Acceptance of Problem Based Learning among Medical Students

Aim: The objective of this study is to determine the acceptance of Problem Based Learning (PBL) among medical students. Material and Methods: This study was conducted among 350 Medical students at the Management and Science University (MSU), Malaysia, during the academic year 2011-2012. A cross sectional study was carried out among first, second, third and fourth year medical students. Students were explained the objective of the study and were invited to participate. Informed verbal consent to participate was obtained and all participants were assured. Data obtained were analyzed using SPSS version 13. T-test and ANOVA test which were conducted to determine if there was a significant difference between the study parameters. Multiple linear regressions were used in multivariate analysis. Results: The majority of the surveyed students were older than, or equal, to 22 years old, Malays, from year 2, with Cumulative Grade Point Average (CGPA) more than 3.3 and family monthly income less than 10,000 Malaysian ringgits (60.3%, 52.3%, 44.0%, 37.1%, 85.4% respectively). Race, year and CGPA were found to be significantly associated with PBL acceptance among medical students (p = 0.001, p = 0.003, p = 0.003; respectively). Overall, the acceptance of PBL among medical students was quite low (39.7%). In multivariate analysis, age and race were significantly associated with PBL acceptance. Conclusion: The acceptance of PBL among the surveyed medical students was low. This suggests that more rigorous and practical training should be given to tutors and students in order to understand the philosophy of PBL.


Introduction
Problem based learning (PBL) is documented as far back as Plato and the Socratic pedagogy and its manifestations have been varied. The philosophy embodies Alfred North Whitehead's observation that "education means, literally, the process of leading out" [1]. Fundamental reforms in undergraduate medical education have been advocated for 100 years. In 1899, William Osler realized that, the complexity of medicine had already progressed beyond the ability of teachers to teach everything that students would need to know [1][2][3]. PBL was first developed in 1969 at McMaster University's Faculty of Health Sciences in Canada and nowadays it is accepted as very important innovation in medical education in Western countries [4,5].
Although PBL is application in medical education that is not free form discovery learning, PBL is rather a rigorous, practical teaching learning process [6]. In medicine, PBL is understood to mean a highly structured, student centered, educational methodology, small group and collaborative problem solving activities [7]. In PBL students are put in an active learning situation by giving them clinical problems and training them to identify what they need to learn to solve those problems. Faculty members go through a tedious exercise to develop a single PBL case. They should be able to determine proper learning resources and subsequently apply what they have learned to solve problems. The tutor's role in PBL is to facilitate this process of active learning by students and foster skills of clinical reasoning and habits of continued learning. PBL is typically carried out in three phases [7,8]. Phase one is Problem analysis. This is the phase in the PBL approach where the students develop the cognitive skills necessary for clinical reasoning. In group discussion PBL settings the students evaluate the patient problem presented to them exactly as they would a real patient, attempting to determine the possible underlying anatomical, physiological, biochemical, or behavioral dysfunctions responsible for the patient's problem. The task of the students is to enumerate all possible causal paths that would explain the progression from the enabling conditions to the signs and symptoms in the given problem scenario. Second phase is Self-directed study. In this phase, students work outside the tutorial session, using any relevant learning resources, e.g. literature, laboratories, specialists, to address any open issues identified in the first phase. Third phase is Synthesis and application of newly acquired information. The third phase begins when the students return from their self-study period. They analyze data and evaluate or justify solutions collaboratively and wrap up the problem [7,8].
The disadvantage of teacher-center learning is the passive nature of the audience in class and limited opportunity for feedback lead to low receptivity [9]. Furthermore, lecturing skills of a high quality are required to hold the attention of students for the commonly prescribed lecture duration of one hour. Very often, the material covered by a lecture can be more easily acquired from a textbook and has little if any clinical application. Many students attend lecture classes because attendance is mandatory or because they do not want to incur the wrath of the teacher who might be their examiner. The shift in emphasis from traditional teaching to an emerging method like PBL is largely triggered by the changing external environment that is the 'global' workplace for which institutions prepare their students. In recent years PBL has taken a greater prominence in tertiary education with curricula directed at independent and team learning [10]. However, PBL can be said to have an adverse effect on some students and even lecturers, who have to adopt a shift in their mindset, as students now need to explore rather than merely receive content knowledge. Similarly, tutors now need to manage the learning process closely instead of simply giving information [11]. Several studies have been published in favor of and against the strategy of problem based learning [11].
