642 PBL Pathway: Action Research—W Richard Chegwidden

Original Article

A Problem-Based Learning Pathway for Medical Students: Improving the Process

Through Action Research
W Richard Chegwidden,1PhD, FRSC

Abstract
Introduction: Problem-based learning (PBL) is student-centred, self-directed and collabora-
tive. In medical education it is based on clinical cases and is widely considered to facilitate the
development of key professional competencies. Whilst PBL is extensively employed in medical
schools worldwide, Lake Erie College of Osteopathic Medicine is one of very few schools that
offer it to pre-clinical students as a major pathway of study. We have identified several problems
associated with implementation of the programme and attempted to provide solutions with 3 new
learning tools. In this study we use action research to evaluate the success of our strategy.
Methods: We examined the students’ perception of the effectiveness of case-based formative
assessment, case-based “question and answer” workshops, and reviews of annotated examina-
tions as learning tools, using a 5-point Likert scale questionnaire. Results: A majority of both
first- and second-year students perceived all 3 learning tools to be helpful. In general, the most
positive responses were received from second-year students. First-year students evaluated case-
based formative assessments more positively when they were about to take examinations.
Conclusions: Case-based formative assessments, case-based workshops and reviews of annotated
examinations were perceived as helpful learning tools by both first- and second-year medical
students in PBL learning pathways.
Ann Acad Med Singapore 2006;35:642-6

Key words: Case-based learning, Formative assessment, Medical education, Problem-based

learning, Self-directed learning

Introduction The Problem-Based Learning Pathway at LECOM

Problem-based learning (PBL) is a student-centred, self- Lake Erie College of Osteopathic Medicine (LECOM)
directed, integrated and contextual mode of learning. It has offers 3 pre-clinical curriculum pathways – lecture-
been widely perceived by many to confer advantages in discussion, independent study and problem-based learning
promoting critical thinking, retention of knowledge, – in its Doctor of Osteopathic Medicine (DO) programme.
independent learning and interpersonal skills. The In the USA, DOs are fully qualified physicians, who are
introduction of the first PBL curriculum in medical education licensed both to prescribe medication and to perform
is commonly attributed to McMaster University almost 40 surgery. In the PBL pathway, 40 students currently
years ago1 although some problem-based components of matriculate each year at the Erie campus. Students in all 3
medical education had already been introduced elsewhere.2-4 pathways follow a common didactic course in Anatomical
Problem-based learning curricula were subsequently Sciences, after which the PBL students study the basic
adopted at Maastricht in the Netherlands and Newcastle in sciences almost completely by PBL. This comprises about
Australia and thereafter the PBL approach soon spread 70% of their total pre-clinical curriculum (Table 1). Groups
worldwide. In 1979, the University of New Mexico Medical of 8 students, each with a facilitator, meet 3 times per week,
School became the first in the USA to offer a PBL pathway to study a sequence of more than 70 patient cases in paper
and, in 1982, Mercer University School of Medicine became presentation. The student groups select learning issues
the first to offer PBL as its sole curricular pathway.5 associated with each case, and these are used to generate
Currently some 70% of US medical schools employ PBL examinations that are administered at intervals of about 6
in the pre-clinical years, but fewer than 6% use it for more weeks. Different examinations are produced for each student
than half of their curriculum.6 group, reflecting their different choices of learning issues.

1
Director of Problem-Based Learning and Professor of Biochemistry and Molecular Biology
Lake Erie College of Osteopathic Medicine, Erie, USA
Address for Reprints: WR Chegwidden, LECOM, 1858, West Grandview Boulevard, Erie, PA 16509, USA.
Email: [email protected]

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 PBL Pathway: Action Research—W Richard Chegwidden 643

Table 1. Subjects Studied Through PBL Cases in the LECOM PBL Pathway

Gross Anatomy Biochemistry Internal Medicine

Embryology Medical Genetics Neuroscience
Histology Immunology Pathology
Behavioural science Microbiology Pharmacology
Physiology
LECOM: Lake Erie College of Osteopathic Medicine; PBL: problem-
based learning

