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C4d deposits on erythrocytes (EC4d): a new biomarker of antibody-mediated rejection in kidney transplantation
Fundamental concepts of problem-based learning for the new facilitator* By Steven L. Kanter, M.D. Associate Dean of Medical Education M211 Scaife Hall School of Medicine
University of Pittsburgh Pittsburgh, Pennsylvania 15261
Problem-based learning (PBL) is a powerful small group learning tool that should be part of the armamentarium of every serious educator. Classic PBL uses ill-structured problems to simulate the conditions that occur in the real environment. Students play an active role and use an iterative process of seeking new information based on identified learning issues, restructuring the information in light of the new knowledge, gathering additional information, and so forth. Faculty play a facilitatory role, not a traditional instructional role, by posing metacognitive questions to students. These questions serve to assist in organizing, generalizing, and evaluating knowledge; to probe for supporting evidence; to explore faulty reasoning; to stimulate discussion of attitudes; and to develop self-directed learning and selfassessment skills. Professional librarians play significant roles in the PBL environment extending from traditional service provider to resource person to educator. Students and faculty usually find the learning experience productive and enjoyable. INTRODUCTION
Problem-based learning (PBL) is a small group learning technique used at a large number of medical schools [1]. Learning results from the activities pursued to achieve an understanding of a selected problem. The goal of a PBL session is not to identify a single solution to the problem presented, but rather to identify several potential solutions (the differential diagnosis in medicine) and to cultivate an understanding of how the solutions were generated and how to discriminate among the solutions. Although many different types of small group learning activities are labeled PBL [2], in this paper "classic PBL" will be defined as the method originally described by Barrows and colleagues [3-5]. Classic PBL has been used as one of several small group learning methods at the University of Pittsburgh School of Medicine during the last five years. Key characteristics of the PBL method include: (1) the primary learning activity is problem solving rather than memorization; * Based on a presentation at the Life Sciences Research and Reference Institute, University of Pittsburgh, School of Information Sciences, Department of Library and Information Sciences, Pittsburgh, Pennsylvania, May 6, 1996.
Bull Med Libr Assoc 86(3) July 1998
(2) the student is an active rather than a passive participant; (3) the teacher functions as a facilitator rather than an instructor; (4) the environment is one of collaborative, group-centered learning rather than competitive, individual-centered learning; and (5) the problem is ill-structured rather than well-structured (see below for concept definitions). In medicine, patients' problems are frequently used, but a variety of other problems may serve as well, such as public health problems, administrative problems, information retrieval problems, and business problems. In this article, patient problems are used as the prototypical example; the reader is encouraged to apply the concepts to his or her own domain. PBL is not the solution for all problems in education; however, it is a powerful tool for allowing students actively to build collaborative problem solving skills that will be required in the work environment. PBL is a primary learning method in which new material is presented rather than a euphemism for "afternoon review sessions with voluntary attendance." PBL sessions with simulated problems complement other types of small group methods, lectures, and experiential sessions. Students and faculty usually find the learning experience most productive and enjoyable [69]. 391
Kanter
Prior work has delineated the beneficial role of the library [10] and the key role of librarians [11] in PBL curricula. Others have described PBL and its impact on the health sciences library and librarian [12-15]. Satterthwaite et al. have noted that librarians possess the requisite knowledge and skills needed to function as facilitators [16]. As librarians seek to fulfill roles as faculty facilitators and as educators about knowledge management, a basic understanding of PBL becomes a necessity. The purpose of this article is to present fundamental concepts of PBL that can serve as a foundation from which the new facilitator can implement and develop his or her role in the small group learning environment. FUNDAMENTAL CONCEPTS Hybrid PBL curriculum A hybrid PBL curriculum is one which includes PBL as one of several learning experiences. For example, the Physicians in Two Thousand Curriculum at the University of Pittsburgh School of Medicine includes lectures, PBL, laboratory experiences, service learning, computer-based simulations, experiential learning, and community based learning. Approximately onethird of scheduled instructional hours in the first two years are designated for small group learning, of which classic PBL constitutes a significant portion [17].
