The Journal of Continuing Education in the Health Professions, Volume 11, pp. 11- 18. Printed in the U.S.A. All rights reserved Copyright 0 1991 The Alliance for Continuing Education and the Society of Medical College Directors of Continuing Medical Education.

Medicine

Problem-Based Learning in Continuing Medical Education:

Some Critical Issues

MARTIN P. KANTROWITZ, M.D. Assistant Dean, Community Professional Education Director, Continuing Medical Education University of New Mexico School of Medicine Box 5 17 Albuquerque, NM 87 13 1

The major goal of continuing medical education (CME) is to help physi- cians provide optimal medical care by changing their behavior to reflect advances in the knowledge base and practice of medicine. This is accom- plished both by imparting new information and by reaffirming that the existing information used by the physician is the most appropriate at that time. Traditional CME, which is teacher-centered and lecture-based, is currently the most popular form in which organized CME is delivered.

However, for many years there have been concerns about whether teacher-centered, lecture-based CME truly fulfills the current needs of physician^.^^^ Miller stated 23 years ago that CME requires the process of continued self-education, not continuing instruction. Manning and Petit state that CME should be linked to practice. It is also important that new, appropriate information to which physicians are exposed in a learning experience be incorporated into their practice of medicine. Traditional approaches to CME do not address whether new information has been incorporated into the working, usable knowledge base of the physician and whether barriers have been encountered that may prevent application of new knowledge in practice.

Good CME practice demands that an assessment of the physicians’ learning needs be completed in order to establish programmatic educa- tional objectives that will meet the educational needs of the physician learner.5 However, a large audience listening to a lecture may be listening to material that was developed in response to a needs assessment of oth- ers.

Is there an approach to the delivery of CME that will address the need for individualized and continuing self-education, practice linkage and incorporation of new information into the physicians’ information base so that it can be used in practice?

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Leaders in the CME field are currently discussing the potential value of applying a learning approach known as Problem Based Learning (PBL) to CME. Will this approach address some -or all of the concerns raised above? At this point it is not yet known what the implications are of applying this educational approach to CME. In order to explore these issues, certain questions must be carefully examin’ed. The purpose of this paper is to describe PBL, discuss the potential use of PBL in CME, offer an example of how it can be used in a CME situation, and define several of the important issues.

What is Problem-Based Learning?

PBL is learning that results from the process of working toward the under- standing or resolution of a problem. The problem is encountered first in the learning process and serves as a focus or stimulus for the application of psoblem-solving or reasoning skills, as well as for the search for, or study of, the information or knowledge needed to understand the mecha- nisms responsible for the problem and how it might be solved.6

In this approach learners address a patient problem, health care deliv- ery problem or research problem as a stimulus for learning in the areas, subjects or disciplines that are appropriate for them at the time. This allows them to further develop their problem-solving skills.

The PBL approach has two main objectives: the first is the acquisition of an integrated body of knowledge related to the problem, and the second is the development or application of problem-solving skills. By working with a clinical case, the learner is encouraged to develop problem-solving, diagnostic, or clinical reasoning skills. The learner must get information, look for cues, analyze and synthesize the data available, develop hypothe- ses and apply strong deductive reasoning to the problem at hand. This approach is very motivating to students; especially medical students, since this challenges them with situations similar to those they will encounter in their profession. PBL teaches skills that should continue to be useful throughout the sEudent’s professional life as patients will constantly act as a stimulus for further learning.6

In problem-based, student-centered learning, not only is knowledge acquired, but skills in using knowledge are a~quired.~

PBL was introduced to undergraduate medical education at McMaster University in Hamilton, Ontario, Canada in 1969. Since then it has been adopted by many other institutions around the world as an alternative to the traditional method of teacher-centered, lecture-based medical educa- tion.8 The typical manner in which PBL is used at the undergraduate level is as follows:

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Problem-Based Learning in CME

*Introduce a problem that acts as a stimulus (a paper case or simulated patient) for learning. *Discuss the problem in a group with a facilitator to guide the process. *Explore issues that need to be addressed in order to help stu- dents understand and deal with the problem. *As individuals in the group recognize deficits in their knowl- edge, they note the type of information that must be learned in order to correct this deficit. Each of these identified informa- tion needs is called a “learning issue.” *Individual students research their “learning issues’’ over a one or two-day period. *The information the students have learned is then discussed and/or presented to the group in a manner that demonstrates that the information has been internalized and integrated with the body of knowledge that the student already possesses. In presenting the information to the group, students must demon- strate understanding, critical acceptance and incorporation of the new information. This may be done by applying the newly acquired knowledge to the original problem or a variation of this problem.

