2013; 35: 806–814

TWELVE TIPS

Cracks in problem-based learning: What is your

action plan?
SAMY A. AZER1, MICHELLE MCLEAN2, HIROTAKA ONISHI3, MASAMI TAGAWA4 & ALBERT SCHERPBIER5
1
King Saud University, Saudi Arabia, 2Bond University, Australia, 3International Research Center for Medical Education,
University of Tokyo, Japan, 4Kagoshima University, Japan, 5Maastricht University, the Netherlands

Abstract
Background: Problem-based learning (PBL) as an educational approach has been adopted by medical and health sciences
faculties worldwide. Successful implementation of these curricula may, however, end a few years later with several problems
reflecting cracks in curriculum maintenance.
Aims: The aim of this article is to discuss these problems, their possible causes and what action can be taken to maintain effective
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curriculum delivery.
Methods: We reviewed the current literature, recent Association for Medical Education in Europe conferences’ sessions on PBL,
explored curriculum design approaches and problems (cracks) identified in PBL programs that may occur a few years after
successful implementation. We have also reflected on our collective experience in a number of universities to develop these tips.
Results: Incorporating the methods described, we have developed the following 12 tips: (1) Pay attention to training new staff for
PBL, (2) Maintain the briefing/debriefing sessions, (3) Review the PBL material and program in light of the previous year’s
feedback, (4) Monitor the delivery of the program, (5) Review management of the PBL program, (6) Encourage research and
publications in PBL, (7) Ensure that assessment reflects PBL principles, (8) Refrain from adding new lectures to the timetable, (9)
Reward contributions to on-going curriculum maintenance, (10) Provide on-going and advanced professional development tutor
For personal use only.

training, (11) Make explicit (and develop) students’ skills required for PBL and (12) Attend to conflict and group dysfunction.
Conclusions: Being vigilant of possible cracks (erosion) in the PBL curriculum that may occur a few years after successful
implementation is mandatory. Erosion of PBL can be minimized or avoided if these tips can be applied.

Introduction feedback to the group. A case is usually discussed over two

tutorials, each of approximately two hours duration. At the end
Problem-based learning (PBL) is an instructional method
of the first tutorial, students identify learning goals or issues
characterized by three elements: problems, tutors, and stu-
that guide their research and self-directed learning (SDL)
dents (Majoor et al. 1990). These three elements are integral to
activities (Hmelo-Silver 2004; Sockalingam et al. 2011). During
the success of a PBL program. The problems (also known as
this period of SDL, students search for information to answer
cases or scenarios) are the instructional materials designed to
their questions, drive their learning, justify their views and help
trigger students’ discussion and learning in the PBL tutorials.
them to explain the case. The group reconvenes (tutorial two)
Cases should reflect real-life situations to drive students’
to discuss their findings and to integrate the new information
learning about basic biomedical sciences and biopsychosocial
to the issues raised by the case (Azer 2008).
issues (Hmelo-Silver 2004; Azer et al. 2012). Cases need to
Several factors contribute to successful group discussion
represent typical cases with the aim to drive students’ learning
(Nieminen et al. 2006; Azer 2009a). These include:
of basic biomedical sciences related to the case in a clinical
13

format. Rare cases or complex cases should be avoided . Providing hands-on tutor training.
20

particularly in the early years (Des Marchais 1999; Jacobs et al. . Providing tutors with a case guide and resources.
2003). In small groups, learners discuss the case, identify the . Providing on-going support to PBL tutors in terms of
cues ( patient’s problems) in the trigger, generate hypotheses, facilitation skills, administration and group management
develop an enquiry plan and then refine their hypotheses issues.
based on the evidence from the history and clinical examin- . Ensuring that tutors have addressed group management
ation (Barrows & Tamblyn 1980). In this process, learners, issues in the first two to three tutorials.
rather than the tutor, are the active participants in the . Introducing students to the PBL process and developing
discussion, with each group member contributing to the their self-directed learning skills.
learning. The PBL tutor, who should be adequately trained for . Ensuring that PBL cases are authentic and written by teams
his/her new role, is a facilitator and evaluator who provides of experts.