Ill-structured problem To simulate problems in the real environment, the classic PBL session begins with an ill-structured problem. In an ill-structured problem little information is presented initially (so that there is a high level of uncertainty for the problem solver), an approach for solving the problem is not immediately evident, and the problem solver is often not clear whether he or she is "on the right track." By contrast, a well-structured problem is one in which most of the information is presented initially, an approach for solving the problem is quickly evident to all but the neophyte, and the problem solver is usually clear whether he or she is "on the right track." Real environments are characterized by ill-structured problems. Group size The ideal number of students in a PBL group is six to nine [18]. If there are twelve or more students in a group, working through an ill-structured problem in a timely fashion is difficult with all students participating. Certainly good small group learning experiences can be achieved with twelve or more students, but an experience more structured than classic PBL is required. 392
Facilitator The teacher in a classic PBL setting assumes the role of a coach or facilitator, rather than the more traditional didactic or instructional role of a lecturer.
Paper case A paper case is a problem usually presented in four to seven parts, in which each part is printed on a separate piece of paper. A problem also may be presented using a computer interface or a standardized patient. PBL unit A PBL unit usually consists of two meetings: a problem presentation meeting and a problem discussion meeting. The reader should be aware that the labelsPBL unit, problem presentation meeting, and problem discussion meeting-are not standardized and a variety of synonyms are in popular use. Some PBL units are designed with three meetings, with the middle meeting used for presentation of additional new material, a data gathering exercise (e.g., a laboratory experience), or other experiential activity (e.g., collecting a blood, urine, or sputum specimen from a fellow student or a real patient).
Problem presentation meeting The problem presentation meeting is the first of two PBL meetings in which the ill-structured problem is presented to the students. The information is structured as facts, hypotheses, and learning issues. Facts, hypotheses, and learning issues In classic PBL, students initially approach a problem by organizing the information given and the information generated by the group into three categories: facts, hypotheses, and learning issues. Defining a fact as a piece of given information, a hypothesis as a proposed explanation for all or part of the patient's problem, and a learning issue as information that needs to be learned in order to solve a problem may seem straightforward. However, a new group of collaborative learners will negotiate what they will generally consider to be a fact, a hypothesis, or a learning issue, and the classification of specific pieces of information will often be debated at length. Different groups will record the same piece of information under different categories. Experienced groups may modify and add to the standard categories of facts, hypotheses, and learning issues.
Learning objectives Learning objectives, also referred to as educational objectives or instructional objectives, are specifications of the performance required to demonstrate competence Bull Med Libr Assoc 86(3) July 1998
Fundamental concepts of problem-based learning
or mastery of defined material. While learning issues are generated by the students working on a problem, learning objectives are generated by the faculty and are used to communicate the expectations of the faculty to the students. Learning objectives can be distributed at various times during a PBL session. Providing the objectives near the end of the problem presentation session prevents objectives written by the faculty from interfering with the formulation of learning issues by students, while allowing students to compare their learning issues to faculty expectations.
Self-directed learning time Self-directed learning is the time between the problem presentation and problem discussion meetings, during which students, individually or in small groups of varying size, pursue an iterative process of seeking information based on the identified learning issues, restructuring the information in light of new knowledge, gathering additional information, and so forth. Students may seek information from print, electronic, and multimedia resources as well as human resources, including teachers, librarians, colleagues, and others. Problem discussion meeting The problem discussion meeting is the second of two PBL meetings in which the problem is discussed in light of the information discovered during the self-directed investigation of the learning issues identified in the problem presentation meeting. THE ROLE OF THE FACILITATOR: A SIMPLIFIED CHRONOLOGY OF A TYPICAL PBL UNIT
A classic PBL unit consists typically of two meetings: a problem presentation meeting and a problem discussion meeting. Depending on the nature of the problem, between one and two hours are usually allocated for each meeting.
