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A Practical Approach to Problem-Based Learning: Simple Technology Makes PBL Accessible David G. Rhodes School of Pharmacy, University of Connecticut, Box U-92/372 Fairfield Road, Storrs CT 06269-2092

A simple, cost-effective approach to implementing problem-based learning (PBL) has been developed, which provides an efficient and economical means of communication between a facilitator and a large number of student discussion groups. Although PBL can be a powerful teaching tool, implementation of PBL in the pharmacy curriculum is often slowed by economic rather than educational issues. Increased personnel needs make up the greatest cost increment, but by using electronic communications, the personnel costs associated with PBL instruction can be significantly reduced. Using this approach as a supplement to didactic instruction, PBL can be implemented for little or no additional cost. This approach is feasible for conventional as well as some distance learning environments.

INTRODUCTION Problem-based learning (PBL) uses realistic situation problems designed to stimulate discussion and exploratory study(1). The problems are solved in groups through interaction with a facilitator who serves to guide the progress and provide specific information requested by the group. PBL succeeds for two primary reasons(2). First, the approach develops competence not only in the area of study, but also in achieving more general problem solving skill objectives. These include critical and creative reasoning, communicating and working in productive collaboration as part of a team, appreciating alternative viewpoints, making reasoned decisions to solve problems in unfamiliar situations, and self-evaluation with the ability to attempt remediation by self-directed learning. Second, PBL uses conditions that have been shown to encourage effective adult learning: active learning, integrated learning, cumulative learning, and learning for understanding. The process is summarized in Figure 1. The problem scenario presented to the group should have a basis in “realworld” experience and/or knowledge acquired earlier in the course. The facilitator acts to keep the direction of the discussion productively focused and should be prepared to provide data likely to be requested by the group, to reply to specific questions, and to direct students to resources which would assist in the exploratory learning process. The instructor’s informational handouts could consist of simulated data, additional facts, or summary information related to the problem, but is distributed by the facilitator only when the groups specifically request it. Information sought independently by the students could include text references, primary literature, electronic searches, personal communication, or even experimentation. Previous work has shown that students find this approach more satisfying, are more likely to retain the knowledge gained, and learn at a higher conceptual level. A study of outcomes resulting from including PBL in the Introduction to Clinical Medicine course at Morehouse School of Medicine, concluded that even high-risk students do better in a problem-based learning environment than in a conventional curriculum(3).

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Fig. 1. The flow of information in analyzing a PBL scenario and the corresponding context or information provided.

There are many PBL success stories in medicine, engineering, and other professional disciplines based in problem solving, but relatively little application in undergraduate education, especially in the basic physical, chemical, and life sciences. Instead, education in these areas is fact-oriented, typically a lecture or lecture/lab format. The primary emphasis is on understanding established principles rather than on learning to think creatively within a scientific discipline. Problem solving is generally used to emphasize lecture material or to practice its utility, rather than as a discovery tool. There are several common concerns that discourage faculty from implement-