Correspondence: Professor Samy A. Azer, Professor of Medical Education, Chair of Curriculum Development and Research Unit, Medical Education
Department, College of Medicine, King Saud University, P O Box 2925, Riyadh 11461, Saudi Arabia. Tel: þ966542307075; fax: þ 96614699174;
email: [email protected]

806 ISSN 0142–159X print/ISSN 1466–187X online/13/100806–9 ß 2013 Informa UK Ltd.

DOI: 10.3109/0142159X.2013.826792
 Cracks in PBL

. Ensuring that each case is presented and discussed in a Table 1. Summary of the 12 tips.
briefing session, a few days before case implementation.
Tip 1: Pay attention to training new staff for PBL
While the successful introduction of PBL therefore requires Tip 2: Maintain the briefing/debriefing sessions
a number of changes at several levels, erosion of even the Tip 3: Review PBL material and program in light of previous year
most successful PBL program may occur (Hendry et al. 2003; feedback
Tip 4: Monitor the delivery of the program
Moust et al. 2005; Hung 2011). ‘‘Cracks’’ in a PBL program, if Tip 5: Review management of the PBL program
unresolved, will culminate in a deterioration of the PBL Tip 6: Encourage research and publications in PBL
Tip 7: Ensure that assessment reflects PBL principles
process with the risk of a reversion to a traditional didactic
Tip 8: Refrain from adding new lectures to the timetable
program. Below are some of the reported ‘‘cracks’’ in PBL Tip 9: Reward contributions to on-going curriculum maintenance
curricula (Moust et al. 2005; Hung 2011): Tip 10: Provide on-going and advanced professional development tutor
training
. Learners may short-cut their case discussions, finishing in Tip 11: Make explicit (and develop) students’ skills required for PBL
Tip 12: Solve conflict and group dysfunction
half the allotted time. Tutorial time is not used effectively to
explore issues, dig deeper, ask questions and search for
evidence.
. The destination becomes more important than the journey, educational committees, PBL tutors, and students involved
with learners focusing on the diagnosis rather than using the in quality control and improvement process at their
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case as a vehicle to explore basic and clinical sciences. respective colleges.

. The discussion during the PBL tutorials is superficial.
Learners do not construct knowledge but tend to present
fragmented pieces of factual knowledge without applying Tip 1
their findings to issues raised in the case.
. Learners do not engage in SDL and are thus unprepared for Pay attention to training new staff for PBL
the second PBL tutorial. A few years after the introduction of a PBL program, new
. Tutors do not attend the briefing sessions and are therefore tutors may not be trained to the same extent as the first few
not familiar with the main issues of the case. batches of tutors. Several factors may contribute to such a
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. Tutors may not have adequate facilitation skills and so decline including appointment of a new PBL coordinator or
dominate the discussion, often delivering mini lectures in a new dean with different priorities. Other factors include:
their area of expertise. (i) training is no longer conducted by an expert, (ii) training
. Administration of the PBL program is neglected and not is reduced to a few sessions covering theoretical information
managed effectively. on PBL without hands-on training, and (iii) training is no
longer a prerequisite for being a PBL tutor and tutors
Tutors have a major role to play in ensuring that the
are allowed to facilitate without an understanding of
program remains on track. Comments from tutors such as
what needs to be achieved during PBL tutorials. Tutors
‘‘There is nothing to discuss in the case’’, ‘‘Students preferred to
therefore conduct PBL according to how they think it should
add this and that to their learning issues so we did not discuss
be done.
them’’, ‘‘There are no basic sciences in the cases to be
The same standard of PBL training should be maintained
discussed,’’ ‘‘We do not need two hours, we could finish in one
and should be conducted by an expert (Dolmans et al. 2002;
hour,’’ ‘‘Students have cases from previous years students and
Azer 2008, 2009a) and should include:
they know the case diagnosis’’ is evidence that erosion is
already underway. . Providing new tutors with an overview of PBL.
To develop these tips, PubMed and MEDLINE were . Ensuring that tutors understand the educational objectives
researched using the following key words, ‘‘PBL cracks,’’ of PBL, its rationale and their role as a PBL tutor.
‘‘PBL erosion,’’ ‘‘PBL maintenance,’’ ‘‘PBL management’’. To . Preparing new tutors with hands-on training in facilitation.
maximize the outcomes of our search, these key words were If possible, this should involve practicing with students.
also searched using problem-based learning instead of PBL. Tutors should receive feedback.
We also examined the abstract books of the Association for . Training tutors on how to provide constructive feedback
Medical Education in Europe (AMEE) conferences from 2006 and how to evaluate their student’s performance.
to 2012 as well as reviewed PBL books and documents created . Ensuring that the training addresses tutor’s queries in terms
by AMEE. We also explored our collective experiences in of process and role.
medical education and PBL whether as full-time academics or
consultant/advisors on PBL curricula at universities in
Australia, South East Asia, Japan, Europe, South Africa and What are the characteristics of an effective PBL
the Middle East. The following 12 tips serve as a series of
training program for novice tutors?
preventive measures that should assist in maintaining PBL A faculty training program should build on adult learning
programs on track and avoiding the appearance of ‘‘cracks’’ theory and prepare trainees on ‘‘why’’ they should learn
(Table 1). something new, i.e. training should ‘‘create a need to know
This article is aimed at curriculum coordinators, directors experience’’ that engages the teacher before coming to the
of PBL programs, unit coordinators, planning groups, training (Anderson et al. 1997).
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 S. A. Azer et al.