The problem presentation meeting For a group of students that has not yet worked together, the problem presentation meeting begins with each group member including the facilitator introducing himself or herself. To assist group process effectively, the facilitator needs to memorize the name of each student in the group immediately. The facilitator then presents some ground rules to guide group process. For example, the facilitator might say, "In this group, you (the students) are responsible for the functioning of the group and the direction it pursues. It is perfectly acceptable to say what's on your mind and it is perfectly acceptable to disagree with another student. If you do not like the direction your group is taking to solve a problem, it is your responBull Med Libr Assoc 86(3) July 1998
sibility to negotiate with the group to change or modify its approach. My role is to make you think harder and more clearly about your assertions, explanations, and problem solving strategies. When I comment, don't assume that I agree or disagree with you-I intend to intervene in both situations." While this explanation is necessary for an inexperienced group of students, if the facilitator is new to an experienced group, the explanation may be useful for the facilitator to affirm his or her role. Next, the facilitator distributes the first page of the problem if a paper case is used. Otherwise, the initial information is accessed by computer simulation of a patient, questioning a simulated or real patient, or other method. The facilitator focuses the group by suggesting that one person read the information aloud. The group then begins to organize information into the three categories of facts, hypotheses, and learning issues. Experienced groups may use additional or modified categories. When no further information can be identified in or generated from the first page of a paper case or other initial information, the group requests the next page of the paper case from the facilitator or accesses subsequent information. The facilitator's role is to ensure that the group has "drilled into" the problem deeply enough with the information at hand prior to accessing new information. The facilitator also assists group process as follows: (1) encouraging a more thorough understanding of material by asking metacognitive questions (e.g., Why did you think of that hypothesis? How do you know that what you are saying is correct? Is your statement important?); (2) promoting synthetic and interpretive thinking skills by asking each student to take one or more turns summarizing the case; (3) involving the quiet or non-participating student by asking direct metacognitive questions (e.g., Do you agree with the hypotheses generated? What do you think are the most important facts identified thus far?); (4) regulating the aggressive, domineering participant by asking mitigating questions (e.g., directed to another group member: Why do you think Sam [the domineering student] feels so strongly about this issue?); (5) monitoring time by asking questions of intent (e.g., How do you plan to organize the rest of this meeting? How do you plan to organize your self-directed study?). Note that the role of the facilitator is not passive. In fact, the facilitator plays an active role in the group, monitoring all verbal and non-verbal interactions to identify opportunities to assist group process and to enhance learning. Approximately the last fourth of the problem presentation meeting should be reserved for refining the learning issues and establishing a plan for self-directed investigation. At this point distributing faculty-developed learning objectives can be most useful. Students find comparing their learning issues with the 393
Kanter
faculty's objectives useful; there is usually a significant concordance. If faculty-developed learning objectives are distributed at the beginning of the problem presentation meeting, they tend to constrain the discussion and inhibit creative exploration of an ill-structured problem. The self-directed learning component The students use the time between the problem presentation and problem discussion meeting to pursue self-directed investigation of the learning issues. Students work individually and collaboratively with students from their own or other groups. Students may contact faculty, residents, friends, peers, and others for information, explanation, and discussion during the self-directed learning period, and the facilitator generally plays no role during this time. The librarian, however, assumes a very significant role. During the student self-directed learning component of PBL, the librarian can fulfill one or more roles including traditional service provider, resource person, and educator [19, 20]. The librarian may direct students to information resources, recommend additional resources that are potentially relevant to a student's line of inquiry, assist students in the information retrieval process, assist students in formulating and refining a line of inquiry, inform students about methods of information discovery, and teach students how to assess the value of