In summary, the PBL approach to learning is one of developing a case that will provide a stimulus for the learners, help them identify knowledge deficits, help them increase their store of information, and integrate this new information with previously internalized knowledge. This approach will also allow learners to demonstrate this new knowledge by presenta- tion, questioning, and feedback from peers as well its by its application to the clinical problem presented. Table 1 summarizes the cardinal differ- ences between traditional medical education and the PBL educational approach .

There are a number of reasons why CME educators are currently exploring the use of PBL in CME. Adult learning theory tells us that learning happens best if it takes place in the context in which it is to be applied and if it is relevant to the learner. If learners can ask their own questions, if they receive fairly immediate feedback, and if they have the opportunity to practice application of this new learning, the learning pro- cess is greatly enhan~ed.~ The PBL approach allows the physician to meet all of these criteria

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Table 1 The Potential for the Use of PBL in CME

Approaches to Learning in Medical Education

Traditional Teacher-directed

Problem-based Learner-directed

Passive learning Active learning

No demonstration of Demonstration incorporated of incorporated material material

All information provided by professor sources

Learner seeks own information

during the learning process. Traditional programs make the assumption that the delivery of infor-

mation will bring about change in the practice of the physician. In PBL such assumptions are not made. In the small-group process physicians must demonstrate that the new information has been incorporated as part of their approach to patient management by discussing the given case, or a similar one, in terms of the new information presented.

The learning principle of the “teachable moment” is an integral part of PBL. The teachable moment is described as a situation in which specific information has a high degree of relevancy and is thus best absorbed by the learner. For example, if Mrs. Jones comes to Dr. Smith’s office with chest pain of confusing etiology, Dr. Smith will be “super-stimulated” to learn information related to the diagnosis of chest pain. This window of openness is referred to as the “teachable moment.” Using the PBL approach, the teachable moment can also be created by presenting a paper case e.g. Mrs. X (as a paper patient) presents to Dr. Smith with chest pain. The intent is to facilitate a situation where Dr. Smith, upon receiving information in one (paper case) situation, can apply that information to a similar situation in real practice.

In order to meet the full potential of the PBL model, it should be used in a group situation since the demonstration of understanding of informa- tion, acceptance of this information, and incorporation of new information are done with a group of peers as part of the learning process. Group dis- cussion also helps to identify barriers to implementation of the learned

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information in real-life conditions. In a situation where there is only one physician - for example in a

very isolated rural area - this learning process can be one of teaching the members of the health care team (considering the team as a group of peers). The fact that the other members of the health care team are famil- iar with the new material will also reinforce its introduction into the prac- tice. Thus, even in a very isolated area, PBL may provide an in-depth, comprehensive teaching technique for a selected physician who becomes a PBL learner and demonstrates this learning by teaching others. If this approach is adopted it will be important to consider a method of quality control to assure that the information imparted by the PBL learner is the most appropriate.

A Detailed Example of the Application of PBL in a CME Setting

There are a number of settings in which PBL can be used in CME. The learning can take place within an organized CME symposium or within the context of a hospital case conference. It can also take place at the practice site of an isolated or rural physician. These three locations may require some slight variation in format, however, the basic principles would be the same.

The following is an example using a PBL approach to CME in a hos- pital setting.

