Documente Academic
Documente Profesional
Documente Cultură
2, 1999
SUM M AR Y This practical guide for health professions teachers ªthat it is the most important development since the m ove
provides a perspective of one of the m ost important educational of professional training into educational institutionsº. Since
developments in the past 30 years. Problem -based learning (PB L) it was ®rst developed by Howard Barrows at M cMaster
is a continuum of approaches rather than one im m utable process. ( B a r r ow s & Ta m b ly n 1 9 7 6 ) , n e w m e d ic al sc h o ol s
It is a teaching m ethod that can be included in the teacher’s throughout the world have adopted PBL as the educational
tool-kit along w ith other teaching m ethods rather than used as and philosophical basis of their curricula and traditional
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the sole educational strategy. PB L reverses the traditional approach schools have included it within their por tfolio of teaching
to teaching and learning. It starts w ith individual examples or m e tho d s o r h ave c on ve r te d th e i r u n d e r g r ad u a te
problem scenarios which stimulate student lear ning. In so doing, program m es to PBL.
students ar rive at general principles and concepts which they then In the UK the General M edical Council (GM C) has
generalize to other situations. PB L has many advantages. It
advocated a problem -oriented ap proach in its recom -
facilitates the acquisition of generic competences, encoura ges a
m endations for basic medical education (GM C 1993).
deep approach to learning and prepares students for the adult
ªM edical schools are well aware of th e m erits of the
lear ning approa ch they need for a lifetime of lear ning in the
learner-centred and problem-orientated approaches and
For personal use only.
If you are not already comm itted to PBL, this booklet · an approach to learning and to curriculum design with a
will: number of speci®ed features; Walton & M atthews (1989),
for example, describe it as a syndrome with eight features.
· make you aware of the nature of PBL;
Charlin et al. (1998) have identi®ed seven educational
· highlight the advantages and limitations of PBL;
principles as to how students learn in PBL;
· help you to consider the range of approaches to PBL and
· a speci®c educational approach based on the relationship
which approach may be most appropriate for your own
between concepts or principles and examples or problems;
situation;
· a range of approaches–a genus with different species
· provide you with hints for implementing PBL.
(Barrows, 1986) or a continuum (Harden & Davis, 1998);
If you are already committed to PBL, the booklet will provide · an umbrella term that involves any learning experiences
you with a deeper understanding of PBL and help you to in which problems are solved. Many would disagree with
place the approach you have adopted within a broader this de®nition, however, and would wish to see some of
fram ework of approaches to PBL. the features, for example those described by Walton &
M atthews (1989) or by Charlin et al. (1998), included
before calling the approach PBL.
W hat is PB L?
S om e de®nitions
An approa ch to learning and curriculum design w ith a num ber
Confusion and misunderstanding often exist about what of speci®ed features
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131
M .H . D av is & R.M . H arden
do this as m embers of a small group or team. Since m ost A speci® c educational approa ch based on rules and exam ples
health care professionals work in teams, and often in m ulti-
In the traditional approach to education, rules and principles
professional or interdisciplinary teams, these skills should
are presented ®rst. Students then apply these to clinical
prove useful after graduation or post basic training.
problems or examples of the rules and principles in action.
In a problem-based approach the order is reversed. Students
Learn ing tackle problems or examples ®rst and in doing so discover
the rules and principles for themselves.
ªActive and student-directed; peer- and tutor-m onitoredº PB L is not a new conc ept, but ha s its origins in
programmed learning, a form of learning package popular
In an experiment by Godden & Baddeley (1975), marine
in the 1960s. Program m ed learning was based on the
divers were asked to m emorize information on shore and
underwater. When tested, they remembered the informa- behavioural psychology theory of stimulus±response. Evans
et al. (1960) in ªThe RULEG system for the construction
tion signi®cantly better in the environm ent in which they
learned it. Learning in context as in PBL assists students to of programm ed learning sequencesº advocated starting the
course of instruction from a generality or rule (RUL) and
organize their long-term memory for ready retrieval (Kriel
et al., 1986).
