As per the vision 2015 of Medical Council of India, the new curriculum has been structured to facilitate horizontal and vertical integration between disciplines, bridge the gaps between theory and practice, between hospital-based medicine and community medicine. There would be sufficient clinical exposure at the primary care level and this would be integrated with the learning of basic and laboratory sciences. The introduction of this restructured curriculum and training programme lays emphasis on early clinical exposure, integrates of basic and clinical sciences, clinical competence and skills, and stress on the practice of inculcating innovative teaching–learning methodologies, which will lead to the generation of medical graduates of global standards.¹ Problem-based learning (PBL) is one of the innovative method of teaching and learning, which is student centered and not subject centered. The PBL approach is based on active learning in small groups, with clinical problems used as the stimulus/triggers for learning.¹ PBL has been introduced in some medical schools around the world. However, their adoption was met with some concern, primarily because of the substantial manpower needed.²

PBL has its origin at McMaster University, Canada. In 1966, a small but influential group of educational innovators framed a new curriculum. The leading members of this group included Jim Anderson, Howard Barrows and John Evans.

Jim Anderson, a professor of anatomy and physical anthropology, is considered the creator of PBL with learning in small group of students. The idea of presenting real-life patient problems and use of simulated patients for educational purposes was the brainchild of neurologist Howard Barrows. Dean Evans was responsible for central organisation of education within the faculty. The (new) medical curriculum, based on PBL, was launched in 1969. The programme attracted broad international attention, especially form universities just starting out. Aside from the work at McMaster University, pioneer work was also being carried out at Newcastle University (Australia), Michigan State University (USA) and Maastricht University (Netherlands).⁶

The learning in PBL is highly context-specific. It serves to teach content by presenting the students with a real-world challenge similar to one they might encounter were they a practitioner of the discipline. Teaching content through skills is one of the primary distinguishing features of PBL from other teaching methodologies and is more inductive: students learn the content as they try to address a problem.

The clinical problems in PBL are typically in the form of cases, narratives of complex, real-world challenges common to the discipline being studied. There is no right or wrong answer; rather, there are reasonable solutions based on application of knowledge and skills deemed necessary to address the issue. The solution, therefore, is partly dependent on the acquisition and comprehension of facts, but also based on the ability to think critically.⁷

PBL tutorials are conducted in several ways. One of the models is the Maastricht ‘seven jump’ process, but its format of seven steps may be shortened. A typical PBL tutorial consists of a group of students (usually 8 to 10) and a tutor, who facilitates the session. The length of time (number of sessions) that a group stays together with each other and with individual tutors varies between institutions. A group needs to be together long enough to allow good group dynamics to develop but may need to be changed occasionally if personality clashes or other dysfunctional behaviour emerges.

Students elect a chair for each PBL scenario and a ‘scribe’ to record the discussion. The roles are rotated for each scenario. Suitable flip charts or a whiteboard should be used for recording the proceedings. At the start of the session, depending on the trigger material, either the student chair reads out the scenario or all students study the material. If the trigger is a real patient in a ward, clinic or surgery, then a student may be asked to take a clinical history or identify an abnormal physical sign before the group moves to a tutorial room. For each module, students may be given a handbook containing the problem scenarios, and suggested learning resources or learning materials may be handed out at appropriate times as the tutorials progress.

The role of the tutor is to facilitate the proceedings (helping the chair to maintain group dynamics and moving the group through the task) and to ensure that the group achieves appropriate learning objectives in line with those set by the curriculum design team. The tutor may need to take a more active role in step 7 of the process to ensure that all the students have done the appropriate work and to help the chair to suggest a suitable format for group members to use to present the results of their private study. The tutor should encourage students to check their understanding of the material. He or she can do this by encouraging the students to ask open questions and ask each other to explain topics in their own words or by the use of drawings and diagrams. Thereby,

Step 1-Identify and clarify unfamiliar terms presented in the scenario; scribe lists those that remain unexplained after discussion.

Step 2-Define the problem or problems to be discussed; students may have different views on the issues, but all should be considered; scribe records a list of agreed problems.

Step 3-‘Brainstorming’ session to discuss the problem(s), suggesting possible explanations on the basis of prior knowledge; students draw on each other's knowledge and identify areas of incomplete knowledge; scribe records all discussion.

Step 4-Review steps 2 and 3 and arrange explanations into tentative solutions; scribe organises explanations and restructures, if necessary.

Step 5-Formulate learning objectives; group reaches consensus on the learning objectives; tutor ensures learning objectives are focused, achievable, comprehensive and appropriate.

Step 6-Private study (all students gather information related to each learning objective).

Step 7-Group shares results of private study (students identify their learning resources and share their results); tutor checks learning and may assess the group. ⁷

Student centered: PBL fosters active learning, improved understanding and retention, and helps in the development of life-long learning skills.⁷

Generic competencies: PBL allows students to develop generic skills and attitudes desirable in their future practice.

Integration: PBL facilitates an integrated core curriculum.

Motivation: PBL is fun for students and tutors, and the process requires all students to be engaged in the learning process.

‘Deep’ learning: PBL fosters deep learning (students interact with learning materials, relate concepts to everyday activities and improve their understanding).

Constructivist approach: Students activate prior knowledge and build on existing conceptual knowledge frameworks.

Human resources: More staff has to take part in this teaching–learning process.⁷

Other resources: Large numbers of students need access to the same library and computer resources simultaneously.

Role models: Students may be deprived access to a particular inspirational teacher who in a traditional curriculum would deliver lectures to a large group.

Information overload: Students may be unsure how much self-directed study to do and what information is relevant and useful.

Tutors who cannot ‘teach’: Tutors enjoy passing on their own knowledge and understanding, so they may find PBL facilitation difficult and frustrating.

Currently, most of the institutions in India do follow traditional type of teaching, which includes Didactic lectures, Practical, Case study, Field visits, Small group discussion like tutorials. Very few institutes have inculcated PBL and a special mention goes to Christian Medical College, Vellore⁸ and Maleka Manipal Medical College, Mangalore⁹ who have been using PBL for teaching their students and have received a favourable feedback regarding this method.

Analysis of educational innovation in general and PBL in specific have claimed that in educational interventions it is impossible to attribute success or failure solely to the intervention, and that teachers’ and students’ behaviour may have a great impact on the outcome. Second, it has been claimed that students in medical schools, who are selected based on high standards, all have the approved prerequisite skills, regardless of the curriculum they are in, to succeed in their studies. Third, PBL is practiced very differently in various institutions, with some demonstrating positive effects and others demonstrating negative ones. ¹⁰ The experience of PBL can be stressful for student and faculty and implementation of PBL may be unrealistically costly.¹¹ To practice PBL, the universities should work and inculcate in their respective curriculum.

PBL is one of the student centric, active and integrated learning processes. In view of its other advantages also, there should be a drive in acceptance of introducing PBL in university curriculum so as to enable its more comfortable use in the institutes for teaching undergraduate/postgraduate students so as to produce more competent and knowledgeable health professionals.

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