information [21-24]. The problem discussion meeting The problem discussion meeting should be a synthetic discussion of the problem, informed by the new information acquired from self-directed investigation of the learning issues identified in the initial meeting. This discussion should emphasize analysis, synthesis, and interpretation of medical knowledge and should not simply degrade into a concatenation of mini-lectures by each student. Additional goals of this meeting include (1) critiquing information resources used by the students; (2) recreating and critiquing the reasoning process used in the problem presentation meeting, examining the relevance and complexity of the hypotheses and learning issues generated; (3) the use of learning aids (e.g., charts, graphs, Web resources) by students to explain concepts to the group; (4) assessment of each student's contribution to the group by both the facilitator and other students with an eye towards providing each student with feedback that will allow him or her to improve performance in the next PBL unit; and (5) assessment of the facilitator (by both the facilitator and the students) with an eye towards providing the facilitator with feedback that will allow him or her to improve performance in the next PBL unit. Problem discussion meetings may also include debate, role playing, and structured controversy [25]. 394
To encourage a more thorough understanding of information resources, the facilitator can promote learning by asking such questions as: Why did you choose that resource? How valuable did you find that resource? How do you know the information in that resource is accurate? How will you better choose resources for your next problem? To advance the selfassessment process, facilitators may ask: What can you do next time to formulate better hypotheses? What can you do to solve the next problem more efficiently? How can you contribute better to the group? As always, the facilitator should be careful not to assume responsibility for directing the group. SUMMARY PBL is a small group learning method that encourages students to learn actively while developing critical thinking skills and building collaborative problem solving skills that will be required in the work environment. PBL is a primary learning method in which new material is presented, and is not a euphemism for afternoon review sessions with voluntary attendance. Students and faculty usually find the learning experience productive and enjoyable, and PBL should be part of the methods of every serious educator. It is increasingly important for professional librarians to understand the fundamental concepts of PBL as they are sought to fulfill traditional service provider, resource person, and educator roles in the PBL process. REFERENCES 1. ALBANESE MA, MITCHELL S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993 Jan;68(1):52-81. 2. FOLEY P, POLSON AL, VANCE JM. Review of the literature on PBL in the clinical setting. Teach Learn Med 1997;9(1):4-9. 3. BARROWS HS, TAMBLYN R. Problem-based learning: an approach to medical education. New York: Springer-Verlag, 1985. 4. BARROWS HS. How to design a problem-based learning curriculum for the preclinical years. New York: Springer-Verlag, 1985. 5. BARROWS HS. The tutorial process. Springfield, Illinois: Southern Illinois University School of Medicine, 1988. 6. YATES WR, GERDES TT. Problem-based learning in consultation psychiatry. Gen Hosp Psychiatry 1996 May;18(3): 139-44. 7. ARMSTRONG EG. A hybrid model of problem-based learning In: Boud D, Feletti G. The challenge of problem based learning. London: Kogan Page, 1991:147. 8. VERNON DTA. Attitudes and opinions of faculty tutors about problem-based learning. Acad Med 1995 Mar;70(3): 216-23. 9. SCHWARTZ RW, DONNELLY MB, SLOAN DA, STRODEL WE. Residents' evaluation of a problem-based learning curriculum in a general surgery residency program. Am J Surg 1997
Apr;173(4):338-41. 10. BLAKE J. Library resources for problem-based learning: Bull Med Libr Assoc 86(3) July 1998
Fundamental concepts of problem-based learning
the program perspective. Comput Methods Programs Biomed 1994 Sep;44(3-4):167-73. 11. SCHILLING K, GINN DS, MICKELSON P, ROTH LH. Integration of information-seeking skills and activities into a problem-based curriculum. Bull Med Libr Assoc 1995 Apr; 83(2):176-83. 12. DONNER RS, BICKLEY H. Problem-based learning in American medical education: an overview. Bull Med Libr Assoc 1993 July; 81(3):294-8. 13. ELDREDGE JD. A problem-based learning curriculum in transition: the emerging role of the library. Bull Med Libr Assoc 1993 Jul;81(3):310-15. 14. MARSHALL JG, FITZGERALD D, BUSBY L, HEATON G. A study of library use in problem-based and traditional medical curricula. Bull Med Libr Assoc 1993 Jul;81(3):299-305. 15. WATKINS MC. Characteristics of services and educational programs in libraries serving problem-based curricula: a group self study. Bull Med Libr Assoc 1993 Jul;81(3):306-309. 16. SATTERTHWAITE RK, HELMS ME, NOURAVARSANI R, VAN ANTWERP M. Library faculty role in problem-based learning: facilitating small groups. Bull Med Libr Assoc 1995 Oct; 83(4):465-8.
