychology theory of stimulus-response.
Evans et al (1960) in The RULEG system for the
construction of programmed learning sequences
advocated starting the course of instruction from a
generality or rule (RUL) and moving towards a statement
of specificity or an example (EG), hence the RULEG
approach. However, some programmers preferred to
start with the examples and move towards an
understanding of the underlying principle by working out
the principle from the examples an EGRUL approach.
They found that this helped students learn just as well
as, if not better than, the traditional approach (Markle
1964, Foord 1964, Gagne and Brown 1962). In PBL in
the health care professions, scenarios are selected as
the examples and by actively working on these problems,
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students are expected to arrive at general principles
(Harden and Davis 1998). The scenarios may be related
to a clinical, community or scientific problem.
Bordage and Lemieux (1991) believe the provision of
prototype cases is important. They arrived at this
conclusion after contrasting the diagnostic and clinical
reasoning skills of experts and novices. Their findings
indicate that the expert has in mind a prototype case
with which he compares and contrasts the patient in
front of him at the time. We tend to tie the solving of
new clinical challenges to how they resemble or differ
from certain prototype cases. The importance of PBL
is that the skilful selection of problem scenarios can
provide students with prototype cases.
A range of approaches
PBL has developed, since it was first employed in
McMaster University in the 1960s, into a genus for
which there are many species and sub species
(Barrows 1986). Each addresses different objectives
to varying degrees. Barrows identifies the more
important learning objectives as
structuring knowledge for use in clinical contexts
developing an effective clinical reasoning process
development of effective self-directed learning skills
increased motivation for learning.
Different PBL methods address these objectives to
varying degrees. We have described different
approaches to PBL based on the relationship between
the two elements in PBL, the problem and the learning
derived from a study of the problem. The EG-RUL
model provides a basis for understanding the relationship
between the problem and the lessons learned. It also
gives an insight into the continuum that exists between
a fully problem-based curriculum at one end of the
spectrum and an information-orientated curriculum at
the other (Harden and Davis 1998).
The PBL continuum is presented as eleven steps which
are summarised in Figure 1 of the Appendix (p 21). As
one progresses along the continuum the relationship
between the RUL and EG changes with increasing
importance being placed on the examples and with the
examples becoming the focus for the learning. The final
stage is task-based learning (TBL), a development of
PBL where the focus is the tasks undertaken by a doctor
rather than a written simulation (Harden et al 1996).
 Problem-based learning: a practical guide
Why should you be interested in PBL?
Some advantages of PBL
PBL has now been in use for more than 25 years and
brings many real benefits to health professions
education. If used appropriately it could result in several
advantages for your teaching programme.
Relevance: Relevance of curriculum content is
facilitated by structuring student learning round
common clinical problems. PBL helps to eliminate
much of the irrelevant and outdated teaching
currently cluttering undergraduate or basic training
programmes.
Identification of core: The PBL approach, through
its identification of core, has the potential to make
an important contribution towards the reduction of
information overload that overburdens many of our
students.
Generic competencies: The approach contributes
to the acquisition of generic competencies or personal
transferable skills such as problem solving,
communication and team working, essential for all
graduates of higher education (Allen 1992). It thus
helps develop education for capability, another
important trend in health professions education which
enables graduates to hit the ground running on
entering their first step on the career ladder.
Student centred: The PBL process involves the
student taking more responsibility for his or her
learning, a feature which is thought to prepare
students for learning in later life. The speed of
developments and of innovation in patient care and
in health care delivery require all health professionals
to make a commitment to keeping up to date through
life-long learning. PBL helps to prepare students for
the adult learning approach they will need to employ
later, in the continuing education phase of their
professional life. There is some evidence in the area
of the management of hypertension, that graduates
of a PBL curriculum may be more up to date than
their peers (Shin et al 1993). The move away from
passive learning and rote memorisation, towards a
more active approach in which the student is actively
engaged in the learning process, can improve
understanding and retention of what has been
learned, by promoting a deeper approach to learning.
Identification of learning issues by students enables
them to set their own goals and take decisions
regarding relevant content. This is a major asset of
the PBL process.
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Integration: Integration has been shown to bring real
benefit to student learning (Schmidt et al 1996). PBL
is an important educational strategy for integrating
the curriculum.
Motivation: PBL is fun and rated enjoyable by both
students and staff. Teachers in traditional curricula
are familiar with the spectre of listless students,
switched off by the information overload which has
been a feature of undergraduate medical education
for at least the past 100 years. Courses which depend
largely on information gathering, will direct students
learning styles towards rote learning of facts and
information. One of the most widely accepted merits
of PBL is its ability to motivate or remotivate students
by freeing them from rote learning. Moreover, the
clinical setting of the scenario is motivating for
students.
Deep approach to learning: PBL encourages a
deep approach to learning. During the PBL process,
students interact with the learning material more than
in an information gathering or theoretical approach.
Concepts are related to everyday experience and
evidence is related to conclusions. These are features
of the deep approach to learning. If, as teachers, we
wish to foster deep as opposed to surface learning
in our students then we can use PBL as a tool or
strategy.
Constructivist approach to learning: PBL
facilitates a constructivist approach to learning. When
generating learning issues, students make use of
existing or prior knowledge to identify what they still
need to learn. Dewey (1929) proposed that learners
construct personal, conceptual schemata or
frameworks for organising and retrieving information.
The process of learning involves activating
appropriate schemata and organising new learning
within the framework. PBL involves this
constructivist approach to learning.
Prototype cases: The scenarios in PBL may in many
instances be considered by students as prototype
cases as discussed above. In general, the literature
on the principles of adult learning indicates that
people learn best when they are ready and motivated
to learn, involved in setting goals and deciding on
relevant content and when they participate in
decisions affecting their learning (Westberg and
Jason 1993). All of these features are aspects of
PBL.
 Problem-based learning: a practical guide
Some Disadvantages of PBL
The advantages of a PBL curriculum have been well
articulated by those who have adopted it into their
teaching and learning programmes. In an editorial,
Norman (1998) suggested that For too long PBL has
been viewed as a self-evidently better approach to
health sciences education, despite an accumulation of
evidence that the outcomes are not much different.
Hemker (1998), writing from the perspective of a
teacher in the Biochemistry Department in the Medical
Faculty at Maastricht University, identified three
objections to PBL.
PBL makes it very difficult for students to identify
with a good teacher. In PBL the teacher serves as a
facilitator rather than acting as a role model. This
may deprive students of the benefits of learning from
