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A Critical Discussion of the Application of Problem-based Learning to Undergraduate Pharmacotherapeutic Teaching

Farmasøytisk Institutt, Universitetet i Oslo, Postboks 1068 Blindern, 0316 Oslo.

Problem-based learning (PBL) has caused a small revolution in the medical education community, and a lot of schools have adopted this method At the Institute of Pharmacy, the University of Oslo, PBL is being applied in a new course in pharmacotherapeutics. The course was established because it was felt that teaching pharmacology using conventional methods was insufficient, since newly graduated pharmacists were not able to apply their acquired knowledge. Useful inspiration and ideas have been obtained from a similar course design at the Institute of Biopharmacy, the University of Uppsala in Sweden. The experience from medical education has been extrapolated to pharmacy education. The students work in tutorial groups. They use written patient cases, the intent of which is to stimulate discussion in order to obtain knowledge about the correct application of drugs. Advantages and disadvantages of introducing PBL as a teaching method in undergraduate pharmacotherapeutic teaching is discussed.

Introduction

Problem-based learning (PBL) has design of education, and it represents an become a well-established approach to the approach to learning and teaching which is based on how adults learn most effectively (Mustard et al., 1982). In spite of its growth, there is continuing confusion about what PBL really is, and whether it can effectively replace the conventional curriculum.

The purpose of this assignment is to discuss the application of PBL to undergraduate pharmacotherapeutic teaching using a new course for pharmacy students at the University of Oslo as a model.

What is Problem-based learning?

PBL has its roots at McMaster University in Canada in 1969, and so far PBL has mostly been used in medical education. PBL at its most fundamental level is an instructional method characterised by the use of patient problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical sciences (Albanese and Mitchell, 1993). Boud (1985) describes the philosophy behind PBL in the following way: “The main thought of PBL is that the start of a learning process should be a problem, a question or a puzzle which the student want to solve”. Curricula which clearly address PBL generally use written case studies with the intent of stimulating classroom discussion. In PBL students, working in small groups, actively discuss and seek to resolve the issues which the case raises using a systematic procedure (Fig. 1) (Schmidt, 1989).

According to Barrows and Tamblyn (1980) and Barrows (1984), a primary goal of PBL is to foster clinical reasoning or problem-solving skills in students. He assumes that through continuous exposure to real-life problems, students will acquire the craft of evaluating the problems, deciding what is wrong, and making decisions about appropriate actions available which can be used to address the problem. A second objective is to enhance acquisition, retention and the use of knowledge (Albanese and Mitchell, 1993). PBL integrates learning of pre-clinical and clinical knowledge, and bridges the gap between the basic and clinical sciences. Another objective is to enhance “self-directed learning” skills.

Design of a course in Pharmacotherapeutics

PBL was initially applied at the Institute of Pharmacy at the University of Oslo in August 1993 as a new course in pharmacotherapeutics for undergraduate pharmacy students. The course is placed in the fourth year of the study, whereas basic pharmacology is taught in the third year using conventional methods. The course is divided into clinically thematic blocks (e.g. hypertension, diabetes). Topics covered are basic pathology with emphasis on the most common diseases, choice of medication and dosing regimen, individual variability in drug response, side effects and important drug interactions. The structure of the course is meant to stimulate the students to search for and use knowledge actively by exposure to real-life situations.

Aims and objectives for the course

The aims are to develop understanding and knowledge about proper drug therapy for various diseases and to develop communication skills with respect to drug information.

The objectives:

After completing each thematic block the student should be able to:

- describe the pathology, aetiology and symptomology of the disease

- evaluate non-pharmacological treatment of the disease

- describe the mechanism of action of the drugs

- suggest an appropriate drug based on the patient’s other diseases, age, etc.