moving towards a statement of speci®city or an exam ple
(E G ), he nce th e R U L EG ap proac h. H ow ever, som e
programmers preferred to start with the examples and move
E xam ples towards an understanding of the underlying principle by
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Students start, in PBL, with a problem that is designed not Bordage & Lemieux (1991) believe the provision of
only as a focus for their teaching but also to arouse their prototype cases is important. They arrived at this conclu-
interest in the topic.Whitehead (1932) describes the `rhythm sion after contrasting the diagnostic and clinical reasoning
of education’ and identi®es three stages in education; skills of experts and novices. Their ®ndings indicate that the
romance, precision and generalization. The rom ance of expert has in m ind a prototype case with which he compares
learning, the excitement of discovery, is provided by the and contrasts the patient in front of him at the tim e. ªWe
problem scenario. tend to tie the solving of new clinical challenges to how they
resem ble or differ from certain prototype cases.º The
importance of PBL is that the skilful selection of problem
Self-directed learning and self-as sess m ent scenarios can provide students with prototyp e cases.
ªD eveloping the learning habitº
Learning does not end with basic training in the health A ra nge of approa ches
professions, but continues for life. By developing self- PBL has developed, since it was ®rst employed in McMaster
directed learning skills, PBL facilitates the production of University in the 1960s, into ªa genus for which there are
lifelong learners. PBL aids the developm ent of students’ many species and sub speciesº (Barrows, 1986). ªEach
assessm ent and criticism of them selves. In the process of addresses different objectives to varying degrees.º Barrows
PBL students have to identify what they need to learn. This identi®es the more important learning objectives as:
promotes the habit of self-assessment essential for self-
directed learning where there is no tutor, teacher or end-of- · structuring knowledge for use in clinical contexts;
term assessment to inform students of their progress. · developing an effective clinical reasoning process;
· development of effective self-directed learning skills;
Charlin et al. (1998) de®ned seven criteria for student · increased motivation for learning.
learning in PBL based on educational principles. The core
Different PBL methods address these objectives to varying
principles are:
degrees. We have described different approaches to PBL
· the problem acts as a stim ulus for learning; based on the relationship between the two elements in PBL,
· it is an educational approach, not an isolated instructional the problem and the learning derived from a study of the
technique; problem . The `E G R U L’ m ode l provides a basis for
· it is a student-centred approach. understanding the relationship between the problem and
th e lessons lear ned. It also g ives an insight into th e
The student learning must involve:
continuum that exists between a fully problem -based
· active processing of information; curriculum at one end of the spectrum and an information-
· activation of prior knowledge; orientated curriculum at the other (Harden & Davis, 1998).
· m eaningful context; The PBL continuum is presented as eleven steps, which
· opportunities for elaboration/organization of knowledge. are summarized in Table 1. As one progresses along the
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Problem-based lear ning
Table 1. Problem-based learning – a continuum (reprinted from education which enables graduates to `hit the ground
Harden and Davis, 1998) running’ on entering their ®rst step on the career ladder.
· Student centred : The PBL process involves the student
taking more responsibility for his or her learning, a feature
that 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 requires all health
professionals to make a commitm ent to keeping up to
date through lifelong 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 som e evidence in the area of the
managem ent of hypertension that graduates of a PBL
curriculum m ay be more up to date than their peers (Shin
et al., 1993). The move away from passive learning and
rote memorization, 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
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M .H . D av is & R.M . H arden
best when they are ready and motivated to learn, involved · O utcomes of the course: The curriculum outcomes will in¯u-
in setting goals and deciding on relevant content and ence the educational strategy to be adopted (Harden et
when they participate in decisions affecting their learningº al., 1999). If the philosophy of the curriculum and the
(Westberg & Jason, 1993). All of these features are aspects course outcomes emphasize factual recall of information,
of PBL. 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
Som e disadvantages of PB L solving or application of know ledge is an intended
The advantages of a P BL curriculum have been well outcome, an approach towards the problem-based end of
articulated by those who have adopted it into their teaching the continuum m ay be more helpful with active learning
and learning programmes. In an editorial, Norman (1998) prom oting d eeper und er stand ing and higher o rd er
suggested that ªFor too long PBL has been viewed as a self- thinking.
