Problem-Based Learning vs. Traditional Teaching in Medical Education

Introduction and Purpose

For more than 50 years, scholars have been debating whether problem-based learning (PBL) is more effective than a traditional educational model (Colliver, 2000). This question remains unresolved. Problem-based learning started in medical settings, but since its inception it has been adopted by other disciplines as well (Barrows, 1996). Examining the literature on problem-based learning as it applies to three populations engaged in various forms of medical education—medical students, nurses, and respiratory therapists—offers a comprehensive perspective on this ongoing debate.

This literature review offers a comparative analysis of the efficacy of problem-based learning compared to traditional methods of teaching. It focuses on research that directly affects the training of doctors, nurses, and respiratory therapists. The central purpose is to determine whether problem-based learning genuinely enhances training outcomes or whether its reputation rests on enthusiasm rather than empirical evidence.

Defining Problem-Based Learning

Problem-based learning has been endorsed and adopted by many institutions (Hoffman, 2006), yet its reputation remains questionable to others. PBL has received mixed reviews on its actual efficacy since its inception. A secondary complication further clouds this discussion: PBL has been adapted at numerous institutions, and these adaptations inevitably blur what PBL actually means. Therefore, a clear definition of what constitutes PBL remains unresolved, making research difficult and definitive answers elusive (Hmelo-Smith, 2006).

The working hypothesis guiding this review is that problem-based learning will prove to be more effective than traditional teaching methods. If this proves true, one can reasonably extrapolate that more patients will experience better care and more positive outcomes in their treatments.

What exactly is problem-based learning? The question remains murky, in part because educators adapt the model to suit their own environments and institutional cultures. However, a general description is useful for this literature review (Hmelo-Smith, 2004).

Medical Education and PBL

Throughout this review, PBL will be defined as follows: Problem-based learning takes shape when students pursue questions that have more than one answer. In this context, students typically must choose actions that are best suited to their patients' health needs. PBL favors authentic activities. The word "authentic" carries special meaning here: it implies that the tools and insights students acquire parallel the actions they will need to use when working with patients. Students typically work in small groups and are largely responsible for their own education. As a result, the teacher's role changes fundamentally—from an all-knowing expert to a facilitator and guide. Overall, students are primarily responsible for directing their own learning (Barrows & Tambly, 1980).

The PBL model has grown exponentially since its inception roughly 50 years ago. Most PBL training has taken shape in various types of medical education settings (Camp, 1996). Understanding its origins and core characteristics provides important context for evaluating its effectiveness across different professional healthcare disciplines.

Problem-based learning was predicated on the notion that medical education required fundamental change. Barrows and Tambly, both medical professors in Canada, created a new teaching paradigm in medical schools called the McMaster system. Their innovation addressed what they viewed as critical deficiencies in traditional medical education.

Most traditional medical students' education relied heavily on facts. Students were expected to absorb and memorize vast volumes of information. Barrows and Tambly objected to this approach, arguing that it mandated memorization rather than problem-solving. They wanted their students to engage with complex clinical dilemmas rather than passively accumulate facts. Since both professors were also practicing physicians, they were acutely aware of the real skills and intelligences required in medical practice. They grew to dislike students' reliance on fact-based knowledge alone, insisting instead that training must be based on knowledge that matched the work students would perform after graduation. Both professors believed in centering the student rather than the teacher. They created the McMaster system at McMaster University, an educational paradigm that embodied their philosophical convictions.

The book they wrote together, An Approach to Medical Education (1980), is largely a detailed description of their philosophical point of view on training doctors for medical practice. It offers a comprehensive description of the essential components their model required and includes careful descriptions of what constitutes a problem-solving paradigm. However, the book primarily offers an enthusiastic endorsement of their own educational philosophy—it is, by their own admission, a prejudiced work celebrating their methods.

Even so, Barrows and Tambly were aware of shortcomings inherent in their new model. They recognized that more resources were needed and that evaluating students' knowledge and skills was critical. Since students determined much of what they would learn, teachers had to evaluate each student's work based on their personal educational goals. Additionally, both professors learned that some students became anxious and uncertain about what they needed to know and to what depth.

Cindy Hmelo-Silver's research (2004) offers a more balanced analysis of PBL's assets and shortcomings. Initially, Hmelo-Silver appears to be a strong advocate for PBL, arguing that it helps students learn factual content alongside deeper thinking (p. 235). She believed that recipients of this form of education would be capable of constructing their own ways of thinking and judging. She provides an in-depth description of the PBL model and shares intricate accounts of methods used to optimize PBL learning experiences.

Despite her opening comments, Hmelo-Silver remains skeptical. She contends that not much empirical evidence fully supports PBL's effectiveness. She argues that the research emerges from one sector—medical schools—and that as PBL proliferates, it becomes increasingly unclear what the paradigm actually consists of. The accumulated results have generated mixed reviews. At best, PBL students appear to "fall short" of traditionally trained students on some measures. Her final criticism suggests that the validity of the research is questionable, in part because studies focus solely on students in higher education.

