Howard S. Barrows

A taxonomy of problem-based learning methods

Summary. The increasingly popular term ‘problem‐based learning’ does not refer to a specific educational method. It can have many different meanings depending on the design of the educational method employed and the skills of the teacher. The many variables possible can produce wide variations in quality and in the educational objectives that can be achieved. A taxonomy is proposed to facilitate an awareness of these differences and to help teachers choose a problem‐based learning method most appropriate for their students.

Facilitating Collaborative Knowledge Building

This article describes a detailed analysis of knowledge building in a problem-based learning group. Knowledge building involves increasing the collective knowledge of a group through social discourse. For knowledge building to occur in the classroom, the teacher needs to create opportunities for constructive discourse in order to support student learning and collective knowledge building. In problem-based learning, students learn through collaborative problem solving and reflecting on their experiences. The setting for this study is a group of second-year medical students working with an expert facilitator. The analysis was designed to understand how the facilitator provided opportunities for knowledge-building discourse and how the learners accomplished collective knowledge building. We examined episodes of knowledge-building discourse, the questions and statements that the students and facilitator generated throughout the tutorial, the change in their understanding of the problem that they were solving, and the collective knowledge that was constructed. The results indicate that the group worked to progressively improve their ideas through engaging in knowledge-building discourse. The facilitator helped support knowledge building through asking open-ended metacognitive questions and catalyzing group progress. Students took responsibility for advancing the groups understanding as they asked many high-level questions and built on each others thinking to construct collaborative explanations. The results of this study provide suggestions for orchestrating knowledge-building discourse.

The clinical reasoning process

Summary. Medical school teachers must have an accurate idea of the doctors clinical reasoning process (CRP) in order to provide students with learning experiences and evaluations that will ensure their acquisition of an effective and efficient CRP. It is difficult to derive this understanding from much that has been written on the subject. It is important to recognize that clinical problems are ill‐structured and that the doctors reasoning is built around a temporal unfolding of information. A model for the CRP is described along with a critique of other models that have been suggested. The results of research that examines components of the process must be seen in relation to the overall process.

Use of Standardized Patients in Clinical Assessments: Recent Developments and Measurement Findings

This article reviews recent developments and measurement findings on the use of live patient simulations or “standardized patients” in performance examinations to assess the competence of medical professionals. The results of large-scale standardized patient-based performance assessments are presented and discussed in terms of their feasibility, reliability, validity, and implications for assessing competence in other professions.

Problem-based learning outcomes: the glass half-full.

Purpose To compare the characteristics and outcome data of students from a single institution with a two-track, problem-based learning (PBL) and standard (STND) curriculum. Method PBL and STND students from nine graduating classes at Southern Illinois University School of Medicine were compared using common medical school performance outcomes (USMLE Step 1, USMLE Step 2, clerkship mean ratings, number of clerkship honors and remediation designations, and the senior clinical competency exam), as well as common admission and demographic variables. Results PBL students were older, and the cohort had a higher proportion of women. The two tracks had similar USMLE Step 1 and 2 mean scores and pass rates. Performance differences were significant for PBL students in two clerkships as well as in the clerkship subcategories of clinical performance, knowledge and clinical reasoning, and noncognitive behaviors. In addition, the proportion of PBL students earning honors was greater. Conclusions The traditional undergraduate educational outcomes for the PBL and STND students are very positive. In several of the clerkship performance measures, the PBL students performed significantly better, and in no circumstance did they perform worse than the STND students.

