The problems of problem-based learning

78 process involves matching the degree of effort put in, to the quality of the desired outcome. By making the topic of the project relevant to many aspects of the MoCeTi Module, we ensure that the learning experience which the project involves helps to reinforce the students ~ understanding. Indeed, genetic diseases and cancer are topics which recur throughout the teaching in Year 1 of the C E L C curriculum. In conclusion, we have used biochemically orientated library-based projects as an educational and assessment tool for large classes of first-year medical and dental students. Although we have encountered several problems in the process, we argue that such projects help to achieve some of the important aims of our curriculum. References I McCrorie, P (1993) Trans Biochem Soc 21,379-383 -'General Medical Council (1991) Undergraduate Medical Education, GMC, London (discussion document from a working party of the GMC Education Committee) 3Newman, A (1993) Biochem Educ 21. 17(I-179 4Carroll, M (1993) Biochem Educ 21, 182-185 ~Newble, D and Cannon, R (1987) A Handbook for Medical Teachers (Second edition), MTP Press, Lancaster

Appendix Library-based Projects Used at CELC in 1992 and 1993

A Cystic fibrosis [1992] You are working as a consultant in the Paediatrics Department of your teaching hospital, where a young boy has just been diagnosed as having cystic fibrosis (CF). Q1 How was the diagnosis of CF probably arrived at? (10 marks) Q2 What treatment is available now for CF patients? (20 marks) Q3 As the consultant, what information would you give pre-clinical students about how the molecular defect is likely to affect the child's cells, tissues and organs? (50 marks) Q4 What are the prospects for gene therapy and for drug therapy for CF patients? (20 marks)

B Cancer cells and chemotherapy [1993] What is different about cancer cells compared with their normal counterparts? How do cancer cells spread from one part of the body to the other? How can we exploit differences in cancer cells in order to treat the disease by means of chemotherapy? These questions lie at the heart of current research into the causes and improved therapy of cancer. They also form the basis of this library project, which represents 5 marks out of the 20 marks allocated to the in-course assessment for Molecules Cells & Tissues. The length of your report should not exceed 1500 words, divided roughly according to the allocation of marks for each question. In marking your report, your personal tutor will give credit for clear, concise presentation and logical organisation of your answers, and for

BIOCHEMICAL EDUCATION 22(2) 1994

appropriate labelled diagrams. In preparing your report, particularly in answer to Q1, you will need to take into account the following concepts: cell cycle, differentiation, oncogenes, growth factors, mutagens, cell morphology, Wherever possible, give relevant examples to illustrate your answers. Focus on the molecular and cellular aspects, not the clinical ones. Q1 In what ways do cancer cells differ from their normal counterparts'? How did these differences arise'? (60 marks) Q2 How do cancer cells spread ('metastasise') away from the primary tumour, from one part of the body to another? (10 marks) Q3 How may differences in the structure and function of cancer cells be exploited for the purposes of chemotherapy? (20 marks) Q4 How do cancer cells become resistant to the drugs used for chemotherapy? (10 marks)

The Problems of Problem-based Learning* E J WOOD

Department of Biochemistry and Molecular Biology University of Leeds Leeds LS2 9.I7", UK Introduction Problem-based learning (PBL) turns the traditional process of teaching on its head. Traditionally, courses involve the transmission of knowledge or information from the teacher to the student. The assumption is that when the student has 'sufficient' knowledge, he or she will be capable of doing something (ie solving problems). The acquisition of knowledge is traditionally tested by examinations that mostly ask for recall of information. As Alan Mehler I has remarked frequently, examinations drive student behaviour. If we ask students to remember and regurgitate in order to pass the examination, then this is what they will do. Unfortunately, it is well recognised that shortly afterwards they forget much of this information - - because it is not used or perceived to be useful. Indeed, the whole process is shallow: the information may be remembered but not understood. Understanding usually requires processing the information and using it. To summarise, the traditional approach is the 'bucket theory', the assumption is that when the bucket (student) is full of information, he or she will be capable of using the information to solve problems. The big problem with this - - and nowhere is it more true than in the field of biochemistry - - is that knowledge is not a static body of information. It is an exponentially-expanding body of knowledge. When we are training biochemists, or medical students, they have perhaps 40 years of working life in front of them. There is no way that the knowledge or information that they 'contain' at the point of graduation * Based on a talk given at the Hungarian Biochemical Society Meeting in Debrecen, August 1993