PBL studies have reported that this strategy has four main objectives which may be summarized as 1) application of basic knowledge 2) develop reasoning 3) self directed learning 4) promotion of team work [12][13][14]. Three core principles of PBL were first identified by Charlin et al. [15]. These principles were that learning should be focused around a problem, the implementation of PBL should be an educational approach and it should be centered on the learner. Curricula following PBL strategies are a very challenging task for the faculty. In order to achieve these, PBL proceedings, PBL formulation and PBL approval checklist are followed [15].
PBL is becoming an emerging pedagogical paradigm in Malaysia but has raised debates on why conventional teaching methods are no longer applicable to today's educational environment [16]. The main concern seems to be every educator's fear of error-increase (as opposed to error-reduction). The faculty of Medicine and Health Sciences, University Malaysia Sarawak (UNIMAS) has adopted PBL as a teaching-learning methodology in its undergraduate curriculum, since its inception in 1996 [17]. Only few studies conducted in Malaysia regarding PBL [17,18]. Therefore, the present study was undertaken in order to determine the acceptance of PBL among medical students.

Materials and Methods
This study was conducted among 350 medical students at the Management and Science University (MSU), Shah Alam, Selangor, Malaysia, during the academic year 2011-2012. A cross sectional study was carried out among first, second, third and fourth year. Students were explained the objective of the study and invited to participate. Informed verbal consent to participate was obtained from all participants. Student responses were obtained using a questionnaire (survey). Information about demographic details like age, race, year, Cumulative Grade Point Average (CGPA) and family monthly income was collected. Student perceptions and opinions about PBL were measured using a questionnaire from a previous study by Usmani et al. [19]. The data about the perceptions and opinions included 23 items and was scored on a 3-point scale (disagree, neutral and agree).
The sum score 23 times the students agree with the items was indicated the acceptance of PBL ( Figure 1).
The questionnaires were distributed among students by simple random sampling techniques. Questionnaires were distributed at the university either before or after their classes with help. The inclusion criteria were, medical student (both gender), 18 year-old students and above, of Malaysian citizenship and can speak, read and understand English. Students who were less than 18 years' old and were nonmedical students were excluded from this study. All participants were given explanation about the purpose of the study and an assurance of confidentiality. Participants were also assured that their participation in the study was voluntary and that they could withdraw at any time during the survey. The protocol of this study was approved by the ethics committee of the Management and Science University, Malaysia. Data obtained were analyzed using SPSS version 13. T-test and ANOVA test which were conducted to determine if there was a significant difference between the study parameters. All tests were analyzed with the confidence interval, α = 0.05. The significance level (p value) was set at 0.05. Multiple linear regressions were performed for multivariate analysis.

Results
A total number of 350 medical students (both gender) participated in this study. The majority of them were older than, or equal, to 22 years old, Malays, from year 2, with CGPA more than 3.3 and family monthly income less than 10,000 Malaysian Ringgits (MYR) (approximately equal to $3000USD) (60.3%, 52.3%, 44.0%, 37.1%, 85.4% respectively) ( Table 1). Regarding factors associated with PBL acceptance: Race, year and CGPA were significantly associated with PBL acceptance among medical students (p = 0.001, p = 0.003, p = 0.003; respectively). For race, Post Hoc test showed differences was between Malay and Indian students on the one hand (p = 0.001). On the other hand difference existed between Malay and Chinese students (p = 0.001). In our study, difference also existed between Malay and other races (p = 0.001). For year, Pos Hoc test showed differences between year 1 and year 3 (p = 0.048). For CGPA, Post Hoc test showed differences between CGPA < 3 and CGPA 3-3.5 (p = 0.002) in the one hand. On the other hand differences were revealed between CGPA < 3 and CGPA > 3.5 (p = 0.019).