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ing PBL at the undergraduate level in the sciences, including content, development, and cost. Perhaps the most serious of these concerns, common to virtually all PBL implementations is the tremendous increase in contact hours. The greatly increased cost of having a facilitator (faculty or teaching assistant) present for all student group discussions deters many individuals and institutions from adopting PBL methodologies despite potential educational benefits. A graduate teaching assistant, whose time commitment would typically involve 10 contact hours per week, could effectively facilitate for perhaps 5-6 groups of four students. Thus, for a single class of 75 students, the extra personnel cost could easily be over $25,000. In addition, one must consider the training of the graduate assistant as well as the language and personal skills necessary to act as a facilitator. If faculty act as facilitators, the real cost is even greater. Finally, students must arrange meeting times within busy class schedules, and these must be compatible with the availability of the graduate assistant or faculty facilitator. We have developed a method to allow PBL to be implemented as a supplement to regular, didactic coursework. The concept is very simple, the method effective, the cost minimal, and the results positive. Using this approach, it is possible for a single instructor to serve as facilitator for 12-14 groups in the time it would normally take to work with two groups. METHODS The class (Bioorganic Chemistry - for first professional year students) is a traditionally lecture-based course which includes elements of physical chemistry, organic chemistry, biochemistry, biotechnology, medicinal chemistry, and some pharmaceutics. The course is, in some ways, a transition from the prepharmacy courses to courses in the professional program. At the beginning of the year, students are assigned to teams of 45 students who remain as a group for one year. All students have been given computer accounts on a campus mainframe system, so each is assured of free access to an electronic mail system. Many students choose to subscribe to an internet service provider (ISP) to access the network. The main computer is accessible from many on-campus terminals in the computer center or the library. Network access through desktop systems is available in the School of Pharmacy Learning Center, the library, in computer rooms located in the dorms, the library, or the computer center. Personal computers can connect by high-speed network from most dorm rooms or by modem access from off campus. Much of the class is taught in a relatively conventional lecture-based format, with PBL activities implemented as outof-class group projects. The approach is very simple; instead of having the facilitator at all of the group meetings, a team representative communicates questions or requests for information to the facilitator through the class email accounts. The facilitator interacts with the students by email, usually using a library of responses based on expected queries, and modifying these as needed. Unexpected questions receive individual replies, which are then added to the response library. Email PBL (EPBL) makes very efficient use of the facilitator’s time without compromising the fundamental advantages of PBL. Some resource information is available in the Pharmacy Library, but it is important that extracted reserve materials or data developed for the problem not be presented to the student unless specifically requested. The process must involve developing the response to the point that the student knows that additional information is needed, and thinking about where that

information might be obtained. Most information is derived from original references, which are left in place in the library so that the research process becomes part of the learning. Students are also encouraged to seek out independent resources (see below). To initiate the process, a situation is distributed to the class, as a handout, a distributed email, or a posting on an internet site. Once the problem is distributed, groups meet to discuss the problem, brainstorming possible solutions and either independently seeking information or asking the facilitator. The responsibilities are to be divided among the group members; one may compose an email to the facilitator while another checks the Merck Index and a third searches the internet. Communications to the facilitator are in the form of questions posed to specific individuals involved in the scenario. For example, the question may be posed “to the patient,” “Did you take any medications in the last 24 hours?” The facilitator answers in the person of the individual to whom the question is asked. Typical characters would include the patient, other health care providers, acquaintances, or anyone else who might be able to contribute. Replies are composed to be true-to-character. If the patient is unable to speak, for example, the reply reflects that fact. Once the students have gathered additional information, the group meets again, shares results, and attempts to refine the approach. More questions may arise, and the process continues until a comprehensive solution is developed. The number of times that the group meets will vary, depending on their progress. Most meet three to four times, but the meetings are usually relatively short (~ 20 minutes). The number of communications with the facilitator is typically 3-4 per group. These submissions typically include 2-4 questions. To keep up with the groups and allow them to progress as rapidly as possible, the facilitator commits to checking for email at least three times per day and should attempt to check more often. At the conclusion of the problem, the group submits a solution for evaluation by the instructor. This approach has been used in class sizes of 60-95. Students were given a problem loosely based upon material that they were scheduled to receive in lecture form approximately one week later. Appendix 1 is the handout given to the students for the first PBL scenario. Student teams were instructed to meet, develop possible solutions, to search for information, and to contact the instructor by email with requests for specific information, indicating to whom (e.g. pharmacist, pediatrician, etc.) in the hypothetical scenario, they were addressing the question. Realistic email responses were developed for each of several different roles (pediatrician, contractor, etc.). All of the groups took advantage of the email contact with the facilitator, and nearly all teams were able to solve the problem effectively. To compare our approach to conventional PBL, classes were divided so that half of the groups used electronic communications and the other half met with an instructor or teaching assistant. In the latter case, meetings were allowed to continue as long as the group wished. Time required for preparation and student contact was monitored by the graduate teaching assistant. This evaluation was carried out for three PBL exercises over two class years in order to compare the student responses to different PBL approaches in the same class context. RESULTS The required time and effort by the instructor and teaching assistants was evaluated for PBL and EPBL. Comparing PBL to EPBL, there are many needs which require equivalent effort. Effort required for identifying an appropriate topic and

