Issue 28 / 4 August 2014

I AM a product of problem-based learning. At the age of 18, with vague misgivings that I was part of an educational experiment, I sat in a tutorial room at the University of Newcastle with seven similarly apprehensive colleagues, ready to “problem solve” our first case.

Over the years, I’ve been asked if the Newcastle approach was better than the other medical courses available at the time but, of course, I don’t know. Thankfully, I only had to do one of them!

This week in MJA InSight, one of our news stories looks at whether problem-based learning (PBL) deserves its place as the main teaching vehicle in many Australian medical schools. We asked medical educators to respond to an MJA “Perspectives” article about the lack of evidence underpinning PBL’s ascendancy, and the need for medical schools to expand their repertoire of learning paradigms and teaching methods.

John Hamilton, a veteran medical educator and ex-Newcastle dean, directed us to a paper he published in the BMJ in 1976, critiquing the (then new) technique. The critique included a quote from John Dewey, a 20th century philosopher and educational reformer, which caught my eye:

“… science has been taught too much as an accumulation of ready made material with which students are to be made familiar, not enough as a method of thinking, an attitude of mind, after the pattern of which mental habits are to be transformed”

This holds true for medical training no matter what methods are used.

The idea that a well trained doctor is one who has learned a “method of thinking” is reflected in our lead news story, about the use of high-sensitivity troponin assays in patients with suspected acute coronary syndromes. The authors of an MJA editorial affirm the potential of these assays to improve patient outcomes by picking up more cases of myocardial infarction. However, they caution that advances in diagnostic technology needed to be accompanied by “more effective clinical practice” — including an understanding of who should have the test, what the results mean and how to use them to improve management.

In our other news story, an expert calls on health professionals to have a more structured and deliberate method of thinking to determine if children presenting to hospital have been victims of abuse or neglect.

Commenting on an MJA editorial about the difficulty of obtaining accurate data about child maltreatment, Emeritus Professor Kim Oates said that when hospitals have clear protocols for identification of child abuse more cases are identified, and that doctors needed help to ask “the difficult but important questions”. Such a protocol has been used for some time in Queensland, and has recently been introduced in NSW.

Back in June our regular blogger Jane McCredie wrote about the ethics of administering anaesthetic agents with the intention of altering memory, sparking reader debate about the extent to which this is possible. This week Simon Hendel provides an anaesthetist’s perspective on anaesthesia and memory, as well as some advice to be mindful of patients’ reduced capacity to retain memories of events immediately after surgical procedures.

Jane’s column this week, looking at how evidence-based medicine (EBM) is just catching up with a common problem, reminds us that while EBM serves medicine very well, there are still gaps in the evidence that require rethinking, support and funding.

I’m not the only one living in the past this week. The ever-nostalgic Aniello Iannuzzi tells us in his comment that “Once upon a time, choosing a university course in health meant a secure and rewarding career” but that the whims of successive governments have dictated that this is no longer so.

He may be right but I am optimistic. If these young graduates have been equipped with “a method of thinking” to undertake lifelong learning and mindful practice, the future looks exciting for them and for medicine.


Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

11 thoughts on “Ruth Armstrong: Medical thinking

  1. Carolyn .jack says:

    I was the result of a PBL based course as well (post grad). What we would have found extremely useful was learning the basics first, then doing PBL. First year PBLs which required a working knowledge of anatomy, physiology and pharmacology were slightly useless for those who did not do the “pre-med” science course but started in other areas, like film and television, parasitology, and justice (a colleague was a former police officer). What would have been much more useful to us was first year didactic teaching, then 2nd – 4th year have PBLs. At least then we would have had some clue what was going on. I believe we succeeded in spite of PBL, not because of it.

  2. Sue Ieraci says:

    More than thirty years after my fairly didactic undergraduate medical education, I am still pleased that I had a good grounding in the basic medical sciences, re-inforced in a post-grad primary examination. There is no substitute for understanding pathophysiology. Having said that, I’ve been working with some excellent medical students – I suspect many of the individual differences come out in the wash in the post-graduate years.


    As I write this I am sure across Australian medical schools -students waiting for a consultant to teach them, a tutor to appear in the tutorial, lecturer (whoever available / no permanent lecturer) who can present 120 slides in 50 minutes appeared randomly in the class, GPs who needs flexible hour put their name in the pool to be a tutor without knowing what is to be taught, university improve their ranking, ignorant parents are happy that their children getting university education, tax payer ‘s money being wasted by the name of educating the nation. Indeed we are becoming intelligent nation! Some of us still look for doctors who have graduated 50 years ago-can we keep them alive till we improve the system?