A good PBL training program should: . Ensuring that the briefing/debriefing session schedule is
received in advance of the block/module and the paper-
. Highlight the educational objectives of PBL and the
work (e.g. tutor guide, other resources) is received at the
rationale for adopting PBL as a learning approach.
beginning of the briefing sessions.
. Offer task-oriented sessions that provide tutors with the
. Encouraging departmental chairs to become PBL tutors.
opportunity to practice facilitation skills.
Their involvement sends a strong message to other aca-
. Focus on skills development and the use of constructive
demics about the importance of PBL tutoring and attendance
feedback to foster learning.
of the briefing/debriefing sessions (Finucane et al. 2001).
. Base the training program on the pedagogy of the PBL
program.
. Explain the roles of a PBL tutor, the role of learners and
What makes a great briefing/debriefing session?
explore different mechanisms that can enable students to
get the best from PBL sessions.
. Encourage tutors to reflect on their motivation for becoming
. Well-organized meetings in which tutors are informed
PBL tutors and how role modelling contributes to develop-
about the schedule of briefing meetings before the start of
ing a conducive learning environment.
the block/module.
. Explore administrative issues, leadership components and
. Conducted by an expert who can cover facilitation skills
instructional development needed for running the program.
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related to the case, explain difficult areas in the case –

. Provide trainees with key publications and other resources
biopsychosocial and biomedical and clinical components in
that they could use and add to what they have learnt.
the case.
. In addition to the briefing/debriefing sessions, the training
. Provision of resources and tutor’s guide in advance of the
workshop should be followed with tasks and planned
meeting.
monthly meetings, to build on the skills developed in the
. A collegial, collaborative and sharing environment.
workshop and to provide feedback and support.
. Feedback on previous cases (debriefing part).
While there is some evidence suggesting that students who
are guided by a subject expert tutor may benefit more than
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students guided by a non-expert staff tutor or by a student Tip 3

tutor (Schmidt et al. 1993; Schmidt 1994), these findings do not
minimize the importance of staff training, particularly in terms Review the PBL material and program in light of
of facilitation of discussion, engaging members in active previous year feedback
participation, and providing constructive feedback (Azer 2008;
Benor & Mahler 1987). During the debriefing sessions, tutors usually provide useful
information about the case in terms of difficulties/challenges,
errors and contradictions. Examples of common errors/prob-
Tip 2 lems encountered in PBL cases (Azer et al. 2012) and tutor
guides:
Maintain the briefing/debriefing sessions . The educational objectives of the PBL cases are not well
represented in the case content nor in terms of the issues
A few years after PBL implementation, some schools may not
raised by learners.
offer PBL briefing sessions, while others assign less priority to
. Cases are not based on a particular template and each is
such meetings, with the quality gradually deteriorating (e.g. ad
written by a different group of authors without having a
hoc scheduling or meetings conducted by non-experts). These
common reference on which to base their cases. This
changes are usually associated with poor attendance, poor
usually results in cases that do not follow a particular
management and reduced emphasis from the Medical
educational pedagogy and inconsistent in terms of their
Education Department/Unit on the importance of attending
length and the educational purpose.
such meetings. Ill-prepared tutors, both in terms of skills and
. Too many cues in the trigger or the same cues are repeated
content, contribute to serious erosion of the PBL process.
in the trigger of other cases. For example, shortness of
An action plan with regard to the briefing/debriefing
breath is repeated in the trigger of the case on bronchial
sessions may include:
asthma, heart failure and chronic obstructive pulmonary
. Ensuring that weekly briefing/debriefing sessions continue disease.
with a PBL expert who is also able to answer tutors’ queries . Scientific errors, grammatical and typographical errors,
about the process and a case expert to prepare tutors for the irrelevant, redundant and contradictory information pro-
week’s case in attendance. vided in the case content (trigger, history component,
. Ensuring that briefing sessions are reviewed on a yearly examination, etc.).
basis in terms of adding value to the tutors’ experience. . Images (e.g. radiology images, pathology slides, etc.) are
Tutors who have facilitated the case previously could share not clear, difficult to interpret or do not match the
their experience during the briefing session. Besides being information provided in the case.
helpful to new tutors, this may also motivate tutors to attend . Cases do not engage learners. They lack authenticity and
despite being familiar with the case. are boring.
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 Cracks in PBL