By contrast, Hank Schmidt (2004), a professor of psychology at Maastricht University in the Netherlands, applauds the PBL model. He notes that PBL has become the instructional choice of many medical schools worldwide—now used in approximately one-third of the world's medical schools. Schmidt contends that PBL is proliferating because it helps learners become immersed in the material, allowing students to spend their time pursuing what they feel is important to learn.

Schmidt's synopsis of how students are taught, combined with his international perspective on data generated in the late 1990s, is especially helpful in determining PBL's efficacy. In his summary of outcomes, Schmidt notes that PBL produced higher levels of professional skills in final-year students at his own university compared to traditionally taught students at an unnamed Dutch school. He also notes that some believe PBL students are likely to become lifelong learners—an inevitable outcome since doctors must continuously update their knowledge. Research from Finland suggests that graduates from innovative programs are more likely to choose careers in primary care. However, Schmidt acknowledges that PBL does not guarantee that doctors will leave their training with more diagnostic competence than their traditionally taught counterparts. As of 1998, his research suggests that outcomes surrounding PBL's value remain mixed.

Richard Epstein (2004) writes that medical education is increasingly moving away from a didactic model featuring all-knowing doctors and toward contextual, problem-based learning. This "paradigm shift" is verified by studies showing that PBL enhances students' reasoning and communication. These studies also suggest that there is no detectable loss of understanding in students' educations. Epstein suggests that PBL's ascendance parallels the influx of easily accessible information. Medical personnel can now extract key information immediately, and since PBL training requires students to actively seek information and construct their own knowledge base, they are especially prepared to do so. Their proactive education, combined with the remarkable depth of instantly available information, offers a rationale for PBL's adoption. According to Epstein, there appears to be no downside to this process.

James Colliver (2000) would strongly disagree. He dismisses assertions favoring PBL's efficacy, and his concerns parallel Hmelo-Silver's earlier remarks. Colliver contends that PBL's popularity is predicated on mass enthusiasm rather than empirically based scientific evidence (p. 259). He asserts that PBL has not proven valid and lacks confirmation as an effective teaching model. His article largely condemns the assertions that PBL proponents make, implicating the cognitive sciences that underpin PBL theory. Colliver believes medical educators must abandon their support of PBL until sufficient empirical proof demonstrates that PBL is, in fact, an effective way to teach.

PBL in Nursing Education

After ten years of administering PBL at the University of Missouri's School of Medicine, Hoffman and her research team examined its overall efficacy. Hoffman believes that the PBL curriculum emphasizes learning in tandem with practical problem-solving, helping students access their own knowledge and grasp relevant information they will use in real practice. To discern the effects of problem-based learning on medical students, Hoffman's team divided students into two groups: those learning via traditional methods and those using PBL, with equal numbers in each group. The mean age at graduation was 24 years. The team relied on four indices to assess outcomes: students' academic aptitudes, grade point averages, performance on the USMLE (Steps 1 and 2), and residency program directors' evaluations of each student. Hoffman's team observed differences between traditionally trained and PBL students, concluding that PBL-trained graduates acquired skills needed for professional practice—an outcome they deemed especially important given today's healthcare complexities.

In 2010, Szogedi and colleagues conducted research to determine if PBL is more effective than traditional learning when training nurses. Their results suggest that PBL is more effective than traditional teaching for nurses trained in cardiopulmonary resuscitation (the research was conducted in Hungary). The study examined 1,775 nurses who had received CPR training, using a comparative analysis across three major universities. Researchers relied on t-tests and exam grades to evaluate outcomes. The t-tests revealed significant differences (t = 3.569; p < 0.001) between conventional and PBL-trained students. Students who received PBL training acquired better final CPR exam grades than their counterparts. The researchers concluded that PBL is superior to traditional training for acquiring theoretical knowledge and skills, though they acknowledged that real-life application might yield different outcomes.

A study by Applin, Williams, Day, and Burok sought to determine if PBL training affected students' self-perceptions about their competencies. Applin's team employed qualitative methods, collecting self-reports from 121 nurses with six months of field experience. They designed a survey using both forced-choice and open-ended questions. The researchers found no empirical differences between PBL and traditionally trained nurses in their self-assessments.

Williams and colleagues (2001) created a comparable study. Like Applin, they used qualitative data to understand how graduates felt about their undergraduate training. A sample of 45 registered nurses who received problem-based education participated in focused ethnography and/or focus group discussions. The qualitative data revealed that graduates described themselves as autonomous, critical thinkers capable of acting as patient advocates. However, Williams's team found no statistical significance between PBL-trained and traditionally educated nurses. Their methodological choice—using qualitative approaches—is described as a "rare viewpoint in the literature," yet an important one. However, the fact that respondents could choose to participate in either focused ethnography or focus group discussions weakened the study's validity, as each group may have focused on different themes.

