Current Anaesthesia and Critical Care (1997) 8, 146-151

© 1997 Pearson Professional Ltd

Focus on: Training, assessment and appraisal

A practical guide to implementing problem-based

learning in anesthesia

P. L. Liu and L. M. P. Liu

In recent years, there has been a tremendous increase in the use of the problem-based learning (PBL)
format in anesthesia education. This article describes the philosophy of PBL and its use in anesthesiology,
and provides a foundation for the implementation of a PBL program. The advantages and disadvantages of
PBL are discussed and pertinent educational literature cited. The importance of faculty development in
organizing a successful PBL program is emphasized. Moderating and facilitating skills in discussion
leadership are highlighted. The responsibilities of learners in a PBL format are discussed. After studying
this article, readers should understand the goals of PBL and be able to utilize the PBL format in an
anesthesia education endeavor.

Problem-based learning format Table Key elements of problem-based learning

Problem-based learning (PBL) is a new method of in Active learning

struction that has been widely utilized in many medical Small groups (less than 10 learners and 1 facilitator)
Learner centered
schools as part of an effort to improve medical educa- Case-based - - clinically relevant
tion1-4. The objective of this manuscript is to provide Problem oriented
a working understanding of the philosophy of PBL,
discuss the advantages and disadvantages of this educa-
tional format, and present the controversies related to of Anesthesiologists (ASA) and the Problem Based
PBL. This paper concludes with a primer on moderating/ Learning Discussion (PBLD) Program utilizing these
facilitating skills. Hopefully, enough interest will be precepts.
stimulated after reading this paper to motivate the reader The primary distinction between PBL and the lecture
to try the PBL format. format, is that PBL involves active learning. This active
Since there is no agreement in the literature as to the method of learning requires the learner's participation.
definition of PBL, for the purposes of this paper, the The learner is required to come to the discussion session
key elements of PBL are those listed in the Table. This prepared to provide a well-researched discussion of the
characterization of the key elements of PBL is an out- issues and problems presented in the case. This active
growth of our PBL experiences. One of the authors (PL) role is critical to the PBL process. Thus, the learner has
participated as a tutor in the Harvard Medical School the responsibility to study the case and to seek answers
New Pathway to General Medical Education Program to issues and problems by researching educational mate-
for 14 years, and developed the American Society rial prior to coming to the session. This is in contrast
with lectures where the learner is the passive recipient of
Philip L. Lin MD Professor and Chair, Department of information selected by the lecturer.
Anesthesiology, UMDNJ-N.J. Medical School, Newark, NJ, USA,
Letty M. P. Liu MD Professor of Clinical Anesthesiology, UMDNJ- PBL also differs from the traditional format because it
N.J. Medical School, Newark, NJ, USA. involves small groups of participants rather than a large

