Bridging the gaps in problem-based learning: an evidence-based intervention in bachelor of medicine and surgery (MBBS) program

Abstract

Introduction

Problem-based learning (PBL) is one of medical education’s most effective student-centered learning modalities. However, a lack of experience has led to several gaps in this useful learning modality, prohibiting it from achieving the desired goals. This study aimed to find gaps in our institution’s PBL strategy, take measures to fill these gaps, and then assess the effect of these measures.

Methods

This interventional study was conducted in a Bachelor of Medicine and Surgery (MBBS) program after receiving ethical approval. The study consisted of three phases: gap identification, intervention, and evaluation. Faculty and student training sessions were conducted to provide insight into PBL processes, followed by a Quality Assessment Questionnaire (QAQ) to assess PBL design and delivery gaps. A PBL revision committee then used the 3C3R model to redesign 136 PBLs, improving alignment with learning outcomes. Pre- and post-intervention scores from the QAQ and formative assessments were analyzed using Wilcoxon signed-rank and paired t-tests.

Results

Pre-intervention QAQ scores averaged 2.7 out of 5, reflecting issues PBL problems and conduction. Post-intervention scores improved to 4.0 (p <.001), indicating a 48.1% enhancement in perceived PBL quality. Post-PBL formative assessments showed significant score improvements across blocks, with an overall effect size (Cohen’s d) of -0.54. Student and faculty satisfaction ratings also increased, averaging 4.3 and 4.8, respectively.

Conclusion

Due to practical novelty, PBL may have certain gaps and deficiencies that must be removed by targeted interventions to achieve the desired outcomes of this state-of-the-art learning strategy.

Trial number

Not applicable

Introduction

Problem-based learning

Medical education is constantly evolving, especially since the late twentieth century. Many new strategies toward student-centred learning have gained popularity in medical education, like problem-based learning (PBL), Team-based learning, Task-based learning, and so on.

Problem-based learning (PBL) is a teaching strategy in which a tutor guides a small group of self-directed learners (8 to 10) as they brainstorm solutions to a problem. The students are given the problem, which may be a clinical, community, or scientific problem, in a method that tests their knowledge, skills, and/or values [1]. The role of a tutor in this scenario is of a facilitator, keeping the students on track, maintaining the academic environment of the session, facilitating the brainstorming, and unfolding the different parts of PBL on its proper time so that learning objectives fashioned by the students in the process are aligned with the objectives of the PBL while evaluating the students [2, 3]. The aim of PBL is not to solve the problem but to use a problem to enhance learning and knowledge. PBL is based on constructivism which aims for the participants to be lifelong learners and promotes self-directed learning [4, 5]. PBL is intended to assist students in constructing a subject knowledge base as well as problem solving concurrently. Students gain domain knowledge by working through the procedures of addressing problems that partly require them to engage in knowledge-acquisition activities like discussions and self-directed learning [6]. Barrows and Tamblyn proposed the PBL method in the 1960s at McMaster University in Hamilton’s medical school program [7]. Students who were frustrated with traditional medical education felt that the large amount of information taught during the first three years of medical school had little bearing on clinically based medicine and actual medical practice [7]. The purpose of the PBL curriculum is to encourage learning by enabling students to see how it relates to and applies to future jobs. It keeps learners more motivated to learn and emphasizes the necessity of having a responsible, professional attitude and collaborative principles [7]. The desire to learn fuels curiosity since it enables the choice of problems with practical relevance. Currently, the PBL strategy has been adopted by many medical schools and other non-medical institutions, such as engineering, maths, law, etc [8, 9].

