For many, it's hard to imagine that some physicians instruct students in classrooms. Doctors are more often viewed as professionals in white coats who poke patients with cold instruments while making ominous sounds. Yet numerous physicians are teachers—just like other educators—and they share many of the same classroom challenges.
In particular, medical educators have been concerned with the notion that teaching is telling and learning is listening, views that have long dominated instruction (Goodlad 1990). For the last two decades, medical schools in the United States and Canada have explored alternative ways of educating future physicians. What they have learned about problem-based education is important for all classrooms.
The McMaster Program
Probably the first work with problem-based learning was done in the '60s and '70s at McMaster University in Ontario, Canada. At a time when European-style formality dominated medical education, McMaster wanted to provide learners a more active role in the educational process. The university also wanted to create a less stressful educational experience for first- and second-year students. The program they developed—problem-based learning—fundamentally altered teacher-student interactions in the classrooms. Competitive arenas changed to cooperative ventures; a one-way flow of data became a free flow of information among colleagues.
At McMaster, problem-based learning focused on two main processes: placing students in small tutorial groups and providing instruction so students investigated real problems that might arise in the treatment of real patients. Using patient records, students were asked to determine a patient's medical problem and devise treatment. The questions generated as students pursued diagnosis and treatment became guidelines for the course's content.
The main teaching method was small-group discussion, which included both students and faculty. In addition, students gathered information from the laboratory, library, and other medical practitioners. Teachers were asked to encourage student participation, provide appropriate information, refrain from harsh feedback, and become fellow learners.
The most significant outcome of McMaster's program was that lecture halls became discussion forums where everyone actively engaged in learning. Classes shifted their focus from facts to an emphasis on meaningful information to help solve patients' problems. Teachers became resources for processes rather than sources of answers to be memorized in order to pass tests.
The New Mexico Experience
In the mid-'70s, representatives from McMaster met with colleagues at the University of New Mexico, where officials decided to implement a similar problem-based curriculum. One of the university's most creative steps was to begin with a small program (20 students) that paralleled the traditional track of 55 students. Faculty members were able to examine the new curriculum and get a comfortable, firsthand view of its details before being asked to implement it. Though the new approach threatened some advocates of the traditional program, it was small enough to be relatively nonthreatening.
As the New Mexico program developed, data indicated that students in the problem-based approach were mastering essential content equally as well as students in the traditional track even though they were not “covering the material” in the same way. This eased the concerns of faculty members who feared students in problem-based learning would miss some crucial facts (Kaufman 1985). New Mexico University also found that students in the new program were less threatened by their environment and more able to pursue learning independently, an indication that they were equipped to be lifelong learners.
Harvard's New Pathway
Problem-based learning expanded again in the 1980s when Harvard University's School of Medicine instituted an educational program called “The New Pathway.” The university created four societies of 40 students each. One of the societies, The New Pathway society, was further divided into small tutorial groups, and each used problem-based formats.
In addition to helping students become better self-directed learners, The New Pathway program accomplished two major tasks (Tosteson 1990). First, it created a schoolwide environment in which change became the vogue. Second, it focused the school's educational program on altering students' attitudes rather than filling them with facts.
Several other medical schools including Rush, Southern Illinois University, Bowman Gray, University of Kentucky, Tufts, Michigan State, Hawaii, Mercer, and Sherbrooke are implementing programs that employ variations on the theme of problem-based medical education. Indirectly, the entire field of medical education is testing the model, and the traditional lecture-dominated approach to medical education is being reassessed.
Implications for Teachers
Although these types of changes in medical education may seem trivial to some, we believe they are important because they represent change in a major bastion of traditional education: medical schools. Emery Wilson, Dean of the University of Kentucky School of Medicine, described the classic confrontation between new and traditional teaching methods: “Changing the curriculum is like moving a graveyard. Faculty members have lectures prepared, and some don't want to do the added work of changing the way they teach” (Gil 1992).
In various medical schools, teacher training for the problem-based approach has been conceptually simple and successful. Teachers are placed in small groups and helped to solve the problems that emerge from their real-life instructional situations. Once teachers relinquish the lecturer's role, they are forced to develop and enhance their repertoire of teaching responses; listening to students; answering questions; helping students frame good questions, formulate problems, and make effective decisions; directing students to appropriate resource materials; and being fellow learners.
Some Questions Remain
Many questions about problem-based education remain unanswered. Is it applicable to all subjects, all levels, and all schools? So far, we can assert that problem-based instruction works in enough medical schools to warrant exploration by most other learning institutions.
The medical model of problem-based learning addresses a tough question for many educators: Can this approach be applied to the basic sciences? Our answer is strongly affirmative. Medical students learn biochemistry, pathology, and microbiology quite well in their problem-based learning classes. Indeed, such students exceed their traditionally trained colleagues in their ability to integrate the basic sciences with clinical assignments. They are able to transfer their learning from one situation to another, a critical test for most educational programs. We believe the trend toward problem-based learning in medical schools will have a ripple effect throughout education. The model is already being applied effectively in social sciences and allied subjects. For example, the Family Practice Division at the Ohio State University Medical School uses problem-based learning to teach interpersonal communication and problem-solving skills to resident students.
Many educational institutions have spent millions of dollars and untold hours of effort revamping their programs without much apparent long-range success (Goodlad 1990). But with little additional cost, medical schools are starting to put students in small groups and help them solve the real problems they will face in treating patients. According to the research data, classroom dynamics change fundamentally, students learn as many facts as those in traditional classes, they enjoy their studies more, and they become lifelong learners (Kaufman et al. 1989). It's an approach to learning that can happen without a new course of study, a mandate from the state legislature, or a large budget increase. It's a model that all educators can use.
