2013 2013; 35: 806–814 TWELVE TIPS Cracks in problem-based learning: What is your action plan? SAMY A. AZER 1 , MICHELLE MCLEAN 2 , HIROTAKA ONISHI 3 , MASAMI TAGAWA 4 & ALBERT SCHERPBIER 5 1 King Saud University, Saudi Arabia, 2 Bond University, Australia, 3 International Research Center for Medical Education, University of Tokyo, Japan, 4 Kagoshima University, Japan, 5 Maastricht University, the Netherlands Abstract Background: Problem-based learning (PBL) as an educational approach has been adopted by medical and health sciences faculties worldwide. Successful implementation of these curricula may, however, end a few years later with several problems reflecting cracks in curriculum maintenance. Aims: The aim of this article is to discuss these problems, their possible causes and what action can be taken to maintain effective curriculum delivery. Methods: We reviewed the current literature, recent Association for Medical Education in Europe conferences’ sessions on PBL, explored curriculum design approaches and problems (cracks) identified in PBL programs that may occur a few years after successful implementation. We have also reflected on our collective experience in a number of universities to develop these tips. Results: Incorporating the methods described, we have developed the following 12 tips: (1) Pay attention to training new staff for PBL, (2) Maintain the briefing/debriefing sessions, (3) Review the PBL material and program in light of the previous year’s feedback, (4) Monitor the delivery of the program, (5) Review management of the PBL program, (6) Encourage research and publications in PBL, (7) Ensure that assessment reflects PBL principles, (8) Refrain from adding new lectures to the timetable, (9) Reward contributions to on-going curriculum maintenance, (10) Provide on-going and advanced professional development tutor training, (11) Make explicit (and develop) students’ skills required for PBL and (12) Attend to conflict and group dysfunction. Conclusions: Being vigilant of possible cracks (erosion) in the PBL curriculum that may occur a few years after successful implementation is mandatory. Erosion of PBL can be minimized or avoided if these tips can be applied. Introduction Problem-based learning (PBL) is an instructional method characterized by three elements: problems, tutors, and stu- dents (Majoor et al. 1990). These three elements are integral to the success of a PBL program. The problems (also known as cases or scenarios) are the instructional materials designed to trigger students’ discussion and learning in the PBL tutorials. Cases should reflect real-life situations to drive students’ learning about basic biomedical sciences and biopsychosocial issues (Hmelo-Silver 2004; Azer et al. 2012). Cases need to represent typical cases with the aim to drive students’ learning of basic biomedical sciences related to the case in a clinical format. Rare cases or complex cases should be avoided particularly in the early years (Des Marchais 1999; Jacobs et al. 2003). In small groups, learners discuss the case, identify the cues ( patient’s problems) in the trigger, generate hypotheses, develop an enquiry plan and then refine their hypotheses based on the evidence from the history and clinical examin- ation (Barrows & Tamblyn 1980). In this process, learners, rather than the tutor, are the active participants in the discussion, with each group member contributing to the learning. The PBL tutor, who should be adequately trained for his/her new role, is a facilitator and evaluator who provides feedback to the group. A case is usually discussed over two tutorials, each of approximately two hours duration. At the end of the first tutorial, students identify learning goals or issues that guide their research and self-directed learning (SDL) activities (Hmelo-Silver 2004; Sockalingam et al. 2011). During this period of SDL, students search for information to answer their questions, drive their learning, justify their views and help them to explain the case. The group reconvenes (tutorial two) to discuss their findings and to integrate the new information to the issues raised by the case (Azer 2008). Several factors contribute to successful group discussion (Nieminen et al. 2006; Azer 2009a). These include: . Providing hands-on tutor training. . Providing tutors with a case guide and resources. . Providing on-going support to PBL tutors in terms of facilitation skills, administration and group management issues. . Ensuring that tutors have addressed group management issues in the first two to three tutorials. . Introducing students to the PBL process and developing their self-directed learning skills. . Ensuring that PBL cases are authentic and written by teams of experts. Correspondence: Professor Samy A. Azer, Professor of Medical Education, Chair of Curriculum Development and Research Unit, Medical Education Department, College of Medicine, King Saud University, P O Box 2925, Riyadh 11461, Saudi Arabia. Tel: þ966542307075; fax: þ 96614699174; email: azer2000@optusnet.com.au 806 ISSN 0142–159X print/ISSN 1466–187X online/13/100806–9 ß 2013 Informa UK Ltd. DOI: 10.3109/0142159X.2013.826792 Med Teach Downloaded from informahealthcare.com by Professor Samy Azer on 03/02/14 For personal use only.