July 25, 2002

     Two weeks ago, I wrote an article based on a recent issue of Newsweek magazine on how future doctors are being trained (Is the cadaver dead?). Although it was never mentioned by Newsweek, I thought of Problem-Based Learning (PBL) having the same concept - doing away with the old didactic approach by emphasizing small-group, case-based learning right from the start, although I admit I am still in the dark, for the most part, as to what PBL really is.

     A day after the column appeared, I got a feedback from Dr. Noel Binayas (1979). I quoted Doc Noel's comments last week but I'm quoting it again here to save you from another click - "The College of Medicine had started implementing the PBL (Problem-based Learning) methodology in our curriculum. Other schools had difficult experiences with its implementation. We had been preparing for this for years; the faculty has fair enough understanding and commitment to see the method succeed. We think it can be done. We're trying the hybrid approach and adapting to available resources. It's certainly not easy. We're patient, and patiently fighting one another in preparing the complicated and numerous modules! I think we're doing better than most... as usual... D'yan tayo magaling!

     Dr. Binayas's comments elicited another one. Dr. Arthur del Rosario (1980), himself a former College of Medicine professor, sent in this comment directed to Dr. Binayas - "It seems to me that this is something new to our school. It sounds good to me. However, I'm quite concerned when you mentioned that "other schools had difficult experiences" implementing the program. If this is so, why introduce a "radical change" and give everybody (students and faculty alike) a hard time? Looking back, the College has produced excellent medical graduates in the traditional system. From my standpoint, I believe that it is more urgent to modernize or update the teaching materials/equipments and improve the student:faculty ratio. Let's make learning a "fun experience".

"You don't have to search far and wide if you want to know more about PBL, as you would if you want to know, say, the divine secrets of the ya-ya sisterhood."

     Perhaps Dr. Binayas can answer that in his next article and possibly enlighten us on how this "radical change" can change the College of Medicine for the better. Dr. del Rosario's point is basically this - if it's not broken, why fix it?

     Here's another comment I received about PBL, a little bit sarcastic but worth quoting - "Ang PBL na naga-pamango' lang sa estudiante, hindi bala? Kag daw masal-an pa nga partido politikal. Hindi bala? Ha, ha, ha!" (PBL just makes students dumber, doesn't it? And it sounds like a political party.) Needless to say, the writer chose to remain anonymous but I find this comment interesting. He or she may or may not be a part of the College of Medicine community, or just somebody with nothing else to do, but I couldn't let the comment pass (he/she read the column and made a comment, let's give him/her at least a little credit for that). Is PBL this controversial to elicit comments like that?

     I have heard about Problem-Based Learning in 1991 when I was still in school, so this concept is nothing new. I have even mentioned in one of my previous columns that this was implemented right after my batch left Roxas Hall for internship (darn, nobody corrected me) simply because I have seen first year students in group discussions instead of listening to lectures (or fellow students 'reporting'). As far as I could remember, they were divided in small groups with their chairs arranged as if they were playing musical chairs. I asked one of the students then and I was told about Problem-based Learning (PBL). The students were given basic clinical cases from which they "brainstormed" to answer accompanying questions that were likely related to or provoked discussions emphasizing the aspects of the basic sciences (Anatomy, Physiology, etc.).

     So it was a surprise when I received Dr. Binayas's comments and I read the Dean, Dr. Victoria Villareal's acceptance speech that PBL has yet to be implemented. I was probably duped by one of the students then that they were 'doing PBL'. Was it a 'trial' run that never got to full implementation? Or was it really a game of musical chairs?

     I don't mean to undermine the efforts of our faculty to improve strategies in teaching students so don't take everything I write here as gospel. It is just my 2-cents' worth. My opinion is a product of limited sources and most of the time I try to provoke reactions to possibly get to the bottom of things.

     Armed with a little knowledge of PBL, I went to my only resource, the Internet. Alas, the resources are all over the place. It is not a secret. You don't have to search far and wide if you want to know more about the subject, as you would if you want to know, say, the divine secrets of the ya-ya sisterhood.

     Problem-Based Learning (PBL) is a medical education reform aimed at making learning more effective and efficient. It was apparently started in the early 1960's by McMaster University in Canada and Harvard University in the United States. The University of Santo Tomas (UST) Faculty of Medicine and Surgery says, in the Philippines, at least 10 medical schools have adopted PBL in their own different ways.

     According to the program introduced by McMaster University, PBL is an educational format that is centered around the discussion and learning that emanates from a clinically-based problem. It is a method that encourages independent learning and gives students practice in tackling puzzling situations in the context of relevant clinical problems, hopefully making it more likely that they will be able to recall the material later in the clinical setting. It is a way of learning which encourages a deeper understanding of the material rather than superficial coverage.