Bull Med Libr Assoc 86(3) July 1998
17. REYNOLDS CF, ADLER S, KANTER SL, HORN JP, HARVEY J, BERNIER GM. The undergraduate medical curriculum: cen-
tralized versus departmentalized. Acad Med 1995;70(8):67175. 18. BARROWS, TAMBLYN, op. cit. 19. WATKINS op. cit. 20. EARL MF, HENSLE K, FISHER JS, KELLEY MJ, ET AL. Faculty involvement in problem-based library orientation for firstyear medical students. Bull Med Libr Assoc 1996 Jul;84(3): 411-16. 21. REYNOLDS, ET AL., op. cit. 22. EARL MF. Library instruction in the medical school curriculum: a survey of medical college libraries. Bull Med Libr Assoc 1996 Apr;84(2):191-5. 23. BRAUDE RM. Medical librarianship and medical informatics. J Am Med Inform Assoc 1994;1:467-68. 24. BALL MJ. The library of the future: an informatics institution. Int J Biomed Comput 1995 Oct;40(2):85-8. 25. JOHNSON DW, JOHNSON FE Joining together: group theory and group skills. 4th ed. Englewood Cliffs, NJ: PrenticeHall, 1991:255-87.
Received July 1997; accepted October 1997
395
University of Pittsburgh Pittsburgh, Pennsylvania 15261
Problem-based learning (PBL) is a powerful small group learning tool that should be part of the armamentarium of every serious educator. Classic PBL uses ill-structured problems to simulate the conditions that occur in the real environment. Students play an active role and use an iterative process of seeking new information based on identified learning issues, restructuring the information in light of the new knowledge, gathering additional information, and so forth. Faculty play a facilitatory role, not a traditional instructional role, by posing metacognitive questions to students. These questions serve to assist in organizing, generalizing, and evaluating knowledge; to probe for supporting evidence; to explore faulty reasoning; to stimulate discussion of attitudes; and to develop self-directed learning and selfassessment skills. Professional librarians play significant roles in the PBL environment extending from traditional service provider to resource person to educator. Students and faculty usually find the learning experience productive and enjoyable. INTRODUCTION
Problem-based learning (PBL) is a small group learning technique used at a large number of medical schools [1]. Learning results from the activities pursued to achieve an understanding of a selected problem. The goal of a PBL session is not to identify a single solution to the problem presented, but rather to identify several potential solutions (the differential diagnosis in medicine) and to cultivate an understanding of how the solutions were generated and how to discriminate among the solutions. Although many different types of small group learning activities are labeled PBL [2], in this paper "classic PBL" will be defined as the method originally described by Barrows and colleagues [3-5]. Classic PBL has been used as one of several small group learning methods at the University of Pittsburgh School of Medicine during the last five years. Key characteristics of the PBL method include: (1) the primary learning activity is problem solving rather than memorization; * Based on a presentation at the Life Sciences Research and Reference Institute, University of Pittsburgh, School of Information Sciences, Department of Library and Information Sciences, Pittsburgh, Pennsylvania, May 6, 1996.