Savery and Duffy (1995) designed a study using multiple methods of observation, including focus group interviews and questionnaires. As expected, the use of multiple data forms enhanced outcome validity. Although students had an overall positive experience with PBL, early in the program students found PBL especially stressful due to its ambiguity—a finding that echoes outcomes reported in Barrows and Tambly's research. Additionally, since students were asked to direct their own learning, the tutor's role remained unclear to them.

Ali and El Sabal conducted a study investigating the effect of PBL on 30 female nursing students' learning approaches and self-directed learning abilities. Their methodology consisted of a quasi-experimental design based on before-and-after effects, using two instruments: the College of Health Science for Females survey and the Self-Directed Learning Instrument. Results indicated that post-test mean scores were noticeably higher than pre-test scores (p = 0.001). Additionally, a significant increase in self-directed learning abilities occurred after the PBL course (p = 0.003). The researchers concluded that successful introduction of PBL in nursing education improves professional performance.

In the same year, Barrow and colleagues published an article on the value and problems associated with PBL training for nurses, noting that "problem-based learning in nurse education has increased internationally in recent years. The presumption is that PBL will enable nurses to develop skills required for professional practice including inquiry, reasoning, interpersonal, and lifelong learning skills" (2002).

Problem-based learning for respiratory therapists is relatively new (Holt, 2005). Additionally, many changes have occurred that have affected respiratory therapists' professional roles. Over the last 50 years, the respiratory therapy career has changed significantly (Beachey, 2004). Most of these changes result from sophisticated medical technology, an aging population, and more informed patients. The net result is that respiratory therapists must now assume greater responsibility for each patient's care (Beachey, 2004).

PBL in Respiratory Therapy Education

To calibrate how effective PBL is for respiratory therapists, Will Beachey, director of a university's respiratory therapist training program, conducted a study using multiple indices to determine if PBL was indeed more effective than traditional training. He employed six indices: graduates' self-assessment, employers' assessment of student competencies, students' competencies in cognitive abilities, psychomotor skills and emotional competencies (assessed via standardized surveys), and students' scores on the National Board for Respiratory Care (NBRC) examination.

Beachey discovered the following outcomes: (1) PBL-trained graduates rated their program's overall quality significantly higher than graduates of traditional programs. (2) There were no significant differences in mean scores on the NBRC examination between groups. Beachey's use of numerous indices indicates a robust and valid study design.

While Beachey conducted an exhaustive study using many indicators, Lynda Goodfellow (2001) focused on one aspect of respiratory therapists' education: their critical-thinking behaviors. She relied on self-reports, a quantitative survey, and self-ratings on seven critical thinking skills. Respiratory therapists also assessed their own critical expertise. Goodfellow found that respondents believed they excelled most at critical thinking, troubleshooting, and communication, with anticipation being their lowest-scoring skill.

Ceconi's work also focuses on respiratory therapists' critical thinking skills. Ceconi studied 100 respiratory therapy students' records at a private university in South Alabama (2006), using two instruments to measure capabilities: the NBRC Clinical Simulation Self-Assessment Exam and graduates' actual exam scores. Her research suggests that PBL has a positive impact on decision-making skills in respiratory therapy students. Although Ceconi's sample size was relatively small (n = 100), her use of multiple indices strengthens her assertions. Additionally, her work would be easy to replicate given the standardized instruments she employed.

Rutkowski's (2003) research on PBL's efficacy offers a balanced synopsis of outcomes. Rutkowski manages a respiratory therapy department and conducted research with staff members within his hospital setting. Seven respiratory therapists participated, with years of experience ranging from one to 20 years. The group consisted of three females and four males with an average of 7.3 years' experience in the field. At the start, students identified six learning issues they hoped to explore. A second phase used a Likert-type scale to assess therapists' attitudes toward PBL's acceptance and usefulness, asking respondents to indicate agreement or disagreement with a series of statements. Interestingly, respondents' favorite educational format was lectures—a format representing reliance on the teacher rather than on their capacity to construct knowledge. This outcome appears contradictory, as 57.1% of participants believed PBL was their preferred learning style. The small sample size, convenience sampling, and the possibility that the researcher's own staff members were respondents appears to skew this study's validity, and the outcome may lack credibility.

Conclusion: Evidence and Ongoing Debate

Skepticism about the efficacy of problem-based learning has permeated the literature since its inception roughly 50 years ago. The research appears to seesaw between practical acceptance of PBL training and theoretical aversion to it. Even so, the PBL model is accruing more evidence-based research and compiling empirical data. As institutions continue to adopt and adapt PBL, future research addressing definitional clarity, consistent methodology, and longitudinal patient outcomes will be essential to resolving this enduring question in medical education.