79 will be sufficient for them to deal with the problems they may encounter during their working lives. It is therefore vital that they are taught the skills of reading and understanding the literature of biochemistry, so that they can keep up with what is published after they graduate. As I said at the beginning, PBL turns traditional learning upside down. It says that there is no way of predicting which particular information will turn out to be useful for solving a particular problem (even if you remember a lot of it). The alternative approach is to start with the problem and train students in the appropriate skills of finding and using information. In this way they learn useful, transferable skills that will be valuable to them for the rest of their working lives. This is not to say that information or 'content' is not important - - the information will indeed be vital in solving problems - - but information is best remembered and understood in the framework of existing knowledge and when it can be seen to be relevant. Nowhere is this more true than with medical students who want to know why they have to learn such a lot of biochemistry before they proceed to the hospital ward. But it also admits that no one person can remember all the information that constitutes biochemistry today and emphasises the point that the skills of finding and understanding knowledge are the important ones. There is a great deal of literature on PBL and indeed a great many institutions are using PBL, especially medical schools. However, it remains a controversial issue, and one that arouses fierce emotions. To quote from Margetson: 2 Why does the idea of problem-based learning evoke remarkably strong, even vehement reactions? Why does the idea often generate a surge of passionate hostility which tends to swamp what should be the careful consideration of an educational issue? In other words, there are problems with PBL - - not only problems with the method, but problems with persuading people and institutions that it is one worthy of consideration for their courses. Indeed the topic is still hotly debated. In The Times Higher Educational Supplement Report 3 on a meeting of the World Federation for Medical Education in Edinburgh, medical schools were again encouraged to reform radically the way they educate students. Doctors, the Report said, needed to be amongst other things, life-long learners and critical thinkers. The Dean of Harvard Medical School said that no individual could master the range of potentially relevant information during medical school training, but must absorb a framework of knowledge, backed by the commitment and skills to sustain a lifetime of learning [my italics]. Before I continue, I should make my position clear. I come from a Department that teaches medical and dental students as well as biochemists. Many of the staff understand the reasons for introducing PBL, but so far we have not wished to institute a 'whole system'. We have introduced problem-based tutorials, mini-research projects and dry practicals into our courses, including the

BIOCHEMICAL EDUCATION 22(2) 1994

medical course, but continue to give conventional lectures and put on practical classes. This may cause me to emphasise the problems of PBL that seem more relevant to my situation.

History To start with I will give a little history and attempt a definition. The background is a feeling that traditional methods (lectures, labs, tutorials) are not adequate or satisfactory. They are strongly information-based and the perception is that (a) information is not all you need to solve a problem (you need other skills too - - but are they teachable?), and (b) that as the amount of information is increasing exponentially, it is impossible for any one person to keep up with it. In 1913 Sir William Osier 4 argued against too great a reliance on courses of lectures and on students' capability of memorising a growing number of items of knowledge. Later there was the Flexner report, 5 which was the first of a succession of Reports indicating dissatisfaction with medical education and making recommendations for change. Integrated systems teaching was introduced in the 1950s in the Case Western Reserve University in the USA and in the late 1960s in McMaster University in Canada introduced PBL. This latter was subsequently examined cautiously by many N American medical schools but by the late 1970s had spread world-wide in medicine and later into other areas of professional training. One problem that we in Europe should be aware of is that in N America, the majority of students entering medical school already have a BSc (or some other) degree. They are therefore older, more mature and have a much greater knowledge base than European students entering directly from high school. This has consequences not only when designing courses, but also when trying to convince one's colleagues that such students can be trained by 'non-traditional' methods.

Definition Problem-based learning is held by some 6 to be 'the most significant innovation in education for the professions for many years; some argue that it is the most important development since the move of professional training into educational institutions'. A definition given by Barrows 7 is 'the learning which results from the process of working towards the understanding of, or resolution of, a problem'. In a recent article in Biochemical Education, Newman, from the University of Toronto, wrote. 8 The term Problem-Based Learning (PBL) has an Alicein-Wonderland quality to it: it means only what the user of the term wants it to mean. In its purest form, a problem is presented to a group of students and the group decides what it needs to know in order to solve it. The learning objectives of such an exercise are student generated and several groups of students simultaneously