evidently `better’ approach to health sciences education, · S tudents and staff: The successful implementation of PBL
despite an accumulation of evidence that the outcomes are requires staff who are motivated and trained in this method
not much differentº. H emker (1998), writing from the of teaching. Student induction in the PBL process is also
perspective of a teacher in the Biochem istry Department in crucial for its successful implem entation. Students need
the M edical Faculty at M aastricht University, identi®ed three training in the appropriate use of the educational resources
objections to PBL: that are provided for them, such as electronic databases
or `drop-in’ facilities in a clinical skills centre. Traditional
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· PBL makes it very difficult for students to identify with a teaching, if delivered well, is almost certainly likely to be
good teacher. In PBL the teacher serves as a facilitator better than PBL implemented badly.
rather than acting as a role m odel. This may deprive · Availability of resources: The availability of resources will
students of the bene®ts of learning from an inspirational in¯uence the approach to PBL to be adopted. Problem -
teacher. The use of PBL, however, does not necessarily based strategies tend to require a range of educational
exclude the opportunities for this to happen. resources such as textbooks , computer-based m aterial,
· PBL does not motivate staff to share knowledge with the videotapes and m odels. Space availability is also an
students. Staff are denied the fun of sharing their proc- important consideration. Implem entation of PBL with
For personal use only.
esses of understanding with their students and of `getting small groups of students needs space for the small groups
a buzz’ out of teaching. On the other hand, many staff to meet and space is required for educational facilities
®nd it rewarding and stimulating, working within a PBL such as a com puter suite or learning resource area. A
context. m ore information-orientated approach requires m ore
· The knowledge acquired through PBL tends to rem ain teaching space in the form of lecture theatres.
unorganized. O rganization of knowledge in traditional · Lear ning context : PBL has been found to be difficult to
courses comes from students being introduced to a topic implement in the clinical setting, although the literature
by experienced teachers able to distinguish between what contains examples of successful PBL experiments in
is important and what is unimportant. The use of study hospitals or ambulatory care (Petrusa & Allensworth,
guides may overcome this potential disadvantage. 1985). TBL is an educational strategy that is particularly
· PBL requires competences many teachers do not possess. useful in the clinical context.
Teachers in medicine tend to teach as they themselves · A ctivation of prior knowledge : PBL builds on the students’
were taught using traditional approaches (Irby, 1996). prior learning. Although Barrows argues that even high
Staff development programmes must be sufficiently robust school pupils have sufficient learning and everyday experi-
to meet these challenges. ence to learn by PBL, many teachers prefer to select
· C oncern has also been expressed about th e cost of approaches in the middle of the continuum when they
implementing a PBL programme. PBL, however, is not feel prior knowledge is insufficient to support PBL or
necessarily more expensive than traditional approaches TBL.
(Nieuwenhuijzen et al. , 1997; Sefton, 1997). · Promotion of g roup skills : PBL approaches that encourage
· PBL may be time consuming for students, particularly if small-group activities help to promote outcomes such as
they need to identify educational resources for themselves. team working and com munication skills.
T he use of stud y g uides, which identify the m ost · S tudent choice : There m ay be advantages in offering
appropriate learning material, will minim ize this potential stu de nts a c hoice of lear ning strateg ies. In som e
drawbac k. circum stances this may be possible. Parallel PBL and
Despite these concerns it is likely that PBL has a role to play traditional tracks have been offered in medical schools
in your teaching, even if it is not the panacea envisioned by such as Harvard and New Mexico although m any have
som e enthusiasts. The strategies for implementing PBL m oved to offering only a PBL programm e. Distance
described in this booklet m ay help you overcome some of learning courses make it possible to offer more easily a
the potential problems with regard to PBL. choice of inform ation-gathering or PBL approaches to
learning. Individual students are able to select their
preferred learning approach (Rogerson & Horton, 1998).
W hat approach to PB L sh ould you adopt?