Direct, standardized assessment of clinical competence

Summary. Doctor ratings of clerkship performance are often discounted as not accurately reflecting clinical competence. Such ratings are influenced by the following uncontrolled variables: case difficulty; differing rater focus and standards; lack of agreement on what constitutes acceptable performance; and collective patient care responsibility masks individual contributions. Standardized direct measures of clinical competence were developed to control these factors and allow direct comparisons of student performance. Students saw 18 patients representing frequently occurring and important patient problems. Student actions and decisions were recorded and subsequent responses to questions revealed knowledge of pathophysiology, basis for actions, use and interpretation of laboratory investigations, and management. Actions and responses were graded using a pre‐set key. The examination covered 73% of designated clinical competencies. Examination scores corresponded with independent measures of clinical competence. Reliability studies indicated that new cases can be substituted in subsequent years with confidence that scores will maintain similar meaning. Costs are £6.95 per student per case, which is modest considering the quality and quantity of information acquired. Methods described are practical for evaluation of clerks and residents and for licensing and specialty certification examinations.

Clinical behaviors and skills that faculty from 12 institutions judged were essential for medical students to acquire

This paper describes a 1988–1989 collaborative mail survey of faculty opinion about clinical behaviors and skills that students should be expected to demonstrate prior to graduation from undergraduate medical school (hereafter called “exit objectives”). Selected faculty from 12 American and Canadian medical schools indicated whether each of 77 objectives was essential for every student to know or demonstrate prior to graduation; useful but not essential at the undergraduate level; or not applicable to their undergraduate program. Their responses provide a glimpse into faculty expectations regarding some of the exit behaviours and skills they deemed essential. Forty-two percent (32) of the 77 objectives were regarded as essential by 75% or more of the faculty members who responded. Essential objectives involved conducting organ system examinations, formulating problems and hypotheses, and gathering fundamental interview, physical, and screening examination data, including emergency examinations of the airway and circulatory systems. Other essential objectives involved collaboration and communication, demonstrating concern for legal and ethical values, and keeping abreast of current information within the discipline. Exit objectives related to the diagnosis and management of specific conditions were regarded as useful but not essential at the undergraduate level. Implications for medical education are discussed.

Three studies of the effect of multiple standardized patients on intercase reliability of five standardized‐patient examinations

Standardized‐patient (SP) cases have been used in a postclerkship examination to assess clinical competence of five classes of senior medical students at Southern Illinois University School of Medicine. Two or more (multiple) SPs have been used to simulate at least half the cases in each examination administered to date. The present studies were conducted to determine the effect of multiple SPs on intercase reliability. In Study 1, for each class, generalizability analyses were performed to determine the intercase reliabilities for cases using a single SP and for cases using multiple SPs. Study 2 was conducted to compare the intercase reliabilities of those few cases that were used in two different classes, simulated by single SPs in one class and by multiple SPs in the other. Study 3 was undertaken to determine directly by statistical analysis of the multiple‐SP cases only, the contributions of multiple SPs to measurement error and, hence, reliability. The results of all three studies showed little or no...

Large Group Problem-based Learning: A possible solution for the ‘2 sigma problem’

Problem-based learning is characteristically carried out in small groups with the teacher in a tutorial role and usually five to seven students. It has been difficult for schools interested in using this method to provide teachers with appropriate skills in sufficient numbers. In a second year immunology course the case method, an interactive teaching method requiring only one teacher for an entire class, was blended with the teaching-learning sequences employed in problem-based learning. The result of this experience suggests that large group problem-based learning may be an acceptable and more feasible alternative to small group problem-based learning.

Developing consortia for clinical practice examinations: The Macy project

A series of workshops demonstrating a model for assessing the clinical performance of medical students with standardized patients (SPs) was conducted between 1989 and 1991, with deans or senior faculty from more than 90 North American medical schools in attendance. Although 80% of these schools subsequently expressed interest in implementing similar programs, the cost in faculty time and resources was an issue of concern. To facilitate the best use of the limited resources available, and with the financial assistance of the Josiah Macy Jr. Foundation, six consortia of schools were established for this purpose: North Carolina, Gulf Coast, Northwest, Southern California, Metropolitan New York, and Upstate New York. Although all consortia share similarities, each has its own vision, purpose, and operational methods. This article describes the consortia generically and in their individual variations.