80

encountering the same problem will end up learning totally different things. Now we are already beginning to detect worrying things - - there may be no one correct 'answer' and the students may end up learning different things! One of the best definitions and explanations of PBL I think, comes from Margetson. 2 He says that PBL 'is a conception of knowledge, understanding and education profoundly different from the more usual conception underlying subject-based learning'. It turns on the question of expertise. On a subject-based conception, expertise is seen in terms of content: experts have a lot of knowledge and have 'covered' much in their learning. The alternative view of expertise is that it is 'the ability to make sound judgements as to what is problematic about a situation, to identify the most important problems, and to know how to go about solving or ameliorating them'. This, of course, presupposes knowledge sufficient for the problem to be perceived and partly understood, but it does not equate expertise with it. Instead it places emphasis on the ability to do, in other words on the ability to find knowledge as required and to put it to use in a given situation. It does not pre-judge what is relevant subject matter. In a way, the problem selects the subject matter needed to deal with it. For the biochemist teaching medical students, this does not say, as our traditional system says, that if you know the whole of the textbook, then you will be able to solve all medical problems. Rather it says: seek the appropriate information as needed to solve the problem. This is one of the first problems of PBL. Not only does it appear to deny systematic knowledge which we textbook writers carefully organise and indeed circumscribe, but also it denies the importance of our subject, Biochemistry. Some of the information required to solve the problem may lie in the sphere of Physiology, or Pharmacology, or Statistics, or Chemistry. This is not only an affront to the vanity of our 'discipline', but also it makes life very difficult in an institution where there are separate Departments of Biochemistry, Physiology, Pharmacology and so on.

(3) They discover that they need more information and there are things they realise they do not understand. The tutor may help them to focus on questions that are particularly important and they decide which to follow up. They divide the task among the individuals of this group. (4) At a second meeting they reflect on what they have learned and this requires that they communicate and explain to each other. New knowledge and understanding are applied to the problem and the original questions may be refined. They have to decide whether they need further information and the tutor may provide further data about the problem, if they can show that they need it. (5) The process continues, but the students are encouraged to reflect on how they are tackling the problem and how they are progressing. They may reflect on what they have learned individually and how they have functioned as a group. The reflection helps them to develop problemsolving skills. I now want to move on to consider briefly the problems PBL may pose for self, staff, institutions and of course for students. I should remind you that traditional courses appear to have an automatic legitimacy - - "we've been doing it this way for a long time, and it works'.

Students Students are familiar or conditioned with traditional methods and may feel threatened if the system is changed. In PBL there is apparently no fixed curriculum and no textbook to learn and regurgitate in the exam. They may actually have to work harder in classes in PBL because they have to remain active. They also have to contribute to the work of the group and this may make them worry about assessment within this framework. Contrast this with what Newman says about his medical students learning in this traditional course in Toronto. 8 'The students appeared to be passive, uninterested, antiintellectual and overwhelmed. The bright and eager entering medical student had been replaced by a mindnumbed automaton who only wanted to know what would be on the next test'.

Format The following is a brief account of how a problem based course might proceed. (For fuller details see ref 9.) The course might operate with groups of six or seven students working with a tutor who is not necessarily a subject expert: instead he or she is a facilitator. (1) The tutor presents a problem (on paper, video, audiotape) and the students are expected to organise their thoughts about the problem. They should attempt to identify the broad nature of the problem and various factors or aspects associated with it. (2) They work as a group, possibly 'brainstorming' in relation to underlying causes, mechanisms and possible solutions.

BIOCHEMICAL EDUCATION 22(2) 1994

Self Problem-based learning turns the teacher, as one with authority and ownership of knowledge, into a facilitator who does not necessarily know the answer, a situation which is less comfortable. There is also the question of requiring time to become informed about the need for change, the nature of the change, and its consequences. It may also be perceived that more work will be required in order to design a new curriculum having thrown away the old one, and an uncertainty about how to design problems or Cases, or how to run the special tutorial groups. But I think the main problem is the loss of control, because PBL encourages open-minded, reflective, critical and active learning. Teachers who have traditionally preferred passive students may see this loss of control as a loss of

81 personal power. The traditional route of a one-way transmission of information from the knowledgeable teacher to the ignorant student has to change to treat the student as an adult. Staff

Similar problems to these personal ones of course, also apply to the staff of the department, but there may be other problems. It may be difficult, even impossible, for a few 'converts' to the idea of PBL to persuade their colleagues that the whole educational system with which they are familiar needs changing. There is a similar problem to the personal perception of loss of power, and that is teachers' distrust of PBL because they believe that students will not achieve the same 'gold standard' of knowledge. PBL appears to devalue academic expertise (normally demonstrated by lecturing to the masses) to replace it with a 'softer' currency, that of guiding small group discussion on a range of issues. These issues may be unfamiliar and indeed outside the territory of the traditional discipline. It therefore takes us into the idea of interdisciplinary or integrated curricula. Institution