T he PB L process
The question for the individual teacher is which of the
range of approaches to PBL should be adopted in your The details of how the PBL process is implem ented differ
teaching. This will depend on a number of issues: from institu tion to institution. H ow ever, the g eneral
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Problem-based lear ning
principles rem ain the same. Students are not regarded as Table 2. Harvard M edical School Six Step M ethod
passive vessels to be ®lled with facts by lecturers or teachers.
(1) Group receives the written problem scenario
They actively learn for themselves using the problem as a
without the opportunity to study it beforehand
focus for their learning.
(2) The student group de®nes the problem
A number of identi®able stages or steps in the PBL
(3) The study group identi®es the learning goals
process have been described. This begins with the problem
(4) Students work independently to achieve the
scenario, which is often presented cold to the students; that
learning outcom es
is, they have not prepared themselves through previous study
(5) The student group is reconvened. The students
of the scenario.
build new learning on to prior knowledge. Students
Students, either working individually or m ore usually in
review whether they have m et faculty learning
groups, read through the scenario and identify unfamiliar
objectives. Further individual work and group
terms or concepts. They inquire into the problem situation.
meetings may be required to achieve this
Som e group members m ay be able to clarify areas of
(6) The group synthesizes and sum marizes their work.
uncertainty or plug knowledge gaps for others during this
The students generalize from the speci®c problem
stage. From their prior learning, the g roup determines scenario to other situations
underlying mechanisms and develops possible explanations
for the problem scenario. Further information about the
scenario may be m ade available to the students if they Table 3. M aastricht M edical School– the seven steps in
request it; for exam ple, in a clinical scenario, the results of PBL
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process by providing a set of learning objectives identi®ed (6) Students work independently to achieve the
by faculty which helps them to relate their work on the learning outcom es
problem to overall course objectives. (7) The student group reconvenes to discuss the
Following this ®rst stage there is a period for individual knowledge acquired
study. Students tackle the learning issues through accessing
a range of educational resources.
W hen the group meets again, students share what they The problem an d its presentation
have learned and apply the learning to the problem scenario.
In this section we look at what makes a good problem
T he studen t group m ay be ab le to exp lain fully th e
scenario and the medium used to present it.
phenomena identi®ed in the problem scenario at this stage
but they may also identify further learning issues which
require another period of individual study. The group W hat m akes a good problem scenario?
learning is then synthesized to explain the observations in
the problem scenario. During this step students organize The selection of problem scenarios for use in PBL has often
prior and new learning around the problem scenario. This been a matter of intuition or serendipity. It is, however, a
aids retrieval of what has been learned when a similar matter of importance. The design of appropriate problem
problem or situation is encountered later in professional scenarios ensures that students cover a pre-de®ned area of
practice. knowledge or learn a set of important concepts, ideas or
techniques. The problem should lead students to a topic or
The ®nal vital step in the PBL process is to generalize
®eld of learning and so meet faculty learning objectives
the learning to other situations in which such knowledge,
(Ross, 1991). The role of the problem scenario (Margetson,
skills and attitudes would be applicable; for example, an
1998) is to act either as a `convenient peg’ on which to hang
understanding of in¯amm ation in a wound-repair scenario
knowledge acquisition or as the focus of a `growing web’ of
is broadened to a general understanding of the in¯amm a-
understanding in practice.
tory process in other situations.
Dolmans et al. (1997) have identi®ed seven criteria for
Individual m edical schools have organized P BL in
effective problem design. The criteria, which are based on
different ways: for exam ple, the Harvard six steps approach
what is currently known about the nature of learning, are:
emphasizes generalisation of what has been learned (Table
2 ). T he M aastr icht se ven jum p appro ach inclu de s (1) Lear ning outcomes: The learning issues likely to be identi-
brainstorming (Table 3). O ther medical schools, such as ®ed by students through study of the problem are
Liverpool, Glasgow and M anchester, have adopted different consistent with faculty learning objectives. A problem
approaches (Bligh & W ilkinson 1997). W hichever approach scenario may address different categories of learning
is adopted, however, the ba sic concept is the sam e– o utc om e s in clu din g sc ien ti®c u nd er sta nd ing , an
through active involvement, students move from the example understanding of health promotion or ethical issues. In
or problem towards the rule, principle or concept and then a system-based programme, the scenario may address
generalize their learning to other contexts or settings. learning related to the different systems.
