Problem-Based Learning in, Physical Therapy: A Review of the Literature. University Experience

Transcription

1 Problem-Based Learig i, Physical Therapy: A Review of the Literature ad Overview of the McMaster Uiversity Experiece Problem-based learig (PBL), as implemeted i the health scieces, is a educatioal method i which the focus of learig is a smallgroup tutorial i which studets work through health care scearios. The goals of the health care scearios are to provide a cotext for learig, to activate prior kowledge, to motivate studets, ad to stimulate discussio. Learig is studet-cetered rather tha facultycetered, ad self-directed learig is emphasized. The method was developed i the McMaster Uiversity medical school program ad has sice bee adopted by may health care professioal schools aroud the world. The theoretical basis ad suggested advatages ad disadvatages of PBL are outlied. Three approaches to PBL have bee idetified i the literature: completely itegrated PBL curricula, trasitioal curricula, ad a sigle-course approach. The advatages ad disadvatages of each approach are addressed. The physical therapist (PT) program at McMaster Uiversity is a completely itegrated problem-based curriculum. The history ad process of PBL i geeral ad i the PT program are reviewed. The implicatios of our experiece for the developmet of other PBL courses ad curricula are discussed. Evidece for proposed differeces i studets' performace ad outcomes i PBL versus traditioal curricula is critically reviewed. Recommedatios are made for implemetig PBL i PT curricula. [Saarie-Rahiika H, Bikley JM. Problem-based learig i physical therapy: a review of the literature ad overview of the McMaster Uiversity experiece. Phys 7'her. 1998;78: Key Words: Educatio: Physical therapist, teachig methods; Learig; Physical therapy; Problem-based learig. Hele sitarie-3ahiikat Jill M Bikley ' Ms Saar-ie-Rahiika died Ma]-ch 30, 1 199fi. Physical Therapy. Volume 78. Number 2. February 1998

2 roblem-based learig (PBL) for health care professioals is a educatioal method i which learig is focused aroud cliical sceario~.]-~ Although the use of health care scearios is a commo deomiator of PBL i the health sciece professios, these scearios aloe do ot fully characterize critical philosophical ad curriculum desig features of PBL. The theoretical basis of PBL is that learig is ehaced by the followig coditios: (1) stimulatio of prior kowledge, (2) learig i cotext to ehace retetio, ad (3) elaboratio of kowledge through di~cussio.~ There are several assumptios that uderlie a problem-based approach to learig, icludig: 1. Studets ca be resposible for the breadth ad depth of learig if give directio, resources, ad feedback. 2. Studets brig with them a wide backgroud of prior learig ad experiece. 3. Learig i small groups ehaces uderstadig, exploratio, discussio, ad debate. 4. Faculty tutors facilitate learig ad traslate cocepts rather tha "teach" or serve solely as iformatio-givers. 5. formatio used to comprehed ad deal with reallife scearios is itegrated from a variety of traditioal disciplies. Several critical features of PBL curricula are desiged to achieve these 1. Learig i small groups with a faculty member as facilitator or tutor is pivotal. 2. The role of faculty is to serve as facilitators rather tha as teachers. heighteig motivatio for learig ad the developmet of lifelog learig skills. There has bee debate as to whether the theoretical basis of PBL is soud ad whether the goals for graduates of PBL medical programs have bee Cocurretly, there has bee growig iterest i PBL by physical therapy educators. The purposes of this article are to discuss the developmet of the PBL curriculum i physical therapy at McMaster Uiversity (Hamilto, Otario, Caada) ad to review the curret literature o PBL. Purported ad documeted outcomes of PBL ad areas requirig further ivestigatio will be outlied, ad recommedatios will be made for the implemetatio of PBL i other physical therapist (PT) programs. Historical Perspective of the McMaster Uiversity PT Program Problem-based learig bega i the McMaster Uiversity medical program i The era that gave birth to PBL was oe i which there was a accelerated growth of techology ad iformatio as well as chagig social attitudes. Dissatisfactio with traditioal medical educatio ad the eed to address the chagig social climate led to the developmet of a revolutioary ew medical school curric~lum.~ The fudametal premise of this alterative approach was that priciples of learig could be used to educate physicias more effectively with PBL tha with traditioal methods. additio, there was a expectatio of icreased retetio of iformatio, greater ability to apply kowledge i cliical cotexts, ad developmet of lifelog learig habits. Although chages have occurred over the years, the origial philosophy ad most of the curriculum desig cocepts remai i place. Admissio criteria ad methods of studet evaluatio to suit the program philosophy were also de~eloped.~ Numerous medical schools i the Uited States ad aroud the world have adopted various forms of problem-based curricula, icludig the medical schools of Harvard Uiversity, the Uiversity of New Mexico, ad the Uiversity of Limburg." 8. Traditioal course cotet, icludig basic scieces, Because iterprofessioal educatio was part of the is ilegrated ito health care scearios. medical school philosophy ad because there was a idetified eed for educatio programs i physical 4. Studets are resposible for their ow learig, therapy ad occupatioal therapy, a PT program was thereby all.owig itegratio of prior kowledge ad lauched at Mohawk Commuity College i Hamilto, H Saarie-Rahiika, PT, was Associate Professor, School of Rehabilitatio Sciece, McMaster Uiversity, Hamilto, Otario, Caada, at the time this article was writte..jm Bikley, PT, COMP, FAAOMPT, is Physical Therapist, Appalachia Physical Therapy, 109A Tipto Dr, Dahloega, GA (USA) (bikleyol@spryet.com). She is also Assistat Professor (PT), School of Rehabilitatio Sciece, McMaster Uiversity. Address all correspodece to Ms Bikley at the first address. TLLS atticle ruas submitted Ortober 24, 1996, ad rum arceptcd September 3, Saarie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