Bull Med Libr Assoc 86(3) July 1998
(2) the student is an active rather than a passive participant; (3) the teacher functions as a facilitator rather than an instructor; (4) the environment is one of collaborative, group-centered learning rather than competitive, individual-centered learning; and (5) the problem is ill-structured rather than well-structured (see below for concept definitions). In medicine, patients' problems are frequently used, but a variety of other problems may serve as well, such as public health problems, administrative problems, information retrieval problems, and business problems. In this article, patient problems are used as the prototypical example; the reader is encouraged to apply the concepts to his or her own domain. PBL is not the solution for all problems in education; however, it is a powerful tool for allowing students actively to build collaborative problem solving skills that will be required in the work environment. PBL is a primary learning method in which new material is presented rather than a euphemism for "afternoon review sessions with voluntary attendance." PBL sessions with simulated problems complement other types of small group methods, lectures, and experiential sessions. Students and faculty usually find the learning experience most productive and enjoyable [69]. 391
Kanter
Prior work has delineated the beneficial role of the library [10] and the key role of librarians [11] in PBL curricula. Others have described PBL and its impact on the health sciences library and librarian [12-15]. Satterthwaite et al. have noted that librarians possess the requisite knowledge and skills needed to function as facilitators [16]. As librarians seek to fulfill roles as faculty facilitators and as educators about knowledge management, a basic understanding of PBL becomes a necessity. The purpose of this article is to present fundamental concepts of PBL that can serve as a foundation from which the new facilitator can implement and develop his or her role in the small group learning environment. FUNDAMENTAL CONCEPTS Hybrid PBL curriculum A hybrid PBL curriculum is one which includes PBL as one of several learning experiences. For example, the Physicians in Two Thousand Curriculum at the University of Pittsburgh School of Medicine includes lectures, PBL, laboratory experiences, service learning, computer-based simulations, experiential learning, and community based learning. Approximately onethird of scheduled instructional hours in the first two years are designated for small group learning, of which classic PBL constitutes a significant portion [17].
Ill-structured problem To simulate problems in the real environment, the classic PBL session begins with an ill-structured problem. In an ill-structured problem little information is presented initially (so that there is a high level of uncertainty for the problem solver), an approach for solving the problem is not immediately evident, and the problem solver is often not clear whether he or she is "on the right track." By contrast, a well-structured problem is one in which most of the information is presented initially, an approach for solving the problem is quickly evident to all but the neophyte, and the problem solver is usually clear whether he or she is "on the right track." Real environments are characterized by ill-structured problems. Group size The ideal number of students in a PBL group is six to nine [18]. If there are twelve or more students in a group, working through an ill-structured problem in a timely fashion is difficult with all students participating. Certainly good small group learning experiences can be achieved with twelve or more students, but an experience more structured than classic PBL is required. 392
Facilitator The teacher in a classic PBL setting assumes the role of a coach or facilitator, rather than the more traditional didactic or instructional role of a lecturer.
Paper case A paper case is a problem usually presented in four to seven parts, in which each part is printed on a separate piece of paper. A problem also may be presented using a computer interface or a standardized patient. PBL unit A PBL unit usually consists of two meetings: a problem presentation meeting and a problem discussion meeting. The reader should be aware that the labelsPBL unit, problem presentation meeting, and problem discussion meeting-are not standardized and a variety of synonyms are in popular use. Some PBL units are designed with three meetings, with the middle meeting used for presentation of additional new material, a data gathering exercise (e.g., a laboratory experience), or other experiential activity (e.g., collecting a blood, urine, or sputum specimen from a fellow student or a real patient).
Problem presentation meeting The problem presentation meeting is the first of two PBL meetings in which the ill-structured problem is presented to the students. The information is structured as facts, hypotheses, and learning issues. Facts, hypotheses, and learning issues In classic PBL, students initially approach a problem by organizing the information given and the information generated by the group into three categories: facts, hypotheses, and learning issues. Defining a fact as a piece of given information, a hypothesis as a proposed explanation for all or part of the patient's problem, and a learning issue as information that needs to be learned in order to solve a problem may seem straightforward. However, a new group of collaborative learners will negotiate what they will generally consider to be a fact, a hypothesis, or a learning issue, and the classification of specific pieces of information will often be debated at length. Different groups will record the same piece of information under different categories. Experienced groups may modify and add to the standard categories of facts, hypotheses, and learning issues.
Learning objectives Learning objectives, also referred to as educational objectives or instructional objectives, are specifications of the performance required to demonstrate competence Bull Med Libr Assoc 86(3) July 1998
Fundamental concepts of problem-based learning
or mastery of defined material. While learning issues are generated by the students working on a problem, learning objectives are generated by the faculty and are used to communicate the expectations of the faculty to the students. Learning objectives can be distributed at various times during a PBL session. Providing the objectives near the end of the problem presentation session prevents objectives written by the faculty from interfering with the formulation of learning issues by students, while allowing students to compare their learning issues to faculty expectations.