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researching detailed information is quite variable (hours-days) but identical effort is involved for EPBL or PBL. Similarly, creating a scenario and developing a set of responses (hours) would be equivalent in either method. If the teaching assistant is computer-literate, the training time for the TA would be similar (see below). Preparation of handouts and distribution of handouts typically takes 1-2 hours. Reviewing responses submitted for grading at the end of the project typically takes 1-1.5 hours. The interactive time is very different. For our projects, PBL groups required an average of 2 meetings per group. Groups could request as many meetings as they wished and the range was 1-4. The meetings ranged from 10 minutes to one hour and averaged almost 45 minutes. For a class with 15 groups, this corresponds to 22.5 hours. Similarly, groups could send as many email requests as they felt were needed. The average number of replies was 3 (range 1-6) and the average time per reply was four minutes (read, compose response, send). For a class with 15 groups, this corresponds to three hours, 13 percent of the time required for conventional PBL. Grading was on a 10 point scale and identical grades were assigned to each member of a group. On two occasions an effort was made to have students grade others in the group, but the responses received did not discriminate strongly and thus did not seem to contribute in a positive way to the evaluation process. This is a potential drawback for any group activity where much of the work is independent. In this process, not only is most of the work done outside the supervision of the instructor, but much of the work is carried out by individuals as delegated research tasks outside the group. The group only sees the final result of the individual effort as they exchange information at the next meeting. For this reason, the PBL approach is probably a better learning tool than a discriminator. Evaluation of student responses was with a simple survey. Students were asked to respond to several statements, using a four-choice (“strongly agree, agree, disagree, strongly disagree”) survey form, and to provide additional, written comments. Table I shows average scores (strongly agree=4, strongly disagree=1) from surveys administered to the class following discussion of the problems. Written responses were almost universally positive (“...productive... research and common sense needed...”, “helpful...to be able to ask questions”, “look forward to more”, “great way to exercise the mind and deductive processes”, “good learning tool”, “I liked the format”). The only negative responses (three percent) objected to projects in general and were not specific to EPBL. In the one semester course, two of five group projects were PBL activities. The time commitment by the students only became an issue when projects with similar due dates were assigned in other courses. Improved coordination between departments has resolved this concern. In general, four to five projects per semester does not appear to be excessive and any or all could be PBL format. The grade weighting of the projects required some refinement over the years. At present, the five projects in aggregate are weighted as one exam grade, or 20 percent of the total. This seems to be an acceptable recognition of the effort involved. What are the advantages of this approach? This method carries with it all of the advantages of the PBL approach but requires far less time from the facilitator. In conventional PBL, the facilitator would need to attend a group meeting which could last 30-45 minutes in order to provide needed information. In the EPBL method, a response typically takes 1-5 minutes, depending on whether the standard reply needs to be edit-

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Table I. Student evaluation Statement The problem was useful. The process was interesting. I learned something about science and pharmacy. I learned more than I would have by listening to a lecture. I learned something new about where to find information I enjoyed working with a team. The email correspondence worked well. I would like to see more of this kind of project. a

Scorea 3.2 3.3 3.2 2.8 3.1 3.3 3.3 2.9

Strongly agree =4; strongly disagree = 1.

ed. Based on our data, this has resulted in an approximately 10fold reduction of personnel time. (This estimate is based on tests in which half the class used EPBL and the other half used conventional PBL.) In the absence of additional university support for personnel, this alone has made PBL feasible. Further, the students become more familiar with electronic media and communications. A typical class will include some students who maintain their own home pages and others who have never used a computer. The cooperation within groups, as students help each other to become accustomed to the systems, is a valuable benefit. Because of the potential difficulty involved in coordinating work and commuting schedules to arrange group meetings, some groups have met online. All communication can easily be archived so as to better monitor the direction that the groups take. There are potential drawbacks, but they are relatively minor. One of the advantages of conventional PBL is the increased personal contact with students. With electronic communication, some of this benefit is lost. Nevertheless, electronic communication is better than no communication, and EPBL does not decrease the amount of contact compared with a didactic approach unless this is the exclusive means of instruction. Our greatest concern was that without direct supervision of the group discussions: (i) the discussion could digress into an unproductive direction, and (ii) the lack of immediate feedback of requested information would slow the exploratory process. Neither of these has proven to be a significant problem. Although individuals might be more inclined to digress, the collective experience of the students in the group tends to be self-regulating. The lack of immediate response has had two positive effects. The group is encouraged to become more selfsufficient in their search for information and the thought process becomes more deliberative. We have observed that as students become more experienced in this approach, they tend to have more frequent, but shorter meetings. There are other communication options that should be considered in this context and for other applications as well. Because the students were able to freely and asynchronously communicate with each other and with the facilitator, the problems could be discussed without scheduling a formal meeting time. Some teams which included commuting students communicated by email in order to overcome scheduling difficulties. Responses from the facilitator were usually returned at least five times per day, which allowed for rapid progress and more continuity. In addition to developing higher level thinking skills, the exercise provided an opportunity, in a basic science course, to introduce the students to concepts that they will encounter in more detail during their clinically oriented training. This helps