an inspirational teacher. The use of PBL, however,
does not necessarily exclude the opportunities for
this to happen.
PBL does not motivate staff to share knowledge with
the students. Staff are denied the fun of sharing their
processes of understanding with their students and
of getting a buzz out of teaching. On the other
hand, many staff find it rewarding and stimulating,
working within a PBL context.
The knowledge acquired through PBL tends to remain
unorganised. Organisation of knowledge in traditional
What approach to PBL should you adopt?
The question for the individual teacher is which of the
range of approaches to PBL should you adopt in your
teaching. This will depend on a number of issues.
Outcomes of the course: The curriculum outcomes
will influence the educational strategy to be adopted
(Harden et al 1999). If the philosophy of the
curriculum and the course outcomes emphasise
factual recall of information, the most appropriate
approach is likely to be situated at the information-
orientated end of the continuum with a passive
approach to learning. In courses where problem-
solving or application of knowledge is an intended
outcome, an approach towards the problem-based
end of the continuum may be more helpful with active
learning promoting deeper understanding and higher
order thinking.
Students and staff: The successful implementation
of PBL requires staff who are motivated and trained
in this method of teaching. Student induction in the
PBL process is also crucial for its successful
implementation. Students need training in the
appropriate use of the educational resources which
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courses comes from students being introduced to a
topic by experienced teachers able to distinguish
between what is important and what is unimportant.
The use of study guides may overcome this potential
disadvantage.
PBL requires competencies many teachers do not
possess. Teachers in medicine tend to teach as they
themselves were taught using traditional approaches
(Irby 1996). Staff development programmes must
be sufficiently robust to meet these challenges.
Concern has also been expressed about the cost of
implementing a PBL programme. PBL, however, is
not necessarily more expensive than traditional
approaches (Sefton, 1997; Nieuwenhuijzen, 1997).
PBL may be time consuming for students, particularly
if they need to identify educational resources for
themselves. The use of study guides, which identify
the most appropriate learning material, will minimise
this potential drawback.
Despite these concerns it is likely that PBL has a role to
play in your teaching, even if it is not the panacea
envisioned by some enthusiasts. The strategies for
implementing PBL described in this booklet may help
you overcome some of the potential problems with regard
to PBL.
are provided for them, such as electronic databases
or drop-in facilities in a clinical skills centre.
Traditional teaching if delivered well, is almost
certainly likely to be better than PBL implemented
badly.
Availability of resources: The availability of
resources will influence the approach to PBL to be
adopted. Problem-based strategies tend to require a
range of educational resources such as text books,
computer-based material, videotapes and models.
Space availability is also an important consideration.
Implementation of PBL with small groups of students
needs space for the small groups to meet and space
is required for educational facilities such as a
computer suite or learning resource area. A more
information-orientated approach requires more
teaching space in the form of lecture theatres.
Learning context: PBL has been found to be difficult
to implement in the clinical setting, although the
literature contains examples of successful PBL
experiments in hospitals or ambulatory care (Petrusa
and Allensworth 1985). Task-based learning is an
 Problem-based learning: a practical guide
educational strategy which is particularly useful in
the clinical context.
Activation of prior knowledge: PBL builds on the
students prior learning. Although Barrows argues
that even high school pupils have sufficient learning
and every-day experience to learn by PBL, many
teachers prefer to select approaches in the middle
of the continuum when they feel prior knowledge is
insufficient to support PBL or TBL.
Promotion of group skills: PBL approaches which
encourage small group activities help to promote
outcomes such as team working and communication
skills.
The PBL process
The details of how the PBL process is implemented
differ from institution to institution. However the general
principles remain the same. Students are not regarded
as passive vessels to be filled with facts by lecturers or
teachers. They actively learn for themselves using the
problem as a focus for their learning.
A number of identifiable stages or steps in the PBL
process have been described. This begins with the
problem scenario, which is often presented cold to the
students; that is, they have not prepared themselves
through previous study of the scenario.
Students, either working individually or more usually in
groups, read through the scenario and identify unfamiliar
terms or concepts. They inquire into the problem situation.
Some group members may be able to clarify areas of
uncertainty or plug knowledge gaps for others during
this stage. From their prior learning, the group determines
underlying mechanisms and develops possible
explanations for the problem scenario. Further
information about the scenario may be made available
to the students if they request it; for example, in a clinical
scenario, the results of patient investigation may be
provided if requested. The additional information may
be available on cards or may be provided by the tutor.
The group will encounter gaps in their understanding
and identify these as the learning issues associated with
the individual problem scenario. These learning issues
should relate to the learning objectives previously
identified by faculty. Some schools choose to assist the
students in the process by providing a set of learning
objectives identified by faculty which helps them to relate
their work on the problem to overall course objectives.
-9 -
Student choice: There may be advantages in offering
students a choice of learning strategies. In some
circumstances this may be possible. Parallel PBL
and traditional tracks have been offered in medical
schools such as Harvard and New Mexico although
many have moved to offering only a PBL
programme. Distance learning courses make it
possible to offer more easily a choice of information
gathering or PBL approaches to learning. Individual
students are able to select their preferred learning
approach (Rogerson and Horton 1997).
Following this first stage there is a period for individual
study. Students tackle the learning issues through
accessing a range of educational resources.
When the group meets again, students share what they
have learned and apply the learning to the problem
scenario. The student group may be able to explain fully
the phenomena identified in the problem scenario at this
stage but they may also identify further learning issues
which require another period of individual study. The
group learning is then synthesised to explain the
observations in the problem scenario. During this step
students organise prior and new learning around the
problem scenario. This aids retrieval of what has been
learned when a similar problem or situation is
encountered later in professional practice.
The final vital step in the PBL process is to generalise
the learning to other situations in which such knowledge,
skills and attitudes would be applicable; for example, an
understanding of inflammation in a wound repair
scenario is broadened to a general understanding of the
inflammatory process in other situations.
Individual medical schools have organised problem-based
learning in different ways: for example, the Harvard six
steps approach emphasises generalisation of what has
been learned (Table 1). The Maastricht seven jump
approach includes brainstorming (Table 2). Other
medical schools, such as Liverpool, Glasgow and
Manchester have adopted different approaches (Bligh
and Wilkinson 1997). Whichever approach is adopted,
however, the basic concept is the same through active
involvement, students move from the example or problem
towards the rule, principle or concept and then
generalise their learning to other contexts or settings.
 Problem-based learning: a practical guide