The PBL Group Session

At the commencement of a PBL case study, all students
in the group are given only the age, gender and chief
Fig. 1. The problem-based learning group session (Adapted from the Ohio
complaint of the patient. In the initial discussions that
State University College of Medicine and Public Health Problem-based
follow, one student plays the role of patient and he/she Learning Pathway Student Handbook by John J Curry PhD).
alone is given details of the patient history. Another student
plays the role of physician. This student interviews the
patient to obtain the history, after which, in the sequence
taught in Clinical Examination classes, he/she requests a
verbal account, from the facilitator, of each aspect of the
physical examination. The student group, by now, should
have drawn up a range of differential diagnoses – although,
before they gain experience, this may be merely a list of
affected systems. They then proceed as a team, requesting
various further data, such as laboratory tests, or diagnostic
procedures. The appropriate information is progressively
disclosed by the facilitator in response to these requests.
This information may be in the form of tabulated data or, for
Fig. 2. Generation of learning issues through the case study process.
example, a radiograph. Supplementary workshops on
diagnostic procedures and their applications are provided
at an early stage to facilitate this process. management team. It is important to note that, whilst
Progression to the definitive diagnosis generally requires arriving at a diagnosis marks the end of each case study, the
2 to 3 group sessions. primary purpose of the PBL group sessions is not to reach
a diagnosis per se, but to use the case as a vehicle for the
The periods between sessions are used for independent generation of learning issues.
study of relevant topics that have been identified by the
students as ones that may further their understanding of the Student Assessment
case. Thus new information will be brought to each new Multiple-choice and matching examination questions,
session, at the start of which one of the students will briefly written for the most part in the style of the medical examining
present the patient as one would on hospital rounds. Every boards, are produced to test knowledge of material covered
student gives a brief verbal evaluation of each session at its by the learning issues submitted. Generally 3 summative
conclusion and, at the end of each case, each member of the examinations are given per semester, each one testing
group evaluates the performance and contribution of information derived from the study of a set of 6 or 7 PBL
every other member. This group process is summarised in patient cases. The examination score comprises the major
Figure 1. component of the student grade. A small additional
For each case the student group starts with a range of component emanates from facilitator and peer evaluations
differential diagnoses and reduces this to the final, definitive of the performance in each group. The student composition
diagnosis. Through the course of this process, learning of PBL groups is changed after each set of cases.
issues are produced by the students (Fig. 2). These represent
areas of knowledge that were required in order to understand Improving the PBL Process Through Action Research
fully the patient case and to reach a diagnosis. They take the Using an action research approach, we identified several
form of designated sections of basic and medical science problems related to the PBL process, applied a strategy to
texts that are a prerequisite for study, stipulated by the PBL address them, and assessed the effectiveness of our strategy.

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644 PBL Pathway: Action Research—W Richard Chegwidden