3 Otario, Caada, i Commuity colleges were a ew alterative to postsecodary educatio i Otario ad had a madate to address areas of educatioal eed i the local commuity. The decisio was made to foster the existig relatioship betwee McMaster Uiversity ad the ewly fouded Mohawk College of Applied Arts ad Techology through a PT program based at the college but with the ivolvemet of uiversity faculty alid facilities. The ew PT program combied traditioal ad PBL, curriculum features. These features icluded itegratio of cliical educatio through a block system, where academic uits were followed by cliical placemets i related cotet areas with itegrated objectives. A problem-solvig approach, as described by Elstei et a1,8 was used with small-group learig i two courses. The goals of these courses were to foster the developmet of cliical reasoig ad resposibility for learig ad to create a forum for studets to address patiet care issues withi a psychosocial framework. 1974, the Caadia Physiotherapy Associatio passed a resolutio that required all Caadia PT graduates to have a baccaluareate degree for membership as of The uiversity ad college leadership agreed that the PT ad occupatioal therapist (OT) programs would be redesiged as ew uiversity-based programs. Followig a trasitioal period i which degrees were grated through a combied college-uiversity degree completio process, a ew uiversity-based program admitted its first class i developig this prograi, physical therapy faculty at Mohawk Commuity College ad McMaster Uiversity were give a opportuity to develop a iovative curriculum i the milieu of the existig iovative medical school curriculum. The professioal climate durig the developmet of the program was oe of evolutio from the physical therapist beig perceived as primarily a techicia to beig perceived as a professioal makig decisios regardig diagosis ad treatmet. The shift away from madatory physicia referral i Caada ad i the Uited States also affected the curriculum developmet. Physical therapy educators were faced with the challege of shiftig the educatioal focus from teachig techical skills to educatig professioals. Cliical reasoig, decisio makig, ad critical review ad itegratio of research ito cliical practice received icreasig eiphasis. A task force desiged to reach cosesus o the geeral desig ad philosophy of the ew McMaster Uiversity PT ad OT programs determied that the programs would be problem-based. The task force icluded physical therapy ad occupatioal therapy faculty ad cliicias, oc.her health care professioals, ad members of the commuity. the developmet of the PT PBL curriculum, plaers had the advatage of a educatioal eviromet i which PBL was the rlorm. There was e~ergig literature o PBL,, ad the lilcul~y tiad years of experiece workig with aspects of PBL i tlie Mohawk Coriuity (hllege prograril alid through observig the McMaster Uriiversi~y 111edica1 prograril. Faculty had the opportuuity to critically evaluatc tlie philosophical basis of PBL ad pla a strategy for a completely itegrated PBL curricului suitable for physical therapy. The McMaster Uliiversity P?' progral is ;i 24iolith secod udergraduate degree program.?'he reciuisite udergraduate degree car1 ecompass ay disciplilie. The curriculum pla doculelits objectives for each of six uits of study (Fig. 1). Cotet stl-ears, such as research, are gradually developed throughout the program. Basic scieces, physical therapy theory, research topics, ad clirlical skills are i~itegrated through the study of health care sceriarios. The major educatioal evet is a series of' siall-group tutorials i which stilderits work through the sce~iariob. The skill ad process of probleiii solvig are ot erilphasized, because the teachig of problem solvig as a process to ehace ctiriical decisiori ~ilakillg is ot supported i the literat~re.!~ listeact, the goals of the health care scearios are to provide a cotext for learig, to activate prior kl~owledge, to ~otivate studets, ad to stimulate discussiori. Additioal scheduled educatioal evets iclilde cliriical skills laboratol-ies arict iquiry semiars. The itet of iquiry seii~i;irs is the i-depth study of' special topics. The ew prograi has maitaied a strog emphasis o a huriia~~istic approach to patiet care ad developig -esporisible ad critical learers. A block syster of academic study uits followed by cliical placemets i related cotet areas has beell maitaied to ehace the itegratio of acadelllic ad cliical learig (Fig. 1). Curriculum Desig Overview of PBL Curricular Desigs Three types of approaches to PBL have bee idetified i the literature: (1) completely itegrated PBL, curricula, (2) trasitioal curricula, ad (3) a sigle-course approach.1 A itegrated PBL curriculul focuses all learig of coterit, icludig basic scie~ice, aroud health care scearios. A trarisitiorial curricului utilizes more traditioal approaches i the early phases of the curriculum, ad there is a gradual shift to cotet itegratio, small-group work, arid stucterit-ce~itered learig as studets progress through the prograi. Problem-based learig has also beell iriiplel~~eted ill oe or more courses ofa curriculu~ as a trial process or i arl attempt to gai some of the proposed beefits of pul. 10,' 1 Physical Therapy. Volume 78. Number 2. February 1998 Saarie-Rahiika ad Bikley. 197

4 o r t t 0 A - - Uit 1 Murub.lcr*trl -.adamlc C V. c. t c 0 - Uit 2 8rrrlrr acuter& - chkd - v C t 0 - Uit 3 c 8- uwy. 0 0 rrdamlc Uit 5 N-'obw 8- umbdc v c t ,-.-- Uit 6 Umb.admlc ELBETM Figure 1. McMaster Uiversity physical therapist educatio curriculum desig. The block system itegrates 8-week academic ad 6-week cliical educatio compoets i related cotet areas i each uit, with the exceptio of uit 1 (13 academic weeks) ad uit 6 (14 academic weeks followed by a 6-week cliical elective). Several advatages ad disadvatages have bee idetified for each desig.1 Completely itegrated programs are associated with relatively high levels of studet stress early i the curriculum.l0 This stress is thought to be due to the challeges imposed by the cocurret expectatios of dealig with a ufamiliar learig method, orietatio to a professioal program, ad the volume of cotet to be leared. Trasitioal curricula provide studets with a more gradual orietatio to the skills required for PBL ad, therefore, are reportedly less stressful for studets.0 t has bee suggested, however, that trasitioal curricula may lose some of the potetial beefit of PBL because cotet is ot itegrated ad related directly to cliical scearios early i the program, although o direct evidece is available to support this premise. Fially, programs that have implemeted PBL o a idividual course basis may achieve some of' the beefits of makig cotet more cliically relevat, but certai disadvatages have bee idetified0.l1: (1) cotusio regardig faculty-studet expectatios may be imposed by presetig studets with opposig philosophies ad methods, (2) faculty ad studet tutorial skills ad self-directed learig strategies may ot develop sufficietly, puttig learig of cotet at risk, ad (3) several key compoets of PBL are ot icluded i this curricular desig, such as itegratio of curriculum, learig i cotext, ad provisio of sufficiet time to lear withi traditioal course sched~les.l0.~' McMasier Uiversity PT Program Curriculum Desig The McMaster Uiversity PT program is a completely itegrated problem-based curriculum. Cotet is orgaized by body systems (musculoskttletal, cardiopulmo- ary, eurological), ad all relevat cotet, icludig basic ad social scieces, theory of physical therapy practice, ad cliical skills, is leared ad itegrated ito each system (Fig. 1). This systems approach is distict from traditioal divisio of cotet ito academic areas of study (eg, aatomy, psychology, statistics).lthis desig, although ot uique to PBL, appears to be commo to most PBL curricula idetified i the literature because it achieves the goal of itegratio of cotet as it relates to patiet care. Study uits may be desiged aroud ay meaigful orgaizatio of cotet, such as the life-spa uits i the McMaster Uiversity OT program.13 Certai cocepts ad topics (streams) that cross body systems ad require developmet throughout the curriculum were idetified durig the curriculum desig phase. Examples of these streams iclude therapeutic agets, patiet educatio, huma developmet, scietific iquiry, ad cocepts such as welless, health promotio, ad professioalism. The streams are itegrated logitudially throughout the curriculum. For example, Figure 2 outlies the developmet of scietific iquiry throughout the curriculum. Withi each academic uit, relevat system objectives are developed ad itegrated with the streams idetified for the uit. The "courses" withi each uit (ie, tutorial, cliical skills, ad iquiry semiars) each deal with a subset of the uit objectives. t was by desig that courses are amed by the educatioal process uique to each evet, rather tha by the cotet covered. The McMaster Uiversity curriculum is detailed elsewhere.l3 This curricular model of itegrated study blocks, or uits, crossed with logitudial streams has bee described by Selletl-Baledog. l Saarie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