Gaps in PBL strategy

PBL strategy for learning involves designing problems for PBL, implementing or conducting PBL, and then assessment of PBL. It is a very specialized teaching strategy, needing lots of expertise and training. The use of resources and instructor facilitation is the main drawback of this approach. Some educators find PBL facilitation difficult and irritating because it calls for more staff to participate actively in facilitation and group-led discussions. Problem-based learning (PBL) requires extensive resources because it demands larger spaces and broader access to computing facilities to effectively support multiple small groups working concurrently [10]. Students frequently complain about feeling overwhelmed by knowledge and having trouble deciding how much study is necessary or whether the information is relevant. The inspirational role models that the traditional curriculum provides may not be available to students [10]. Based on the published literature, gaps in PBL can be divided as,

1. 1.

Gaps in designing problems for PBL.

2. 2.

Gaps in conducting PBL.

Gaps in designing problems for PBL

The success of PBL courses and curriculum is significantly influenced by the design of the problems [11]. While designing problems for PBL several gaps are usually encountered. One major issue is the use of well-structured and overly simple problems that fail to encourage brainstorming and self-directed learning. Another challenge is the mismatch between the intended learning objectives and the learning objectives generated by students. Sometimes, some problems lack real-world applicability, making it difficult for students to transfer their learning to similar situations. Similarly, problems that do not address relevant and current conditions often fail to motivate students effectively. These gaps were found and reported previously by various researchers in their studies [12,13,14,15,16,17]. Several models have been proposed to address the above issues and design quality problems for PBL, including the Shaw model, Dolman’s model, and the Hung 3C3R model [18,19,20]. The 3C3R PBL problem design model is a systematic approach created expressly to assist instructional designers and educators in developing effective PBL problems for all levels of learners, hence enhancing PBL’s qualities and resolving implementation challenges identified in prior PBL research [21]. This model has two components: core components and processing components. To promote content/concept learning, core components (3 C) like content, context, and connections are used; processing components (3R), like researching, reasoning, and reflecting are concerned with the learners’ cognitive learning processes and problem-solving abilities.

Gaps in PBL conduction/delivery

Issues in the PBL conduction are the,

1. 1.

Facilitators are not properly guided and trained on the process of conducting PBL. They are sometimes not fully aware of institutional strategy and curriculum programs so they are not able to meet the objectives of the PBL [22,23,24]. Students are also not properly oriented on the process of PBL, their different roles in the PBL, and the different steps or jumps of PBL [25].

2. 2.

The assessment of PBL is sometimes not aligned with the objectives/outcomes of the PBL, not covering all the learning domains [26].

3. 3.

There is no culture of students’ reflection and feedback on the process of PBL [27].

The rationale behind this study was the lack of achievement in the proposed learning objectives/outcomes of the curriculum in general and those of PBLs in specific.

The main purpose and objective of the study was three-fold,

1. 1.

To find the gaps and deficiencies in PBLs that are currently included in the curriculum.

2. 2.

To develop and implement a strategy to fill these gaps in order to achieve the desired learning outcomes.

3. 3.

To measure and assess the effects of the improvement strategy.

Methods

This interventional study was conducted at one of the renowned colleges of medicine in Saudi Arabia from 29th September 2023 to 30th August 2024, after the approval of the college’s ethical review committee (Approval # ERC_SU_20230026). The study comprises 3 components: gaps identification, intervention (improvement strategies), and evaluation of the impact of these strategies. Below is the schematic representation of the study design.

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Participants and sampling

We targeted the two primary stakeholders of the PBL process, the students and the faculty. The sampling was done through convenience sampling, inviting all the faculty members (n = 39) and students (n = 145) to participate in the study, among whom 31 faculty members and 129 students attended the workshops (n = 3) and orientation sessions (n = 1 per academic year). The faculty members were ranked as assistant professors (n = 16), associate professors (n = 7), and professors (n = 3), with few demonstrators (n = 3), and were related to different specialities and domains. Verbal informed consent was taken from all the participants during the training sessions while filling out the quality assessment questionnaire (QAQ), by giving them the choice of opting out of the study and not filling out the QAQ.

Gap identification and intervention design

The study’s first and second components, i.e., gap identification and intervention, were started side by side.