. Tutor guides lack information about strategies to facilitate . Discussion of the learning issues in tutorial two tends to be
the discussion and the areas that should be emphasized in in the form of a presentation with no links to the case and
the tutorials. They lack drawings, diagrams and adequate without applying knowledge learnt to the issues raised in
explanation of the different parts of the case. Medical and the case during tutorial one.
specialized terms are not adequately explained.
Identifying these problems at an early stage is important.
The action plan regarding this challenge may include: An action plan to prevent this may include:
. Form a committee to review the PBL cases and tutor guides. . Arranging regular visits from a member in the training team
Include a subject and an educational expert as well as the to the tutorials. The aim is to ensure that the discussion is at
original case writers. Peer revision adds to the scholarly the required depth, the PBL process is being followed and
value of the work and its authenticity. that the groups are functioning.
. Improve the quality of the radiological and pathological . Encouraging tutors to attend the briefing/debriefing
images. sessions and invest in improving the quality of such
. Rewrite or replace poorly constructed cases with new ones. meetings.
. Correct any grammatical and typographical errors, ensuring . Designing advanced facilitation training programs for all
that cases are clearly written. experienced PBL tutors. The aim of such training is to foster
. Ensure that the cases stimulate SDL. their facilitation skills further and enable them to handle
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. Review and update the tutor guides, based on the feedback such challenges.
from tutors. . Reviewing and updating the PBL program on a regular
. Ensure that there is a logical sequencing within the basis. Attend to minor problems as if left unresolved at an
curriculum (Neville & Norman 2007). earlier stage, they usually develop into major issues.

Tip 4 Tip 5
Monitor the delivery of the program
Review management of the PBL program
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Attention should be given to the hidden curriculum. A hidden

The Director of Medical Education needs to identify gaps
curriculum is a set of influences that function at the level of
between the curriculum on paper (designed curriculum), the
organisational structure and culture (Hafferty 1998). In add-
implemented curriculum and the experienced curriculum
ition to the formal curriculum, learners may access to a range
(Coles & Grant 1985). Is the designed curriculum able to
of resources and study aids such as previous examination
create the right goods (Gibbs 2011) and are there management
notes, summary notes from students from previous cohorts,
obstacles that challenge its successful implementation? A new
tutor guides (Ozolins et al. 2008; Zhang et al. 2011), potentially
program usually receives considerable attention, but as other
compromising discussion during PBL tutorials. This can lead to
issues emerge, priority for the program declines with admin-
short-cuts during the PBL tutorial, with learners focussing on
istration of the program waning.
the diagnosis rather than using the case to drive their learning.
Because the management and organizational issues in
If tutors are not sufficiently trained to deal with this, the
relation to a PBL program vary in different colleges, the
educational principles of PBL may be compromised. Some of
following questions may be helpful in terms of maintaining the
the following might suggest to the tutor that learners have
administration:
access to such resources:
. Organisational structure and strategic planning:
. Learners finish the case discussion well ahead of the
designated tutorial time. ‘‘What is the organizational structure and strategic planning
. Issues raised in the case are not discussed in depth and of the PBL program . . . .?’’
learners do not explore cognitive elements embedded in ‘‘Are members aware of the organizational structure?’’
the case such as generating hypotheses, making an enquiry ‘‘What are the vision and mission statements of the program?’’
plan, interpreting patient’s symptoms and signs and inves-
. Program goals and objectives of the program:
tigation findings, using available evidence to refine hypoth-
eses, justifying their views and linking their basic science ‘‘What are the goals and objectives of the PBL program?’’
knowledge to the case. ‘‘What are the challenges we have faced?’’
. Tutorial time is not used to ask open-ended questions, ‘‘What are the causes . . . contributing factors?’’
debate issues or explore concepts in depth. ‘‘What solutions do we have in the short and long-term?’’
. Students adding learning issues to their list before trying to
. Service identification:
identify what they need to know to understand the case.
. Students not refining their hypotheses on the basis of ‘‘What services are we considering to enhance the success of
evidence, resulting in poorly defined learning issues. the PBL program?’’.
. Ignoring self-directed learning time and depending ’’Are there any obstacles . . . What are they . . . .?’’
on lectures to collect information about their learning ‘‘Is it possible to customize our services to the faculty to ensure
issues. optimal outcomes?’’
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 S. A. Azer et al.

