Following on from the previous post, this article will describe the 8 step approach used during PBL sessions. It should be noted that medical schools have different approaches to PBL but the 8 step process is the core foundation.
Step 1
Read the case and clarify unknown terms or concepts
After the Chair has assigned someone to read the first of the Case Opening triggers, the Group clarifies unfamiliar words or concepts. If there is no consensus, the medical dictionary can be consulted and the Resource persons can do an online search.
Step 2
Define the phenomena (key features)
The Group then identifies the “phenomena” or key points. Initially, in the early years, these key points may be words, like “stem cells”. Later, these phenomena become descriptors (e.g. pale, listless) or a chief presenting complaint (e.g. chest pain). The Scribe documents this on the white board in the form of a free-flowing map, spider diagram or fishbone, etc. These key points should be FACTS (i.e. what is known). Assumptions and hypotheses follow in the next step.
Step 3
Explain the problem and produce as many explanations as possible (brainstorm, hypothesize and elaborate)
Students then try to explain the problem (i.e. hypothesize) through sharing prior knowledge and experience and establish the Group’s understanding of the facts that have been provided. Students should explain why they have come up with a particular hypothesis. They should challenge each other’s thinking, such that there is considerable debate and discussion as they grapple with what they know and what they don’t know. Examples of questions to ask when faced with a difficult, unexpected or puzzling situation, could be:
- What is going on here?
- Do I have the entire picture?
- Have I thought of all the possibilities?
- Have I had experiences with this before?
- What is the best way to handle this?
- Am I right about this or should I look at it in another way?
- What does this finding mean?
- Do I have all the facts?
- Do I know enough about this problem?
- What more information do I need?
- Where can I find it?
- How will I know if it is valid?
During Step 3, the Scribe, with the help of other members of the Group and who is expected to be contributing to the brainstorming and hypothesizing, makes sure that all the hypotheses, explanations and relationships that have been discussed are documented on the white board. The white board should be viewed as ‘work in progress’. It should have lots of question marks, arrows and lines linking different ideas. The purpose is to document as many ideas as possible as group members think broadly about the issues presented in the trigger.
When students encounter something that they do not understand, it may be appropriate to list this as an LI. If possible, include the LIs that are linked to particular hypotheses. If this lack of understanding is impeding the progress of the session, the Resource persons could look up some information in a textbook or on the web. This should, however, be a last resort because if too much time is spent looking up information, students may not identify their gaps. Most of the informationsearching should be done during the self-study time after the Case Opening.
During the early stages of PBL, the Facilitator’s role is to guide students (rather than lead the discussion). The occasional metacognitive or Socratic question is useful for refocusing the group or an individual’s thought processes. After a few semesters, students should be taking ownership of the process, asking these questions of each other so that the Facilitator can be more of an observer.
Step 4
Review Steps 2 and 3; arrange proposed explanations to produce a coherent description
The objective of this stage is to ensure that all possible explanations and hypotheses have been exhausted to the sequentially released triggers, that the basic sciences, behavioural or social considerations have been discussed and thoroughly explored. Using the map on the white board, group members should form links between ideas, identify gaps in their knowledge and understanding and grasp of concepts. The hypotheses and explanations are then ranked in terms of the most likely mechanisms underlying the case presentation.
The group should also consider how they might differentiate between their hypotheses, what questions they could ask, what the next step may be, etc. This brainstorming map is kept by the Recorder as it will be used on the final day to review knowledge and understanding gained during the week as a result of self-study and other learning activities so that misconceptions can be ironed out and knowledge gaps filled when the Group reconvenes.
The Recorder is responsible for ensuring that all the summaries on the white board are documented. The minimum that is expected is a map of some sort that reflects the group’s brainstorming, the hypotheses generated and the LIs. Recording will probably involve one or more photographs of the white board, unless the Recorder is adept at using electronic mapping tools.
Step 5
Formulate learning issues (LIs) and identify possible resources
Throughout the Case Opening, students will have identified issues where further research is required as well as other questions that may have arisen. The PBL “problems” are vehicles for learning the social and biomedical sciences. In order to explain what is going wrong (i.e. the abnormal), one always needs to know the normal. The LIs generated should therefore always address the normal structure and function at the appropriate level as the foundation for understanding normal structure and function in Year 1 and, in addition, pathophysiology in Year 2.