146
 IMPLEMENTING PROBLEM-BASED LEARNING IN ANESTHESIA 147

audience in a lecture hall. Working in small groups discuss the issues in a collegial setting with peers. The
brings a number of instructional issues related to small PBL discussion session fosters teamwork in problem
group dynamics into play. Small groups create pressure solving and the concept that learners can learn from their
to perform satisfactorily in front of peers. The roles that peers.
group members assume are important. Who controls The objective of PBL is to permit the learners to attain
the agenda? Who are the information providers? Who insights by the process of their own deliberations, and,
challenges whom? Who is the timekeeper? Do all the thus, permit them to experience the thrill of discovery
members of the group participate? learning. Again, this issue of active engagement in the
Evaluation of students in a PBL program also differs intellectual process is a valuable asset of this learning
from students who are taught through lectures. When the paradigm.
lecture format is used, evaluations are generally based In cognitive psychology the distinction between the
on the results of written examinations. PBL permits the novice and an expert is that the expert can categorize
faculty members to individually access each member of new knowledge and material. They know what they
the group based on the individual's contribution to the know and they know what they do not know. They can
discussion. It is difficult for an individual student to hide recognize what is the new in relation to the old material.
in a small group, and members that do not participate They can evaluate what the risk/benefits ratios are of a
in the discussion are noticed. number of practice options and will make medical judge-
The PBL format is based on a case involving a patient ments and decisions on the basis of weighing alternative
or a situation that the learner may encounter clinically. strategies. Not only must the learner read and absorb
Utilization of cases as the centerpiece of PBL ensures new information, but also the learner should learn
that the issues and content of the educational experience to make judgements and decisions based on the case
will be clinically relevant. The manner in which the case data and the newly acquired data in order to solve the
is presented should lead the learners to the key topics problems arising from the case. The process is much
and dilemmas. The most engrossing cases are based more complex than merely reading information or
on real life medical conundrums. Forcing students and listening to orally presented material. This process is
practitioners to confront case-based problems provides much more aligned to the reality of medical decision
the learners with a model that they can adapt to cases making in practice. Many of the arguments presented
that they will encounter in their future medical practice. in support of PBL originate from the belief that PBL
Thus, PBL is a model that encourages lifelong learning. produces better problem solvers. Unfortunately, most of
It is a format that simulates the problems, realities, and the papers on this topic have not been able to confirm
nuances of medical practice. this thesis. Supporters also contend that active learning
A distinctive characteristic of human nature is that we in a clinical context makes medical material easier to
are intrigued by problems. PBL capitalizes on our innate recall.
fascination with the challenges represented by problems. The faculty members' role is that of a moderator/
We are driven to attempt to arrive at a solution mad we facilitator. The PBL moderator/facilitator assists the
are exceptionally pleased when we feel that we have learner/discussants in identifying the key issues of the
succeeded in finding one. As foreign a concept as this case and helps the group by facilitating and moderating
may be, PBL can be fun! Ideally this should be the goal the discussion and monitoring the quality of the discus-
of every PBL session: PBL should be fun! This is the sion. In this role, the faculty members are not to provide
secret ingredient in the success of PBL. The concept that information or solutions. They are there to facilitate the
education and learning can be pleasurable and enjoyable learners in a process of self-discovery.
is the yeast that makes this academic dough rise. Moderation and management of small groups are
In the PBL format, learners have the freedom to skills that the discussion leader must master in order to
pursue topics to the limits of their energy level. The be effective. It is distinctly different form lecturing skills.
choice of educational resources is the prerogative of Adult learners are much more comfortable and efficient
each student; making the learner responsible for pre- in their learning when they can understand and control
paring for the discussion session, so that they can answer the learning process. The concept of being learner
questions and defend strategies for solutions that may centered is a critical element in the success of PBL.
arise, which exposes them to the task of managing and The faculty member serving as the moderator/facilitator
utilizing information and educational resources. This must be prepared to allow the learners to control the
format challenges the learner to become the manager of agenda. The learners can set their own pace and dwell on
the vast array of information that is currently available. the issues that they choose. The moderator/facilitator
With the ubiquitous presence of computers in this infor- must allow the learners to identify the key issues in the
mation age, PBL beckons the learner to become a master case. Philosophically, the faculty member relinquishes
of modern informafics. PBL participants may utilize control to the learners. Trust the learners, they will
textbooks, consult with colleagues, use computer-aided come through for you! This adage should be the motto
literature search programs, journal articles, or other edu- for PBL faculty. In particular, faculty must overcome
cational resources to prepare for the discussion session. the urge to be information providers and give mini
The learner/discussant ultimately should be prepared to lectures.
148 CURRENT ANAESTHESIA AND CRITICAL CARE