Problems Related to the PBL Process 3. Case-based workshops. To enrich the learning
In implementing our PBL programme we have identified experience and enhance perspective, case-based workshops
several concerns, both emanating from the students’ are provided on student request to cover material with
transition from a traditional, didactic, educational which students may experience particular difficulty. These
background, and inherent in the fundamental PBL process. are conducted on a question and answer basis, in order to
Two of these are addressed here. promote the PBL approach of student-driven enquiry.
1. Maintaining a study schedule. How do we ensure that Effectiveness of Strategy
the students maintain an adequate work-rate in the absence
A preliminary procedure has been initiated to measure
of a traditional class schedule? This is particularly relevant
the effectiveness of our strategy to address the concerns we
in the US, where a large majority of the students entering
identified. We have begun to assess student responses to
the DO programme have been accustomed to being
each of our 3 learning tools through self-reporting, using a
examined with greater frequency in their previous academic
Likert psychometric scale.7
programmes. Consequently their established pattern of
information acquisition may have been characterised by Methods
short-term memorisation immediately prior to examinations. Both first- and second-year pre-clinical medical students
A proportion of our students appeared to persist with this in the problem-based learning class were asked to respond
type of approach, attempting to reach the diagnoses for a to several statements, relating to the effectiveness, as
group of cases in the fastest possible time, and then learning tools, of the case-based formative assessments
attempting to memorise the information related to all the (quizzes), annotated examination reviews and case-based
cases in the group in the time period immediately preceding workshops. The students were asked to indicate their level
the examinations. In these circumstances, contrary to the of agreement with the statements over the following scale:
fundamental tenets of PBL, learning is not undertaken in
Strongly disagree (1) – disagree (2) – neutral (3) – agree (4)
the context of each case.
– strongly agree (5) (Table 2). The questionnaire also
2. Acquisition of perspective. In the absence of the allowed for additional student comment.
guidance provided by a traditional didactic curriculum,
Thirty-nine from a total of 40 first-year students, and 35
how can we ensure that the students acquire a good
from a total of 37 second-year students completed the
perspective of the study material, recognising the important
questionnaire.
facts to know and concepts to understand? In the absence
of the guidance that non-PBL students may receive in Results and Discussion
lectures, their learning strategies may be misdirected or
Table 2 compares the responses of first- and second-year
inefficient. It is particularly important that this matter is
medical students to statements concerning the effectiveness
adequately addressed in any PBL programme.
of our 3 learning tools, on a 5-point Likert-type scale.
Although this type of psychometric scale does not lend
Addressing the Concerns
itself to rigorous statistical analysis, the mean response is
We addressed these concerns with the following 3 learning presented as an indicator.
tools.
The second-year students were in stronger agreement
1. Case-based formative assessment. To motivate students than the first-year students with all statements, except that
to maintain effective study schedules, at the end of each the case-based quizzes assisted them in maintaining a
case we require that the students, taking one learning issue consistent work-rate through each set of cases. This
each within a group, should each produce 3 multiple- exceptional response may reflect the second-year students’
choice questions, in the style of the medical boards. These proximity to their medical board examinations which
questions are then pooled to produce an informal quiz of up had, in itself, tended already to maximise their work
to 24 questions, followed by student analysis of each ethic. Their more positive responses to all the other
question, before proceeding to the next case in the set. statements may perhaps be attributed to their more
These quizzes do not contribute to student grades. extensive experience.
2. Examination reviews. To impart perspective of the The percentage of students who responded positively to
study material, after each summative examination, the each statement (responses 4 or 5) is also shown in Table 2.
students reconvene in their PBL groups to study an annotated The most frequently selected response to each statement
version of their examination, in which the provenance of (mode) is presented in parentheses alongside each
each question is provided, along with reference to where percentage value. With both of these metrics, a
the answer may be found in the relevant, required text. similar pattern is evident to that observed for the mean

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 PBL Pathway: Action Research—W Richard Chegwidden 645

Table 2. Comparison of First- and Second-year Student Responses to Statements Evaluating Learning Tools

Statement posed to students Mean student response % students responding 4 or 5

st nd
1 year 2 year 1st year 2nd year
(n = 39) (n = 35) (n = 39) (n = 35)
The formative evaluations associated with each case
1. Facilitated my learning 3.74 4.06 67 (4)* 74 (4)
2. Helped me to maintain a consistent work-rate through each set of cases 3.85 3.57 69 (4) 57 (4,5)
3. Encouraged me to learn contextually (in the context of each case) 3.71 3.91 54 (4) 71 (4)
The review of annotated examinations
1. Facilitated my learning 3.95 4.54 72 (4) 97 (5)
2. Enhanced my perspective of the material in the learning issues 3.74 4.57 64 (4) 97 (5)
3. Enhanced my understanding of the material in the learning issues 3.69 4.51 62 (4) 97 (5)
4. Enhanced my ability to analyse examination questions 4.08 4.63 62 (4) 97 (5)
5. Aided my preparation for subsequent examinations 3.67 4.49 69 (4) 94 (5)
6. The annotations were a valuable feature of the reviewed form of the examinations 4.31 87 (5)
The case-related workshops
1. Facilitated my learning 3.79 4.40 63 (4) 91 (5)
2. Enhanced my perspective of the material in the learning issues 3.68 4.31 63 (4) 94 (4)
3. Enhanced my understanding of the material in the learning issues 3.82 4.34 68 (4) 94 (4)
4. Aided my preparation for examinations 3.42 4.29 42 (3) 83 (5)
*The most frequently selected response (mode) to each statement is shown in parentheses

