Carrera, Larisa Ivón MD; Tellez, Tomás Eduardo PhD; D'Ottavio, Alberto Enrique PhD
When our medical school in Argentina decided to implement a problem-based learning (PBL) curriculum, the economic environment and other factors presented particularly difficult challenges, ones familiar to any medical school in a developing country. Below, we give an overview of PBL, provide some background information on medical education in Argentina, discuss the situation faced by our school in attempting to create and implement a new PBL curriculum, and then suggest a more suitable alternative to a pure PBL curriculum for developing countries when this type of format is being considered.
Problem-based learning (PBL) originated at McMaster University Faculty of Health Sciences, Canada, in the 1960s, and, soon after, other medical schools—notably the University of Limburg, Maastricht, The Netherlands, the University of Newcastle, Australia, and the University of New Mexico, United States—began incorporating and adapting this curricular format. The foundations of PBL are active, adult-oriented, problem- and student-centered learning. PBL curricula typically feature a number of elective courses, and faculty meet with small groups of students (five to ten) in both inpatient and outpatient settings. Advised by tutors and experts, students actively and independently develop the educational skills that will allow them to process, organize, understand, and evaluate scientific information and to become lifelong self-directed learners. PBL integrates the basic and clinical sciences, with cases forming the triggers for student learning. Throughout the course of study, students are given both formative, corrective evaluations and more conventional summative evaluations. PBL emphasizes meaning/understanding rather than rote learning and memorizing.1–4
A strong group of PBL supporters have long argued the advantages of a well-planned and implemented PBL curriculum over a lecture-based format, visualizing this model as a new paradigm in medical education2,5–7 However, others have complained that there are disadvantages to PBL as well as not enough evidence of its value. The pros and cons of PBL continue to be debated in the literature.2,8,9
Basic Requirements for Successful Implementation of a PBL Curriculum
There are at least four basic requirements for successfully implementing a new PBL curriculum. Some of these are also important for other types of curricula that are not “pure PBL.”
▪ A low number of students in each tutorial group. Ideally, these students will come from relatively homogeneous educational backgrounds that include some postsecondary preparation (in which students acquire the basic skills needed for independent learning).
▪ An appropriate number of tutors and experts in biological, psychological, and social areas with uniform pedagogical and scientific backgrounds who are needed because of the integrated learning strategy of PBL and its link with the scientific method.
▪ Hospitals and community care centers, within an orga nized health care system, that can be used as teaching sites throughout the curriculum.
▪ Adequate financial resources to provide specially equipped rooms and libraries for use by tutors and students. Even in relatively wealthy countries and medical schools, it is often difficult to meet these requirements (in fact, one of the arguments against PBL is that it is costly both in terms of money and also in terms of faculty time and space requirements10).
Medical Education in Argentina
According to the Argentinean Association of Medical Schools, there are 26 medical schools in Argentina, eight are public and 18 are private. All public education in Argentina is free. Although all public universities are autonomous, each is entirely dependent on the government for income; needless to say, Argentina's current economic crisis has further limited the already small amount of resources dedicated to research and facilities, and there is significant competition for funds among public institutions.
Students enter six-year medical school programs right after high school; there is no intermediate degree program. The Higher Education Federal Law of 1995 stipulated that universities with fewer than 50,000 matriculated students can set policies for all schools, including medical schools, within the broader university. If the number of matriculated students exceeds 50,000, each school (faculty) within the university can establish its own admission policies. Consequently, there are a wide variety of admission policies and therefore a wide range of medical school admission numbers (from about 150 matriculants each year, plus or minus 50, to 1,500, plus or minus 500). Some schools have instituted preparatory courses and/or examinations that students must take before entering the university or medical school. Since 1995, our medical school has required applicants to attend a preparatory course, the Vocational Challenging Course. This has led to some changes in our admission numbers (from 1,500 matriculants, plus or minus 500, to 1,000, plus or minus 200). However, these courses generally are not sufficient to overcome the deficiencies students bring to their university education, which is a result of varied types of secondary education, often poor.
OBSTACLES OUR PBL CURRICULUM FACED
In Argentina, Flexner's paradigm of medical education is still predominant in both public and private medical schools. Although some schools are now considering implementing PBL curricula, only a few are training students using PBL methods and principles.
Our medical school, Rosario University School of Medicine, is the first medical school in Argentina to adopt a six-year “pure” PBL curriculum, meaning that PBL is the only method used throughout the entire curriculum. This implementation was approved by both a university council and a faculty council, and then was subsequently approved for temporary implementation (2002–2004) by the National Universities Evaluation and Accreditation Commission. However, when it approved this trial period for the PBL curriculum, the Commission also stipulated that Rosario's admittance numbers must be significantly reduced. This is a goal the institution is finding difficult to achieve.