- suggest appropriate dosage based on knowledge about pharmacokinetics of the drug

- know about the most important problem-drugs

- evaluate advantages and possible drug interactions by combination of drugs

- identify possible side effects of the drugs

Course structure

The students are divided into groups of 5-8 students with a tutor. Small tutorial groups are the main teaching resource in PBL (Barrows, 1985). While working on the case, the group uses the PBL method consisting of seven steps (Fig. 1) (Schmidt, 1989). The group meets twice a week for about 1.5 hours each time. On the first meeting they define the problems, analyse the problem and formulate the learning objectives regarding a particular case (step 1-5). On the second meeting they synthesise the acquired information (step 7). In between group-sessions the students are individually responsible for their self-directed learning (step 6).

The course uses written case studies with the intention of stimulating discussion. Cases describe a patient or a customer at the pharmacy and his/her main problem or situation while conveying information the students need to critically analyse the problem. In this course a variety of different case formats are used, but cases are usually brief stories with one particular focus. Similarly Barrows (1984) indicates that cases can be written in a variety of formats.

Problem-Based Learning “The Seven Steps”

Step 1: Clarify terms and concepts not readily comprehensible

Step 2: Define the problem

Step 3: Analyse the problem (brainstorming)

Step 4: Draw a systematic invetory of the explanations inferred from step 3

Step 5: Formulate learning goals

Step 6: Collect additional information outsidethegroup

Step 7: Synthesise and test the newly acquired information

Fig. 1. The problem-based learning process (Schmidt, 1989).

Our department tutors are both experienced and non-experienced pharmacists in respect to the content of the problems. The main role of the tutors is to guide and support the group in the process of problem-solving. The tutor is supposed to stimulate and motivate the students in their approach to learning and not to come up with the solutions of the problem. The skills of the tutors have been described to be the backbone of problem-based learning (Barrows, 1985).

Each subject is concluded by a classroom discussion where the groups present the results of their work with both a physician and a pharmacist present. These discussions also include short student-lectures of 10 minutes duration, which focus on certain topical subjects. Each student present one such lecture during the course. These activities is supposed to stimulate and motivate the students in order to obtain communication skills, which is one of the aims of this course. Two lectures are included in each clinical thematic block. One which relates to the pathology of the disease is held by a physician. The other lecture, which relates to the drug therapy for the disease is held by a pharmacist.

Finally the course is concluded by an individual written examination. Here, the students are supposed to show a critical analysis of a variety of patient-cases with respect to proper application of drugs to individual patients. The examination reflects the teaching method applied during this course.

Discussion

A. Consequences of applying PBL - for the students

Practical application of knowledge

The Department of Pharmacology decided to apply PBL in pharmacotherapeutic teaching because the central importance of teaching pharmacology in a clinical context with real-life situations was recognised. Pharmacy graduates from the old-style curriculum reported that they were not able to apply their knowledge in their daily work as pharmacists. It has been postulated that education is most effective when it is undertaken in the context of future tasks (Glaser, 1982). PBL has the potential to structure knowledge for use in a clinical context (Barrows, 1985). In pharmacy education, most subjects (including pharmacology), may be perceived as theoretical. It is therefore important that basic pharmacology and other basic subjects are presented in a clinical context which the students understand and recognise as important for their future professional performance (Hammarlund-Udenaes and Koch, 1993). The objective is to make the student understand and apply their knowledge, not just retain it. Therefore the case studies should be as close to the real-life situations as possible. In our course, students report that by working through written patient cases they feel competent to discuss the decisions they have made in the classroom discussion with teachers present.

In the evaluation after the course the students indicate that the aims of the course were, to a great extent, reached. This evaluation was performed two months after the course, when the students were having their practice period in a pharmacy. They reported that they felt able to apply their pharmacotherapeutic knowledge actively in then-work with customers and patients. The Institute of Biopharmacy at the University of Uppsala in Sweden also reports that both students and teachers are very satisfied with a similar course design in pharmacotherapeutics which was introduced in 1989 (Hammarlund-Udenaes et al., 1990).