1 Group receives the written problem scenario without the opportunity to study it
beforehand.
2 The student group defines the problem.
3 The study group identifies the learning goals.
4 Students work independently to achieve the learning outcomes.
5 The student group is reconvened. The students build new learning on to prior knowledge.
Students review whether they have met faculty learning objectives. Further individual
work and group meetings may be required to achieve this.
6 The group synthesises and summarises their work. The students generalise from the
specific problem scenario to other situations.

Table 1: Harvard Medical School - Six Step Method

1 Students, working in a group, clarify the text of the problem scenario

2 Students define the problem
3 Brainstorming is used to identify explanations for phenomena observed in the problem
scenario
4 The group reaches interim conclusions about the problem
5 The group formulates the learning objectives
6 Students work independently to achieve the learning outcomes
7 The student group reconvenes to discuss the knowledge acquired.

Table 2: Maastricht Medical School - Seven Steps in PBL

The problem and its presentation

In this section we look at what makes a good problem
scenario and the medium used to present it.
Presentation
of problem
Solution Learning related
of problem to problem
+
What makes a good problem scenario?
The selection of problem scenarios for use in PBL has
often been a matter of intuition or serendipity. It is,
however, a matter of importance. The design of
appropriate problem scenarios ensures that students
cover a pre-defined area of knowledge or learn a set of
important concepts, ideas or techniques. The problem
should lead students to a topic or field of learning and so
meet faculty learning objectives (Ross 1991). The role
of the problem scenario (Margetson 1998) is to act either
as a convenient peg on which to hang knowledge
acquisition or as the focus of a growing web of
understanding in practice.
Dolmans et al (1997) have identified seven criteria for
effective problem design. The criteria, which are based
on what is currently known about the nature of learning,
are:
1 Learning outcomes: The learning issues likely to be
identified by students through study of the problem
are consistent with faculty learning objectives. A
problem scenario may address different categories
of learning outcomes including scientific
understanding, an understanding of health promotion
or ethical issues. In a system-based programme, the
scenario may address learning related to the different
systems.
2 Phase of the curriculum: The problem should be
consistent with the phase of the curriculum and stage
of student learning. It should enable students to build
on and activate prior learning.
3 Relevance and motivation: The problem scenario
should be relevant to the students future practice as
healthcare professionals and if not, should be of
sufficient intrinsic interest to motivate the students
and encourage them to spend more time on self-
study.

