Response to commentaries on “the problems with problem-based learning” in Biochemistry and molecular biology education
As I was about to mail to Biochemistry and Molecular Biology Education (BAMBED)1 my essay entitled The problem with problem-based medical education: Promises not kept , I found myself gripped by the anxiety that my article would call down upon me thunderbolts in the form of a rash of e-mails, letters, and articles filled with angry and scathing criticisms of the views I expressed about the educational sacred cow we know as problem-based learning (PBL). This anxiety intensified when the editor informed me that BAMBED would be publishing half a dozen articles in response to the ideas and opinions I had expressed in my Promises not kept article. However, after reading the six thoughtful and well-written articles that appeared in BAMBED from leaders in medical education from the United Kingdom, Canada, and the United States [2–7], I was pleasantly surprised to find that, for the most part, the authors agreed with the central points of my paper, namely that: 1) the concept of PBL is right and highly defensible; 2) PBL is preferable to a predominantly lecture- and laboratory-based curriculum; 3) PBL at most medical schools has fallen far short of institutional expectations and the aspirations of its proponents; and 4) reasonable remedies are available that must be applied if PBL-style undergraduate medical education is to attain or fulfill those high expectations and aspirations. At the same time, however, I was both surprised and disappointed to find among the responses to my article no comment from my colleagues at the University of New Mexico School of Medicine, which, in the words of Herreid , was at one time “in the vanguard of the PBL movement.” I wonder: do my colleagues at the University of New Mexico agree with the ideas and assessments I articulated in my piece in BAMED, or have they given up on or grown tired of PBL?
The authors of the six responses cited above all seem to appreciate the attributes of PBL: 1) it provides for contextual learning, that is, learning that is relevant to and centered around real cases or clinical scenarios; 2) the process allows for active, student-centered collaboration between tutor and student; 3) in principle (although still yet to be proven), it should promote life-long learning; 4) most students find it a more enjoyable way to learn than sitting in a lecture hall all day, listening to one slide presentation after another; 5) it develops problem-solving skills; and 6) it can be a vehicle for bringing basic scientists and clinicians together for a noble and worthy scholarly purpose.
The authors of those six papers also seemed to agree on the reasons why the PBL movement has stalled or is floundering at most medical schools where it has been tried. The foremost of these reasons applies not just to the PBL paradigm but to medical education in general, be it PBL, PBL-lite, or traditional lecture- and laboratory-based medical education. The attitude of most clinicians and basic scientists is that educating and training medical students just is not very important or rewarding. Too often the medical school faculty places a higher priority on providing service to patients, in the case of the clinicians, or, in the case of basic scientist-researchers, landing large extramural grants that bring overhead dollars and extramural support for faculty salaries. I find it both ironic and disturbing that the mission statement of virtually every medical school opens with the bold assertion that the training of medical students and resident doctors is the institution's highest responsibility and goal, when, in actual practice, teaching seems to always take a distant third place behind clinical and research activities that directly bring hard currency into the school's budget.
This discrepancy between rhetoric and reality is not just ironic, it is a hypocrisy widely tolerated by administrators and grant-flushed faculty. Inexplicably, the substandard job we are doing educating medical students is not appreciated by the trusting and innocent citizens and taxpayers whose labor supports the highly prized, tenured (and largely unaccountable) positions we hold or to which we in the medical academy aspire. I suspect that if the legislators in places that have a state-funded medical school were aware of how little time and effort the faculty devoted to educating medical students, these politicians would find creative ways to use the education component of the budget to motivate Ph.D.-level basic scientists to take their teaching responsibilities more seriously. I urge legislators who control their state's budget for higher education to examine the efficiency and productivity of basic scientists at allopathic versus osteopathic medical schools, and when they do they should use quantitative as well as subjective methods of assessment. They would be surprised to discover that at most osteopathic medical schools in the United States only one dozen or so Ph.D. instructors, dedicated and committed to teaching, are providing their students with a better education than do the 70–80 Ph.D. instructors who occupy tenure or tenure-track positions at a comparably sized allopathic institution. It would be unfortunate, indeed, if it required the threat of reduced state funding to motivate medical school administrators and faculty to put more effort into educating medical students.