Student satisfaction

The present course is well accepted by the pharmacy students. They indicate that this working method is motivating and j, stimulates their interest in the subject. They even describe the course and the j PBL method as enjoyable. Similarly others have reported PBL to have an important role in student motivation, as die students find the learning environment more stimulating and humane than with traditional methods of teaching (Norman and Schmidt, 1992). On the other hand Berkson (1993) points out that the experience of PBL can be stressful for both students and faculty. Some of our students found the PBL method frustrating and difficult in the beginning of the course. However, an evaluation m the middle of the course, indicated that most students were satisfied with the PBL method once they were more acquainted with it. This is in agreement with Oscarsson et al. (1993).

Connection of prior knowledge and new information

The primary goal of this course is to combine prior knowledge in basic pharmacology with new information about various diseases in order to obtain knowledge about the application of drugs. The psychological principles of learning indicate that current learning is affected by past learning, and students use knowledge they already possess to understand and structure new information. In order to be successful, Albanese and Mitchell (1993) indicate that the instructional method must activate this prior knowledge, and new information must be actively related to existing knowledge through elaboration processes. PBL provides opportunities for elaboration of knowledge. Use of patient cases with information about drugs and diseases in this pharmacotherapeutic course provides opportunities for connecting prior knowledge and new information.

Lifelong learning

PBL have been reported to provide students with opportunity to take greater responsibility for their own learning with respect to what and how they will learn. This is often referred to as “student-centred” and “self-directed learning” (Blumberg and Michael, 1992). As postulated by many authors, use of small tutorial groups as the central educational event may develop independent life-long learning skills by students (Neufeld et al., 1989).

Development of the personality?

Some studies indicate that students from PBL curricula tend to develop positive personal qualities compared with students from traditional curricula. Friedman et al. (1990) mention qualities as empathy, information and communication skills, as well as a will to continuing life-long learning. Students from PBL curricula have been identified as having higher level of professional and psycho- social safety than students from conventional curricula. As low levels of self-confidence seems to be a common problem for newly graduated pharmacists as well as preregistred medical doctors (Vikanes et al., 1992), it is worthwhile trying PBL as a teaching method.

A positive, non-threatening social milieu with good relationships between tutors and students is an important supposition for learning. The base group gives opportunities for transient feedback on statements and behaviour. The group process may perform skills in giving and receiving positive and negative criticism. The PBL method may also give the students cooperation and collaboration skills (Brichman-Hansen. 1993).

Learning outcome and assessment

Some studies report that there are small differences between the overall knowledge or competence of students trained by PBL and by conventional curricula, and Berkson (1993) reports that the graduate of PBL is not distinguishable from his or her traditional counterpart. In these studies examination marks are used as a measure, and some studies report that students from PBL curricula obtain worse results in basic subjects than other students (Albanese and Mitchell, 1993). Multiple-choice examinations have mostly been used, and these do not facilitate the PBL process of learning. However, students from PBL curricula perform better in clinically related subjects, and there are substantial differences related to the retention of knowledge and learning skills, that may be attributable to PBL. There is a strong theoretical basis for the idea that PBL students may be better able to transfer concepts to new problems (Norman and Schmidt, 1992). On the other hand Coles (1992) has postulated that PBL is an unnecessary complication to the educational scene, and he has outlined a contextual learning model which should be applied instead of conventional courses. However, this confusion may partly be due to the examination form used. In the present course we therefore found it important to design the examination in a similar format as the teaching method, and individual written exams with patient cases are used. The students report that this examination method correlates well with the teaching method.

B. Consequences of applying PBL-for the teachers/tutors

Department satisfaction

The teachers and the tutors report that they find the present course and PBL motivating. They found it extremely stimulating to see the students’ increasing competence during the course, and felt that they developed both professionally and personally while in close collaboration with the students. Others report the same feedback from teachers/tutors, even though application of PBL is approximately 10% more time-consuming for them (Mårtenson, 1990). However, it is important to be aware that PBL demands a change of attitude and flexibility on the part of the teachers. PBL is a “student-centred” teaching method, in contrast to the traditional “teacher-centred” method. For a lot of teachers the crossing from lecture-based teaching to PBL curricula seems threatening and difficult. The role of the teacher changes from effecting knowledge to developing knowledge. Base groups replace to a great extent the lectures, and the task of the teacher is to prepare for learning and to be sure that the students work upon the material in an internalised way.