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M .H . D av is & R.M . H arden
(2) Phase of the curriculum :The problem should be consistent labour and the role of doctors and midwives during labour.
with the phase of the curriculum and stage of student Situations such as breaking bad news, dealing with the
learning. It should enable students to build on and bereaved or confrontational situations all make useful stimuli
activate prior learning. for a problem-based approach to learning which can be
(3) Relevance and m otivation : The problem scenario should presented to students on videotape.
be relevant to the students’ future practice as health- Com puter. The computer may also be used to deliver
care professionals and if not, should be of sufficient PBL. `PC Challenges’ is a com puter simulation in which a
intrinsic interest to motivate the students and encourage group or an individual is presented with a time-dependent
them to spend more tim e on self-study. simulation of patients with cancer-related pain (Harden et
(4) Integ ration : The problem scenario should present basic al., 1998). Students have to manage the patient with the
science concepts in the context of a clinical problem to aim of discharging the patient from hospital with the pain
encourage integration of knowledge. Such integration controlled. This can be used as a vehicle for PBL. Students
has been shown to improve clinical diagnosis (Schmidt can take `time out’ from the m anagement of the patient to
et al., 1996).
look at what they already know that can help them and what
(5) Cues :The problem scenario should contain cues to guide
they need to know and learn. They m ay obtain further
the student and to stimulate discussion. It should further
information about managing patients with cancer-related
encourage students to elaborate and to search for
pain on-line or in an accompanying text `HELP’–Helpful
explanations.
Essential Links to Palliative Care (CM E, 1995).
(6) Open problem : The problem scenario should not be so
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Problem-based lear ning
In PBL, students require a m easure of support. This may be in an authentic way and the skill to express oneself in a
supplied through a facilitator in a PBL group or through language understood by studentsº;
supportive resource material provided, for exam ple, in a (5) perhaps one of the most contentious issues in PBL is
study guide. The amount of external support required is whether the group facilitator should be an expert in the
dependent on the prior learning of the students and on content m atter related to the problem. Some argue that
their understanding of the PBL process. Internal support such competence frequently distracts from the tutor’s
m ay also come from other members of the group through a role of facilitator. Others believe that subject-matter
collaborative learning process in which students learn from experts who have also been appropriately trained in
For personal use only.
each other. Where there is a high level of internal support facilitation skills are likely to be the best facilitators
the need for external support is reduced (Figure 1). The (Davis et al., 19 92). Schm idt (1994) found ªthat
greater the internal student support in terms of prior learning students need a m inimum level of structure to pro®t
and experience with the PBL process, the less external from PBL instruction. This structure can be internally
support is required. provide d through pr ior kn ow led g e available fo r
W here the level of prior learning is lower, greater external understanding the new subjects, or offered by the
support is required. This support may come from the group environment in the form of cues of what is relevant and
facilitator (or tutor) or from material pre-prepared by faculty. what should be the focus of activities. If prior knowledge
In some situations a faculty facilitator may not be required falls short, or if the environment lacks structure, students
but this is likely to be exceptional. Duek et al. (1996) studied will turn to their tutors for help and direction. Under
tutorless groups and concluded that ªthe reliance on a tutor- those conditions, students who are guided by a subject-
less format may not be appropriate when other sources of matter, expert tutor may bene®t more than those students
structure are absent from the curriculumº. Students have guided by a non-expert staff tutor or by a student tutor.º
sometimes been used as group facilitators. In conclusion, it could be argued that the best tutor is the
subject-m atter expert who understands the course and the
curriculum and who has the appropriate group facilitation
The process of facilitation
skills. The second choice would be a medically quali®ed
If learning is the active construction of meaning, teaching member of staff who is not an expert in the area but who
can then be de®ned as the facilitation of learning. Nowhere understands the course and the curriculum and has the
is this de®nition more apt than in PBL. Here, ªthe teacher appropriate group facilitation skills. The third choice would
serves as both a monitor and stimulus to the process by be someone who has an understanding of the curriculum
asking leading questions, challenging thinking and raising and the appropriate group facilitation skills but who does
issues or points that need to be considered. The teacher not have medical understanding or knowledge. There are,
attempts to help students help themselves in the educational how eve r, m any e xam ples o f whe re n on-exper ts an d
processº (Barrows & Tamblyn, 1980). These authors see the non-medically quali®ed facilitators function effectively. What
teacher’s role in PBL as that of a guide, helping ªthe student are essential, however, is group facilitation skills and
develop skills in scienti®c reasoning, self-study and self- appropriate personal qualities.