. Resource allocation: the subsequent knowledge-gathering and learning will

undoubtedly contribute to the quality of the program.
‘‘What resources (faculty, staff, and infrastructure) are
. Being successful in research provides a solid foundation for
available . . . ?.’’
an academic career. Having research-intensive faculty on
‘‘Are we using these resources optimally?’’
the program lends credibility to the institution both intern-
. Coordination and management: ally and externally.
‘‘Who will coordinate each of the . . . ?’’
‘‘How will communication between the Department of
Medical Education and the different medical schools be Tip 7
facilitated?’’
Ensure that assessment reflects PBL principles
. Monitoring, evaluation and feedback:
While schools may implement PBL, they might not introduce
‘‘What are the mechanisms to be used in monitoring each of any changes to the assessment system. Such inconsistency
these processes?’’ between the curriculum and assessment will negatively impact
‘‘How has the evaluation process been implemented?’’ on the maintenance of the curriculum and the educational
‘‘What standards do we have to assess this process?
benefits of the program. To this end, if assessment focuses on
‘‘How can the feedback be used to improve the standards and
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factual knowledge gleaned from lectures and ignoring the

maintain quality teaching and learning?’’
learning and skills development during PBL tutorials, students
will fail to adopt deep learning strategies. PBL is underpinned
by two important educational objectives: The development of
Tip 6 the cognitive skills of identifying problems, generating and
refining hypotheses, interpreting laboratory findings and using
evidence to justify one’s views, and secondly, enhancing non-
Encourage research and publications in PBL
cognitive skills such as communication and interpersonal
A successful PBL program should be based on educational skills, demonstrating commitment and accountability, collab-
principles and best available evidence. This is particularly orative learning and being a team member.
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important in the initial stages of planning, designing and Assessment in PBL, whether formative or summative,
developing the curriculum content. Maintaining a link between should therefore focus on these two educational objectives.
medical education research and program review and improve- Such assessment should:
ment lends credibility to the program and enables curriculum
stakeholders to place an emphasis on scholarly endeavours . Matches the design and the objectives of the curriculum.
such as research. Faculty development is, however, required if This may necessitate extensive revision of the assessment
academic staff members are expected to engage in educational system already in place. Learners need to be familiar with
scholarship (Irby et al. 2004). Research in medical education any new assessment tool before it is used summatively.
particularly in the area of PBL is likely to involve different . Involve the provision of feedback to each student in the
aspects of the program; learners, tutors, facilitation skills, PBL group after two to three cases, depending on the length
group process, learning, case construction, curriculum design, of the module/block. The Socratic approach in giving
SDL, staff and students’ training, learning resources, feedback, feedback has been useful (Azer 2008).
mentoring, reflection, integration, change management, basic . Assessing students’ cognitive skills using PBL style of
sciences, simulation, and early clinical exposure (Dolmans questions (What if . . . .? (Azer 2008) and Extended-
et al. 2005). Matching Questions.
How can research improve the quality of a PBL program?
. A successful PBL program should be adapted to local
Tip 8
circumstances and culture. Incorporating research into the
quality assurance process can assist in identifying the many
Refrain from adding new lectures to the timetable
factors that may impact on the PBL process and working on
improvement of the program. There are so many cultural When PBL is implemented, the focus usually changes from
influences about which we know little and which would be didactic, passive learning to active engagement on the part of
of interest to other schools. students. Learners need to develop the skills required for
. Research can drive educational innovation. Research group discussion. They also need to master the process of
involves looking critically at our own situation, evaluating, active and self-directed learning, as well as learn to provide
comparing with the literature and perhaps developing evidence to justify their views (Moreno-Löpez et al. 2009;
theoretical frameworks. This whole scientific process helps Schmidt et al. 2011). They also need to shift their learning
staff to keep up to date and drives innovation. from passive memorization of facts to critical thinking. If
. The reward and recognition for undertaking research is students do not engage with these processes, it may be difficult
motivating for faculty. to successfully implement PBL. Such difficulties may raise
. Today, research often involves collaboration with other concerns about PBL from academics and the demand to
disciplines and schools. This outward looking approach and resume didactic teaching such as new lectures to cover the
810
 Cracks in PBL