-10 -
 Problem-based learning: a practical guide
4 Integration: The problem scenario should present
basic science concepts in the context of a clinical
problem to encourage integration of knowledge. Such
integration has been shown to improve clinical
diagnosis (Schmidt et al 1996).
5 Cues: The problem scenario should contain cues to
guide the student and to stimulate discussion. It should
further encourage students to elaborate and to search
for explanations.
6 Open problem: The problem scenario should not be
so complete or closed that it is difficult to sustain
discussion or that no further explanation is needed.
7 Student activity: While all problems should be
designed to promote active involvement by students
in acquiring the necessary information, some
problems may be constructed which will require more
work by the student; for example, more detailed
library searches or a small piece of investigative
work.
Considerations in the choice of medium
Problems are usually presented to students in print.
However, other media may be used. Newspaper
clippings, audio tape, videotape and computer simulations
may all be used. In TBL, the real life task carried out by
the student provides the learning stimulus (Aspegren et
al 1998).
A number of factors need to be taken into account when
selecting the most appropriate medium to present the
problem to students. These factors have been identified
by Harden (1983) in the context of patient management
problems but several are also relevant to PBL. These
are:
the ability to communicate the necessary information
ease of use
ease of production
Newspaper clippings: Newspaper clippings may be
used as PBL triggers. In the International Medical
University in Kuala Lumpur in Malaysia an article
Curbing Prostatic Disease was used to focus student
learning about the anatomy of the prostate, the diseases
that affect it and their pathophysiology, and diagnostic
tests for disease of the prostate.
Audio-tape triggers: The problem may be presented
on an audio-tape. At the University of Newcastle, New
South Wales, an audio tape of a simulated emergency
call to a general practitioner regarding an elderly patient
who has collapsed was used as a trigger for learning
about initial management and differential diagnosis of
the collapsed patient.
-11 -
Videotape: Videotapes may also be used. At the
University of Dundee Medical School, a videotape of a
patient during labour is used to introduce the problem to
multiprofessional groups of nursing and medical students
in a session where the learning objectives relate to the
mechanism of labour and the role of doctors and
midwives during labour. Situations such as breaking bad
news, dealing with the bereaved or confrontational
situations all make useful stimuli for a problem-based
approach to learning which can be presented to students
on videotape.
Computer: The computer may also be used to deliver
PBL. PC Challenges is a computer simulation in which
a group or an individual is presented with a time-
dependent simulation of patients with cancer related pain
(Harden et al 1998). Students have to manage the patient
with the aim of discharging the patient from hospital
with the pain controlled. This can be used as a vehicle
for PBL. Students can take time out from the
management of the patient to look at what they already
know that can help them and what they need to know
and learn. They may obtain further information about
managing patients with cancer-related pain on-line or in
an accompanying text HELP Helpful Essential
Links to Palliative Care (CME 1995).
SACARA is a problem-based computer programme
designed to update nurses on the topic of wound
management (Davis et al 1997). Clinical scenarios are
presented to cover common problems relating to a range
of commonly occurring wounds. Help files can be
accessed when further theoretical or scientific
information is required to tackle the problem. Through
group discussion or individual consideration of a series
of questions, nurses arrive at management decisions
which they can then compare with those of experts.
They are then given feedback on their management.
Tasks as part of the health professionals daily
activities: The problem may be presented as a simulation
using the range of media identified above or as a task
undertaken by a doctor TBL (Harden et al 1996). In
TBL, the tasks carried out by the student, trainee or
practitioner are used as a focus for learning. In TBL in
dentistry, the following tasks served as a focus for
learning during the first postgraduate year (CME 1989):
handling a patient with caries and undertaking the
necessary restorations
undertaking treatment of a patient with a periodontic
problem
handling a case of acute dental pain
undertaking treatment of an endodontic problem
management of a patient needing partial or complete
dentures
 Problem-based learning: a practical guide
undertaking minor surgical procedures (eg tooth
extraction, root extraction, etc).
These tasks relate to the competencies the dental
vocational trainees are expected to master during the
training year such as communication with patients or
their relatives, diagnostic skills, treatment planning,
implementing treatment, prescribing, referral and
management of other members of staff.
Facilitating PBL
Presentation
of problem
Student
support
Solution Learning related
of problem to problem
The extent to which facilitation is
necessary
In PBL, students require a measure of support. This
may be supplied through a facilitator in a PBL group or
through supportive resource material provided, for
example, in a study guide. The amount of external
support required is dependent on the prior learning of
the students and on their understanding of the PBL
process. Internal support may also come from other
members of the group through a collaborative learning
process in which students learn from each other. Where
there is a high level of internal support the need for
external support is reduced (Figure 1). The greater the
internal student support in terms of prior learning and
experience with the PBL process, the less external
support is required.
Internal support by
student group
External support
required
Figure 1
Where the level of prior learning is lower, greater external
support is required. This support may come from the
group facilitator (or tutor) or from material pre-prepared
by faculty. In some situations a faculty facilitator may
-12 -
In a study guide for junior hospital doctors working in
Paediatric units in the UK, produced for the Scottish
Council for Postgraduate Medical and Dental Education
by the Dundee Centre for Medical Education, the
learning is focused round normal children and various
examples of sick children the junior doctors might be
expected to see during the rotation (CME 1996).
not be required but this is likely to be exceptional. Duek
et al (1996) studied tutorless groups and concluded that
the reliance on a tutorless format may not be appropriate
when other sources of structure are absent from the
curriculum. Students have sometimes been used as
group facilitators.
The process of facilitation
If learning is the active construction of meaning, teaching
can then be defined as the facilitation of learning.
Nowhere is this definition more apt than in PBL. Here,
the teacher serves as both a monitor and stimulus to
the process by asking leading questions, challenging
thinking and raising issues or points that need to be
considered. The teacher attempts to help students help
themselves in the educational process (Barrows and
Tamblyn 1980). These authors see the teachers role in
PBL as that of a guide, helping the student develop
skills in scientific reasoning, self-study and self-
evaluation. They recommend that teachers should
respond as an information source to a direct enquiry
only after they are sure that students have exhausted
their own logic or information base and feel that the
information provided will facilitate further work with the
problem at the time, without sacrificing the value of self-
study.
There are several different types of competence
associated with group facilitation in PBL. These are:
1 Skills in facilitation of the small group learning;
2 An understanding of the programme for the week
or for the course, including the ability to help the
student relate the work on the problem to the learning
opportunities during the week or course;
3 An understanding of the overall educational
programme and the ability to help students place the
work undertaken in tackling the problem within the
overall framework of the curriculum and the overall
learning outcomes for the curriculum. This includes
an appreciation of the stage of learning of the students
and what they have already studied;
 Problem-based learning: a practical guide
4 Schmidt and Moust (1995) found that personal
qualities of facilitators, such as the ability to
communicate with students in an informal way, an
empathetic attitude and the creation of an atmosphere
in which the open exchange of ideas is facilitated,