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to establish a context for the chemistry. In the example included here, students were exposed to such issues as noncompliant patients, toxic responses to heavy metals (not normally encountered formally until the third professional year), and individual sensitivity to environmental influences. Forcing the issue in regard to electronic communication has helped many students overcome an “energy barrier” to gain access to these tools. Providing each student with an account has encouraged discussion, and has “leveled the field”, providing an alternative communication tool for otherwise withdrawn students. The present system works well, but establishing “chat rooms” for group meetings may be useful, especially for offcampus students. The approach used here can easily be generalized to a broad spectrum of courses in both basic sciences and pharmacy practice. Problems benefit from development as interdisciplinary activities. Active consultation among faculty from different areas of expertise will help to assure accuracy and integrate the curriculum. Such cooperation among faculty should allow projects to serve multiple functions, thus preventing overburdening the students’ schedules with redundant projects, and allowing faculty in different classes to refer to the same case for different reasons. Ultimately, the question is whether the learning is effective. Compared to the material normally covered in this part of the course, the students take home a far greater depth of information than they ordinarily would. For example, material on complexation and chelators would be covered in a 20-30 minute section in a unit on noncovalent interactions. The explanation of the structural chemistry still takes as long, but now the discussion is in the context of a child who can be helped rather than in terms of dry facts. Of equal importance, the students’ awareness of resources is improved. In one offering of the problem (see Appendix) sources discovered by students and cited in their reports included eight different monographs, three internet web sites, USPDI, the Merck CD ROM, package inserts, and two poison control centers contacted by telephone. While these might well have been discovered by assigning a research paper, the students were animated by the process used here. CONCLUSION There is a clear need for creative approaches to instruction which promote higher level thinking and involve the students in the learning process. When students progress to become professionals, they will need to be self-motivated learners. To do so effectively, they should be aware of what makes the learning process successful and what resources are available. They should have experience working in teams to deal with problems which might prove unmanageable for an individual. If instructors can impart some of these skills in addition to the content component of the curriculum, our graduates will be more likely to succeed. Once one is convinced of this need, the practical questions arise. “With what approaches can one promote higher level thinking?” “How do we pay for it?” While problem-based learning has proven to be one good response to the first question, personnel costs often preclude implementation. It is hoped that the simple approach described here will make PBL more feasible in a greater number of settings. By eliminating important difficulties such as personnel costs, this approach could significantly increase the application of PBL in pharmacy education as well as in other fields.

Acknowledgements. The author wishes to thank the several classes of students who participated in the first implementations of this method and to the teaching assistants (Maha Kebir and Siddhesh Patil), who worked with the students and helped with data compilation. Am. J. Pharm. Educ., 63, 410-414(1999); received 7/21/99, accepted 10/27/99. References (1) Schmidt, H. G. “Problem-Based Learning: Rationale and Description,” Med. Educ., 17, 11-16(1983) (2) Engel, C. “Not Just a Method but a Way of Learning” in The Challenge of Problem Based Learning, (ed. D. Boud and G. Feletti), Kogan Page, London (1991) (3) Herbert-Carter, J. “Curricular Changes and Improved Performance by High-Risk Students on the National Boards,” J. Assoc. Acad. Minor. Phys., 4(3); 82-88(1993)