limitations/challenges experienced with PBL. If you feel that A sense of ownership through sharing responsibilities and
adding new lectures to the timetable will fix the problem, the making contributions:
following may assist you with this decision:
. Helps to create a successful curriculum that can be
By introducing more lectures, one would be:
implemented by staff and enjoyed and appreciated by the
. Subscribing to more emphasis being given to factual students.
knowledge than to a more student-centred, inquiry-based . Facilitates the implementation of the curriculum, minimises
approach to learning. staff resistance to the change and enables sustainable
. Disturbing the balance between curriculum content and curriculum maintenance.
SDL which may result in a loss of independent learning time . Enables the Medical Education Unit to identify challenges/
and as well as contributing to a busy schedule. problems and work with faculty members to resolve issues.
. Not examining the real source of the ‘‘crack’’, i.e. what . Helps to create a sense of achievement and willingness to
needs to be improved in terms of the PBL cases, students’ move forward by all those involved.
self-directed learning skills, tutors’ facilitation skills and . Engenders confidence in faculty members to accept the
curriculum management. change and be part of the process.
. Ensures successful communication between different
The action plan may include:
departments, the medical education unit and students.
. Reviewing the PBL process and resolving any challenges in
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A lack of ownership can be a major challenge to the

the PBL process before adding new lectures (Schmidt et al.
survival of the curriculum and may result in criticism from
2009).
departments about any problems observed by academics
. Reviewing the content of the lectures and evaluate their
instead of collaborating, working on resolving challenges and
educational objectives. A small committee can look into this
demonstrating that academics are part of the team. Such
process and identify any overlap and repetition in lectures
division may weaken the position of Medical Education and its
(van Berkel & Schmidt 2005). Encourage interactive large
ability to manage the curriculum.
group sessions (Azer 2009b; White 2011).
An action plan should therefore include:
. Reviewing how content is best delivered, e.g. student-led
seminars or be replaced by a multimedia or a computer-aid . Ensuring that departments are well represented in different
For personal use only.

learning exercise that can be part of the students’ SDL. working groups, committees and teams involved in the
Some sessions can be conducted in the computer skills curriculum review and maintenance.
laboratory and facilitated by a tutor. . Building bridges and sharing responsibilities amongst
various departments and tasks.
. Rewarding academics who have contributed to the curricu-
lum review and maintenance.
Tip 9 . Supporting members who take leadership roles.
. Avoiding dependence on certain faculty members to do all
Reward contributions to on-going curriculum tasks but rather look for new academics to collaborate on
maintenance tasks with the medical education unit.
. Emphasizing and acknowledging the contributions of
Key to successful implementation of PBL is the need for the
departments and academics to the success achieved.
Medical Education Department/Unit to engage with and
include academic staff in basic science and clinical depart-
ments. This collegiality contributes to engendering a sense of
contribution and willingness for common successful outcomes Tip 10
(Bolden 2011; Patricio et al. 2012). Academics from various
departments may take responsibilities such as coordinating a Provide on-going and advanced professional devel-
block/module, becoming a PBL tutor, sharing in teaching in opment tutor training
early clinical exposure, chairing an academic phase, becoming
As van Berkel and Dolman’s (2006) modelling research
a member of a task group or joining the teams writing PBL
suggests tutors have a key role to play in the PBL group,
cases. Such activities bridge the gap between the Medical
functioning by stimulating active and collaborative learning
Education Unit and the departments and can be of great help
and developing learners’ self-directed learning abilities. As
in facilitating tasks to be accomplished and during the on-
new tutors (faculty members and casual) join the programme
going revision and maintenance of the program.
at regular intervals, longitudinal faculty development training
The Medical Education Unit should establish a system for
should be offered, not only to orient newcomers but also to
rewarding academics and clinicians who have played a role in
provide continuing professional development of facilitation
the development and maintenance of the new curriculum and
skills (McLean 2003; McLean & van Wyk 2006). For Young and
should regularly invest in building such bridges with aca-
Papinczak (2012), facilitators hold the key to sustaining PBL.
demics (Reid et al. 2012).
Some of the common reported problems involving tutors
Why is it important for academics to have a sense
include:
of ownership during the on-going maintenance of the
program? . Not being au fait with the curriculum learning outcomes
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 S. A. Azer et al.