Regarding the perceptions and opinions of medical students towards BPL, the majority of them (66.3%) agreed that PBL develops their confidence in self-directed learning 54.9% of the students reported that PBL developed the competence in self-directed learning. More than half of the students agreed that the role of facilitator in the process is helpful (53.4%), 53.1% of the students reported that PBL facilitated the improvements of their problem solving skills. However, only 36% of the students reported that a proper training of PBL was given to them before the implementation of this application (Table 2).
Overall, the acceptance of PBL among medical students was low (39.7%). Furthermore, the majority of the students (51.7%) indicated that they do not accept PBL (Figure 1). In multivariate analysis (Table  3), age and race were found to be significantly associated with PBL acceptance. With every increase of one year in age of the students, acceptance of PBL increases 0.027 points. Non-Malay students had an average of 2.318 points higher acceptance of PBL compared to Malay students.

Discussion
Recently, PBL has been increasingly gaining popularity in Malaysia, however it is of great concern that PBL should only be implemented after careful deliberation. This strategy requires rigorous planning, faculty training and most importantly, commitment and proper understanding of the philosophy behind its implementation [4] (Khoo 2003).
In this study CGPA showed significant influence on the acceptance of PBL among medical students. similar finding was reported by Adnan et al. [18], who showed that students in different groups of CGPA revealed varied effects of PBL. Hwang and Jang [20] also reported that the positive impact of the PBL method on good "graders" was associated with their strong motivation for the study. Hwang and Jang [20] observed that good graders were stimulated by the integrative learning of scenario-based discussion and the interactive relationship with a tutor and group members, which may have contributed to their strong motivation. However, many poor graders with poor learning attitudes expressed frustration at not being able to catch the essential content of the course readily by the PBL method, leading to lower selfconfidence in learning [20].
In this study year and race showed significant influence on the acceptance of PBL among medical students. For the 'year' factor, the possible explanation may be associated to the circumstances (add s) that when the students progress to the following year, they may start to adapt with the PBL compared to the new students. For the 'race' factor, the possible explanation may be associated with the circumstances (add s) that the Malay students were the majority of students in this   university. Wun et al. [21] suggested that PBL, starting from the early years of a medical curriculum, was associated with more active student participation, interaction and collaboration in small-group tutorials. In this approach, they are also given the responsibility to take charge of their own learning by using the given problem as a guide to indicate the scope of what needs to be taught [21][22][23].
In our present study 39.7% of medical students accepted PBL as a new teaching method in this university. A similar finding reported that the perception of implementing PBL shows interesting variations, although most of the faculty is in favour of implementing this strategy [24]. The respondents' negative perceptions towards PBL were consistent with the findings from previous studies [25,26]. The most frequently perception mentioned was uncertainty about the accuracy of the acquired knowledge. Their uncertainty is also shown in relation to the completeness of content material and how to approach the problem. Heavy workload was one of the negative perceptions held by students [26]. Other studies showed that the use of PBL produced no statistically significant difference in knowledge acquisition from the teacher based lecture method in a nursing course for undergraduate nursing students [27] and a pharmacology course for graduate nursing students [28]. Furthermore, in a four year follow-up study, Rideout et al. [29] found that students taught by the PBL method had no statistically significant differences in theoretical knowledge in pathophysiology and professional knowledge as well as in their pass rates of National Nursing Registration Examination compared with the students taught by the lecture method. In a review study by Smit et al. [30] mentioned that there is no evidence consistent enough that has proven that PBL was superior to other educational strategies. There is not enough proof that it increases one's knowledge or performance in the clinics and hospitals but there is moderate amount of evidence that it results in higher satisfaction.
PBL consists of 7-jumps; the 7-jump process is formally designed so that the students solve the problem in a coherent manner and also achieve their course objectives around which the problem is designed [30,31]. Also, for this strategy to be accepted, students must be assessed via PBL not only by formative assessment but also by summative assessment [31]. Here, however lies the weakness of PBL that in spite of major efforts there are only a few assessment tools reflecting learning outcomes particularly attributed to PBL [31]. These results confirmed findings from previous studies regarding positive and negative experiences of students in problem-based learning courses, particularly with regard to the development of independent learning and interactional skills, anxiety created by this method of learning and influences on group learning [30,[32][33][34].
