Response to: The problem with problem-based medical education: Promises not kept by R. H. Glew

Authors

  • Clyde Freeman Herreid

    Corresponding author
    1. National Center for Case Study Teaching in Science, University at Buffalo, State University of New York, Buffalo, New York 14260
    • National Center for Case Study Teaching in Science, University at Buffalo, State University of New York, Buffalo, New York 14260
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Just recently, I wrote an article [1] entitled “The death of problem-based learning?” I was then unaware of the excellent analysis of problem-based learning (PBL)11 by Robert Glew [2]. I made three points in that article that relate to Glew's concerns. First, the term PBL is used so loosely that it has become practically meaningless. I came to this conclusion after being a consultant to the two major undergraduate programs in the United States, the University of Delaware and Samford University, who have received prestigious grants, set up faculty development programs, and run conferences for faculty instructing them on the virtues of PBL. Also I have spoken to hundreds of PBL enthusiasts. PBL seems to be practically anything that is not a traditional lecture. Burrows [3] anticipated this corrosion of the method in medical curricula. Glew does not focus upon this problem, yet I believe it to be a significant factor in assessing the effectiveness of the method (which Glew does point out is not receiving adequate attention. On a related point, contrary to Glew's statement that “an extensive literature seems to indicate that the PBL approach has worked well in many educational settings other than medical schools …,” I know of no published quantitative data that supports this assertion.)

Second, PBL in its authentic form, faculty tutors working with small groups of students, is just too expensive. Glew does not quite put it this way, but this is my experience as a consultant to some medical schools that are abandoning PBL. Glew comes at the point by stating that both clinical educators and basic scientists (the folks who are acting as PBL tutors) are under pressure to generate dollars either by seeing more patients or by working on grant-supported research. The reward system is not geared to educating medical students. This apparently partly explains faculty reluctance to invest much time or enthusiasm into PBL. But there is another piece to the puzzle. According to faculty and students I have interviewed, after the first wave of enthusiasm for PBL has passed, the tutors look for replacements; they are tired and recognize they get neither reward nor recognition. They have sacrificed enormous amounts of time to deal with only small groups of students in contrast to the lecture method. Yet no one is there to step in and take their places. The system begins to crumble.

Third, PBL is simply a version of case-based learning. The use of stories to teach has been around for thousands of years. It began to be used in a formal way and called case study teaching at Harvard over 100 years ago in the law and business schools. Sometimes the method of instruction was discussion, sometimes lecture, and sometimes with small groups. In all of these incarnations the use of the story line and problem analysis was at the heart of the case. The particular form of case study approach that we call PBL was developed with great success at McMaster University Medical School and later transplanted with the results that Glew describes so well.

So now, what to do about Glew's dilemma? 1) We can try to make PBL better, train the tutors, motivate them, and overhaul the reward system. Glew clearly favors this solution. Yet I believe this is unlikely to happen except rarely. The system in the United States is driven by money not education. Even if an epiphany does occur, I am still puzzled by the fact that Glew says not enough science is getting taught by the PBL approach. I think this suggests that perhaps the wrong cases are being used. In PBL most of the learning is done by the students themselves and not by the tutors who are only there as guides not as lecturers.

2) We can watch the slow deterioration of authentic PBL and lament the fact that faculty and administrators did not really understand the commitment necessary to make it work. It is especially poignant that Professor Glew is a member of the University of New Mexico Medical School. His institution was in the vanguard of the PBL movement. Indeed it established training programs for medical schools and other institutions: it was the Mecca. Clearly something is dreadfully wrong when a leader falters. Glew tells us what the problems are. They are not going to go away.

3) Try to salvage some of the good things that PBL does and capture them. The use of story lines, active learning, and small groups are not limited to PBL. These techniques are part and parcel of case methods in general. There are many powerful case strategies that do not require using a faculty tutor sitting with a group of 6–12 students [4, 5]. (Clearly Glew's suggestion of using clinical educators/basic scientist pairs is even more expensive.)

Finally we should realize that the entire medical school curriculum does not have to be set up around cases or PBL. There is a place for lectures. Medical students are experts at learning by this method. They, like us, are survivors of the lecture method. Although the lecture method is not ideal for many students, it works reasonably well for lots of subject matter. Medical faculty should look for ways to use cases at key moments in a course or use them for entire courses, which is happening at schools like Ohio State University Medical College or Umea University's medical school in Sweden. One does not have to turn the entire curriculum over to the method. It is not all or nothing.

Footnotes

  1. 1

    The abbreviation used is: PBL, problem-based learning.

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