     Sounds complicated? Take heart. Nobody said this is going to be as easy as getting copies of past examinations from the xerox lady.

     I found PBL sample cases from a number of web sites but I might add to the complication if I relate them here. I am not about to make a doctoral thesis. Besides, the concept may be the same but the process of implementation may be different from country to country and from school to school.

     UST is one of the medical schools that has effectively implemented PBL. It is interesting to note that in Dr. Villareal's speech, she referred to her younger brother, Dr. Tony, a pathologist and professor of the College of Medicine at UST as an adviser in PBL module-making. Now, that's a top-notch source.

     The curriculum of the UST Faculty of Medicine and Surgery (as it is in other medical schools) has long been traditional, teacher-oriented and teacher-centered. "Students were passive and teacher-dependent," so says their web site. "They memorized facts and figures to pass their examinations and relied on lectures, handouts and old test papers. In addition, there was a mismatch between what students learned and what was useful for healthcare delivery. This was mainly because of two reasons: advances in science resulted in explosion of new information that made it impossible to learn everything; and there was difficulty in foretelling future advances and developments."

     The UST web site adds, "Recognizing the need and responding to the responsibility of the school in achieving its mission, the UST Faculty of Medicine and Surgery took a paradigm shift from a traditional to an innovative curriculum; faculty resistance, logistics and cost problems, notwithstanding. It evolved after a study and observation of other schools' curricula both here and abroad and comparing foreign and local circumstances. Modules were planned, developed, written, evaluated, plotted and modified or revised accordingly by multidisciplinary teams."

     Implementing PBL effectively is not a walk in the park as the UST experience would attest. In a recent news item (July 17, 2002) from The Varsitarian, the official student publication of UST, students are finally adjusting to the method after years of complaining. "When we started the PBL, I would get letters from the students or they will have their picture taken like this, to show how sad they are about it," says UST Dean Dr. Angeles Tan-Alora, as quoted by The Varsitarian, while depicting a sad medical student with both arms under her chin wearing a long face. When the Faculty first implemented the PBL during the school year 1999-2000, it received a lot of negative feedback from its faculty and students. "When the PBL started, there were a lot of complaints and no one wanted to greet me. When they saw me they frowned or avoided me," Tan-Alora said in The Varsitarian news item. However, she said things changed when the students began to get used to the system. But in terms of faculty satisfaction, Tan-Alora told the paper that a number of professors are still resisting the system. "The natural tendency of man to change and the lack of confidence are some of the factors why there is still resistance. The PBL is not just a minor change, it is a major one so naturally there is much resistance."

     According to most PBL literature I've read on the Internet, this learning style has been incorporated as a curriculum component in a number of medical schools around the world and there is ample evidence that students learn at least as well using a problem-based learning format as they do in a conventional curriculum. How PBL will work for us remains to be seen.

     There is a lot to learn from UST's example if we are to fully implement this program. I checked their Medical Informatics Website and I started wondering that they may be way ahead of us in terms of resources. USTLRU.com, LRU being Learning Resources Unit, was established in 1982 to enhance the study of medicine through non-traditional classroom methods. They believe that through the power of the internet and medical informatics, USTLRU will empower the students as the faculty fully shifts to the PBL curriculum.

     So it really was PBL I saw then, and not musical chairs. The faculty has been preparing for years, and as Dr. Binayas said, they have fair enough understanding and commitment to see the method succeed. That is to their credit and we applaud them. It's hard "patiently fighting one another" trying to implement a system with very limited resources. We hope the "fighting" doesn't get out of hand.

     By the way, what is the traditional classroom method anyway? I am not sure what it really is, perhaps you can tell me based on your own experience. As far as I could remember, during my first two years of medical school at least, we were divided into groups, and each group assigned chapters to report. A classmate then read or, in rare cases, explained a chapter in front of the class with the help of a few visual aids while the professor listened at the other end of the room. It is no different from reading the chapter at home. Examination scores were not dependent on whether you've listened to your classmate or not and the higher scores did not necessarily belong to the reporter. We studied to pass, not to learn. Fast forward to the hospital wards, we had to open our books again as if we had never opened them before. Of course, this is not a generalization, lest the geniuses feel offended. I am just making a point.

     Is PBL a Path to Better Learning and should replace Plain, Boring, Lectures? You be the judge. It may take some time before we can get to a solid conclusion.

     Meanwhile, please Pass the Bud Light.

Comments regarding this week's column are welcome. Please fill up the fields below and click Send to Author. Suggestions for future column topics are also encouraged.

     The author's e-mail address is at drgarcia@wvsumedaa.com

     All views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members. For comments, please e-mail the author.