The new curriculum was implemented in 2002. The obstacles faced in implementing PBL were not insignificant, and our medical school is still working to fully overcome some of them. Below, these obstacles are described in some detail. The reader will note that the obstacles reflect difficulties in achieving some of the four requirements for successfully implementing a PBL curriculum, mentioned earlier.
Generalist versus Specialist
In Argentina, medical schools train generalist physicians through a six-year curriculum. However, the complexity, heterogeneity, and fragmentation of its health care system drive postgraduates to pursue specialist rather than generalist careers for better professional placement and job security. In fact, medical students think about specialization from the very beginning of their studies. Hence, PBL's goal of producing well-rounded general physicians is viewed by many students as having little relevance to their goals.11
The Student Population
Most entering students come from a variety of educational backgrounds, with wide variation in grades, test scores, learning skills, and so on. Students have varied levels of knowledge in biology, mathematics, chemistry, and physics; differ widely in their abilities to understand instructions or express ideas (in oral, written, and/or graphic ways); and present a range of language and mathematical skills. Students who have significant deficiencies in these areas are more likely to drop out of any institution of higher learning, but they are even more likely to be unsuccessful in a PBL program, which requires the ability to process and discuss ideas and learn independently.12 In other countries, where students enter medical school after receiving a baccalaureate degree, they arrive at medical school with a set of learning skills that cannot be acquired in the kind of short, preparatory courses offered by Rosario and other Argentinean schools. Further, the variety of students' backgrounds and the varied sizes of entering classes produce classroom situations in which students with advanced learning skills mix in large groups with students who are far less educationally advanced.
Human and Financial Resources
Implementing a PBL format requires a suitable number of full-time teachers uniformly trained as experts or tutors who are committed to this curricular model. In Argentina, the number of available full-time experts and tutors (chosen among professors and instructors) is progressively diminishing because academic salaries are low and a serious commitment, financial and otherwise, to full-time teachers is lacking in our country. In this sense, it is helpful to point out that a full-time professor earns on average $9,000 (in U.S. dollars) per year, at present. Further, faculty members' scientific, pedagogical, and interdisciplinary backgrounds are frequently too heterogeneous for them to be successful PBL tutors. And although younger faculty members are more open to this new format, older faculty members are generally more reluctant to use it.
Regarding financial resources, annual budgets for medical schools in Argentina are significantly lower than those for medical schools in developed countries. Although this bothersome financial situation may be improved through foreign credits, tariffs, grants, donations, family student contributions, production and selling of educational material, and educational services and merchandising, among others, the differences between the financing available to medical schools in developed and developing countries are still very significant.13 As noted above, PBL requires specially equipped rooms and well-stocked libraries, all of which cost money that many Argentinean universities do not have to spare.
OUR RESPONSES TO THE OBSTACLES
Given the significant obstacles faced by our medical school in implementing a PBL curriculum, readers may wonder why the attempt was made and how these obstacles are being overcome. In the specific case of Rosario University School of Medicine, the school's administrators decided to implement a PBL curriculum because they believed that (1) PBL offered an educational paradigm superior to the dominant Flexner paradigm, and (2) the obstacles to implementing a PBL curriculum could be overcome.
To mitigate the limitations of previous training that many students and many medical teachers bring to PBL education, Rosario modified some of the content and requirements of its preparatory course for entering students to better prepare them for PBL learning. Complementarily, pedagogical courses were developed to train faculty to become effective tutors. Finally, extra funds to create effectively equipped spaces for tutorial groups were obtained, mainly from the National Health Primary Care Program, the Rosario National University, contributions from students' families, and the production and selling of educational material and educational services. However, the institution continues to work to accommodate the heterogeneous educational backgrounds of both students and faculty, which can hamper the work of tutorial groups.
During the first year, students were animated, in the very beginning, about courses in the biological, psychological, and social areas such as growth, development, and nutrition. These areas belong to the two-year cycle of promotion of health and prevention of illness and contain modules with problematic situations focused in the different human ages (childhood, adolescence, and young and older adult). Even though some successes and failures have already been observed in students, teachers, and especially in the program implementation itself, it will take several years before the school's administrators can truly evaluate the impact of this new curriculum. Consequently, evaluation is one of the major challenges to be faced from now on to prepare for possible reapproval by the National Universities Evaluation and Accreditation Commission, whose assessment will take place from 2005 to 2007.