5 map.1 Focua dq*d*rtshrdy - Focua Rooalr E Cutla R -@*gmffo T-) m E m E(lbdivawr Figure 2. Example of logitudial itegratio of scietific iquiry throughout the curriculum. Each logitudial stream is developed throughout the curriculum i a similar maer. Cliical Skills Laboratory 9:OO-12:00 am 9:00-12:W am Problem-Based 1:30-4:W pm 1:m-3:30 pm 1:00-3:30 pm Figure 3. Sample weekly academic schedule. Uit plaers may coordiate special resource sessios for studets, such as aatomy resource sessios i uscheduled time, depedig o the study uit ad studet learig eeds. Study Uit Desig, Tutorial Process, ad Health Care Sceario Developmet Study Uit Desig Uits of study are typically 8 academic weeks followed by 6 cliical weeks (Fig. 3). The exceptio to this is uit 1. Academic: blocks are divided ito three courses: tutorial, cliical skills laboratories, ad iquiry semiars. Studets have approximately 16 scheduled hours per week (Fig. 3). Tutorials are desiged for small-group learig aroud health care scearios. The cliical skills laboratories focus o hads-o cliical skills ad relevat measuremet issues. quiry semiars are desiged for larger groups to discuss broad health care cocepts ad professioal issues. A faculty member, desigated as uit chair, is resposible for the overall coordiatio of each study uit. The resposibilities of the uit chair iclude coordiatio ad ogoig review of the followig: idetificatio ad preparatio of appropriate tutors, developmet of uit Physical Therapy. Volume 78. Number 2. February 1998 objectives ad health care scearios, itegratio of the three courses, ad studet/faculty evaluatio. Uit chairs work closely together with the goal of esurig that the uit is appropriately itegrated ito the curriculum ad that logitudial streams are developed i each uit. Because self-directed learig is oe of the premises of PBL, schedules are developed with the goal of providiiig ustructured time to lear. t is our experiece that studets sped large amouts of time accessig resources ad readig.10,14the ratio of oscheduled study time to scheduled study time for studets i the McMaster Uiversity PT program has bee reported to be approximately 3:1.14 No comparable data are available for studets i traditioal PT programs. The Tutorial Process The major educatioal evet i each uit is the tutorial. Studets meet twice per week for 2.5 to 3 hours per sessio ad work through health care scearios that are Saarie-Rahiika ad Bikley. 199

6 desiged to address study uit objectives. Tutorial groups are typically composed of six to ie studets ad a faculty tutor. our view, this group size is optimum whe balacig faculty resources ad the learig eviromet. The basic sequece for PBL i a tutorial settig i the McMaster Uiversity PT program is similar to that described by Barrows ad Tambly15: 1. detificatio of the objectives of the sessio ad settig of a ageda. 2. teractio with the health care sceario: elaboratio, discussio, ad activatio of prior kowledge. 3. detificatio of self-study questios raised durig discussio. 4. Self-directed study betwee tutorials (typical break is 2-3 days). 5. Discussio of acquired iformatio ad applicatio to the sceario. 6. Review ad sythesis of what has bee leared. 7. Evaluatio (self, peer, tutor) at ed of each tutorial. The success of the tutorial process depeds o selfdirected, resposible, ad participatory learers, a facilitatory ad kowledgeable tutor, ad a carefully desiged health care sceario. The role of studets, icludig motivatio to lear ad the ability to participate i the discussio i a meaigful maer, caot be uderestimated i the process. The role of ogoig selfevaluatio combied with studet ad tutor evaluatio is desiged to build the skills ad attributes ecessary to maximize studets' learig i the tutorial group. Tutors may be physical therapy faculty members, faculty of other related health sciece disciplies, or commuity PT cliicias. The questio as to tutor expertise i the field of study has bee debated.16-l"arrowslh stated that a uderstadig of the PBL process ad skill i tutorig are more importat tha kowledge i the field, but expertise i both is the ideal circumstace. At the outset, a decisio was made that tutors i physical therapy at McMaster Uiversity would be expert i their uderstadig of PBL ad i the skill of tutorig as well as kowledgeable (ot ecessarily expert) i the field of study. Several studies of medical studets i PBL programs have examied the effect of tutor cotet expertise ad have cofirmed that kowledge i the field is importat. Silver ad WilkersolVemostrated that tutors with more cotet expertise teded to domiate the tutorial discussio, potetially jeopardizig the developmet of studet resposibility for learig. Davis et al,l"owever, foud a isigificat differece i tutorial iteractio whe comparig expert ad oexpert tutors but higher levels of studet satisfactio ad higher examiatio scores for groups where tutors were cotet experts. Eagle et all7 foud that medical studet tutorial groups with cotet expert5 developed approximately mice as may learig issues, ad these issues were estimated to be three times more cogruet with the objectives of the health care scearib. additio, these authors foud that the groups with expert tutors spet approximately twice as much time per sceario i overcomig learig deficiecies idetified withi the groups. l7 There is evidece that tutors who are cotet experts are more directive, thus determiig to a larger degree tha oexperts what the tutorial group discu~ses.~~~~~ experieced tutors behave differetly i the role tha do experieced tutors i that they ted to be more ~ilet.~~.