seem to be important in promoting student learning.
Qualities also helpful include a willingness to become
involved with students in an authentic way and the
skill to express oneself in a language understood by
students;
5 Perhaps one of the most contentious issues in PBL
is whether the group facilitator should be an expert
in the content matter related to the problem. Some
argue that such competence frequently distracts
from the tutors role of facilitator. Others believe
that subject matter experts who have also been
appropriately trained in facilitation skills are likely to
be the best facilitators (Davis et al 1992). Schmidt
(1994) found that students need a minimum level of
structure to profit from PBL instruction. This
structure can be internally provided through prior
knowledge available for understanding the new
subjects, or offered by the environment in the form
of cues of what is relevant and what should be the
focus of activities. If prior knowledge falls short, or
if the environment lacks structure, students will turn
to their tutors for help and direction. Under those
conditions, students who are guided by a subject-
matter, expert tutor may benefit more than those
students guided by non-expert staff tutor or by a
student tutor.
In conclusion, it could be argued that the best tutor is
the subject matter expert who understands the course
and the curriculum and who has the appropriate group
facilitation skills. The second choice would be a
medically qualified member of staff who is not an expert
in the area but who understands the course and the
curriculum and has the appropriate group facilitation
skills. The third choice would be someone who has an
understanding of the curriculum and the appropriate
group facilitation skills but who does not have medical
understanding or knowledge. There are, however, many
examples of where non-experts and non-medically
qualified facilitators function effectively. What are
essential, however, are group facilitation skills and
appropriate personal qualities.
Staff development
Newer approaches to health professions education make
many demands on the medical teacher and the different
roles of the teacher have been described (Harden 1997).
-13 -
Many teachers are more comfortable with the role of
information provider as in lectures or clinical teaching.
Few have experience of the role of facilitator and feel
comfortable in this role. Many find difficulties in
implementing a PBL approach and an extensive staff
development programme is mandatory prior to the
introduction of a PBL course. Models for faculty
development for PBL have been described (Irby 1996).
A staff development programme should address the
competencies expected of the tutor as described in the
previous section. The staff development programme
may be provided as:
a formal course which includes active involvement
of staff and a study of examples of PBL
guided on-the-job experience with a new facilitator
initially sitting in with an experienced facilitator during
PBL sessions
self-study through the use of books and other
resource material, for example, reading this booklet.
Role of study guides
Much attention has been paid to the role of the tutor in
PBL facilitation. Less attention has been paid to the use
of study guides as a form of support. Student study guides
have been described by Rowntree (1986). They can
help students to manage their own learning (Laidlaw
and Harden 1990) and can support PBL as used in the
undergraduate medical curriculum at the University of
Dundee Medical School. The guides provide:
a description of the problem scenarios or tasks
assistance with identification of learning issues
information about how the problem or task contributes
to the overall learning outcomes for the medical
course
a description of other learning opportunities available
such as lectures, sessions in the integrated learning
area and clinical skills centre.
The study guides have been rated by students as one of
the most helpful and popular features of the course and
have been identified by external evaluators as an
example of good practice. The guides can also be made
available to students in electronic format (Harden and
Smyth 1994).
 Problem-based learning: a practical guide
Student assessment and PBL
The approach to student assessment should be reviewed
at the same time as PBL is introduced as a learning
strategy. Student behaviour and approach to learning is
influenced by the assessment tools used (Harden 1992).
If the assessment process emphasises factual recall and
rote memorisation, PBL may appear less attractive to
students and students may be less enthusiastic to
participate in the PBL process. If, on the other hand,
the assessment process tests a deeper learning,
understanding and/or problem solving, then the relevance
of the PBL will be apparent.
Student assessment in PBL is governed by principles
similar to those applied to the assessment of students
more generally. The assessment should be designed to
test the individual students ability to fulfil the curriculum
outcomes or objectives. Student assessment benefits
from a mixed menu approach which is designed to test
a range of curriculum outcomes.
If the curriculum outcome to be assessed is knowledge,
this may be effectively and efficiently tested using
multiple choice questions (MCQs).
If the curriculum outcome to be assessed is problem-
solving, then modified essay questions (Knox 1975)
provide a method capable of testing higher order thinking
and application of knowledge. The extended matching
item format (Case and Swanson 1993) is an extension
of the multiple choice format that may be used to test
clinical decision making, data interpretation and other
intellectual activities that require recall and recognition
of knowledge and problem solving.
The objective structured clinical examination (OSCE),
(Harden and Gleeson 1979), provides a robust
framework for testing a range of curriculum outcomes
such as clinical methods, data interpretation, health
promotion and disease prevention and can be designed
to assess ethics, attitudes and problem solving.
Relationship of PBL to other educational strategies
and curriculum developments
Skilful curriculum design involves employing a
sophisticated blend of educational strategies to obtain
the desired educational outcomes. The SPICES model
(Harden et al 1984) identifies a range of educational
strategies and provides educators with an instrument
for analysis of the curriculum and for future planning.
-14 -
Some PBL schools have adopted the progress test. This
provides students and staff with feedback about student
progress (Blake et al 1994; 1996). The progress test is
usually MCQ based and covers the whole curriculum
making revision for the test impractical. It is claimed,
therefore, that it does not disrupt the learning process
or drive learning styles and is unlikely to prejudice the
educational philosophy of the curriculum the students
are following.
The triple jump method has been designed to assess
student ability in the PBL process (Painvin et al 1979)
but it is not widely used.
An innovative approach which offers potential is the
use of portfolios for assessment (Snadden & Thomas
1998). Students can include in their portfolio, evidence
of work undertaken in relation to the problem and their
reflections on how this work has helped them meet the
curriculum outcomes. The portfolio may include material
such as case histories, log books, checklists of clinical
skills mastered and other personal achievements such
as publications in their records of achievement or
portfolios. Assessment of the portfolio can test
curriculum outcomes such as independent learning,
record keeping and other areas difficult to assess by
traditional approaches. Portfolio assessment can also
measure group work and individual contributions to
groups.
One issue for consideration is whether the students
performance in the PBL group should be assessed by
their tutor and/or other members of the group. While
the objectives of so doing are worthwhile, practical
considerations include the reliability of the procedure
and the effects the process may have on tutor/student
relations.
Student centred teacher centred
Problem-based information gathering
Integrated discipline-based
Community oriented hospital based
Electives with a core curriculum standard course
Systematic apprenticeship
SPICES model
 Problem-based learning: a practical guide
PBL contributes to a more student-centred curriculum.
It requires students to work out for themselves what
they need to learn and to undertake the necessary studies
to meet these needs. However, faculty usually identify
the learning objectives and develop the problem
scenarios; in other words, the curriculum outcomes
remain firmly in faculty control. Moreover, students are
required to adopt a problem-based approach to learning
as determined by faculty and attendance at PBL group
sessions is often made compulsory.
PBL is a useful approach to delivering an integrated
teaching and learning programme. Other approaches to