The belief in PBL as the best substitute for Flexner's paradigm, the temptation to get on the bandwagon so as to not be perceived as behind the times, and a “pioneer” mentality (which assumes all obstacles can be overcome with enough energy and commitment) may lead schools in developing countries to attempt to create “pure” PBL curricula at their institutions. Although it certainly is tempting to incorporate educational innovations from the United States, Canada, and Europe in countries like Argentina, the particular situation of each medical school and its home country must be taken into account when considering curricular changes, because the problem seems to be not the PBL format itself but rather the local circumstances. Consequently, the everlasting questions—What? Why? When? How? Who? What for?—should be answered before carrying out any effort in this regard.
Clearly, several characteristics of Argentinean medical schools are barriers for the attainable implementation of a complete and pure PBL format. These difficulties may be also found in other countries with similar economic constraints and educational systems. Schools in similar circumstances should consider whether a PBL curriculum is even appropriate for them. Furthermore, if they put it into practice, their institutional leaders and faculty members will need to surmount the drawbacks we have discussed and should expect to wait several years to know how well they have faced their challenges and achieved their goals. In the meantime, they will also have to track the new program through reasonable periodic objective evaluations or adjustments and comparisons with those from other countries.14
The arguments reviewed above, along with the enduring debate about PBL in current literature,8,9 the uncertain results from reports comparing PBL with conventional teaching,15 and the need for more studies of PBL outcomes and PBL applications in other professional schools16 certainly create a case for exploring alternatives to implementing pure and complete PBL curricula in countries like Argentina. In fact, the progressive implementation of a hybrid model has been reported in other developed and developing countries4,10,15,16 and may prove to be a more suitable alternative for Argentina and other developing countries. Even though we at Rosario took the opportunity to explore, with other professors, the planning and implementation of a hybrid model, the approval of the pure PBL curriculum led us to participate in this curriculum by incorporating some of its activities (tutorial groups, expert supervisions, systematization meetings, laboratories for skill development) into our academic responsibilities. However, if the challenges and obstacles to be overcome become increasingly problematical for planners, teachers, and students, we cannot disregard the possibility that elements belonging to a hybrid model could eventually be incorporated. To sum up, considering the available research on curricular innovations such as PBL and the particular situations of their countries may help medical school faculty in all parts of the world to avoid wrong decisions or to avoid planning and implementing curricula that may fail.
1. Jayawkdramarajah PT. Problems for problem-based learning: a comparative study of documents. Med Educ. 1996;30:272–82.
2. Camp G. Problem-based learning. A paradigm shift or a passing fad? Medical Education Online. 1996, Vol. 1:1–10.
3. Knowles ME. The modern practice of adult education. Cambridge, England: Prentice Hall, 1980:57–8.
4. D'Ottavio AE. On being a doctor. Thinking about medical formation and practice. In: Pérez JN, Riestra, G (eds.) Rosario, Argentina: Homo Sapiens, 2001.
5. Savery JR, Duffy TM. Problem-based learning: an instructional model and its constructivist framework. Educational Technology. 1995;35:31–5.
6. Norman GR, Schmidt HG. The physiological basis of problem-based learning: a review of the evidence. Acad Med. 1992;67:557–65.
7. Barrows HS. The essentials of problem-based learning. J Dent Edu. 1998;62:630–33.
8. Fenwick TJ, Parsons J. A critical investigation of the problems with problem-based learning (Research Report No. 143) U. S. Department of Education, (ERIC Document Reproduction No. ED409 272), 1997.
9. Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med. 2000;75:259–66.
10. Anderson WL, Glew RH. Support of a problem-based curriculum by basic science faculty. Medical Education Online. 2002;7:10–5.
11. D'Ottavio AE, Miguel JC. Postgraduate specialization of Argentinean medical students in the 1960s and 1990s. Acad Med. 1998;73:1029–30.
12. Cesolari JAM, D'Ottavio AE, Zapata GO, Rossi AR, Villar IJ, Merli SA. Factors with potential influence on early attrition during the first year of the medical career. Compensatory proposals. Medicina y Sociedad (Argentina), 1991;14:31–35.
13. Jaim Etcheverry G. The Educative Tragedy. Buenos Aires, Argentina: Fondo de Cultura Economica, 1999.
14. Frye AW, Solomon DJ, Lieberman SA, Levine RE. Fitting the means to the ends: one school's experience with quantitative and qualitative methods in curriculum evaluation during curriculum change. Medical Education Online. 2000;5:1–7.
15. Nandi PL, Chan JNF, Chan CPK, Chan P, Chan LPK. Undergraduate medical education: comparison of problem-based learning and conventional teaching. Hong Kong Med J. 2000;6:301–6.
16. Jaffarey NA. Problem-based learning. J Pak Med Assoc. 2001;51:266–7.