  4. Dr Harry Haber says:

    I studied medicine over fifty years, where anatomy physiololgy were the basic medical subjects, I felt that the basics study helped me understands how the body worked, having had students trained  in problem based  learning  I felt that they lacked this understanding of the basics. I hope Sydney   university is now considering a mix  of having basic knowledge and PBL being combined

  5. Genevieve Freer says:

    Greg is right.

    Our universities take oversease students for financial gain, just as PBL without core basic education is for the universities’ financial gain, cost-cutting by omitting  basic  pre-clinical and clinical science.

    Australian students are expected to teach themselves the basics, which is like learning English without knowledge of the alphabet, which is empirical, just like trying to learn Maths without knowledge of numeracy, again empirical.

    Why should Greg teach overseas students for no remuneration, when these students are paying $60,000 per year to attend Sydney Uni?

    Even rural placements of urban students  earn metropolitan universities funding, despite the fact that rural students doing rural placements are most likely to return to rural areas where they are needed  to work.

    Perhaps it is time that we clinicians who train students have more input into the curriculum.

  6. Dr Hasina Yeasmin says:

    I completely agree with Greg .
    There should be paid dedicated team of educators to serve and control the quality of medical teaching. In need students do not even know who to turn to? A good teaching and learning environment is completely absent in medical system. At least in medicine students wants to learn-need to capitalise that! Where do all fees go- we wonder!
    But I cannot agree with Yossarian sorry. All learning is self-learning but education is not. If education is self-directed then we do not need universities, curriculum etc etc. You agreed that there were false teaching by experts that is the product of lack of quality teaching and education overall. Good on you-you have taught yourself so did your expert tutors-so who do we trust.
    We general public are on the receiving end of you all!

  7. Adam Doyle says:

    I came from a medical school where both PBL and didactic teaching were implemented. To be honest, although I hated the PBLs at the time, they helped me to realise that all education is really self education. If you can’t justify to yourself and others why something is true, then you haven’t really learnt it. I can’t count the number of times I’ve been taught patently false things by clinical tutors since graduating. If PBL taught me a healthy skepticism for those who extol truth, then maybe it has fulfilled its role. 

  8. Greg Hockings says:

    PBLs are attractive to medical schools because they don’t have to use clinicians as teachers, in contrast to bedside teaching. I wonder how much longer our medical schools will be able to survive by using unpaid clinicians, such as VMOs and registrars, to teach in their non-existent spare time. I have taught for over 20 years with no remuneration, and was happy to do so, but now I find that most of my students are from overseas and paying exorbitant fees into general university revenue while I continue to give my time and expertise for no remuneration.

  9. Dr Hasina Yeasmin says:

    Sadly I as a non-medical public losing trust on any teaching that include medical teaching.
    Under the curtain of PBL method ten different tutorial sessions taken by ten different so called expert tutors reaching ten different diagnoses is very common in current medical teaching. Quality of teachers (so called experts, if there is one who comes on time or decides not to come at all) is unpredictable and often no teaching at all (students not allowed to the ward, do happen quite often). Discrepancies in teaching between hospitals are far beyond imagination. Students actually learn by themselves. Of course there is no insight of any problem; no lateral thinking ability- taking away the confidence that once medical was a “science”. Cost cutting leads to reducing the course from 6 years to 5 years in some universities. Those who teach have no idea what are to be covered in the lecture and go what he/she thinks important! A Great way to learn indeed.
    I am not sure what “medical teaching” doing with our brightest students to serve the distressed. No wonder when they face third party examinations they have to work hard adding more diseases to DSM-for mental health.

  10. Judith O'Malley-Ford says:

    The author of this article states that  she “is a product of problem based learning”. I hate to be the one to tell her, but it shows, in the articles that she writes for this segment. That’s not necessarily a compliment.

    You can’t learn “times tables” by problem based learning any more than you can learn anatomy, physiology or any other “-ology” to be a doctor trained by the same method.

  11. Randal Williams says:

    I have been banging on for years about the diificulties of a PBL approach in undergraduate medical courses. Students have diificulties trying to deal with this straight out of school with no teriary scientific background and a common complaint was a feeling of being “thrown in the deep end without first learning how to swim’ . PBL in medical training originated at Harvard, which is a postgraduate course where most have done a scientifically related College degree, which gives a much better foundation. Unfortunately PBL it was taken up with missionary zeal in some undergrraduate courses in places like Newcastle and Adelaide, with a general and detrimental decrease in didactic teaching, leaving students short-changed. Thankfully I think some balance is coming back.

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