. Slipping into the ‘‘content expert’’ role and neglecting . Not engaging in or short-cutting the PBL ‘‘process’’ (e.g. not
‘‘process’’ brainstorming, not activating prior knowledge, not generat-
. Skipping steps in the PBL ‘‘process’’ (Moust et al. 2005). ing hypotheses, not elaborating and discussing)
. Having their own personal views and rules for conducting . Not knowing what is required of a self-directed learner
sessions and ignoring faculty training approaches. . Not being sure how to integrate knowledge or identify
learning issues
These problems may be avoided by: . Lacking skills in scribing on the whiteboard, providing
. Explicitly articulating the role of the ‘‘tutor’’. PBL was justification for their views, and debating issues rather than
originally implemented in a graduate programme but has arguing
been adopted in undergraduate medical education. In such Many of these difficulties can be obviated by making
circumstances, learners mostly enter directly from school, explicit to all stakeholders what is required in terms of the
requiring considerable guidance and scaffolding in terms expected learning outcomes of PBL. The following should
strategies and skills required for learning in PBL (e.g. critical help in this regard:
thinking, brainstorming, self-directed learning; Taylor &
Miflin 2008). More attention might then be required in terms . The PBL philosophy and the underpinning rationale for the
‘‘process’’ should be explained.
of the PBL ‘‘process’’ rather than content, with the ‘‘tutor’’
. The importance of group work relates mainly to the
facilitating (Fr. facile ¼ easy) learning rather than tutoring
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elaboration stages where misconceptions can be ironed

(McLean 2003). A name change, from ‘‘tutor’’ to ‘‘facilitator’’
out through discussion and for individual learners to assess
may be necessary to make the facilitation role explicit. In
their level of understanding relative to their peers.
Latin ‘‘tutor’’ means ‘‘to protect’’ or ‘‘to guard’’. More recent
. Being aware of the underlying rationale for other steps
definitions imply an individual engaged in one-on-one
in the process (e.g. activating prior knowledge – self-
session. Neither definition is thus appropriate for the PBL
assessment, hypothesizing – critical thinking) will hopefully
tutor.
obviate ‘‘erosion’’ of process.
. At regular intervals, get tutors to reflect on their learner-
. Part of this erosion may arise as a result of PBL becoming
centredness. Lueng and colleagues’ (2003) inventory can be
‘‘stale’’. Invigorating cases with videos, role-playing, images,
the starting point for a workshop in which tutors discuss
For personal use only.

and adopting a staged approach to the complexity of

their facilitation style (e.g. collaborative, facilitatory).
problems will help keep students engaged as their skills
. Develop a series of workshops focussing on developing
develop.
discrete skills such as Socratic questioning, dealing with
. Insecurities can be minimised if the learning issues
difficult students and providing feedback.
identified by the students are clearly articulated, either in
. Where possible, use videos of tutors (which may be
the form of a question or with the appropriate verb to
themselves) to demonstrate good practice. This will encour-
indicate the level of understanding required (e.g. list versus
age self-assessment and reflective practice.
describe). The tutor’s guidance in the early stages of PBL is
. Including tutors’ narratives of their experiences of how they
critical in this regard.
dealt with issues serves to develop a sense of belonging.
. Promoting metacognition, i.e. making students aware of
. In terms of the curriculum, all tutors should be aware of
how they think (Tanner 2012) is the key to assisting
where the students have come from and where they need to
students to develop into the autonomous learners we
go (McLean & van Wyk 2006).
expect. The facilitator’s role in this process rests with the
types of questions asked.

Tip 11
Tip 12
Make explicit (and develop) students’ skills required
for PBL Solve conflict and group dysfunction
Learners enter medical school with differing educational Conflict in the PBL group could progress to group dysfunction.
backgrounds. For many, particularly those who enter their Group dysfunction can arise as a result of:
medical studies directly from school, PBL will be very different
. Personal issues such as a dominating personality in the
from their prior learning experiences. With advertised out-
group. Such members tend to impose their views on the
comes of deep understanding, problem-solving ability, self-
group, dominate the group discussion, or do most of the
directed learning (Belland et al. 2009), scaffolding of learning
group work. Tension is likely to occur in the group
and skills development are important (Taylor & Miflin 2008).
particularly if two or three members dominate. They may
Some of the most commonly reported difficulties that
oppose the views of others, argue about minor issues, or
learners experience adapting to PBL include:
perhaps divide the group members into factions, harming
. Working in a group the group dynamics and hence group function (Hitchcock
. Not knowing ‘‘how much’’ (i.e. breadth and depth) is & Anderson 1997). Negative tension will impact on group
required in terms of learning discussion and may culminate in a lack of contribution by
812
 Cracks in PBL

