Roles and responsibilities of the problem based learning tutor in the undergraduate medical curriculum

British Medical Journal, March 6, 1999 by Gillian Maudsley

Summary points

Undergraduate medical curriculums that use problem based learning rather than a traditional approach need a different type of medical educator

With problem based learning, students working in small groups facilitated by tutors identify their own learning objectives from problem scenarios

Available evidence indicates that tutors must use their expertise subtly and sparingly, and balance this with an informal empathetic style

Tutors can gain much from facilitating adult learning, but must move away from authoritarianism and dispensing facts

Over recent decades, many countries have recognised that traditional undergraduate medical education must change substantially in order to match the changing healthcare needs of the population and become more centred on the students.[1 2] This changes the role of medical educators. Problem based learning is one approach to reform that has international credibility. Numerous undergraduate medical curriculums have incorporated problem based learning; in 1992-3, 27 North American medical curriculums were using this approach, 14 of them across the board.[3]

In 1993, three systematic reviews of problem based learning in undergraduate medical education were published. These reviews, spanning 20 years, were cautiously optimistic about the short term and long term outcomes of problem based learning compared with traditional approaches.[4-6] They found that the results for students' evaluation of the programme; students' attendance, mood, and clinical performance; and faculty attitudes were better for problem based learning--even allowing for different definitions, curricular context and costs, and study design in the evidence base. Evidence about the coverage of basic science and curricular costs is conflicting,[5] but Berkson believed that the students' enjoyment[4] of the adult learning route to competence[6] countered these concerns or unrealistic expectations.

Traditional medical schools face many dilficulties--from the resistance of staff[7] to underresourcing[6]--in converting comprehensively to problem based learning. These pitfalls were illustrated in the unsuccessful attempt to convert Otago Medical School, New Zealand.[8] The pioneering problem based undergraduate medical curriculums originated in new medical schools--McMaster, Canada; Maastricht, Holland; and Newcastle, Australia. Nevertheless, large scale conversion continues, and includes (since the mid-1990s) the first British medical schools--Manchester, Liverpool, and Glasgow. This reflects the recommendations of the General Medical Council[2] and worldwide imperatives to incorporate theories of adult and problem focused education.

Problem based learning is characterised by certain ground rules.[9] It is a combination of educational method and philosophy. Philosophically, problem based learning is centred on the student and on problem-first learning, whereas in subject based learning teachers transmit knowledge to students before using problems to illustrate it. Problem based learning aims to enable students to acquire and structure knowledge in an efficient, accessible, and integrated way. The method involves learning in small groups, in a "tutorial" system. The tutor facilitates the group's self directed generation of learning objectives from triggers in successive case scenarios that set the context (see box). These objectives guide self directed learning between sessions, and then in subsequent sessions, students reapply, synthesise, and appraise their learning.

Problem based learning encourages medical educators to rethink and change their educational role away from one in which they predominantly transmit facts. Tutors are "shadowy" figures in published reports on student centred, problem based learning. Their legitimate role can be undermined by wrongly viewing "student centred" as "tutor inactive." Tutors can also overcompensate for the possible effects of their specialist content expertise by intervening much less than necessary when students' discussions enter these subject areas. Fear of derailing students' self motivation must be balanced against the need for timely, thought provoking comments that guide the breadth and depth of learning without imparting facts.

This paper examines the roles and responsibilities of problem based learning tutors in undergraduate medical curriculums. It explores the expected relationship between tutor and student and what tutor-development should promote, and it discusses who can be considered an "expert" problem based learning tutor and the effects of the tutor's content expertise.

Roles and responsibilities of tutors

The problem based learning tutor is not authoritarian. Barrows and Tamblyn believed that the tutor should have expertise in group facilitation (process expertise) rather than in a subject area (content expertise)[10] Ross disliked the tutorial label; he viewed problem based learning sessions more as professional strategy meetings than teaching sessions.[11] In problem based learning,[12 13] the tutor facilitates or activates[14] the group to ensure that students progress satisfactorily through the problem. According to Margetson, the tutor does this by "questioning, probing, encouraging critical reflection, suggesting and challenging in helpful ways--but only where necessary."[15] Most new tutors in problem based learning are challenged by the "where necessary" (deciding when and how) part of intervention.