Stakeholders’ training

Faculty development workshops were arranged with the help of the faculty development unit, and medical education department, who trained the faculty/facilitators on conducting PBL. For students, orientation classes were conducted to educate them in detail about the whole process of PBL. The details of these workshops and orientations are summarized in the table below.

Table: Faculty and Student Training and Orientation on PBL.

Session No

Faculty Development Workshops (3 h each)

Student Orientation Sessions (2 h each)

Session 1

History, purpose, and learning theories of PBL

Introduction to PBL, objectives, and pedagogy

Session 2

Hands-on training in problem development and session facilitation

Step-by-step guide to PBL conduction and roles

Session 3

Faculty reflections, challenges, and solutions for improvement

Active engagement in simulated PBL discussions

Gaps identification strategy

Though the main aim of these training sessions and orientation classes was to streamline the PBLs conducted in the institution, one objective was to give insight to the students and faculty members regarding PBL so that they could compare the PBLs carried out in the institution with the textbook PBLs and their learning objectives, thus helping the gap identification in a more systematic way and making the study more reliable. This process involved (as shown in the Fig. 1 above),

Quality assessment questionnaire (QAQ)

The Quality assessment questionnaire (QAQ) is a five-point scale-based data collection tool consisting of standardized questions adopted from the published research on the subject and modified according to our institution [28, 29]. This QAQ consisted of 18 questions pertaining to the structure of the problems used in the PBL and the delivery of PBL sessions.

Preintervention evaluation of PBLs

At the end of the trainings (for faculty) and orientation sessions (for students), the participants were subjected to the QAQ questionnaire to evaluate the PBLs of the institution. Before filling out the QAQ questionnaire, the study was explained to the participants; informed consent was taken, and they were given the choice of opting out of the study and not filling out the QAQ, filling out the QAQ anonymously, or filling the QAQ along with their identity.

Identification of gaps

Based on the participants’ preintervention QAQ responses, the curriculum committee, the medical education department, and the subject experts analyzed the PBLs for their different components, such as the problem, the delivery of the PBL, the assessment, and the intended and achieved outcomes. This process led to identifying gaps in the PBLs conducted in our institution.

Addressing the gaps

A PBL revision committee comprising medical education experts, faculty representatives from basic and clinical sciences, and curriculum committee members was formed to address the identified gaps in the PBLs, including the gaps in the problems, delivery or conduct, and assessment. The PBL revision committee included faculty who participated in the pre- and post-intervention assessment and training, ensuring continuity in identifying and addressing gaps. The 3C3R model, one of the best models for designing PBL problems, was adopted to revise the PBL problems [20].

Outcome measures of the intervention

The outcome and the effectiveness of the intervention were measured by,

Post-intervention assessment by quality assessment questionnaire (QAQ), comparing the student’s performance in post-PBL formative assessment containing 20 multiple choice questions with the previous years (pre-intervention performance), and post-PBL satisfaction feedback from the students and the tutors. The previous year’s data was accessed several times during the study period from 20th September 2023 to 30th August 2024.

Statistical analysis

The collected data were analyzed using the Statistical Package for Social Sciences version 22 (IBM Corporation; Armonk, NY, USA) and MS Excel (Microsoft Corporation, Washington, USA). Shapiro Wilk test was performed to analyze the distribution of data. Then paired t-tests were used for normally distributed data (formative assessments), and Wilcoxon signed-rank tests for non-normally distributed data (QAQ scores) were used to compare pre- and post-intervention scores. A p-value < 0.05 was considered statistically significant. Effect sizes (r-value and Cohen’s d) were calculated to assess the magnitude of observed changes. The results were presented as tables and graphs.

Results

Gaps identification

Based on the input from the stakeholders (students and tutors), the PBL revision committee identified the following gaps in the PBLs. Table 1 summarizes these gaps with a few examples.

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Problems revision

After identifying these gaps, a total of 136 PBLs of different blocks from different academic years were revised according to the 3C3R model. The curriculum committee assessed, analyzed, and approved these revisions. Table 2 shows the details regarding these problems.