~ our view, the ideal tutor uderstads that his or her role is oe of a sesitive facilitator, ecouragig studets to delve ito issues ad cocepts at their will while balacig the costraits of objectives of the health care sceario with available time. Based o our experiece ad recet literature, the tutor who is a PBL expert ad kowledgeable i the field best fills this role. Developmet of Health Care Scearios each academic study uit, studets typically sped betwee two ad four tutorials workig through oe health care sceario. Health care scearios are carefully desiged to ecourage studets to address the objectives of the uit. Scearios usually depict coditios, ijuries, or diseases that are frequetly dealt with i physical therapy practice, but they may be more prototypical, desiged primarily to illustrate a critical cocept. Each sceario is desiged to meet a subset of the study uit objectives ad is accompaied by a tutors' guide, which outlies the objectives of the study uit, potetial study resources uique to the sceario, ad the suggested umber of tutorials to be spet o the sceario. The experiece of the McMaster Uiversity PT program with respect to curriculum desig ad health care sceario developmet idicates that health care scearios must be carefully desiged to make it easier for studets to meet objectives ad balace the activatio of prior kowledge with ew learig. Scearios may rage from simple aatomical ad coditio-specific scearios to complex multisystem health care problems that icorporate a rage of psychosocial, health care, ad professioal issues. We have recogized aecdotally for may years that subtle differeces i scearios may alter how studets discuss ad develop ew learig issues. Solomo et a120 reported that the age of the patiet i a health care sceario had a direct ifluece o the 200. Soorie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

7 discussio of developmetal topics. This fidig has implicatios for developig health care scearios whe a objective such as huma developmet is to be addressed as a importat objective of the sceario. This pheomeo has importat implicatios whe selectig patiet data such as socioecoomic status, geder, ad race for iclusio i health care scearios. additio, studets' backgrouds must be cosidered whe developig scearios. Studets whose basic sciece ad physical therapy backgrouds differ develop differet learig issues from the same health care sceario.1 Solomo ad ~olleagues'~ suggested that the complexity of scearios should be adapted based o studets' backgrouds to maximize studets' acquisitio of ew kowledge. Curriculum Challeges Cliical Skills Teachig ad learig cliical skills i a problem-based PT curriculum was ucharted territory. Traditioally, cliical skills ted to be preseted i a facultydirected eviro~imet, with skills idetified by the faculty ad taught through a process of demostratio-questiopractice. Oe of the curriculum challeges faced by the McMaster Uiversity PT program has bee to shift this paradigm to a more studetdirected process, where cliical skills are itegrated with other kowledge. The model for cliical skills is that learig is i cotext ad the evaluatio of skill developmet is formative as well as summative. A example of oe model used for cliical skills is that skills are leared aroud cliical vigettes, or brief health care scearios, that are desiged to facilitate cotextual learig. Studets idetify learig issues ad hypotheses whe the vigette is itroduced. Betwee cliical skills laboratories, studets idepedetly address learig issues ad idetify ad practice cliical tests that they ca use to assist i differetiatig amog hypotheses. At a subsequet skills laborator).., studets describe, demostrate, ad practice these skills. Feedback is provided by faculty members at that time. Differetial diagosis, implicatios of cliical fidigs, ad determiig appropriate cliical tests are addressed by the cliical skills vigettes. Studets are expected to lear the techical aspects of cliical skills, but they also must address the iterpretatio of test results, icludig a uderstadig of the measuremet properties of tests. Learig the cocepts ad implicatios of measuremet i the cotext of patiet care may facilitate the ogoig applicatio of this kowledge to cliical practice. summary, cliical skills are drive by cliical scearios, ad cocepts relevat to cliical practice are itegrated. There is a strog expectatio that studets be self-directed, resposible learers, eve though faculty determie the specific topics ad skills to be leared. Logitudial tegratio The term "logitudial itegratio" was coied by Selle-BaledoglQo describe a curricular model with itegrated study blocks (uits) crossed with logitudial streams (topics). Durig the curriculum plaig phase, umerous topics ad cocepts were idetified that were ot specifically related to ay oe system-based study uit ad that required icremetal developmet throughout the curriculum. These topics ad cocepts ca be divided ito three categories: (1) health care cocepts, (2) theoretical basis of physical therapy, ad (3) professioal issues. Examples of health care cocepts iclude welless ad disability, a holistic approach to patiet care, ad patiet educatio. Examples of the theoretical basis of physical therapy iclude aatomy ad physiology, huma developmet, therapeutic agets, ad commuicatio skills. Examples of professioal issues iclude strategies for developmet of selfdirected learig skills, commuicatio skills (verbal, writte), ad self- ad peer-evaluatio skills. The objectives to be developed for each of these streams are idetified for each study uit. The curriculum challege is to build o these cocepts sequetially, expectig studets to build o kowledge from previous uits, with miimal repetitio. The developmet throughout the curriculum of a holistic approach to patiet care is exemplified by the progressively icreasig complexity of health care issues, from the simple, sigle-joit musculoskeletal problem with few psychosocial issues idetified i uit 1 to the complex, multisystem problem with may psychosocial issues idetified i uit 6. This curriculum desig feature requires that all faculty egage i detailed plaig of the etire curriculum ad to follow through i their respective uits. additio, tutorial problems become uique to the curriculum ad iterdepedet. Studet ad Faculj. Role Shifts Selfdirected learig is a process by which idividuals take the iitiative to diagose their learig eeds, formulate learig goals, idetify huma ad material resources, choose ad implemet learig strategies, ad measure learig outc~mes.~vhe ratioale origially proposed for self-directed learig was that proactive learers lear more, that the process meets our eed to be idepedet as we mature, ad that the skills of iquiry ecessary to keep pace with expadig kowledge are developed. Oe of the primary goals of PBL is to develop selfdirected learers-for-life.'" Studets i PBL programs are explicitly ad implicitly expected to be resposible for their learig, icludig accessig Physical 'Therapy. Volume 78. Number 2. February 1998 Saarie-Rahiika ad Bikley. 201