This brings us to the institutional level. We are happy with departmental structures which are based on the idea of circumscribing our subject areas in which we are the experts. Changes give rise to both philosophical and practical problems that are not easy to resolve. We, in our separate departments, all perceive an exponentially increasing amount of knowledge, but any demands that we teach less are very hard to accommodate. There is obviously too much in the curriculum for the students to learn and yet no one is prepared to teach less. The dilemma here is summed up by Newman. 8 The stress level, the fact-overload and the inability to focus study-time in the midst of a deluge were major problems facing the students. The curriculum became sclerotic; no system committee was ever willing gracefully or otherwise either to reallocate time within its domain or to yield time to any other system. Assessment

One of the biggest problems with PBL is that of assessment. We need to assess whether the course is satisfactory, in other words to evaluate the educational programme, and we need to assess the students. As regards the programme, we have to evaluate in order to improve, to justify, and to compare with other programmes pursuing similar objectives. Good quality evaluation studies are currently hard to find, and this leaves us in an awkward position when trying to advocate PBL - - there is little comparative research. Martensen et al "j (1985) reported that with respect to students' knowledge of biochemistry assessed by short-answer questions when taught in the PBL format rather than traditional lecture, that they showed no difference at the end of the B I O C H E M I C A L E D U C A T I O N 22(2) 1994

course. However, they did show a dramatic difference in retention 2-4 years later. This implies that knowledge learned in context - - useful knowledge m is better retained. Abanese and Mitchell jt say that compared with conventional instruction, PBL is more nurturing and enjoyable, and that PBL graduates perform as well, and sometimes better, on clinical examinations and faculty evaluations. The other aspect is assessing students. We should surely be assessing what students can do rather than what they can remember. At least we should demonstrate that our PBL graduates are no worse than others, and hopefully better in those areas involving self-directed learning or group skills. If we are claiming that the central role of PBL is the acquisition of problem-solving skills, then we must devise some methods to measure such skills, more or less independent of knowledge. The modified form of essay question of the type which asks the question: 'What would you do next in this situation?' may be appropriate. But here again much more needs to be done. Initially, in the McMaster Progra m, there were no examinations, the assessment being purely tutoriailybased. Tutors completed an extensive written report at the end of each unit, indicating for each student 'satisfactory' or 'unsatisfactory'. Both tutors and students were uneasy with this process however and soon more 'objective' methods were added to supplement the tutor's report - - modified essay questions, oral exams, case studies, etc. This information was fed to the tutors as raw material but still there were no grades. The perception was that 'grades' and 'scores' given an inherent illusion of precision and that this was to be avoided. Nevertheless, if students are being turned out with the appropriate skills and knowledge, then the teachers are obliged to assess them in a meaningful, reliable and valid fashion. Knowing that students are driven by assessment, perhaps we should use evaluation intelligently to cause students to learn those things or skills that we consider appropriate. Conclusions

I have described the basis of PBL but one may be left with the feeling that it is a splendid t h i n g . . , but you can see many personal and institutional reasons why it would not work for you or your Institution. The reasons for change seem to me to be good ones, but it is natural to be wary of giving up traditional methods, and one foresees all the likely problems with students, self and institutions. A possible route, suggested by Veila t2 in a Letter to the Editor of Academic Medicine, is a combination of traditional and non-traditional approaches. He recalls that the GPEP Report t3 did not recommend the abolition of traditional approaches but only that they be given less emphasis and less time so that appropriate tactics can be acquired by students in the process of engagement in problem-solving and independent learning. There is a considerable literature on PBL especially, but not entirely, in medical schools, which is well worth reading.it

82 Perhaps the most important thing, if you want to change, is to convince your Dean of the need. A new program needs strong commitment from the centre. A good place to start is to read about the Harvard Medical School, where in 1984 after 2 years of extensive discussion and planning, Dean Tosteson presented the curriculum committee with his final plans for radical reform of medical education - - the New Pathway. ~2 There are several published articles from Harvard and other schools, where the individuals involved in the proces reflect on how the change was affected. The story is as much about politics and persuading people as it is about education.