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Pre- and post-intervention QAQ scores

As a tool to evaluate our intervention’s effectiveness, we compared pre and post-intervention QAQ scores. The Shapiro-Wilk test showed a non-normal distribution of pre- and post-intervention QAQ responses (P <.001). The Wilcoxon rank test showed significant improvement in all aspects of the PBLs with a mean r value of -0.71 (P <.001), with most of the aspects showing an r value above − 0.80 (P <.001), showing a huge effect size of the intervention. The overall post-intervention QAQ score rose to 4.0 as compared to the pre-revision score, which was 2.7, indicating a 48.1% improvement in the PBL quality. The pre- and post-intervention QAQ score comparison of each question’s response on a five-point scale is shown in Table 3.

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Pre- and post-intervention post-PBL formative assessment scores

A comparison of student pre- and post-intervention post-PBL formative assessment scores showed a statistically significant improvement (P <.001). Cohen’s “d” for paired t-test showed the mean effect size of -0.54, with several blocks showing a d value above − 0.80 (P <.001), which is a huge improvement. The mean score showed a 30% overall improvement as compared to the previous year, with some blocks showing 40% improvement. The detailed comparison is shown in Table 4.

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Satisfaction ratings

Another indicator of our intervention was post-session feedback from students and faculty regarding each PBL individually, which showed an average satisfaction rate of 4.8 and 4.1, respectively, on a five-point scale. The average rating of the PBLs on the basis of problem quality, PBL discussion, structuring of objectives, application of knowledge, and achievement of the learning objectives was 4.3 on a five-point scale.

Discussion

In this interventional study, we identified and addressed key flaws in our institution’s problem-based learning (PBL) strategy, focusing on both content and delivery. While PBL may not always outperform conventional methods in every learning domain, its holistic benefits in fostering lifelong learning and professional competence make it a valuable pedagogical approach. Problem-based learning, widely regarded in professional education as more effective than conventional methods, supports critical thinking, teamwork, and communication skills, as underscored by Terry B. et al., Samantha H et al., and Shanley PF et al., in their research in medical education [30,31,32]. Despite all of its benefits, problem-based learning (PBL) is an extremely specialized and demanding field, needing thorough preparedness, a lot of training on the part of both the teachers and the students, infrastructure, and resources. The gaps in our PBL strategy were mostly because of the lack of training and preparedness by the teachers, students, curriculum, and problem designers. Smith DK et al., in their book, state that if students are not trained on the PBL, the dynamics of the session will be compromised, resulting in deficient learning [33]. In their book, Peter M. S. et al. made a similar assertion [34]. Hitchcock M et al., in their article regarding dysfunctional tutorial groups, put much emphasis on faculty training for a productive PBL. According to him, a lack of small-group management training will result in faculty being unable to implement problem-based learning efficiently [35]. William K Lim inferred similar conclusions in his article [36].

The targeted workshops on PBL greatly impacted our PBL revision strategy, enhancing awareness of PBL components and potential gaps in its approach. Through structured feedback (the QAQ questionnaire) from tutors and students—the core participants—we gained valuable insights into specific gaps and loopholes, which informed our revision strategy. This QAQ covered all the aspects of PBL, from planning and designing a problem to the last step of the PBL delivery.

The problem revision was a very delicate, skilful, and exhausting task during this study. This multidisciplinary task involved members from all medical disciplines, medical education, and quality. The problem is the foundation for generating the whole scheme of the PBL, including the objectives to address the different learning domains. Literature published on PBL in medical education has put a special emphasis on the problems in PBL. Henk JM et al., in their study on the determinants of achievements in PBL, state that the quality of the problem is an independent predictor of the quality of student learning [36]. A similar inference has been reported by Majoor GD et al. in their study on PBL construction [37]. So, keeping this fact in mind, we gave special attention to the problem-related gaps in our PBL revision strategy, focusing on the gaps mentioned in the published literature and also in the methodology section, and thus tried to make it a worthwhile practice [12,13,14,15,16,17].