Role of the Tutor

As pointed out earlier the tutors must be skilled in facilitating small-group learning (Barrows and Tamblyn, 1980). The tutors’ most important challenge in PBL is to allow each student, with the help of others in the group, to recognise his or her own educational difficulties (Barrows, 1985). Prior to the commencement of the course our tutors attended a two days course in how to be a tutor of PBL. There it was shown that a tutor may interact on the three following stages: the group dynamics, the PBL process and the content of the problem (Helgesson et al., 1993). With respect to the first issue, the tutor needs to be able to handle small group dynamics. This involves managing the more aggressive students who may dominate the group and the retiring member of the group who does not contribute. The second role of the tutor is to keep the PBL process on the track through non-directive comments. The role is not passive, but the tutore are supposed to sit back and wait, and create a group environment which stimulates analysis and reflection.

Even after having this tutor course, which we found of great importance, our tutors found their work frustrating from time to time. The groups performed differently, because of unequal prior knowledge as well as different personalities. As also reported from the pharmacotherapeutic course in Sweden (Hammarlund-Udenaes et al., 1990), one or two of our groups had problems, and both tutors and students felt frustrated. However the tutors felt, as Barrows (1985) reports, that once comfortable in the tutor role, the rewards of seeing students grow into mature thinking professionals is very satisfying. It is still important to be aware that there are a lot of problems arising with respect to the group dynamics.

Tutors are not necessarily expected to be experts in the content of the problem to which a solution is sought. However, Barrows (1988) states that the ideal circumstance is for the tutor to be expert both in the tutoring process and in the discipline being studied by the student. If this is not possible, the next-best tutor is a teacher who is skilled m the tutoring process. Others indicate that tutor expertise in the content is necessary if the student is to develop the capacity for effective, continuous, life-long learning (Eagle et al., 1992). On the other hand expert tutors tend to take a more directive role in the tutorials. They speak more frequently and for longer periods and may suggest more of the topics for discussion. This may lead to less student-to-student discussion, which is important for developing students’ skills m active, self-directed learning (Silver and Wilkerson, 1991).

Feasibility and cost

In relation to other conventionally taught courses at our department, we found the present course very resource demanding. Similarly, others report that application of PBL is unrealistically costly (Hammarlund-Udenaes et al., 1990; Berkson, 1992). PBL is time-consuming for the teachers and the tutors. In the present course we use different teachers who are experts in different topics, and this invokes a lot of administration as well as financial cost. It is also important that the teachers and the tutors are motivated to use the PBL approach.

Additionaly, training of tutors in the process of small-group facilitation is of great value, and finances are needed for this purpose. PBL also requires another room set-up than traditional teaching. There is a large requirement for small group rooms, while lecture theatre requirements are small. A well-stocked library with important reference literature and search-facilities are also needed.

Problembasert læring vil føre til mer vellykket jakt på våre usynlige fiender i kroppens molekyler. Foto: Anders Chr. Cederløv, Nordlys.

Conclusion

After completing the first year teaching pharmacotherapeutics using a problem-based learning approach, our department find application of this method very promising. The course is well accepted by the pharmacy students. As a tool for teaching pharmacotherapeutics in a clinical context in order that the students are able to practically apply their knowledge in their future work, PBL seems to be more effective than traditional teaching methods.

PBL is challenging for both students and teachers, because it is quite different from the traditional teaching methods at the university. It has been postulated that application of PBL requires rebuilding of the whole curriculum in order to be successful. However, our experience at the University of Oslo indicates that this is not a prerequisite for the successful application of PBL. The undoubted benefits which this approach may offer, have been recognised in a pharmacotherapeutics course which co-exists within a traditional curriculum. Perhaps the biggest challenge to the successful implementation of PBL to educational establishments does not concern the approach itself, but rather lies in the traditional thought-patterns of academic staff with regard to teaching.

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