We need to keep in mind that state medical schools are public institutions with responsibility to the public. The state medical school is a public trust, and faculty members are servants of the public. Medical school faculty members at these state-supported institutions need to be reminded that they are employees of the public and that taxes pay their salaries. Because the mission statement of the medical school undoubtedly specifies teaching, the responsibility of the teacher is to educate the medical students. When a tenured or tenure-track faculty member signs his or her contract, he or she accepts responsibility not only to the administrators of the institution but to the public of the state as well. Faculty must understand that teaching is a responsibility they are obliged to conduct on behalf of the interests of their employer, namely the public and the community as a whole.
There are several reasons why educating medical students is perceived to be of so little value in the wider medical school community. First, because extramural education-type grants are usually considerably smaller than those held by bench- or epidemiology-based researchers, they are therefore less valued by bottom-line, dollar-oriented deans and vice presidents. Second, at most medical schools, the rewards, incentives, and recognition for teachers are lacking or, at best, grossly inferior to those provided for successful researchers. It should surprise no one that clinicians and basic scientists, like most human beings, respond to incentives. However, I am loathe to have administrators resort to financial bonuses to encourage and reward faculty to teach. After all, is teaching not one of the reasons why we hire faculty in the first place? So why should faculty need a bonus to do what they have been hired to do? It seems to me that having to give a bonus to a biochemist or physiologist to motivate him or her to tutor medical students for some 30 or 40 h over the course of a year is just as odious as having to bribe an extortionist technician in some back-water, Third World country to install a telephone in one's home.
I have distilled from the six responses to my piece on PBL  the suggestions that were offered for closing the gap between the promises and achievements of PBL. The overall message of these thoughtful educators is that the medical school culture needs to change and that, in the words of Hughes and Wood , in order to effect that change we will have to “get everyone on board,” administrators, clinicians, and basic scientists. Following are summaries of some of those recommendations.
TEACHING: THE CORE RESPONSIBILITY
The message must go out to the entire medical school faculty that teaching is an important and valued activity. Furthermore, when faculty are hired, in addition to adding up the number of publications and totaling the grant dollars and the clinical earnings the candidates list on their curricula vitae, we need to document and evaluate critically their contributions to teaching.
I endorse Rangachari's  exhortation to the basic scientists that they “dismount their high horses and deal with the needs of students,” and to the clinicians to stay current with regard to basic science knowledge without which they risk practicing medicine by algorithm. If it were left to me, every faculty member would be involved to a significant extent in some aspect of medical education, whether in the lecture hall, the laboratory, or as facilitator of tutorials. On this score, no free passes should be issued.
Medical school administrators, deans, and chairpersons in particular, ought to inform faculty during the recruitment and hiring process that teaching undergraduate medical students is a core responsibility. Furthermore, this message should be emphasized verbally and in writing at each and every end-of-year assessment session the chairperson has with each faculty member in the department. Finally, when the Faculty Handbook of the medical school prescribes that promotion from the rank of assistant professor to associate professor with tenure will be awarded only to those individuals who have excelled in two of the three major responsibility domains of the institution (e.g. teaching, research, and service), the members of the promotion committee, chairperson, and dean who review a candidate's credentials are obligated to measure the candidate against the published promotion standards of the institution and not use a double standard. In practice, however, the promotion guidelines are often violated, especially when the candidate is the principal investigator on several high-priced extramural grants that carry with them overhead and salary monies of a magnitude guaranteed to induce a Pavlovian response in even the most principled dean or chairperson.
The situation is unlikely to change if we continue to simply make platitudinous pronouncements about the importance of teaching in whichever of the many forms it might be conducted. The culture of the medical schools must change if we are to deliver on the promises of PBL or whatever vehicle we choose to use to educate medical students. However, exhortation alone will not bring about this change. Change will require investment of resources in education. There is a need for incentives and encouragement for faculty who wish to devote a substantial part of their career to educating medical students. We need more and better equipped classrooms, and related facilities (e.g. the dissection laboratory). Chairpersons should cease using the threat of an increased teaching burden as a means of motivating faculty to publish and write grants. As is often the case in many medical schools, the culture is such that one of the prominent fears of a research-oriented faculty member who learns that the renewal application for a million-dollar National Institutes of Health grant has just been triaged is that the chair will assign the faculty member to a task equivalent to that of sweeping out the Augean stables, namely teaching medical students.