APPENDIX. SAMPLE PROJECT Handout Presented to Students Team Project #1 September 5 You work in a pharmacy in a residential area of Hartford, and are talking with Mrs. Smith, a patient who is concerned about her 3 year-old son, Tom. She asks you to suggest a vitamin supplement. “Any particular reason you want a supplement for Tom?” “He has lost some weight, and has complained of headaches; I thought it might be a nutritional deficiency of some kind.” “Have you noticed anything else about his health?” “Occasionally he has had constipation, abdominal pain, or vomiting, but you know how kids are always picking up some kind of “bug” from their friends. You know, he’s had a lot of these little tummy bugs, so he usually seems pretty tired. I think that’s why he’s getting sick all the time - he’s tired and he needs vitamins.” Your Recent Records for Tom Show: 1/23 filled a prescription for amoxicillin for otitis media 2/2 filled a prescription for trimethoprim-sulfamethoxazole for otitis media 6/10 filled a prescription for the first 5 weeks of an oral iron supplement for anemia 8/1 change of address (you recall chatting with Mrs. Smith about the extensive renovations involved in restoring the old house that they have moved into.) • •

What do you suggest that Mrs. Smith do for Tom? What drug treatment will Tom need?

Meet with your team to discuss this problem. Decide what additional information you need, and try to find it. Distribute your responsibilities. For general information, look in the library or elsewhere. You may email me (in the role of anyone involved in the case) to pose specific questions. I will check my email at least 4x/day (2-3 on the weekend), and will respond ASAP. Remember, you are in the role of the pharmacist, and can communicate with other health care professionals or anyone else who might be able to provide information. You could have made other observations in your ongoing relationship with Mrs. Smith. If asked for details, I will provide them if they are the kind of thing you could reasonably know. You should tell me who I am and then ask the question(s). Examples: “Question for Tom’s pal, Biff: Have you ever played soccer with Tom?” or “Question for Mrs. Smith: Do you have a good recipe for potato salad?” Once you have additional information, reconvene your group and continue your discussion. This is a thought question. Think about it. Talk about it. Ask good questions of the right people. Before Wednesday, you should submit (with your group mem-

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bers listed) a brief description of your conclusions, and answers to the two questions above. We will discuss the problem in class, so answers must have been handed in by then. Good luck; have fun! Course Context This example is the used in the beginning of the fall semester of the first professional year. In this class, the students are working on noncovalent interactions, which includes discussion of chelators. The example is based on lead poisoning due to renovations ongoing in the Smith’s new house. Details of the Case The information given not only provides some clues as to the immediate cause, but also suggests other details that might be useful and allow for extended analysis. • If asked, Mrs. Smith reports that she and her husband have not experienced any recent illness. This is intended to reflect the fact that children are more susceptible to lead toxicity and due to their play habits may have higher exposure. • Although Tom was treated for anemia earlier in the year, it is possible that his treatment was stopped prematurely, since there is no record of a refill on the iron supplement. Tom’s age makes him more susceptible to lead toxicity, but if he is also anemic, he would be even more susceptible. • This possibility is supported by the fact that the patient’s parents may be noncompliant. The antibiotics given earlier in the year suggest that Tom did not receive all of his initial prescription. Questions to Mrs. Smith and the pediatrician, Dr. Feelgood, reveal that the amoxicillin was not completed and that the aggressive follow-up was to avoid the possibility of a resistant strain. Introducing noncompliant patients in a basic science course the first week of the students’ first semester of pharmacy courses helps to introduce the students to realistic situations that they begin to experience in their Pharmacy Practice courses. Tom is suffering from lead poisoning. Lead toxicity is most common(1) among children under 5 years of age, and symptoms can include “weakness, irritability, weight loss, vomiting, personality changes, ataxia, constipation, headache, transient abdominal pain, opaque flakes in the GI tract, and a “lead line” on the gums.” The Smith family move (2 weeks after the iron prescription should have been renewed) could have represented a move to a residence with leaded paint. Follow up questions confirm this (see below). 1.

Hay, W.W., et al., Current Pediatric Diagnosis and Treatment, Appleton and Lange, Norwalk CT (1995).