Step 1. Perform a needs assessment that includes information based on the physician’s perceived needs. To be complete, the needs assessment should also include information from peer review, morbidity and mor- tality data, and other quality assurance sources. Step 2. Assemble a group of three to ten physicians. Within the group there should be someone who has had some training as a PBL group facilitator. This group will have been organized based on needs assess- ment information that demonstrated similarity of interests. This step illustrates the direct responsiveness of PBL to the needs of the physi- cian and the community. Step 3. Present a paper case. This case should be one that will be seen as relevant by all members of the group. For example: a 29 year old male has just suffered his first seizure. The patient has no knowledge of recent trauma and denies any history of alcohol or drug abuse. At this time, the case will be discussed. This step facilitates the active involvement of the physicianbearners from the beginning of the pro- cess. Step 4. Identify a list of learning issues. These may include: What are

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the most likely causes of a seizure in a 29-year-old male? What lab tests would be important at this time? What criteria would be neces- sary in order to determine whether the patient should be referred to a speciaht? These issues could either be raised as part of the PBL learning packet or they could be developed by the physician/learners. Step 5 . Each physician selects one or more learning issues to be researched within a reasonable time frame. Step 6. The group reconvenes and presents their learning issues to each other. All members will be active participants in this discussion which should be centered around solving this patient’s problem and describing which parts of this case would be applicable to their prac- tice of medicine. This step helps demonstrate the incorporation of the information and the identification of barriers to implementation in the practice. Step 7. Ask the participating physicians to evaluate the learning pro- cess or to reflect on their learning experience. This gives them active input regarding future sessions. First-year University of New Mexico medical students who participate

in a community-based preceptorship program9, lo are examples of individ- uals using PBL in the context of a practice site. In this program medical students live in a small rural community during a four-month preceptor- ship. These individual students use PBL almost exclusively to learn clini- cal science information as well as the sciences basic to medicine. At these isolated practice sites, the students are able to follow all of the previously mentioned steps and present the information that they have learned to a fellow student, to the physician-preceptor, and/or to other medical staff.

Some Important Questions

In examining PBL as a potential CME modality, it is important to raise a number of questions. Below is an agenda of issues that must be addressed if CME is to consider employing a PBL approach.

1) While PBL has been an effective method of learning at the level of the medical student, it usually takes an extende,d period of time for stu- dents to learn the techniques involved. Most physicians in practice have never experienced the PBL approach. If the learner has not previously been introduced to PBL (e.g., in medical school), will there be sufficient time to learn the process of PBL while the physician has the time con- straints imposed by the practice of medicine? Will physicians who gener- ally prefer and accept new information from knowledgeable authority (faculty) be comfortable in adapting new ideas developed entirely by a

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Problem-Based Learning in CME

peer group? Are there enough experienced PBL facilitators to teach the techniques? Are there incentives for the physician to learn the techniques?

2) An inherent requirement of PBL is the availability of a wide range of learning resources. If PBL takes place at the physician’s site, will appropriate learning resources be available to explore the learning issues that are raised? Innovative ways will have to be developed to deal with accessibility of resources. Access to computer data bases, and other tech- nological innovations may be required. How can learning resources be made accessible to isolated physicians? What is the role of CME in mak- ing these resources accessible? Can PBL programs be implemented with limited resources? What are the actual costs? (e.g., materials, facilitators)

3) More information is needed to understand the effectiveness of PBL on the adult learner. The spectrum of physicians’ learning styles varies within the profession. While a more passive style of learning will appeal to some, it could be postulated that the active learning approach of PBL will appeal to others. Will the PBL in CME approach benefit some learn- ers and not others? By using the PBL approach, do physicians learn more (or less)? Do they retain it for a longer (or shorter) time? Is PBL the most efficient learning technique for physicians to use?

4) Physicians have free choice to decide what they will study, when they will study, and in what manner they will study. Will PBL be attrac- tive enough to be selected over the existing CME alternatives? Will grad- uates of traditional medical schools prefer traditional CME programs over PBL, and vice versa?

Conclusion

In summary, the issues discussed in this paper have raised a number of questions.

There is evidence that there is renewed interest in research in CME issues. For example, the number of submissions of work-in-progress to the semi-annual Research in Continuing Medical Education conference has increased logarithmically. The Society of Medical College Directors of Continuing Medical Education and the Alliance for Continuing Medical Education are placing increased emphasis on CME research activities.

As there is a spectrum of knowledge to be learned and a spectrum of learning styles among physicians, there must be a spectrum of learning approaches that are made available to practicing physicians. If PBL is to take its place in that spectrum, a number of issues that PBL raises must be critically examined.

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