Curriculum design

An essential first step in implementing a PBL curriculum is to have a curricular document in place. In line with the PBL philosophy, the implementation committee at UCCSMS set out to design a curriculum that allows active student participation and places content to be learned in a relevant clinical context. To achieve this, we adopted the Maastricht “seven-jump” PBL format [15] and modified it slightly to incorporate a plenary seminar session. This plenary seminar brings together the various tutorial groups to present the content learned in that PBL cycle to colleagues and faculty. The rationale behind this plenary session is to equip students with presentation skills and afford faculty the opportunity to correct misconceptions. In a hybrid PBL curriculum, it is essential for the curriculum document to clearly outline and delimit the roles of other teaching and learning activities to avoid unnecessary overlaps. Finally, it is imperative to institute a proper curriculum governance to ensure that curriculum is being implemented properly. At UCCSMS, the Curriculum committee works together with other committees to ensure that the objectives of the curriculum are adhered to.

The development of the UCCSMS curriculum involved a number of retreats with content experts. The contribution of various clinical and basic scientists and that of medical educators to the curriculum cannot be overemphasized. These, notwithstanding, most of these experts were unfamiliar with PBL and therefore opposed some of the ideas, not because the ideas lacked substance, but rather because the experts could not fully appreciate those ideas. This situation has to be managed well to avert the potential of ending up with a dysfunctional curriculum with a PBL façade. It might be necessary to precede such curricula design retreats with a PBL workshop to introduce and tune the minds of content experts to the objectives of the retreat. Getting the PBL curricular document ready is an important first step; however, the implementation of the curricular document is daunting and requires the cooperation of faculty members, students, non-academic staff, and the wider university community.

Resource limitations

In a PBL curriculum, students study in small groups of about 6 – 10 members and each of these groups is assigned a faculty member (facilitator) whose role is to facilitate the learning process at the tutorial group meetings. The human resource implication of this setting is massive: - a class of 40 students will need at least four facilitators (lecturers) instead of one. To put things in perspective, UCCSMS currently uses PBL at five levels (from 200 to 600) with each level having 4 to 6 tutorial groups. This translates into 25 groups requiring 25 facilitators (lecturers) during tutorial group meetings. For larger classes of 100 or more, the requirement for facilitators can be daunting. This constitutes a huge increase in the cost of running a PBL curriculum as compared to lecture-based learning (LBL). The debate as to whether this excessive faculty cost is justified is ongoing. However, a study to evaluate this cost-benefit question concludes that PBL does not place unreasonable demands on the time of faculty [16].

The other resource implication of a PBL curriculum is infrastructure. Directly related to having tutorial groups is the need for tutorial rooms. Ideally, PBL tutorial rooms should be purpose-built and well designed with adequate illumination and ventilation to provide a pleasurable learning environment for students and faculty. Poorly lit and ventilated tutorial rooms could make student uncomfortable and eager to end tutorial sessions before time [17]. Here again, more rooms are needed for a PBL curriculum as opposed to an LBL one. For instance, at UCCSMS, we had to come up with enough tutorial rooms to accommodate all of our 25 tutorial groups. This is a challenging task even when tutorials are scheduled at different times to allow multiple tutorial groups to use a single tutorial room. Adequate learning resources including well-resourced libraries, reliable internet connectivity, functional clinical skills laboratories, and basic science laboratories facilitate self-directed learning (SDF) in a PBL curriculum. In spite of being vital to a PBL curriculum, the provision of these facilities is an uphill task in resource-poor settings. Similarly, the provision of logistics such as flip charts, markers, projectors, etc. is an additional strain on the inadequate education budget in such settings.

Dealing with tutors

Becoming a PBL tutor represents a significant change in role for some faculty members [3]. Some consider it a demotion from their acquired or ambitioned status as eminent academics to an insignificant facilitator of learning. For others, there are genuine feelings of uncertainty about their roles as PBL facilitators: they are unsure about how, how often, and when to intervene, how detailed and directive they should be, and whether they should be content experts or not. Faculty perceptions on PBL curricula are generally positive [18–20] but that notwithstanding, these issues need to be addressed to prevent faculty from becoming frustrated and opposed to the curriculum. A PBL training workshop for newly engaged faculty and periodic refresher courses for old faculty are crucial in this respect. At UCCSMS, signs of faculty’s frustration and opposition to PBL were implicit rather than explicit. It manifests occasionally as apathy and absenteeism from PBL tutorials. Faculty members who are unsure about PBL may also push to add more lecture slots to the weekly time table and in so doing rob students of their self-directed learning (SDL) time. Some may even attempt to schedule lectures at SDL periods without recourse to the module coordinator. Subsequent sections of this article will describe the faculty development strategy (with regards to PBL) at UCCSMS and how this threat has been dealt with.

PBL scenarios

Scenarios also referred to as cases or problems, play a pivotal role in PBL. They are essentially learning objectives transformed into scenarios and they allow students to learn clinical, basic and behavioural science concepts in an integrated manner [21]. Thus, the success of PBL, as a learning or an educational strategy hinges heavily on the quality of the scenarios and the range of the scenario bank [22, 23]. Good scenarios integrate several disciplines, encourage discussion of cognitive domains, promote collaboration and encourage self-directed learning [22]. The most effective scenarios: (a) address one or more learning objective(s) in the module guide; (b) activates prior knowledge and builds on existing knowledge; (c) are commensurate with the level of the students; (d) are relevant to the future profession of students; (e) stimulate critical thinking and encourage self-directed learning.

Undoubtedly, getting PBL scenarios is not an easy task. It requires teams of educational and subject experts, staff training, and expensive writing retreats. Some universities avoid this stress and purchase PBL scenarios from elsewhere but purchased scenarios may be socially and culturally inappropriate and often require adaptation and further fine-tuning before they can be used. The number of scenarios needed per module/block will depend on the length of the block and the variant of PBL being used. UCCSMS generates its own scenarios and faculty is tasked with writing PBL scenarios for the various modules. Presently, only a few faculty members have written majority of the scenarios used in UCCSMS and although the PBL training for new faculty includes a session on scenario writing, majority of faculty are yet to write their first PBL scenarios. The factors that motivate faculty to write scenarios need further study.

Assessment drives learning

The cliché: “assessment drives learning” has proven to be true in many settings, particularly in medical education [24]. However, institutions that use PBL curriculum appear not have adequately aligned their assessment with the educational philosophy of PBL. This undermines the effectiveness of PBL and dampens students interest in PBL since their efforts seems not to be rewarded. Assessment at UCCSMS is structured to match our curriculum and it spans three main categories: formative, continuous, and annual assessment [25]. By definition, formative assessments are non-scoring, however they provide valuable feedback for faculty and students and thus, they are obligatory. Continuous assessment constitutes 60% of student’s marks for the academic year and student’s assessment during PBL tutorial group sessions and presentation constitute 15% of the continuous assessment marks. This may still not be enough motivation if as sometimes happens, the majority of the questions require recall of facts rather than critical thinking and application of knowledge.