8 appropriate resources idepedetly ad spedig as much time ad effort as required to lear the cotet. There is freedom to choose resources ad to set learig priorities. To assist studets i developig a uderstadig of whe a appropriate depth of learig has bee achieved, they receive ogoig iformal ad formal evaluatio (self, peer, ad faculty). Physical therapist curriculum cotet is traditioally facultycetered. Problem-based learig programs shift the emphasis from faculty-cetered learig to more studetcetered learig. t is importat to ote that learig may be self-directed while still facultycetered. A example of this is a assigmet of a idepedet study topic by faculty. The goal of havig studets idetify their ow learig eeds ad build o previous kowledge may ot be achieved eve though they are demostratig self-directed learig. The shift from faculty-cetered learig to studetcetered learig progresses throughout the McMaster Uiversity PT program. Studets may have difficulty idetifyig ad prioritizig cocepts ad topics that require further study early i the program, but these skills are developed through self-evaluatio ad peer ad tutor feedback. Although studet-cetered learig is a importat compoet of a PBL curriculum, there are several caveats: (1) The shift i resposibility for learig is developed i a icremetal maer through ogoig self, peer, ad faculty evaluatio, (2) all course cotet is ot equally suited to studetcetered learig (eg, maual cliical skills require specific guided feedback, ad the learig will be appropriately more facultycetered), ad (3) studetcetered learig must occur withi the cotext that there is core curriculum cotet required to practice as a physical therapist ad for program accreditatio. our experiece, the trasitio to studet-cetered learig ecessitates a paradigm shift for faculty members. Studets' cofusio regardig faculty expectatios may udermie the process if this paradigm shirt does ot occur. Faculty members must become facilitators of learig, rather tha givers of iformatio. Although cotet expertise ad the ability to trasmit iformatio ad traslate cocepts i a uderstadable maer remai importat, other attributes ad skills are importat for faculty members. These attributes ad skills iclude (1) strategies for fosterig self-directed learig, (2) uderstadig whe studet-cetered versus facultycetered learig is desirable ad clearly articulatig these expectatios to studets, (3) the ability to give, receive, ad act o feedback from studets ad other faculty, ad (4) commitmet to the global program curriculum i order to facilitate logitudial itegratio. t is our experiece that faculty may be called o to share expertise i their field directly with studets less frequetly i a PBL program tha i a more traditioal curriculum. Faculty must be prepared to work at multiple levels of studet uderstadig at a give time because studets develop questios at various levels ad paces. The relatioship betwee faculty ad studets teds to be oe of metor ad resource rather tha a more formal teacher-studet relatioship. our view, the shift i faculty role requires cosiderable preparatio ad support. The eed for clearly defied formal support has also bee documeted i the literat~re.*~-2~ Problem-based learig ad tutorial traiig workshops are critical i developig the faculty members' role as t~tor.2~'~ The McMaster Uiversity PT program pairs iexperieced ad experieced tutors for traiig. Tutors also meet with uit chairs regularly to discuss uit objectives, tutorial group progress, ad health care scearios. Evaluatio by studets is also a importat source for developmet of tutorig skills. volvemet i ogoig curriculum review is expected, ad may faculty members are ivolved i research projects to ivestigate the process ad outcomes of PBL. Studet Evaluatio the origial McMaster Uiversity medical school program, the focus of studet evaluatio was verbal feedback withi the tutorial group, rather tha formal traditioal studet evaluatio. Oe of the challeges faced i developig the McMaster Uiversity PT prcl gram was to determie the appropriate combiatio of studet evaluatio methods to meet the goals of reasurig kowledge ad cliical skills as well as attributes such as self-directed learig, ability to work with ad lear i a small-group settig, ad ability to apply kowledge i cliical settigs. To accomplish this task, traditioal ad otraditioal evaluatio methods are used. Ogoig formal ad iformal peer ad faculty feedback is give regularly i tutorial groups. Traditioal methods of studet evaluatio such as multiplechoice examiatios ad writte reports are used i additio to more otraditioal methods such as modified essay questio examiatios" ad the objective structured cliical examiatio27 for cliical skills. Problem-Based Learig Outcomes: Review of Literature The followig advatages of a PBL curriculum over traditioal curricula have bee purported or documeted: 1. Studets will have ehaced problem-solvig ad cliical reasoig skill~.~.2~ 2. Studets will be more selfdirected, ethusiastic learers, ad graduates will be resposible learer~-for-life.l~2~ 202. Saarie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

9 3. Studets' kowledge will be better retaied, retrieved, ad applied i cliical settig^.^,^.^^ 4. Graduates will demostrate a more holistic approach to patiet care.7 5. Problem-based learig is more ejoyable for studets (ad fa~ulty.~,z~ 6. The curriculum is iheretly curret ad evidece-based. The followig disadvatages of a PBL curriculum have bee purported or documeted: 1. creased fiacial ad faculty time e~pediture.~ 2. Lower levels of cotet-specific k~wledge.".~ There is a icreasig amout of literature that addresses may of the purported advatages ad disadvatages of a PBL curriculum versus a traditioal curriculum.s7 Each issue will be addressed idividually. Problem-Solvig ad Cliical Reasoig Skills i Studets ad Graduates of Problem-Based learig Curricula Oe of the origial goals of PBL was to provide studets wirh practice usig a problem-solvig proce~s.~.~.'~ Recet evidece suggests, however, that cliical expertise is more related to kowledge tha to expertise i problem solvig ad that it is rare for cliical experts to use a defied problem-solvig proces~.~ NormaY described a more rapid process tha problem solvig that ivolves compariso of the curret situatio or set of cliical fidigs with previous istaces i memory, or patter recogitio. The more expert the cliicia, the more likely it is that patter recogitio will be used except i corplex situatios. Studies9Z9." have show o differece i problemsolvig processes or ability betwee studets i PBL curricula ad those i traditioal cul.ricula. The difficulty i measurig a cogitive process such as problem solvig or cliical reasoig has bee discussed by BerksoSs Experiece ad evidece have led may PBL experts to rethik the goal of teachig the process of problerri solvig, ad it is o loger cosidered to be a primary objective of PBL. The goal of tutorial health care scearios is to provide a cliical cotext for the acquisitio of kowledge, rather tha to solve the problem. There are o studies that have directly compared the effects of varyig the emphasis o the problemsolvig i PBL programs. Self-Directed Learig Skills Ehaced self-directed learig behaviors, as evideced by high levels of resource use ad time spet studyig, have bee reported for studets i PBL curri~ula.