integration are available and many systems-based,
multidisciplinary programmes are not problem based.
PBL is also a useful approach for multiprofessional
education (Harden 1998) with students from the
different professions contributing from their disciplines
perspective to the problem as presented (Mires et al
1998).
Conclusions
PBL is an important development in health professions
education with the advantages and the disadvantages
well documented.
It contributes to the sophisticated blend of educational
strategies consistent with current trends in curriculum
planning.
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 Problem-based learning: a practical guide
Appendix: The continuum of problem-based learning
R M Harden and Margery H Davis
Summary
Problem-based learning (PBL) has been recognised as
an important educational strategy and has been adopted
in many medical schools. There is confusion, however,
about what constitutes PBL. In the SPICES model for
educational strategies PBL is presented as a continuum.
This paper describes eleven steps in the continuum
between problem-based learning and information-
orientated learning. Task-based learning is viewed as
the final step at the problem-based end of the spectrum.
The continuum presented recognises the two key
variables the problem and the information or principles
The concept of a continuum
Since the potential value of problem-based learning in
medical education was highlighted by Barrows &
Tamblyn (1980), the educational strategy has attracted
increasing attention. New schools have adopted it as a
major feature of their curriculum, established schools
have incorporated it in curriculum revisions, and reports
on medical education have featured it among
recommendations as to good practice (Walton 1994,
General Medical Council 1993).
Many courses purport to be problem-based. It is often
far from clear, however, in what way this is reflected in
the curriculum. What is problem-based learning? is a
question not infrequently asked by medical teachers and
those engaged in curriculum planning and development.
Views range from a rigid definition which identifies it
with the approach adopted in schools such as McMaster
and Maastricht, to suggestions that anything which
includes problem solving can be designated problem-
based learning (Barrows 1986). Problem-based
suggested Barrows (1986) must be considered a genus
for which there are many species and subspecies.
Problem-based learning may be best thought of as a
syndrome comprising a number of components (Walton
& Matthews, 1989). The term PBL can have, according
to Barrows (1986), many different meanings depending
on the design of the educational method employed and
the skills of the teacher. He identified the need for a
-18 -
derived from a study of the problem. It builds on the
rul-eg/eg-rul approaches introduced in programme
learning in the 1960s.
The continuum offers a useful taxonomy to describe
PBL. It emphasises the range of options and in so doing
helps to avoid a polarisation of view-points between
enthusiasts and traditionalists. The continuum can be
used as a tool for curriculum evaluation and
development.
taxonomy to facilitate an awareness of these
differences and to help teachers to choose a problem-
based learning method most appropriate for their
students.
Problem-based learning features as one of six
educational strategies described by Harden et al (1984)
in the SPICES model, each strategy presented as a
continuum between two extremes. In the case of
problem-based learning, the extremes are problem-based
learning and information-orientated learning. Educators
or teachers find it helpful to identify where on the
SPICES continuum they locate their current teaching
practice and where they would like their curriculum to
aim. It is unclear, however, as to whether the
intermediate points on the continuum between the two
extremes represent simply quantitative differences, eg
the proportion of curriculum time devoted to problem-
based learning, or whether there are qualitative
differences as one progresses on the spectrum between
an information-orientated and a problem-based
approach.
This paper describes eleven points on the problem-based
learning continuum and the qualitative differences
associated as one moves along the spectrum. Eleven
points have been described previously on the integration
continuum between discipline-based teaching and
integrated teaching (Harden 1998).
 Problem-based learning: a practical guide
The basis for the continuum
The key variables in PBL are the problem and the
information gained. The taxonomy proposed by Barrows
(1986) was based on the design and format of the
problems and on the role of the teacher in PBL.
Barrows acknowledged, however, that the sequence in
which the problem is offered and the information
acquired is also a variable.
The continuum described in this paper is based on the
two essential components in problem-based learning
the problem and the lessons learned from a study of the
problem. These two components of the education
process and their relationship can be traced to the rul-
Steps on the continuum
The eleven steps represent a move from a rul-eg to a
eg-rul approach with increasing emphasis being given
to the problem as a focus for the learning. They are
summarised in Figure 1. A short explanation and example
are given for each step.
1 Theoretical learning
This is the stage furthest from the problem-based end
of the continuum. The emphasis in the teaching is on
the presentation and the acquisition of information or
theoretical rules. Opportunities to apply the information
to simulated problems or to the real world are not
planned as part of the curriculum, and if they do occur
are accidental. The approach tends to encourage rote
learning. Examples of this stage of the continuum are
the traditional lecture and the standard textbook.
2 Problem-orientated learning
The emphasis in this step remains, as in step one, on the
provision of information with little, if any, opportunity to
apply the information as part of the formal educational
programme. Consideration has been given by teachers,
however, to the nature of the information provided and
attempts made by them to ensure that the information
or practical rules presented is in a format relevant to a
practitioner in his or her practice. The information
presented is identified by expert practitioners in the area,
or by a more formal needs analysis. Lectures with a
practical slant on topics such as the management of
patients with myocardial infarction, and the publication
of protocols or guidelines on a range of patient
management topics typify this stage of the PBL
continuum. Many courses in the medical curriculum,
particularly those in the early years of training, fall into
this category.
-19 -
eg and eg-rul approaches developed in the context of
programmed learning in the 1960s. Concepts and
principles, it was recognised, are built out of examples.
This led to a classification of the subject matter of
programmes by Evans, Homme and Glaser (1962) into
concepts or rules (ruls) and examples (egs). Principles
can be stated and exemplified, a rul/eg approach, or
educed from examples and illustrations, an eg/rul
approach, (Leith 1966).
The approaches have been developed as the basis for a
description of the stages in the continuum between
information-orientated and problem-based learning.
3 Problem-assisted learning
At this stage of the continuum, practical information is
presented as in step 2. In addition, planned opportunities
are made available in which the student applies the
knowledge in a practical context. This application
process helps to ensure that the information is not dead
or inert. It helps the students to see the relevance of
the information and assists them to understand the
subject and to master and retain the key principles or
concepts. A lecture on a topic may be followed by a
practical class or by clinical experience in the hospital
wards, outpatient department or the community.
Students can then see, in these contexts, examples in
practice of the topics covered in the lecture. Many
textbooks now apply the same approach and include
exercises or activities relating to the contents of the book.
4 Problem-solving learning
In this approach the focus for the students learning is
on tackling a specific problem. The emphasis is on
solving the problem and not on learning information
related to the problem. This contrasts with later steps
in problem-based learning where tackling a problem is
a vehicle for learning about a number of issues related
to the problem and where generalisation from the
problem to other areas is a key part of the process.
Case discussions concerning specific patients and
activities in practical classes where the underlying theory
is not explored, fall into this category. Students may be
given a case history of a patient and have to solve the
problem of what is going on and what should be done
on the basis of the evidence provided.
 Problem-based learning: a practical guide