Pros, cons and controversy in problem-based view, arguments have been made that lecturing is more
learning desirable because it is less faculty intense, and there is
no need to find suitable classrooms for PBL. Despite the
There is a great debate raging in medical schools con- lack of data to substantiate the claim that PBL is superior
cerning conversion of the traditional teaching method to the traditional curriculum, the groundswell in favor
to the PBL format. In Canada and the United States of PBL continues because students, faculty and adminis-
there has been a groundswell towards PBL. A recent tration like it. Each study raises new intriguing insights
review has attempted to analyze the literature and as well as questions. Like most innovations, PBL will
evaluate the advantages and disadvantages of PBL. It is have to stand the test of time. However, we can certainly
safe to conclude that there is no clear-cut answer in use it in our curriculum and have fun with it. In fact,
support or against PBL versus traditional teaching for- anesthesiology is a pioneer among medical specialties in
mats. Indeed, the data suggest that there are small differ- its use of PBL and the specialty contributing in an active
ences between the formats. However, they are not nearly manner to the continuing dialogue.
as great in quality and or quantity to justify the massive
educational revolution towards PBL.
Implementing a problem-based learning
Many studies have compared medical school gradu-
program
ates trained in the traditional educational programs
versus programs that emphasize PBL. 2'4'7 Almost all The ASA undertook an innovative experiment by allow-
show little difference in the outcome of graduates when ing us to develop a PBL pilot program for its annual
the results of licensing examinations and similar evalua- meeting in 1992. This program has been very successful
tion instruments are used. A few of these studies indicate and has become the foundation for further expansion of
that graduates from traditional programs perform slightly PBL into other areas of anesthesia education. PBL is
better. being used in anesthesia resident and medical student
The happiness index amongst students in PBL pro- education as well as by other anesthesia organizations
grams has been shown to be higher than that of students for postgraduate education. An extrodinary statistic is
in the traditional curriculum; 6'11 this is a major asset that >98% of ASA problem based learning discussion
of PBL. A review of outcomes indicated that medical (PBLD) participants indicated on evaluation forms
students at PBL schools enjoyed their experience more. that they plan to take another PBL session and would
In medical schools where 2 tracks exist, the PBL track recommend PBL to a friend.
is more popular. This attitude towards the learning One of the innovative modifications to classic PBL
environment is an important factor and should not be that is used in the ASA PBLD program is giving the
underestimated in its promotion of a positive educational leaner/discussant a list of references in a sealed enve-
result. lope. By enclosing pertinent references for the case,
Surveys of graduates of medical schools that used the the learner/discussant can save time by opening the enve-
PBL format to teach their students indicate that these lope. Alternatively, the learner/discussant may choose
physicians do not feel disadvantaged. 6 Other studies sug- to study independently and seek solutions to the case
gest that PBL graduates are more sensitive to patient's problems by using their own educational resources. Prior
psychosocial needs. Studies examining ratings of resi- to the discussion session, the learner/discussant may then
dents by residency directors indicated that PBL gradu- choose to compare his references with those provided
ates were rated higher. 6 Many studies tout the faculty by the moderator facilitator.
preference for PBL because the format (small groups) The key to the success of the ASA PBLD program*
provides greater and richer interactions with students. was the inculcation of the philosophy of PBL in the
One purported advantage of PBL is that student re- faculty and the faculty development program that was
tention of material is better because they learn material undertaken. At the annual meeting prior to the ASA
in a clinical context. 8 Although one article9 questions the PBLD program, faculty development workshops are
'backward reasoning' nature of PBL learners (emanating held. There are discussions on the philosophy of PBL
from hypothesis to data) as contrasted with more efficient and practice PBL sessions are conducted where faculty
process used by experts, the author does concede that can practice their moderating/facilitating skills and
there are suggestions that retention of information in receive constructive feedback on their performance. A
the context of patient problems is higher. This degree of PBL moderator/facilitator guide has been developed and
recall is one of the primary virtues of PBL. PBL students is provided to the faculty. The last portion of this paper
are generally less likely to memorize, and they attempt to contains the guide that we developed and used for this
develop an understanding of concepts rather than memo- purpose. This outlines the critical moderator/facilitator
rize lists. 9'11 This should create a more able clinician, t° skills that we encourage PBLD faculty to develop.
Clearly, PBL students use library resources more and
employ a wider variety of educational resources. 24611
''' *ASA PBLD books have PBL cases, case objective, model discussion
outline and references for each case presented at the ASA annual
An unbiased evaluation of the literature suggests that meeting. A case writing guide is also included. Books may be obtained
the efficacy of PBL remains controversial despite its from the American Society of Anesthesiologists, 520 N. Northwest
wide dissemination. From a practical, economic point of Highway, Park Ridge, Illinois 60068-2573, USA
 IMPLEMENTINGPROBLEM-BASEDLEARNINGIN ANESTHESIA 149