other members. This will definitely hinder positive learning Education Departments, module/unit coordinators and PBL
outcomes (Wells et al. 2009; Lim 2012). tutors with concrete measures to identify and manage cracks in
. Lack of social skills and effective communication skills. the program that may occur a few years following the
Students distrust each other and they are not working as a introduction of PBL. It is vital to identify such cracks as early
team. For example, members do not share resources or as possible so that an action plan for addressing inadequacies
educational material with other members. Some members can be developed with your team. Continuous evaluation and
know the correct answer but they keep it for themselves feedback from students, tutors as well as those involved in
rather than share their knowledge with others. Such program management should provide an insight in terms of
fragmentation in the group and its dynamics will have an the origin of the problems. The cause for such problems may
impact on the group function and the willingness of other be interrelated. Being vigilant of possible cracks (erosions) in
members to continue in such group. the curriculum that may occur a few years after successful
. Lack of accountability to the group. Members miss tutorials, implementation is mandatory.
or come late to the tutorials. They tend not to prepare their
learning issues and do not complete tasks that they agreed
Declaration of interest: The work was supported by
to work on in time. They tend not to take responsibilities.
College of Medicine Research Centre, Deanship of Scientific
Such behaviours could result in resentment from other
Research, King Saud University, Riyadh, Saudi Arabia. The
group members and could slow group discussion or create
authors report no conflicts of interest. The authors alone are
Med Teach Downloaded from informahealthcare.com by Professor Samy Azer on 03/02/14

imbalance in the group functionality.

responsible for the content and writing of the article.
. Lack of etiquette in the group, as well as a lack of care and
respect towards other members. Such behaviour will impact
on the learning environment and hence the learning Notes on contributors
outcomes of the group. Groups with such problems either
SAMY A. AZER, MD, PhD (USyd), MEd (UNSW), FACG, MPH (UNSW), is a
did not establish ground rules in the first tutorial and/or Professor of Medical Education and the Head of Curriculum Development
their tutor did not refer them to the group ground rules and Research Unit, College of Medicine, King Saud University. He was the
when problems appeared. It is also possible that the tutor Professor of Medical Education and Chair of Medical Education Research
did not ensure that different roles were assigned and rotated and Development Unit, Faculty of Medicine, Universiti Teknologi MARA,
Malaysia. Formerly, he was the Senior Lecturer in Medical Education at the
For personal use only.

in tutorials (e.g. scribing on the whiteboard, recording

Faculty of Medicine, Dentistry and Health Sciences, the University of
information, checking the medical dictionary for difficult Melbourne and the University of Sydney. Over the last few years, he has
words and new terms, reading for the group, contributing to conducted a number of training workshops to students on learning and
the discussion). how to enhance their learning approaches. He is one of the Associate
Editors of BMC Medical Education and on the Editorial Board of
The action plan for such situations could be: MedEdWorld, UK.
MICHELLE MCLEAN, Professor, Medical Education, Faculty of Health
. Ensuring that ground rules are established by the group
Sciences and Medicine, Bond University, Gold Coast, Australia.
during the first tutorial. When problems occur, members
HIROTAKA ONISHI, Assistant Professor, International Research Center for
should be reminded of the agreed ground rules. Medical Education, University of Tokyo, Japan. Formerly, he was an
. Ensuring that members are aware of their roles in PBL and Associate Professor at Medical Education and Research Unit, International
that a system has been developed ensuring rotation of these Medical University, Malaysia.
roles. MASAMI TAGAWA, MD, PhD, MHPE, is the Director and Professor of the
. Using constructive feedback at the end of tutorial two Center for Innovation in Medical and Dental Education, Kagoshima
(about 10 min) to discuss with the group the areas in which University Graduate School of Medical and Dental Sciences, Kagoshima,
Japan. For the last four years, she has been the Director of Faculty
they are doing well, areas requiring improvement and what Development Committee of Kagoshima University School of Medicine, and
action should be taken for the next tutorial. has conducted a variety of training programs, including tutor training and
. Training PBL tutors to resolve conflict in the group and case-creating workshops for faculty, and introductory sessions of PBL
managing different types of group dysfunction. tutorials for medical students.
. Providing support to PBL tutors who feel that they are ALBERT J.A. SCHERPBIER, Professor of Medical Education, Dean, Faculty
unable to handle conflict or difficult issues in their group. of Health, Medicine, and Life Sciences, Maastricht University, the
Netherlands.
The director of the PBL program should be available for
help and support.
. Using school/university policies regarding dysfunctional References
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