response values. The differences between the responses of contextually. Since it is difficult to construct a cogent
first- and second-year students to the statements on argument against this statement, their response may
examination reviews and on workshops become even more simply be a reflection of their not wishing to participate
pronounced. in formative assessments. Indeed, it should be noted
that similar considerations may be relevant in places
A closer analysis of the responses of first-year students
throughout the data.
proved somewhat revealing. Fifteen first-year students
(Group A) responded immediately to the questionnaire Five second-year students commented positively on the
when it was distributed, at the time that they were completing annotated examination reviews, and their comments on the
their last case study before studying for their final PBL value of the annotations led to the incorporation of a
examination. The remaining 24 students (Group B) did not statement specifically addressing this in the first-year
respond until some time later, after they had studied for questionnaire. Twelve first-year students commented
their examination. The data from these 2 groups of students positively on the examination reviews, 6 of whom
is compared in Table 3. Clearly the students who completed commented extremely positively. One commented that it
the questionnaire after studying for their PBL examination was “one of the strongest learning tools I have ever
showed a much greater appreciation of the value of the encountered”.
case-based formative assessments, but placed less value on Most comments related to the case-based workshops
the examination reviews. Many studies have demonstrated expressed individual views about specific workshops. The
the importance of formative assessments such as these in only comments that were entirely negative referred to the
improving academic performance.8 coverage of material that was not subsequently tested in
Fourteen of the second-year students commented examinations.
positively on the case-based quizzes, although 5 of the 14 The high rate of response to the questionnaire, by both
considered that their value diminished as they fell behind years of students, suggests that they considered the process
with the related learning. Four commented negatively. In to be worthwhile, which represents a positive outcome of
contrast, only 6 first-year students commented positively this study. It is well established that motivational beliefs
on the case-based quizzes, whilst 8 commented negatively. play an important role in the achievement of educational
Six first-year students disagreed (1 strongly) that the case- goals.9 The more positive responses of the second-year
based formative assessments encouraged them to learn students, almost across the board, may reflect their sharper

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646 PBL Pathway: Action Research—W Richard Chegwidden

Table 3. Comparison of Responses of 2 Sub-groups (A & B) of First-year Students to Statements Evaluating Learning Tools

Statement posed to students Mean student response % students responding 4 or 5

1st year (A) 1st year (B) 1st year (A) 1st year (B)
(n = 15) (n = 24) (n = 15) (n = 24)
The formative evaluations associated with each case
1. Facilitated my learning 3.13 4.13 40 (3,4)* 83 (4)
2. Helped me to maintain a consistent work-rate through each set of cases 3.33 4.17 47 (4) 83 (4)
3. Encouraged me to learn contextually (in the context of each case) 3.20 4.04 47 (4) 61 (4)
The review of annotated examinations
1. Facilitated my learning 4.27 3.75 80 (5) 67 (4)
2. Enhanced my perspective of the material in the learning issues 4.20 3.46 87 (4) 50 (3,4)
3. Enhanced my understanding of the material in the learning issues 3.93 3.54 67 (4) 58 (4)
4. Enhanced my ability to analyse examination questions 4.20 4.00 80 (4,5) 83 (4)
5. Aided my preparation for subsequent examinations 4.13 3.58 73 (5) 67 (4)
6. The annotations were a valuable feature of the reviewed form of the examinations 4.47 4.21 93 (5) 83 (5)
The case-related workshops
1. Facilitated my learning 3.93 3.70 60 (5) 65 (4)
2. Enhanced my perspective of the material in the learning issues 3.93 3.52 67 (4) 61 (4)
3. Enhanced my understanding of the material in the learning issues 4.07 3.65 73 (4) 65 (4)
4. Aided my preparation for examinations 3.73 3.22 47 (3) 39 (3)
A:Students completing questionnaire before studying for PBL summative examination
B: Students completing questionnaire while/after studying for PBL summative examination
* The most frequently selected response (mode) to each statement is shown in parentheses

focus on these goals as they approached their medical LECOM model. I also wish to acknowledge the role of Dr Wayne A Krueger,
my predecessor as Director of Problem-Based Learning, for his role in
board examinations. initially establishing the program at LECOM, and my current colleagues,
Conclusions the Assistant Directors of PBL, Dr Donald G Linville and Dr Beth Callihan
Ricci. I am grateful to Dr Janet Baker and Dr Ann Stephanie Stano for expert
Our study demonstrated that a majority of both first and advice on educational research.
second-year medical students in our PBL class perceived
case-based formative assessment, annotated examination
reviews and case-based workshops to be helpful learning
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Annals Academy of Medicine