Guide to moderating and facilitating problem- b. each group will be different and present new chal-
based learning sessions lenges and opportunities
i. not information provider: teacher is informa-
1. What is PBL? tion provider in a lecture, but in this format the
a. no fixed definition faculty is moderator/facilitator. This is why the
b. no consensus on what constitutes PBL case writer expended so great an effort in creat-
2. Components of the ASA PBLD program as designed ing a case that will take the learners to learning
by Philip Liu: issues that the case writer has set for them!
a. active learning ii. moderating and facilitator skills are used to
b. small group produce learning in the students
c. learner centered iii. allow the students to experience the joy of
d. case based insight and understanding in the course of their
e. problem oriented active learning: the role of the teacher in this
3. Philosophy mode is to be a facilitator
a. 'learner centered' not 'teacher centered' 5. Moderating/facilitating skills
- P B L allows the learners not the teacher to a. moderating/facilitating skills are different from
control the agenda traditional teaching skills. This is learuer-centered
b. active learning where time constraints are more education.
relaxed b. is your PBL session solitary or a series of PBL
- this is the dilemma that is confronted in PBL sessions? The ASA PBLD is a single session
c. traditional PBL requires student investigation and format. In the ongoing format you want to know as
reading much as possible about the learners so that you can
- will your students take the time? - The ASA be more effective to them as individuals. In a
PBLD program provides the learner/discussants single session the challenge is to mold a group of
with a sealed envelope with reference list. This strangers into an effective discussion group
is a compromise. The learners may opt to open i. 'opening set': Creating the right learning
the envelope if they are pressed for preparation environment for a small group session among
time. Alternatively, the learners may opt to strangers
pursue their own primary independent study - introduction: 'breaking the ice'. Have the
pathway. Providing the learners with reprints or participants introduce themselves and tell a
text assignments is another instructional strategy little about themselves and their anesthesia
to save the students some time. In some cir- practice or background
cumstances this is a more realistic method than - do the learners know each other? What do
unstructured instructional options! they bring to the session? Questions, theories
d. objectives of PBL session or thoughts generated from the case. En-
i. produce learning in discussants/learners courage them to get their food and drink so
- content that the session can get underway
- problem-solving - e s t a b l i s h i n g the environment. Smile and
- judgment encourage the thought that you are confident
- differential diagnosis and will provide the group with a wonderful
ii. inquisitive, thorough, and rational discussion of learning experience. We are going to have
a case and the problems it presents fun! This is the attitude you wish to convey!
iii. penetrating risk/benefit analysis of clinical Remember your body language and facial
options expression is a powerful mood setting device
iv. opportunity for all participants to contribute to even before you utter your first words!
the discussion Establish the ground rules. Use first names.
v. aura of satisfaction and contentment at conclusion State that you will try not to be an agenda
- group should feel 'good' about the discussion setter or information giver. Tell the group
- a i m for a high 'happiness index' at the to feel free to get more food. Have the case
conclusion available (should be in their PBLD case
- participants who have worked hard in pre- books). You may want to bring a few extra
paration for the session should be allowed to copies for those that do not bring the case.
feel that they have an opportunity to present Tell the group to feel free to refer to the case.
their information and strategies. Explain that the flip chart and blackboard
- the entire group should feel happy about are resources that they may choose to use.
their efforts ! Do the students understand their role of
4. Role of moderator/facilitator being discussant/learners? Use the food and
a. your creativity is the boundary of your limits, in a social context of the environment to promote
spontaneous environment the informal, collegial aspect to the session.
150 CURRENT ANAESTHESIA AND CRITICAL CARE

Pay attention to non-verbal cues from the - d e c o Encouragement of all to talk,

r u m .

participants and be aware of your own non- holding down speechmakers, modulating
verbal behavior. overbearing group members
ii. clues form the opening set period. Have they - information providers
read the case? What are their feelings about -agenda setters
the case? Are they excited about the upcoming - group consensus builders
session? - silent majority
iii. promotion of discussion. Dilemma of having - establishing collegial, non-threatening envi-
freedom of student control of learning agenda ronment
versus covering content of the case as moder- - OK to take 'time out' from the case to talk
ator/facilitator about process, i.e. is the discussion covering
- start by reading the case or having a group the molecular mechanisms of the drugs we
member summarize it propose giving to the patient in the case?
- follow up with an open-ended question to the How can we be more effective in this group
group, e.g. what do you think the issues are task?
confronting us? v. times for intervention
- be willing to wait as long as 45 s until a - group is far afield
member of the group responds to your open - group is off base, i.e. too much time on
ended inquiry. Be patient, it may seem like psychosocial aspect of the case rather than
an eternity, but eventually someone will speak content issues! Need for greater analysis in
up! By patiently waiting you are setting the discussion, getting the explanation to the
tone that the group will be responsible for molecular level or debate on data in the
generating the discussion! literature! Moderator intervention to pro-
- allowing discussion to flow. Use of non- mote focusing of the discussion
verbal encouragements such as intelligent - c o n t r o v e r s y too heated (seldom occurs),
grunts, nods and smiles of support becoming personal - need to defuse it!
- active listening and monitoring vi. do not miss cues to change agenda: much
- leading while remaining silent is a key to better than introducing a new topic de novo,
effective moderating/facilitating but opportunity to change the topic in context
- n o n - statements: nodding, smiling,
v e r b a l of earlier and future discussion
attentively listening, frowning, laughing, vii. cover the content
sleeping, looking bored. Resist standing and - d o not permit group to become bogged
going to the flip chart while encouraging the down in peripheral issues!
learners to use that resource. Air time as a - e n c o group to use the flip chart to
u r a g e