~~~~' Studets i two problem-based PT prograts were reported to sped 2 to 4 hours searchig for literature ad 4 to 11 hours i self-directed study per tutorial sessio. The lower rages of time spet were rcported for studets with a greater backgroud kowledge ad with less uscheduled time for study. Both PBL groups reported usig joural resources as a itegral part of their study, eve i the first several weeks of the program. These fidigs suggest that studets i PBL curricula are egaged i self-directed learig, are diagosig learig eeds based o prior kowledge, ad are searchig for a variety of appropriate resources. lo No direct comparisos of resource use ad study time betwee studets i traditioal PT programs ad those i PBL programs are available. RakiN cocluded that studets i PBL programs placed more eiphasis o jourals ad o-lie searches ad made greater use of the library ad self-selected refereces tha did studets i traditioal medical programs. Studets i PBL programs also feel more competet with iformatioseekig skills.31 Vero ad Blake7 cocluded o the basis of a metaaalysis that there is a greater degree of idepedet study i PAL programs versus traditioal programs. There are several issues to cosider whe drawig coclusios regardig learig processes, such as selfdirected behaviors i studets. Studies ofte do ot iclude a represetative traditioal compariso group. Berkso5 suggested that eve subtle differeces amog curricula, such as library orietatio, may accout for the differeces reported i self-directed learig behaviors. a study comparig kowledge of medical school graduates 5 to 10 years after graduatio, the PBL group demostrated more up-to-date kowledge tha a tradi- tioally educated group of graduates dero~trated.!~z t is ot clear whether this differece was related to differeces i udergraduate educatio, retetio of iformatio, or self-directed learig skills, because the graduates were ot pretested at graduatio. Further work is eeded to compare graduates of PBL programs with those from traditioal programs with respect to self-directed learig habits. Cliical performace Oe of the goals of PBL is to provide studets with a cotext for learig that maximizes kowledge retetio ad icreases the ability to apply kowledge i a cliical settig. Two meta-aalysesk7 showed a tred that favors studets i PBL programs with respect to cliical performace. The aalyses were restricted, however, by Physical Therapy. Volume 78. Number 2. February 1998 Saarie-Rahiika ad Bikley. 203

10 small sample size ad lack of valid measures of cliical performace of health care professioals. Cotet-Specific Kowledge ad Kowledge Retetio Lower levels of cotet-specific kowledge for studets i PBL programs compared with studets i traditioal programs have bee do~umeted."~~~v two stud- ie~,~~," lower kowledge scores were foud for studets i PBL curricula compared with studets i traditioal curricula. The researchers reported that there was o loger a differece i kowledge scores at follow-up testig 12 weeks34 ad 2 years later.35 These fidigs suggest that studets i PBL curricula demostrate lower cotet-specific kowledge scores but that these differeces may be ullified by differeces i retetio betwee studets i PBL curricula ad studets i traditioal curricula. t has bee postulated that a traditioal examiatio format does ot adequately evaluate the studets i PBL programs.z9 Studets i PBL programs may be placed at a disadvatage whe performace is measured usig traditioal f~rmats.~vurther work is eeded to develop valid measures of kowledge ad cliical performace for studets ad graduates of both traditioal ad PBL programs. Holistic Approach to Patiet Care Oe of the goals of the McMaster Uiversity PT program is to ecourage studets ad graduate cliicias to deal with all aspects of patiets' problems, icludig physical ad psychosocial aspects. These aspects of patiet care are explicitly stated as objectives for the health care scearios. The potetial differeces i how studets i PBL programs versus studets i traditioal programs relate to patiets was explored i a meta-aalysis by Vero ad Blake.7 There is o published evidece that studets i PBL programs are differet from studets i traditioal programs with respect to a holistic appr~ach to patiet care. Ejoymet by Studets ad Faculty several studies, there have bee direct or idirect measures of studet ad faculty perceptios of PBL. Moore-West et a136 reported less distress i medical studets i PBL programs tha i their traditioal couterparts. Over the years, high levels of studet stress have bee observed i the first moths of the McMaster Uiversity PT program. The followig disadvatages may cotribute to the stress experieced by studets i PBL programs: ucertaity regardig appropriate depth of study, time costraits, group coflicts, ad difficulty idetifyig ad searchig for resources.1 Lower levels of stress have bee reported for studets i a program with a trasitioal versus a completely itegrated PBL curriculum, suggestig that acclimatizatio to a ew educatioal methodology at the same time as embarkig o the demads of a professioal program is difficult. Feedback from peers ad tutors, combied with a familiarity with the process, may alleviate these disadvatages. Two meta-aalyses idicate that studets ad faculty prefer PBL learig method^.^.^ This fidig must be iterpreted with cautio due to the potetial bias of self-selectio o the part of both faculty ad studets ito a PBL eviromet. Advatages of PBL cited by studets i problem-based PT programs were sharig of kowledge, opportuities to develop group skills, simulatio of cliical process, tailorig of learig eeds, better retetio of iformatio, ad more effective learig.1 Maiteace of a Curret, Evidece-Based Curriculum The foudatio of a PBL curriculum is the health care sceario. Studets search for ew literature with each ew sceario studied, ad the curriculum iheretly keeps pace with chages i physical therapy practice ad literature. Differeces betwee PBL ad traditioal curricula i this area have ot bee documeted i the literature. Fiacial ad Time Expeditures A study of the cost of PBL versus traditioal medical school curricula suggested that for up to 100 studets, o icreased costs were associated with PBL." Faculty i the traditioal program spet a large part of their educatioal time i preparatio for studet cotact, compared with more direct studet cotact i the PBL program.37 Shahab~di~~ compared the amouts of time take to cover the same cotet usig a lecture format versus a PBL format i two groups of studets usig five sample health care scearios give to supplemet a traditioal curriculum. Shahabudi estimated that studets would require 22% more time to cover cotet usig a PBL format (120 weeks) versus a lecture format (98 weeks). Potetial errors i estimatig the time from this study iclude the difficulty i accoutig for curricular overlap i both methods, the effect of prior kowledge i both studet groups, ad the difficulty i geeralizig results to other types of programs with differet curriculum desigs ad staffig patters. additio, the degree to which studets ad tutors were familiar with the process of PBL was ot documeted. The time required for PBL, particularly whe balaced by evidece that retetio of kowledge may be better i studets i PBL curricula, warrats further ~tudy.~~,s~ Recommedatios for Developmet of Physical Therapist Problem-Based Learig Curricula Faculty preparatio Mre believe that faculty preparatio is critical to the successful implemetatio of a PBL curriculum. The 204. Saarie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