In the later part of our study, we assessed the effectiveness of our PBL improvement strategy using certain indicators. The first indicator was the students’ and faculty’s response to the PBL quality assessment questionnaire (QAQ), which was previously taken before the revision of the PBLs and then retaken on the revised PBL strategy. Comparing it with the pre-revision QAQ response, there was a 48.1% improvement in the PBLs (4.0 VS 2.7 on a five-point scale). Paul R et al., used a similar questionnaire named the course experience questionnaire to assess the quality of learning experience in education [38].

Another indicator for assessing the effectiveness of our PBL improvement strategy was the students’ performance in the PBL sessions. The mean (SD) score in all the PBLs of all blocks was 4.1 (0.59) out of 5, which is significantly higher than the previous year’s score of 3.8 (0.52) (P <.05). This score is awarded by the pre-set rubrics that assess all the learning domains, i.e., knowledge, skills, and values. Joan C T et al., in their review article on the assessment of the effectiveness of PBL in undergraduate medical education, used improvement in the learning domains as an indicator of the effectiveness of PBL [39]. Though in his review, few articles concluded that the knowledge domain of learning is negatively affected by PBL as compared to other learning modalities, one of these was based on teachers’ opinions and not the real practices and exam statistics [40, 41], the rest of the studies favored improvement in all learning domains, including knowledge as an indicator of the effectiveness of PBL [42, 43].

Another indicator of the effectiveness of our PBL improvement strategy was the students’ and faculty’s satisfaction and PBL rating in post-PBL feedback, which is taken at the end of each PBL session. The average satisfaction rate for the PBL sessions on a five-point scale by students and the faculty was 4.8 and 4.1, respectively. In the published literature, student and faculty satisfaction ratings have been used as an indicator of the effectiveness of PBL. In their article, Petra M C et al. considered students’ satisfaction rate as an indicator of PBL effectiveness in improving performance [44]. Though we had a favorable faculty satisfaction rating, the published literature is more neutral, and it is mostly due to the lack of faculty training and infrastructure [45, 46].

Although we had very satisfactory results in our indicators for the effectiveness of the PBL improvement strategy, the beneficial effects of PBL in medical education are beyond these measurable learning parameters. However, our findings stem from our institutional PBL curriculum, hence may offer insights for other institutions facing similar challenges, and may differ from institution to institution. Nevertheless, the problem-solving, communication, and clinical reasoning skills acquired through this modality have a lifelong impact on medical professionals. These skills not only groom the personality of the medical professionals but also have a huge impact on the patients’ and community care.

Limitations and future plan

One of the study’s limitations is that we did not measure the effects of our PBL improvement strategy on the three learning domains separately but studied it collectively on all the domains. Another limitation of the study is the subjectiveness of the gap identification process, which might have affected the reliability, particularly as it relied on feedback from the stakeholders with variable approaches, including students, tutors, and content experts. For future perspectives, we plan to add more reliable approaches, including external reviewing and benchmarking, and measure the long-term effects of PBL on the three learning domains separately to see which domain it hits the most.

Conclusion

Although it is more than sixty years since the PBL strategy was introduced into education, the worldwide acceptance of PBL is still quite new and even controversial in some cases. This practical novelty has led to many flaws and gaps in PBL due to a lack of experience and expertise. That is probably why, even being one of the most effective student-centered learning strategies, especially in medical education, problem-based learning (PBL) is not achieving its deserving goals. Institutions’ PBL strategies frequently have gaps, like the quality of problems in the PBL, a lack of training and expertise resulting in a faulty approach to the PBL, a lack of periodic revision of the PBL and evaluating its learning outcomes, and the lack of infrastructure. Proper addressal of all these gaps is necessary to get the core of problem-based learning (PBL). While our interventions were successful in our context, their applicability to other settings should be evaluated individually.

Data availability

“The relevant data material can be obtained from the corresponding author to the authorized on proper request.”

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