clue to dynamism of the session diagram mechanisms, create differential

- analysis of air time. Who is the principal diagnoses, and create tables, list symptoms
speaker? Is participation good from all the etc. - written form forces organization and
members of the group? systemization of thoughts with clearer
- moderator/facilitator should not give a mini explanations !
lecture viii. session is boring. Liven things up by creating
- allow periods of silence. Silence is NOT controversy, move to a role-play, convert to
down time! Silence is a time for thinking, oral board examination format, create activity!
reflection, synthesis, evaluation and other ix. monitor the pace and tenor of the discus-
important mental activity. Good discussions sion and make decisions about intervention
will have periods of silence! consciously!
- s e q u e n c e of speakers. Is the sequence: x. monitor individual members of the group: is
faculty-student-faculty-student-faculty? - this one afraid to speak out? Are most of them
this is not a good learner centered model, bored? Look at their eyes. Are they bright,
this is a teacher centered model! Sequence attentive and excited or dull and bored?
should be: s t u d e n t - s t u d e n t - s t u d e n t - f a c u l t y - xi. redirecting a floundering discussion. Some-
student-student. This is a learner-centered times the discussion will seem to be floun-
model with the encouragement of learning dering: 'like robots in heat. Lots of activity
from peers with no conceptual ignition!' You need to
- m a i n t a i n i n g group function - moderating recognize this and inject some activity and
functions provide some direction with direct and leading
- identify the players: what are roles of the questions. Some groups may not have pre-
individuals in the group? pared satisfactorily. Do not despair! Provide
iv. roles and responsibilities within a group them with direction and even some facts.
- time keeping Make the best of the situation. You can
 IMPLEMENTING PROBLEM-BASED LEARNING IN ANESTHESIA 151

convey disappointment, but try to salvage the evaluation of issues raised in discussion
-

discussion by at least demonstrating why the analysis of conclusions and issues that are
-

case and problems within the case excited you. yet to be resolved
xii. questions. Questions are your tools to sculpt, from the moderator to the discus-
- t h a n k s

mold, enliven and create the nature of the sants

discussion Allow the students to develop the elements
-

- open-ended of the conclusion. Opportunity for the

- focusing moderator to dispel misinformation that
xiii. promote higher cognitive levels may have been stated during discussion
- ask if the discussion is on a factual level or xxiv. improving your discussion leading skills
should the group be analyzing, synthe- - replay the session in your mind and think
sizing and evaluating the elements of the of other options you might have chosen
problem? evaluate the quality of the session
-

- ask for facts - are there any: content omissions, hurt feel-
- ask for philosophy ing, group ambiance, unresolved issues? Is
- ask for hypothesis formation the preparation of the participants satis-
- what are the methods used to confirm or factory or unsatisfactory?
reject the hypothesis? - d e v e l o p strategies to improve future
- whom should you ask to speak? sessions. Expect to have difficulty doing
xiv. recognizing slower learners, encouraging all all these moderating/facilitating skills
questions simultaneously on your first attempt!
xv. deciding when to call on quiet group mem- - learn, practice, learn some more, practice,
ber and ask them a 'softball' question learn again and practice some more. You
xvi. moderate the dominant group members can do it! PBLD is fun and rewarding!
xvii. identify the group members that you can rely
In conclusion, a guide to PBL in anesthesia education
on for cogent responses
has been presented. The lack of confirmatory evidence
xviii, supporting and encouraging quiet group
in the medical literature that PBL is clearly better than
members. Tell them how insightful their
medical lectures, education should not deter the reader
comments are when they venture to speak!
from trying the PBL format. We believe that PBL can
xix. resist the temptation to give a mini lecture.
be fun and this alone is sufficient to justify its use as an
Trust the students, they will come through
educational tool.
for you!
xx. evaluation of learner/discussants. What is the
R e f e r e n c e s

quality of the contributions of individuals

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