Self-directed learning time Self-directed learning is the time between the problem presentation and problem discussion meetings, during which students, individually or in small groups of varying size, pursue an iterative process of seeking information based on the identified learning issues, restructuring the information in light of new knowledge, gathering additional information, and so forth. Students may seek information from print, electronic, and multimedia resources as well as human resources, including teachers, librarians, colleagues, and others. Problem discussion meeting The problem discussion meeting is the second of two PBL meetings in which the problem is discussed in light of the information discovered during the self-directed investigation of the learning issues identified in the problem presentation meeting. THE ROLE OF THE FACILITATOR: A SIMPLIFIED CHRONOLOGY OF A TYPICAL PBL UNIT
A classic PBL unit consists typically of two meetings: a problem presentation meeting and a problem discussion meeting. Depending on the nature of the problem, between one and two hours are usually allocated for each meeting.
The problem presentation meeting For a group of students that has not yet worked together, the problem presentation meeting begins with each group member including the facilitator introducing himself or herself. To assist group process effectively, the facilitator needs to memorize the name of each student in the group immediately. The facilitator then presents some ground rules to guide group process. For example, the facilitator might say, "In this group, you (the students) are responsible for the functioning of the group and the direction it pursues. It is perfectly acceptable to say what's on your mind and it is perfectly acceptable to disagree with another student. If you do not like the direction your group is taking to solve a problem, it is your responBull Med Libr Assoc 86(3) July 1998
sibility to negotiate with the group to change or modify its approach. My role is to make you think harder and more clearly about your assertions, explanations, and problem solving strategies. When I comment, don't assume that I agree or disagree with you-I intend to intervene in both situations." While this explanation is necessary for an inexperienced group of students, if the facilitator is new to an experienced group, the explanation may be useful for the facilitator to affirm his or her role. Next, the facilitator distributes the first page of the problem if a paper case is used. Otherwise, the initial information is accessed by computer simulation of a patient, questioning a simulated or real patient, or other method. The facilitator focuses the group by suggesting that one person read the information aloud. The group then begins to organize information into the three categories of facts, hypotheses, and learning issues. Experienced groups may use additional or modified categories. When no further information can be identified in or generated from the first page of a paper case or other initial information, the group requests the next page of the paper case from the facilitator or accesses subsequent information. The facilitator's role is to ensure that the group has "drilled into" the problem deeply enough with the information at hand prior to accessing new information. The facilitator also assists group process as follows: (1) encouraging a more thorough understanding of material by asking metacognitive questions (e.g., Why did you think of that hypothesis? How do you know that what you are saying is correct? Is your statement important?); (2) promoting synthetic and interpretive thinking skills by asking each student to take one or more turns summarizing the case; (3) involving the quiet or non-participating student by asking direct metacognitive questions (e.g., Do you agree with the hypotheses generated? What do you think are the most important facts identified thus far?); (4) regulating the aggressive, domineering participant by asking mitigating questions (e.g., directed to another group member: Why do you think Sam [the domineering student] feels so strongly about this issue?); (5) monitoring time by asking questions of intent (e.g., How do you plan to organize the rest of this meeting? How do you plan to organize your self-directed study?). Note that the role of the facilitator is not passive. In fact, the facilitator plays an active role in the group, monitoring all verbal and non-verbal interactions to identify opportunities to assist group process and to enhance learning. Approximately the last fourth of the problem presentation meeting should be reserved for refining the learning issues and establishing a plan for self-directed investigation. At this point distributing faculty-developed learning objectives can be most useful. Students find comparing their learning issues with the 393
Kanter