Typical Student Questions and Responses The following questions are direct quotes of email posted by students. Most of the responses are extracted from the library of replies generated to address anticipated questions. Some questions (e.g., the AIDS question) required writing of new replies to be added to the response database. The database helps not only in accelerating response time, but in maintaining consistency in responses. Student Questions Addressed to Dr. G. I. Feelgood — Tom’s Pediatrician • Can you tell me anything about Tom Smith’s recent history? “Well, within the last year, his chart shows a few visits. I saw him on January 23; diagnosis otitis media and prescribed amoxicillin suspension. On February 2 he was in for a recurrence of the same problem and I prescribed Septra. His mother didn’t understand how important it was to finish the amoxicillin, and had stopped as soon as he seemed to be feeling better. On June 8 I saw him for a routine checkup and asked for blood work to be done to test for anemia. Two days later I wrote a prescription for an iron supplement. That’s all I have on my records, do you have any specific questions?” • Does Tom have any allergies? “There’s no indication of anything on his chart, but I don’t know whether he’s been specifically tested by a specialist.” 414

•

•

Could you suggest an allergist send Tom? Do you think it’s a good idea? “Well, I’m not sure you’ll learn anything. It doesn’t look like an allergic reaction to me. If you want to give Mrs. Smith a name, tell her I said to try Dr. Easy over on Main Street.” What were the results of Tom’s lab tests for iron? “The results were in the ‘moderate’ range. The Serum Fe/TIBC (:g/l) was 500/4500.”

Dr. S. N. Easy - Allergist - Asked by Dr. Feelgood to Test for Drug Allergies • Do you have any results for Tom’s tests? “Yes - let’s see... It took a couple weeks to fit him in, but when we finally did the tests, we found no allergies. We did the drugs you asked about and ran some dust and dander tests as well.” Student Questions Addressed to Mrs. Smith • When Tom had his ear infection last winter, why did he have two different antibiotics? “Oh, the doctor gave me one prescription, some pink bubble-gumflavored stuff, and I gave him some every day. It worked great. Well, when we had used about half of the bottle, I accidentally knocked the bottle over, and it all went on the floor. Since Tom was feeling OK, I didn’t worry about it. A few days later Tom started crying all over again and it turns out that the ear infection had come back! We got some new medicine, and that took care of the problem.” • Have you been giving him his iron medicine? “No, we ran out of that a month or so ago. He didn’t like taking it, so I didn’t bother getting the refill.” • Are you giving him any other iron supplements, like Flintstones with iron? “No, should I? That might be a good idea ‘cause the other stuff was so expensive. I could just give him 3 or 4 of the Flintstones, right?” • Have you or your family had any similar problems with the GI symptoms? • Have you had any trouble with food poisoning or anything? “Nothing to speak of - well nothing that we all had. My husband and I had some bad shrimp a couple months back, but Tom didn’t eat any of that so he was fine.” • What can you tell me about Tom’s diet? “I’m pretty fussy about what he eats. I had a couple of nutrition courses when I was at UConn, so I’m pretty aware of what a child needs.” • Tell me about your home renovation. “At the beginning of August, we moved into a beautiful old place built in 1895. It’s a spectacular home, but it really needed attention. We couldn’t afford two places at once, so we have the renovation going on upstairs while we live in the downstairs, and when they’re finished upstairs, we’ll move up while they do the first floor. They’re refinishing all of the old trim molding. Under all of that old paint there is some beautiful wood, so we’re going to stain and varnish it. But the mess! The sandblasting leaves this fine dust everywhere - on the floors, the tables, the chairs, it’s everywhere! I just can’t keep up with it.” • Do you think Tom might have AIDS? “AIDS!?!?!?!?!?!?? - Ohmygod !!!” Student Questions Addressed to Mr. Bill Demup - Contractor Working on the Smith’s House • Do you know what the paint composition is in the house? “Of course not, I’m not a chemist!” • Do you think there’s any lead in the paint? “Hard to say, but my crew and I don’t take any chances with these old places. We always use goggles and dust filters when we sandblast, but when we’re in old places like this, say - over 30 years old, we use coverall protection and a special respirator. That place is over 100 years old; great construction - solid, but there must be 20 coats of paint on some of those trim moldings.

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