INTEGRATION IN THE MEDICAL CULTURE
Integrate Ph.D.s and M.D.s into the educational culture. I agree whole-heartedly with Goodenough's  assertion that “basic science Ph.D.s are not well integrated into the culture of the medical school, medical students, or clinical faculty.” The frequency, periodicity, and seriousness of interactions between basic scientists and clinicians ought to be greatly increased. Who can argue with the recommendation that basic scientist-clinician pairs serve together as tutors [1, 4]? The 1-hour-per-week sessions that are convened to prepare the clinicians and basic scientists for the case or cases coming up the next week are a useful way for the two groups to educate each other and exchange ideas about teaching strategies.
Another potentially valuable but grossly underutilized instrument for bringing basic scientists and clinicians together is the weekly grand rounds. One great achievement to which medical school deans should aspire is to get every Ph.D.-basic scientist to attend any one of these weekly conferences on a regular basis, be it in the Department of Internal Medicine, Obstetrics and Gynecology, Pediatrics, or otherwise. Alternatively, basic scientists would benefit from regular attendance at the Pathology Department's Clinical Pathologic Conference. Conversely, in a perfect world every clinician would participate in the weekly Journal Club or seminar program of that basic science department to which his or her interests are most closely aligned. The few clinicians and basic scientists I know who take advantage of these opportunities for cross-fertilizing, cross-discipline forms of informal Continuing Medical Education all agree that it is one of the most pleasant and efficient ways of keeping abreast of advances in biomedical knowledge or of newer ways in which the sciences basic to medicine relate to human disease. It is axiomatic that collegiality between basic scientists and clinicians and the overall sense of community are enhanced when members of these two tribes get together on a regular basis for some scholarly purpose.
TEACH THE FACULTY TO TEACH
In addition to adjusting the attitude of medical school faculty vis-à-vis teaching, a better job of teaching new faculty how to teach needs to be done . The problem may be especially relevant for the basic scientist. Whereas several decades ago a Ph.D. would usually spend just 2 or 3 years as a postdoctoral fellow before entering the tenure stream as an assistant professor, basic scientists today are often hired after having spent as many as 10–15 years in the capacity of postdoctoral fellow, during which time they had little or no teaching responsibilities whatsoever. Compounding the problem is that fact that, although job descriptions for academic positions at medical schools invariably state that evidence of teaching experience is expected, in actual practice the number of grants and publications the applicant lists on his or her curriculum vitae dwarfs any consideration of the applicant's teaching credentials—grant dollars, overhead monies, and extramural salary support almost always trump numbers of lectures delivered, laboratories supervised, classes taught, or tutorials facilitated. If we want basic scientists who are committed to teaching, then the place to start is at the stage of faculty recruitment and hiring. Unfortunately, as pointed out by Goodenough , it is common that “the Ph.D. faculty is hired without a word uttered to them about expectations for training of medical students.”
The problem is further compounded when the chairperson grants a new faculty hire an extended “honeymoon” period that relieves the latter of any significant teaching duties so the new faculty can put all effort into securing a grant from the NIH or some other extramural funding source. I have no problem with the 1- or 2-year honeymoon that gives a new faculty member some time to get a research program up and running; but, I do not think it promotes the educational mission of the institution when the period goes much beyond 2 years.
How do you teach a new faculty member to teach? One way would be to pair him or her with an experienced faculty member who is widely recognized as being an exceptionally gifted teacher. The latter could advise the former about effective teaching strategies. Second, the new faculty member would be encouraged to attend lectures delivered by expert teachers. I have seen many instances in which much benefit was derived by having a newly recruited faculty member co-tutor with an expert. Finally, in this regard, frequent and prompt assessment and constructive criticism of the new faculty member's performance in the lecture hall or tutorial can be helpful.