Terminology Description Example

1 Rul Theoretical learning. Information provided Traditional lecture.

(Th) about the theory. Standard textbook.

2 Rul Problem-orientated Practical information Lecture with practical

(PT)
learning. provided. information. Protocols or
guidelines.

3 Problem-assisted Information provided with Lecture followed by

Rul Eg learning. the opportunity to apply it practical or clinical
to practical examples. experience. Book with
problems or experiences
included.

4 Problem-solving Problem-solving related to Case discussions and some

Eg learning. specific examples. activities in practical
classes.

5 Problem-focused Information is provided Introductory or

Rul Eg Rul learning. followed by a problem. foundation courses or
The principles of the lecture. Information in
subject are then learned. study guide.

6 Rul Eg
Problem-based A combination of Students have the option of
mixed approach problem-based and an information orientated
Eg Rul
information-based or problem-based
learning. approach.

7 Problem-initiated The problem is used as a Patient management

Eg
learning. trigger at the beginning of problems are used to
Rul
learning. interest the student in a
topic.

8 Problem-centred A study of the problem A text provides a series of

Eg
Rul learning. introduces the student to problems followed by the
(Sp)
the principles and rules information necessary to
specific to the problem. tackle the problems.

9 Problem-centred Following the presentation Students derive the

Eg
Rul discovery learning. of the problem students principles from the
(Sp) have the opportunity to literature or from work
derive the principles and undertaken.
rules.

10 Problem-based The development of the The investigation of

Rul
Eg
(G)
learning. principles includes the patients with thyrotoxicosis
generalisation stage of is extended to a more
learning. general understanding of
thyroid function tests.

11 Task-based learning. The problem is the real A set of tasks undertaken

Eg
Rul world. by a healthcare
(T)
professional are the basis
for the problem presented
to the student.