evaluationº. They recommend that teachers should respond
as an information source to a direct enquiry ªonly after they
Staff development
are sure that students have exhausted their own logic or
inform ation base and feel that the information provided will Newer approaches to health professions education make
facilitate further work with the problem at the time, without many dem ands on the medical teacher and the different
sacri®cing the value of self-studyº. roles of the teacher have been described (Harden, 1997).
There are several different types of competence associ- M any teachers are m ore com fortable with the role of
ated with group facilitation in PBL. These are: inform ation provider as in lectures or clinical teaching. Few
137
M .H . D av is & R.M . H arden
have experience of the role of facilitator and feel comfort- If the curriculum outcome to be assessed is problem
able in this role. M any ®nd difficulties in implementing a solving, then modi®ed essay questions (Knox, 1975) provide
P B L ap proac h an d an e xt ensive sta ff d eve lopm en t a method capable of testing higher order thinking and applica-
programme is m andatory prior to the introduction of a tion of knowledge. The extended matching item format (Case
PBL course. M odels for faculty developm ent for PBL have & Swanson, 1993) is an extension of the multiple-choice
been described (Irby, 1996). format that may be used to test clinical decision making, data
A staff developm ent program me should address the interpretation and other intellectual activities that require recall
com petences expected of the tutor as described in the and recognition of knowledge and problem solving.
previous section. The staff development programm e may be The objective structured clinical exam ination (OSCE)
provided as: (Harden & Gleeson, 1979) provides a robust fram ework for
· a formal course which includes active involvem ent of staff testing a range of curriculum outcomes such as clinical
and a study of examples of PBL; methods, data interpretation, health promotion and disease
· guided on-the-job experience with a new facilitator initially prevention and can be designed to assess ethics, attitudes
sitting in with an experienced facilitator during PBL and problem solving.
sessions; Some PBL schools have adopted the progress test. This
· self-study through the use of books and other resource provides students and staff with feedback about student
m aterial, for example, reading this booklet. progress (Blake et al., 1994, 1996). The progress test is
usually M CQ based and covers the whole curriculum making
Role of study guides revision for the test impractical. It is claimed, therefore, that
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138
Problem-based lear ning
to learn and to undertake the necessary studies to meet B AR ROW S , H.S. & TAM BLYN , R.M . (1980 ) Problem-based Learning: an
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B LAKE , J., JOH NSO N , A., M U ELLER , C.B., N OR M AN , G., K EANE , D.,
objectives and develop the problem scenarios; in other words,
C UN NING HAM , J., C O ATES , G. & R OSENFE LD , J. (1994 ) Progress
the curriculum outcomes remain ®rmly in faculty control.
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M oreover, students are required to adopt a problem -based
Health Sciences Education , 5, pp. 1±6.
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UK , Postgraduate M edical Jour nal, 73, pp. 449±459 .
1 9 98 ) with stu de nts from th e differen t professio ns
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contributing from their disciplines’ perspective to th e diagnostic thinking of experts and novices. In Research in M edical
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A PBL curriculum can be community based or hospital B O U D , D. (1985 ) Problem -based learning in perspective, in D. B OU D
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practical alternative to free response questions,Teachin g and Learning
m odules. Such curricula may or may not be problem based.
in Medicine 5, pp. 107 ±115.
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