More definitive, outcome-based assessment of PBL is needed. Goodenough  comments, justifiably I believe, that much of what I had to say in my article about PBL was “anecdotal and not quantitative.” He also makes the point that medical educators “don't know how to measure outcomes (of pedagogical methods),” including PBL. He argues for a definitive analysis of PBL programs and urges educators to come up with serious assessment paradigms to achieve this goal. Although I endorse Goodenough's recommendation, my concern in this regard is that much of the assessment we get will likely come from biased proponents of PBL who will base their rosy, predetermined conclusions more on the results of focus group sessions and student opinion polls than on long-term and wide-ranging quantitative analyses of the data that have been accumulating on PBL-style curricula over the past 25 years or so. Sorely needed are objective assessments of PBL by disinterested scholars with extensive experience in epidemiological approaches to problems and expertise in sophisticated statistical methods of analysis. The medical education literature is replete with essays, including one of my own , that are based more on anecdotal than definitive data. It is difficult to understand why medical school administrators have allowed this situation to exist, especially since there is a substantial literature demonstrating how assessment can be used to improve education . However, a concern I have is that professional educators and associate deans in the Office of Undergraduate Medical Education at medical schools where PBL is practiced gather outcome data on PBL efficacy but limit access to the educational data by faculty they regard as outsiders, thereby greatly inhibiting scholarly analysis of the effectiveness of PBL. One of the problems related to PBL has been the reluctance of the faculty who control and guard such data to make student performance information readily available to the wider medical school community . It seems to be the case in many instances that, at the same time medical education administrators are restricting the wider faculty's access to the institution's student data bases, they themselves are not utilizing these extensive and invaluable data resources to provide their own faculty or the educational community at the national or global level with critical scholarly, published assessments of the PBL curriculum whose merits they proclaim and extol.
FLEXIBLE EDUCATIONAL METHODS
Value and evaluate all educational methods. Educators should understand there is no one-size-fits-all PBL strategy. In this regard, I found Savin-Baden's article  interesting and informative on several scores, but in particular for having described so concisely and clearly the half dozen or so forms PBL has taken at medical schools world-wide. Herreid  thinks the term PBL is used so loosely that it has become practically meaningless and that almost anything that is not a traditional lecture is being regarded as PBL. Clearly, regardless of how “authentic” the PBL is , substantial faculty support, training, and organization are essential to its success. PBL has widely different meanings in the medical education community. Hughes and Wood  pointed out the importance of considering the backgrounds of the student body when deciding how rapidly and extensively to introduce PBL strategies into the medical curriculum. They cite the example of Great Britain where the majority of students who begin medical school at 18 years of age might not have the level of maturity or preparation required for them to profit from a full-bore, PBL-style curriculum. Their paper raises practical questions regarding the pace and extent to which PBL should be introduced into the undergraduate medical curriculum.
TEACH IN CONTEXT
The scope and content of PBL curricula ought to be reviewed, as should all curricula. Goodenough  took me to task for not ranging far enough and for not being sufficiently specific with regard to the important question of what kind of science we should be offering to medical students. He is right when he chastises me for emphasizing molecular detail (e.g. pathophysiological mechanisms) and ignoring more macroscopic, people-to-people and global issues such as the health consequences of poverty, pollution, lack of availability of drugs to Third-World populations, and drug-resistant infectious agents. I am grateful to Goodenough for suggesting that medical educators ought to expand the range of subjects covered in the undergraduate curriculum by shifting the focus from molecule-to-molecule interactions to interactions between individuals and populations, and to seek a proper balance between the two ends of the medical education spectrum. I suspect Goodenough would prefer to see medical students opt for Master of Public Health programs rather than Master of Business Administration programs. So would I.
The experience of having expressed critical judgments in this journal about the shortcomings of PBL-style medical education and then of having to consider the cogent responses of my peers to those opinions has led me to a few basic recommendations or conclusions. First, stop hiring and promoting Ph.D.-basic scientists who would rather walk barefoot through poison ivy than teach medical students. Second, if you have a cadre of clinicians and basic scientists of sufficient critical mass who are passionately and sincerely committed to doing the best they can, collectively and as individuals, to educate medical students, then it makes little difference whether the vehicle you use to do so is pure PBL or a strictly lecture-based curriculum. However, based on experience acquired during the 20 years I spent participating in the delivery of a traditional-style medical curriculum and, more recently, another 15 years I spent tutoring extensively in a PBL-based curriculum, and assuming that rigorous and definitive outcome assessments of the two approaches were to show that it makes no significant difference in the quality, efficiency, productivity or compassion of the doctors we turn out of our medical schools, I would opt for the PBL approach for one reason: it is simply much more enjoyable and much less stressful to learn and teach in a tutorial setting than in a large lecture hall. But, no matter which method we choose to educate medical students, as educators we will surely continue on the long path of deterioration or, in the least, fall far short of our lofty or even modest expectations if we do not immediately commit ourselves to doing a better job of mobilizing, motivating and rewarding many more faculty of the basic scientist and clinician specializations to participate in the honorable and gratifying task of educating and training the next generation of physicians.
The abbreviations used are: BAMBED, Biochemistry and Molecular Biology Education; PBL, problem-based learning.