Figure 1: Problem-based learning: a continuum

-20 -
 Problem-based learning: a practical guide
5 Problem-focused
learning
In some instances teachers feel it is necessary to initiate
the learning process by giving students some information
and the relevant vocabulary before they face the problem
presented. In a three step process, some information is
first presented about the subject. This information might
be an overview of the topic, essential vocabulary, or
key principles without which it may be difficult for the
student to appreciate the problem to be presented. In
the second step of the process, students are presented
with a problem. They identify the learning issues related
to the problem and study these. In the third step, students
review the principles and the concepts relating to the
topics that they have mastered and go on to look at how
these can be applied in contexts different from that
illustrated in the original problem.
This three step approach to problem-based learning is
often adopted where there is concern that the students
previous experience or studies are such that time-
wasting difficulties may arise if the student is confronted
with the problem at the first step. Sometimes an
introductory lecture is used to introduce students to the
subject and this is followed by the first PBL group
meeting. Occasionally, an introductory course precedes
the PBL part of the course. Study guides may be used
to introduce the students to the topic (Laidlaw and
Harden 1990).
6 Problem-based mixed
approach
Students may be given the option to choose from a
problem-based or an information-orientated approach.
They may choose to start with the problems, and then
move on to a specification of the learning issues and
mastery of the underlying principles. Alternatively, they
may start with information on the topic, and then proceed
to tackle the problems. The provision of the two options
may be difficult to implement in a face-to-face
curriculum, although this can be found in curricula set
up with alternative tracks. In distance learning, however,
students choice with regard to educational strategy is a
very real possibility. Rogerson and Cumming (1997)
have described how in a distance learning course for
nurses, learners can be given freedom to choose their
learning strategy. Some nurses were found to choose a
more information-orientated approach, some a more
problem-based approach, and some moved back and
forward between an information and a problem-based
approach.
-21 -
7 Problem-initiated learning
In problem-initiated learning the student encounters the
problem first. The problem is a trigger designed to
arouse students interest in the topic. It may also be
used to give them a general idea of the area being
studied. The problem is not intended, however, to be
the main focus for the students learning.
A problem was used to introduce doctors to an
educational programme on melanoma with the aims of
arousing the readers interest in the topic, and raising
their awareness of the need to study the subject in more
detail (Laidlaw et al 1996). In the SELECT distance
learning programme for surgeons produced by the Royal
College of Surgeons of Edinburgh, and the Dundee
Centre for Medical Education, a series of case studies
are designed to help set the scene in each module. These
provide the trainee with an idea of the scope of the
topic. They are not intended as the major focus for the
students learning during the programme, although they
are referred to at various stages during the programme.
8 Problem-centred learning
In problem-centred learning the problem, for the first
time, becomes a major focus for the students learning.
A study of the problem leads the student to learning the
principles and rules required to arrive at a solution to
the problem.
The information is relatively accessible and available to
the students in the literature or resource materials
provided, or in the more formal sessions including
lectures. Less emphasis is placed on the students
identifying the learning issues and finding the answers
for themselves. Students after the initial presentation
of the problem have to assemble the facts from a limited
number of facts made available to them. This is the
compromise position described by Barrows (1986). He
equates this with patient management problems where
the choices available to students are limited (Harden
1983). A problem-centred text may introduce the
relevant information to the student through a series of
problems.
9 Problem-centred
discovery learning
As in problem-centred learning, the problem provides
the major focus for the students learning. Students
are, however, given more opportunity to work out for
themselves the principles and rules. This may be
achieved through a process of discovery learning. The
time-scale is such that there is a significant period of
time over which there is the presentation of the problem
 Problem-based learning: a practical guide
and a discussion of its solution. Whether the time
required for a discovery learning approach is justified
by the end results is a matter of controversy.
Students meet usually in a group and identify the learning
issues related to the problem with which they have been
presented. They consult the appropriate references and
resource materials, undertake some activity necessary
to find the required information and then return to the
problem at a second meeting. Students review the
information which they have acquired and arrive at a
solution to the problem. Students have to assemble the
important facts required to tackle the problem from, as
Barrows (1986) describes, a free enquiry, as occurs in
the real world, using clinical reasoning.
In a problem relating to nutrition and the community,
using a discovery learning approach, students might be
expected to carry out a nutrition survey in the local
population and use this as a basis for their work on the
problem.
10 Problem-based
learning
Whitehead (1932) described three stages of learning
the romance stage, the stage of precision and the stage
of generalisation. In problem-based learning, the
problem provides the romance stage. In steps eight
and nine of the continuum, as described above, the
learning stops with a mastery of the learning issues
specific to the problem. Emphasis is given in true
problem-based learning to the generalisation from the
problem under discussion, to other situations. The
implication is that one does not have to have a problem
covering each topic or area of medicine a criticism
PBL
1 The problem Usually a written simulation
or scenario
2 Learning outcomes Implicit in the problem as
presented to the student
3 Learning content Sessions scheduled in timetable
4 Learning in groups Usually in groups (may be
individual)
5 Stage of training Early years (may be used in
later years)
6 Multiprofessional More difficult to implement
education
Table 1: Comparison of problem-based learning (PBL) and task-based learning (TBL)
-22 -
sometimes levied against problem-based learning. The
final group discussion in problem-based learning is
scheduled to include an opportunity to review the general
application of the principles and rules mastered.
Students mastering the principles of feedback, as they
study one problem for example, would look at how these
principles might be applied in other situations. The
treatment of a patient with thyrotoxicosis would be
generalised from the treatment of the patient whose
problem is presented, to the treatment of thyrotoxicosis
more generally or the laboratory investigation of a patient
with thyrotoxicosis to thyroid function tests more
generally.
11 Task-based learning
Task-based learning (Harden et al 1996) can be
considered as the eleventh step in the problem-based
learning continuum. All of the principles described for
problem-based learning focusing the learning on a
problem, building new knowledge on what the student
already knows, active learning and a student-centred
approach to learning apply to task-based learning as
in problem-based learning. The differences between
TBL and PBL are shown in Table1. The key difference
is that the focus for the learning in TBL is not a simulated
patient problem or scenario presented on paper or
occasionally in some other form, but rather the tasks
that are undertaken by a healthcare professional.
Mitchell et al (1998) described how the approach was
adopted as a basis for a curriculum in the training of
junior doctors in child health. In task-based learning,
the learning is based in the real world of clinical practice.
TBL
An example in clinical practice of the work
undertaken by a healthcare professional
Need to be made more explicit and related
to the stage of training of student
Usually part of experiential learning
Usually individually (may be in groups)
Later years (may be used in early years)
Easier to implement
 Problem-based learning: a practical guide

Conclusions
The problem-based learning continuum represents a based is often meaningless as it covers a wide range
qualitative as well as a quantitative shift from of approaches. Describing a programme in terms
information-orientated to problem-based learning (Figure of where it stands on the continuum removes this
2). As one moves along the continuum more emphasis ambiguity or uncertainty.
is placed on the problem, students are more challenged,
3 The eleven step model encourages curriculum
their prior knowledge is activated in the learning process,
developers and teachers implementing a programme
there is more emphasis on discovery learning and learning
to have a frank debate of the stance to be taken
is acquired in a meaningful context.
locally with regard to problem-based learning. It
This eleven stage problem-based learning continuum helps to ensure that local teachers are aware of the
offers a number of advantages. principles underlying the agreed approach. This can
provide the basis for a staff development programme
1 Firstly, it emphasises that opinions about problem- with regard to problem-based learning.
based learning need not be polarised, with teachers
4 The continuum offers a useful tool for curriculum
either for or against the approach. Instead problem-
evaluation. The schools perceptions of where they
based learning can be regarded as offering a range
stand on the continuum can be evaluated against the
of options.
students perceptions and what is happening in
2 The continuum described provides a taxonomy or a practice.
method of describing problem-based learning.
Labelling a curriculum or a course as problem-
---
---
---
---
---
---
---
---
---

Information orientated Problem-based

Increasing emphasis on the problem
Students more challenged
Activation of prior knowledge
Discovery learning
Learning acquired in a meaningful context

Figure 2: Qualitative difference in the continuum between information-orientated and problem-based learning

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