Acknowledgement The author is grateful to F Vella for critically reading this manuscript.

References ~Mehler, A H (1992), Biochem Educ 20, 10-14 2Margetson, D (1991), 'Why is problem-based learning a challenge'?', chapter 4, in Boud, D and Feletti, G I (editors) The Challenge of Problem-based Learning, Kogan Page, London, p 42 3 Times Higher Educational Supplement (Aug 00 issue, 1993) page 00, 'Doctors take radical care', report Wojtas, O 4Osler, Sir W (1913) Lancet 1047-1050 5Flexner, A (1910), see Vella, F (1991) Biochem Educ 19, 178-181 ~'Boud, D and Feletti, G I (1991) (editors) The Challenge of Problembased Learning, Kogan Page, London, p 13 7Barrows, H S and Tamblyn, R M (1980), Problem-based learning: An Approach to Medical Education, Springer-Verlag, New York ~Newman, A (1993) Biochem Educ 21, 170-179 'JEngel, C E (1991) 'Not Just a Method by a Way of Learning', chapter 2 in Boud, D and Feletti, G I (editors), The Challenge of Problembased Learning, Kogan Page, London, p 23-33 l~Martensen, D, Eriksson, H and Ingelman-Sundberg, M (1985), Medical Education 19, 34-42 i~ AIbanese, M A and Mitchell, S (1993), "Problem-based Learning: A Review of Literature on its Outcomes and Implementation Issues', Academic Medicine 68, 52-81 12Vella, F (1993), 'GPEP Recommends Traditional and Non-traditional Approaches', Letter to the Editor, Academic Medicine 00, 000-000 13Muller, S (1984). 'Physicians for the Twenty-first Century: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine', J Med Educ 52. Part 2 U M o o r e , G T (1991), "Intiating Problem-based Learning at Harvard Medical School', chapter 8 in Boud, D and Feletti, G I (editors), The Challenge of Problem-based Learning, Kogan Page, London, pp 80-87

Announcement PABMB Symposium on Mitochondrial Biogenesis

Salamanca, Spain. 28 September 1994 Info: Prof J M Medina. Dpto Bioqufmica y Biologfa Molecular Edificio Departamental Avda. Campo Charro s/n 37007 Salamanca, Spain

BIOCHEMICAL EDUCATION 22(2) 1994

One Source of Aid for Central and Eastern Europe PETER N CAMPBELl.

Biochemistry and Molecular Biology University College London Gower Street London WCIE 6BT, UK Introduction One only has to observe strangers raking through the skips outside one's house to be reminded that one man's garbage is another man's treasure. This truism applies not only to household refuse but also to laboratory apparatus and so it occurred to me to suggest to FEBS (the Federation of European Biochemical Societies) that we in the West should try and salvage apparatus that might prove useful to the impoverished laboratories in Central and Eastern Europe. Since ~recycling' is an 'in' word I suggested the name Scientific Apparatus Recycling Scheme (SARS). In late 1990 FEBS agreed to support SARS and I was much encouraged when the European Commission (EC) made two grants to help with the initial phases. It soon became apparent that SARS should be expanded to encompass scientific journals and books.

Scope of the Scheme I had in mind at the start that we would confine SARS to rather simple apparatus such as bench centrifuges that were being rejected on rather niggling grounds of safety but I soon found that I was being offered electron microscopes and ultracentrifuges. I was worried that the recipients would not be able to utilise such equipment but fortunately we have been able to have the electron microscopes dismantled carefully with instructions for reassembly. Offers of apparatus, journals and books have come from all over the UK and have encompassed university departments and libraries, research institutes, industrial laboratories, laboratory suppliers and publishers, and the flow continues. I have taken a rather broad view of biochemistry but have steered clear of hospital equipment. I have recorded to date nearly 200 packets of journals, about 50 packets of books and more than 500 items of equipment. I have tried to enlist the help of other potential donor countries, so far without success.

Practical arrangements It became clear at the outset that a warehouse was essential so that the items could be collected and sorted. I was fortunate in that the publishing subsidiary of the Biochemical Society, Portland Press, made available a warehouse at Colchester and I was doubly fortunate that Pickfords Removals had a depot alongside. Portland Press are also able to lend me a forklift truck and other handling equipment. As I receive the items, I record and number them so that I can add them to a list that I circulate to the constituent Biochemical Societies of FEBS in Central and Eastern Europe. It is the responsibility of these societies