At the end of the session, facilitated by the LI Tracker, the Group will compile a list of explicit and prioritised LIs (in the form of questions or a statement with a verb) that will guide the individual group members’ learning for the rest of the week. These LIs will be partially supported by the other scheduled activities for the week. LIs should be clear, defined and achievable within the timeframe. Vague LIs like ‘inflammation’ or ‘cells’ are not helpful because they do not specify what should be learned or establish the boundaries and depth of student learning.
Step 6
Fill in gaps in knowledge, skills, etc. (self-study)
At the end of the Case Opening, students engage in self-study and attend sessions which have been designed to address key elements of the knowledge and skills required during the week.
Step 7
Case Wrap-up: Report back: Synthesis, integration and application
Before the session starts,
- The Recorder should make available the Case Opening summaries with the map and hypotheses (white board or plasma screen)
- The LI Tracker needs to display the LIs on one of the smaller boards
In Semester 1, the session will start with the Facilitator inquiring about the resources each student used. This might continue for several weeks until the Facilitator is sure that the students are accessing the appropriate resources.
That out the way, the Chair then assigns a member of the group to summarise the key issues in the case and what hypotheses the group rejected and accepted. The Chair then suggests to the group how he/she plans to run the session. Revisiting the case is an essential part of this. Revisiting each trigger may be necessary in the light of students’ new knowledge, understanding and skills.
Like Steps 2 and 3, which are key steps in the PBL process, Step 7 is also important as it the synthesis and integration step – applying new knowledge, understanding and skills to the ‘problem’. The Case Opening concentrated on activating prior knowledge, elaboration and identifying gaps in knowledge and understanding, leading to the development of LIs and several days of self-study. On the final day, group members revisit the conclusions and decisions made during the Case Opening and integrate their new knowledge and skills into their understanding of the case. They should be able to explain this without using their notes.
A method for a student to check his/her level of understanding is to use his/her own words to explain something to another person and check if they understand the explanation. As selfassessment is not easy, it is during this second PBL session that students can test whether they have done enough by comparing their level of understanding with that of their colleagues.
The final day should be interactive. Using the Case Opening summaries and the case information, students should be checking to ascertain if the hypotheses they generated to explain the case were rational. The underlying processes/factors should now be able to be fully explained. Group members and the Facilitator should monitor the quality and depth of the discussion, asking questions if something is not clear or appears too superficial.
The Chair should conclude the discussion with some form of wrap-up so that all group members leave with the same understanding of the principles and concepts learnt during the week in terms of the case.
This wrap-up could take a number of forms by asking questions like:
- What if this patient had been a child?
- What if the patient had been female?
- If the results had shown…, would we have come to the same conclusions?
Step 8
Group feedback and individual reflection
During some of the Wrap-up sessions, e.g. at the end of a block in Semester 2, the Chair will ask the Reflector to lead the feedback to Faculty. Group members should be sending their thoughts to the Reflector during the week.
Conclusions
So reading about the process of PBL can be a lot to take in at one time however over the semester, every student will become accustomed to the process. By the second semester of med school, everyone in the group is familiar and can undertake the roles with minimal input from the facilitator.
I am adding a quick summary to go over the Case Opening and the Case Wrap Up.
Summary of Case Opening
- Be presented with a ‘problem’ which should trigger several questions
- Brainstorm the issues, using prior knowledge and experience (divergent thinking; elaboration; collaborative learning and learning context)
- Generate hypotheses based on available evidence (hypothetico-deductive reasoning; critical thinking; convergent thinking)
- Reflect on and revise hypotheses in the light of new evidence as each trigger is released
- Provide a framework for each student to identify what he/she needs to know to explain the underlying mechanisms of the problem.
- These become the LIs, which are then addressed through selfstudy
- Identify which resources might be suitable to use during self-study
Summary of Case Wrap Up
- Make sure that students used appropriate resources and were able to glean the most important information from their resources
- Share resources, summaries, websites, etc. that aided learning (i.e. adding value to the group)
- Use newly acquired knowledge to fully explain (elaborate on) the phenomena of the case and refute or confirm hypotheses generated during the Case Opening
- Provide an opportunity to share learning, enabling confirmation of understanding and developing skills with respect to communicating complicated learning
- Iron out misconceptions. If all students have done all the LIs, any differences in understanding can be identified and sorted out (which may mean checking online or in a textbook)
- Gauge whether each student has covered sufficient breadth and depth, compared with the other students (i.e. self-assessment)
- Articulate and apply new knowledge to other scenarios. What if …?