11 eed for faculty preparatio is outlied i two descriptive reports.z4,z5 t is our experiece that PBL is ehaced whe faculty uderstad ad embrace the philosophy ad process of PBL. A willigess to make the paradigm shift from iformatio-giver to facilitator of learig ad the ability to trust studets' capacity to lear are critical i our view. completely itegrated PBL curricula, there are additioal demads o faculty members to uderstad how each curricular compoet is itegrated with ad affects the rest of the curriculum. Workshops, idepedet readig, ad faculty discussios have bee used to achieve this goal i the McMaster Uiversity PT program. our view, pairig of iexperieced ad experieced tutors is also useful i tutor traiig. Studet Preparatio We believe that studets must uderstad the philosophy ad process of PBL to successfully assume greater resposibility for their learig ad to uderstad the role of faculty as facilitators. Studets require orietatio to the tutorial process to maximize the learig that takes place durig tutorials. our opiio, this orietatio must iclude uderstadig of group processes as well as givig ad receivig feedback. Studets should be provided with workshops o PBL ad the tutorial process as well as iformatio o skills emphasized i PBL curricula, such as iformatio searchig ad critical appraisal of the literature. Cliical Educatio Plaig Cliical educatio is a extesio of the process of learig through cliical scearios. Studets i a PBL curriculum are expected to cotiue to use the process of PBL, albeit related to a real patiet, icludig itegratig prior kowledge ad searchig for ew skills ad kowledge. Resposibility for meetig learig objectives ad searchig out appropriate experieces ad resources is carried ito the cliical settig by studets i PBL curricula. Studets may seem more demadig of cliical educators to esure that there are opportuities to meet learig objectives. The primary role of the cliical educator becomes oe of facilitator, rather tha the more traditioal iformatio-giver. our view, appropriate orietatio ad traiig of cliical educators is importat i order to exted the PBL process ito cliical educatio. Curricul'ur Maiteace A fully itegrated PBL curriculum requires that faculty be aware of all aspects of the curriculum ad how chages i oe study uit may affect the other study uits. For example, a chage i age i oe cliical sceario from a youg child to a middle-aged perso may mea that studets do ot address a aspect of pediatrics iteded origially. additio, where there is logitudial itegratio of cocepts, faculty must uderstad the cotet covered i other study uits. Curriculum plaers must be prepared to ivest time together o a regular basis to review ad revise the curriculum, as eeded. Summary The McMaster Uiversity PT program is a completely itegrated PBL curriculum. There is a icreasig amout of evidece available that examies the purported advatages ad disadvatages of this educatioal method. may cases, this evidece is descriptive ad quasiexperimetal due to the difficulty i obtaiig matched groups of studets i traditioal ad PBL health care professioal programs ad cotrollig cofoudig variables. additio, the paucity of valid measures of cliical ad professioal behaviors ad performace of health care professioals limits compariso of studet outcomes. the area of cliical performace, two meta-aalyses demostrated that graduates of PBL medical school curricula were superior to graduates of traditioal medical school c~rricula.~~~ Lower levels of cotet kowledge have bee reported for medical studets i PBL programs versus their traditioal ~outerparts."~~z~~~4~39 O the other had, improved kowledge retetio was demostrated i two st~dies.~~,~~ Compariso of curret kowledge of medical school graduates of PBL versus traditioal curricula betwee 5 ad 10 years after graduatio demostrated that the graduates of PBL curricula had more up-to-date k~wledge.~' The developmet of self-directed ad resposible learers is oe of the goals of PBL. There is evidece that medical studets i PBL programs place more emphasis o jourals ad literature searches tha studets i traditioal programs do." High levels of resource use ad time spet studyig have bee reported for PT studets i two PBL programs.l0.l4 There is evidece that medical studets require more time to cover the same cotet i a PBL format tha i a traditioal format." Direct comparisos of learig processes, icludig comparisos of self-directed learig behaviors ad time to cover cotet, betwee PT studets i PBL programs ad those i traditioal programs are ot available. Some author^^.^ have reported that studets ad faculty prefer PBL learig methods. Potetial bias is itroduced by self-selectio of studets ad by faculty selfselectig a PBL versus a traditioal eviromet. Eagle et all7 reported that the fiacial cost of a PB, medical school program was o differet tha that of a traditioal medical school program for up to 100 studets. There is limited evidece directly comparig the time Physical Therapy. Volume 78. Number 2. February 1998 Saarie-Rahiika ad Bikley. 205

12 ad fiacial costs associated with PBL versus traditioal 12 Selle-Baledog H. Ratioale uderlyig the desig of a programs, ad further work is eeded i this area. prohlem-based curriculum i problem-based learig as a educatioal strategy. : Bouhuijs PAJ, Schmidt HG, va Berkel HJM, eds. problem-~ased Learig as a Edumtioal Strategy. Maastricht, the Neth- summary, evidece comparig PBL ad traditioal erlads: Publicatios; methods is primarily from studies of medical studets 13 Saarie H, Salvatori P. Educatig occupatioal ad phvsiotheraad programs' The studies studets pists for the year 2000: Wlat, o aatomy course? Physiothmfl Caada. i PBL programs ad studets i traditioal programs ;46:81-86, with respect to outcomes are difficult to iterpret due to potetial cofoudig factors ad lack of valid measures of cliical ad professioal performace of health care professioals. Evidece exists that studets ad graduates of PBL programs demostrate aspects of professioal behavior, icludig resource use ad keepig uptodate with the literature, that are superior whe compared with studets i traditioal programs. Further research is eeded to clearly elucidate the differeces i learig processes, outcomes, ad time ad fiacial costs betwee PBL ad traditioal PT educatio 14 Williams R, Saarie-Rahikka H, Norma GR. Selfdirectecl learig i problem-based health scieces educatio. Acud 'Wed. 1995;70: Barrows HS, Tambly RM. Probh-Based Leaig: A Appoarh lo Medical Educatio. New York, NY: Spriger Publishig Co c; Davis WK, Nair R Paie ME, et al. Effects of expert ad oexpert facilitators o the smallgroup process ad o studet performace. Acad Med. 1992;67: Eagle CJ, Harasym PH. Madi H. Effects of tutors with case expertise o problem-based learig issues. Arad Med. 1992;67: methods. 18 Barrows HS. The TutorialProcess. New York, NY Spriger Publishmg Co lc; Ackowledgmets 19 Silver M. Wilkerso LA Effects of tutors with subject expertise o We ackllowledge the support ad cotributios of Pro- the problem-based tutorial process. Acad Med. 1991;66: fersor Stra~Ord' Dr Patricia Dr 20 Solomo P, Blumberg P, Shehata A. The ifluece of a patiet's agc Bikle~. Sue A Lett, Ms Diae Stratford, ad o problem-based tutorial discussio. Acad i2led. 1992;67:s31-s33. Mr Victor Rahiika. 21 Wilkerso L, Hafler JP. Lu P. A case study of studetdirected Refereces 1 Barrows HS. A taxoomy of problem-based learig methods. Med Edur. 1986;20: Solomo P. Problem-based learig: a directio for physical therapy educatio? Physiotherapr Theq ad Prartice. 