faculty's objectives useful; there is usually a significant concordance. If faculty-developed learning objectives are distributed at the beginning of the problem presentation meeting, they tend to constrain the discussion and inhibit creative exploration of an ill-structured problem. The self-directed learning component The students use the time between the problem presentation and problem discussion meeting to pursue self-directed investigation of the learning issues. Students work individually and collaboratively with students from their own or other groups. Students may contact faculty, residents, friends, peers, and others for information, explanation, and discussion during the self-directed learning period, and the facilitator generally plays no role during this time. The librarian, however, assumes a very significant role. During the student self-directed learning component of PBL, the librarian can fulfill one or more roles including traditional service provider, resource person, and educator [19, 20]. The librarian may direct students to information resources, recommend additional resources that are potentially relevant to a student's line of inquiry, assist students in the information retrieval process, assist students in formulating and refining a line of inquiry, inform students about methods of information discovery, and teach students how to assess the value of information [21-24]. The problem discussion meeting The problem discussion meeting should be a synthetic discussion of the problem, informed by the new information acquired from self-directed investigation of the learning issues identified in the initial meeting. This discussion should emphasize analysis, synthesis, and interpretation of medical knowledge and should not simply degrade into a concatenation of mini-lectures by each student. Additional goals of this meeting include (1) critiquing information resources used by the students; (2) recreating and critiquing the reasoning process used in the problem presentation meeting, examining the relevance and complexity of the hypotheses and learning issues generated; (3) the use of learning aids (e.g., charts, graphs, Web resources) by students to explain concepts to the group; (4) assessment of each student's contribution to the group by both the facilitator and other students with an eye towards providing each student with feedback that will allow him or her to improve performance in the next PBL unit; and (5) assessment of the facilitator (by both the facilitator and the students) with an eye towards providing the facilitator with feedback that will allow him or her to improve performance in the next PBL unit. Problem discussion meetings may also include debate, role playing, and structured controversy [25]. 394
To encourage a more thorough understanding of information resources, the facilitator can promote learning by asking such questions as: Why did you choose that resource? How valuable did you find that resource? How do you know the information in that resource is accurate? How will you better choose resources for your next problem? To advance the selfassessment process, facilitators may ask: What can you do next time to formulate better hypotheses? What can you do to solve the next problem more efficiently? How can you contribute better to the group? As always, the facilitator should be careful not to assume responsibility for directing the group. SUMMARY PBL is a small group learning method that encourages students to learn actively while developing critical thinking skills and building collaborative problem solving skills that will be required in the work environment. PBL is a primary learning method in which new material is presented, and is not a euphemism for afternoon review sessions with voluntary attendance. Students and faculty usually find the learning experience productive and enjoyable, and PBL should be part of the methods of every serious educator. It is increasingly important for professional librarians to understand the fundamental concepts of PBL as they are sought to fulfill traditional service provider, resource person, and educator roles in the PBL process. REFERENCES 1. ALBANESE MA, MITCHELL S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993 Jan;68(1):52-81. 2. FOLEY P, POLSON AL, VANCE JM. Review of the literature on PBL in the clinical setting. Teach Learn Med 1997;9(1):4-9. 3. BARROWS HS, TAMBLYN R. Problem-based learning: an approach to medical education. New York: Springer-Verlag, 1985. 4. BARROWS HS. How to design a problem-based learning curriculum for the preclinical years. New York: Springer-Verlag, 1985. 5. BARROWS HS. The tutorial process. Springfield, Illinois: Southern Illinois University School of Medicine, 1988. 6. YATES WR, GERDES TT. Problem-based learning in consultation psychiatry. Gen Hosp Psychiatry 1996 May;18(3): 139-44. 7. ARMSTRONG EG. A hybrid model of problem-based learning In: Boud D, Feletti G. The challenge of problem based learning. London: Kogan Page, 1991:147. 8. VERNON DTA. Attitudes and opinions of faculty tutors about problem-based learning. Acad Med 1995 Mar;70(3): 216-23. 9. SCHWARTZ RW, DONNELLY MB, SLOAN DA, STRODEL WE. Residents' evaluation of a problem-based learning curriculum in a general surgery residency program. Am J Surg 1997
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17. REYNOLDS CF, ADLER S, KANTER SL, HORN JP, HARVEY J, BERNIER GM. The undergraduate medical curriculum: cen-
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Received July 1997; accepted October 1997
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