1994;10: Neufeld VR, Woodward CA, MacLeod SM. The McMaster MD Program: a case study of reewal i medical educatio. Arad Med. 1989;64: Schmidt HG. Problem-based learig: ratioale ad descriptio. Med Edur. 1983:17: Berkso L. Problem-based learig: Have the expectatios bee met?.4rad 'bled. 1993;68:s79-s88. 6 hlbaese MA, Xlitrhell S. Problem-based lealig: a review of lit~rature o its outcomes ad implemetatio issues. Arad Med. 1993:68: Vero DTA, Blake RL. Does problem-based learig work! a meta-aalysis of evaluative research. Ard Med. 1993;68: Elstei AS, Shulma LS, Spratka SA. Mediral Problem-.Solvig: A Aalysis of Cliical Reasoig. Cambridge, Mass: Harvard Uiversity Press; Norma GR. Problem-solvig skills, solvig problems. ad problembased learig. kfed Edur. 1988;22: Solomo P, Bikley JM, Stratford PW. A comparative study of learig processes ad outcomes i two problem-based curriculum desigs. Joural ofphysira1 TheraB Educatio. 1996;10: Mpklebust R. Stalsberg H. Marteso D. troducig problembased learig withi a lecture-domi~iated curriculum. : Bouhuijs PAJ, Schmidt HG, va Berkel HJM, eds. Problem-Based Learig as a Educatioal Stratep. Maastricht, the Netherlads: Network Publicatios; discussio i four problem-based tutorial g~oups. Acad Med. 1991;66: s79-s Kowles M. Self-Directed Lamig. Chicago, 111: Follett Publishig Co; Dolmos DHJM, Schmidt HG. What drives the studet i problcmbased learig? Med Educ. 1994;28: Holmes DB, bufma DM. Tutorig i problem-based learig: a teacher developmet process. Med Educ. 1994;28: Grad'Maiso P, Des Marchais JE. Preparig faculty to teach i a problem-based learig curriculum: the Sherbrooke experiece. Ca Med Assoc J. 1991; 1 44: Stratford PW. Pierce-Fe H. The rrlodified essay questio. Ph?s Thm. 1985;65: Black NM, Harde M. Providig feedback to studets o cliical skills by usig the objective structured cliical examiatios. [bled Edur. 1980;20: Barrows HS. Feltovich PJ. The cliical reasoig process. Med Edur. 1987;21: Norma GR, Schmidt HG. The psychological basis of problembased learig: a review of the evidece. Acad Med. 1932;67: Neufeld VR, Norma GR, Barrows HS, Feighter p. Cliical problem-solvig of medical studets: a logitudial ad cross-sectioal aalysis. hled Edur. 1981; 15: Raki JA. Prohlem-hased medical educatio: effect o library use. Bull Med Libr Assoc. 1992;80: Shi JH, Haes RB, Johsto ME. Docs a problem-based, selfdirected udergraduate medical curriculum promote cotiuig cliical competece? Cli vest Med. 1991;14:A bufma A. Mei S. Waterma R, et al. The New Mexico Experimet: educatioal iovatio ad istitutioal chage. Acud bled. 1989:64: Soarie-Rahiika ad Bikley Physical Therapy. Volume 78. Number 2. February 1998

13 34 Coulso RL, Osbore CE. Problem-based learig of the cardiovac cular system usig the problem-based learig module. Physiologist. 1983;26: Eisestadt RS, Barry WE, Glaz K. Problem-based learig: cogitive retetio ad cohort traits of radomly selected participats ad decliers. Acd Med. 1990;65:s11-s Moore-West M, Harrigto DL, Mei SP, et al. Distress ad attitudes toward the learig eviromet: effects of a curriculum iovatio. Teachig ad Learig i Medicie. 1989;1: Mei SP, Martiez-Burrola N. The cost of problem-based versus traditioal medical educatio. Med Educ. 1986;20: Shahabudi SH. Cotet coverage i problem-based learig. Med Educ. 1987;21: vited Commetary commed the authors of this article for a very timely cotributio to the literature relative to physical therapy educatio. Problem-based learig (PBL) has become almost a "buzzword" i physical therapy educatio i recet years. Thus, a literature review ad discussio are importat ad saliet at this time whe may developig educatioal programs are embracig this method of istructio. Although the literature regardig PBL i physical therapy educatio is sparse, the medical educatio literature cotais umerous refereces, ad may of these refereces are oted i this article ad should be reviewed by ayoe iterested i PBL. Accordig to the authors, the purposes of this article were (1) to discuss the developmet of the PBL curriculum i physical therapy at McMaster Uiversity, (2) to review the curret literature o PBL, (3) to outlie purported ad documeted outcomes of PBL ad areas eedig further ivestigatio, ad (4) to make recommedatios for implemetatio of PBL i other physical therapist programs. The first compoet is well covered, with tht: authors givig a historical perspective of the McMaster Uiversity curriculum. Their review is illustrated with clearly delieated figures describig how the curriculum is structured ad how horizotal "streams" such as research are icluded i a trascurricular maer. t is with the ext two compoets of the article that the authors ivite cotroversy, however, with their obviously biased preferece for a completely itegrated PBL curriculum such as that at McMaster Uiversity. Review of PBL Literature their overview of the three essetial approaches to PBL (completely itegrated curricula, trasitioal curricula, ad sigle-course approach), the authors suggest that "the trasitioal curricula may lose some of the potetial beefit of PBL because cotet is ot itegrated ad related directly to cliical scearios early i the program, although o direct evidece is available to support this premise." O the cotrary, the medical literature is replete with examples of articles promotig the "middle groud" or a "hybrid" betwee the two educatioal methods (those of covetioal curricula [CC] ad PBL) i order to capitalize o what is valuable i both types of medical ed~catio.'-~ fact, two medical schools (Uiversity of New Mexico, Michiga State Uiversity) have recetly chaged from offerig two separate, cocurret tracks (CC ad PBL) to offerig oe combied track, with icorporatio of the best elemets of both method^.^ Aother fact oted by Vero6 is that there are sigificat ad problematic issues i attemptig to compare these "two types of educatioal methods" because there are so may variats i the format of PBL, depedig o the istitutio. The issue of study time i self-directed learig is aother problematic issue, ad the authors are correct i their statemet that there are o comparable studies of physical therapist studets i traditioal (CC) programs. The authors referred to the study by Williams et al,9 where it was foud that the ratio of oscheduled to scheduled study time for physical therapist ad occupatioal therapist studets at McMaster Uiversity was approximately 3:1, but they did ot ote that this oscheduled study time decreased from the first year to the secod year, which Williams et a19 preseted as possibly related to "bur out." Other authors2~%also ote that, especially early i a PBL curriculum, studets are stressed ad tryig to accommodate to a ew learig eviromet ad they sped umerous hours o "extraeous uimportat material" ad later lear to focus better ad seek out the ecessary iformatio from the appropriate sources. PBL Outcomes-Review of the Literature The authors offer a log list of advatages of a PBL curriculum ad oly two disadvatages. There are some obvious omissios i this sectio of the article. Superior problem solvig i graduates of PBL curricula has ot bee documeted i the literature.0j1 The outcome of these graduates beig more self-directed learers-for-life has bee documeted i several st~dies,'.~j~,~ but Physical Therapy. Volume 78. Number 2. February 1998 Hayes. 207