In the present study more than half of the participants (52.3%) reported that the PBL strategy is interesting. This may be due to that PBL encourage students to do more self learning and student centre learning; moreover the students improve their communication skills. A similar Malaysian study showed that 78% of students perceived that PBL sessions were interesting [17].
In the present study, 39.7% of the study participants agreed that PBL strategy takes more time than conventional lectures. A similar finding reported that participants feel that PBL is too time consuming [24]. Mistrust and time consuming relating to PBL is also reported by Chakravarthi et al. [35]. The success of PBL is the focus on the collectivism of mutual trust and confidence of each individual [36].
In our present study, more than half of the participants (53.4%) agreed that the role of facilitator in the process is helpful. Woltering et al. [37] reported a higher percentage of students (74.5%) who indicated that the facilitators provided a positive learning environment. Other studies reported that students preferred tutors who had knowledge in both basic and clinical science areas, had appropriate facilitative tutorial skills and had positive personality traits [38][39][40]. The effectiveness of PBL depends on the tutors' quality and the students' motivation [38][39][40]. The tutor's role in a PBL tutorial differs from that in a conventional tutorial. In PBL, tutors are expected to facilitate or activate student learning and to promote effective group functioning by encouraging the active participation of all members, monitoring the quality of learning and intervening when this is necessary [40][41][42]. Tutors also play active roles in the scaffolding of student learning by providing a framework that students can use to construct knowledge on their own [43]. Because it encourages students to think more deeply and offers some modeling of the types of questions students should be asking themselves during problem solving, the tutor student relationship can be viewed as supporting a type of cognitive apprenticeship [44,45].
Several studies reported that tutor expertise has a significant effect on student learning outcomes [46] whereas other studies indicate that it has no noticeable effects [47,48]. One hypothesis that may explain this contradiction is that the subject matter expertise of the tutor impacts on student learning more significantly when the cues and scaffolds within the problems and resources are insufficient to guide students in the process of identifying what is important to study [43]. In such situations, students are more likely to depend on their tutor for guidance and thus a tutor who is more knowledgeable in the subject matter is of more benefit [43]. Other advantage in a PBL setting is that the boundaries between the facilitator and student are also noticeably reduced. This provides opportunities for the student to be empowered in raising pertinent questions to challenge existing issues in relation to a PBL problem [49]. One of the main issues in PBL is the role of the tutor. The tutor guides the tutorial group through the learning process, encourages students to attain a deeper level of understanding and ensures that all students are actively involved in the group processes [50]. New attitudes and skills are required of the teaching faculty so that they are willing and competent to allow students to take an active role in guiding their own learning [31]. In this light, PBL requires the faculty to evolve from being the "Sage-on-the-stage" to "Guide-by-theside". The goal of the tutor is not to feed facts and information, but to develop reasoning skills. An important goal of PBL is to improve reasoning and problem solving skills of students. The most common area of enquiry relating to desirable PBL tutor characteristics concerns the issue of whether or not the tutor should be an expert in the content matter related to the problem under study. Two studies have examined the effectiveness of student learning with different types of tutors [51,52]. Like a good coach, a tutor needs enough command of whatever the learners are working on to recognize when and where they need help the most [52]. Content experts, however who do not understand the importance of being a guide and facilitator rather than a purveyor of information, can be tempted to give answers rather than help, learners find their own answers. In such cases, the content expert may be prone to reverting to a lecture mode, destroying the PBL R2=0.812, p=0.001 process. So the ideal tutor should be an expert in both learning content and learning process, which is rare to find among human tutors. The tutor intervenes to as small an extent as possible, posing open-ended questions and giving hints only when the group appears to be getting stuck or off track. In this way, the tutor avoids making the students dependent on him for their learning [52].
In our present study, more than half of our participants (53.1%) mentioned that PBL improved their problem solving skills. This is in agreement with Tsou et al. [53]. Tsou et al. [53] stated that students in their study claimed that they were more active in learning and had better learning skills and confidence in self-direct learning as compared with students from lecture-based curriculum. This is also in agreement with Morales-Mann and Kaitell [54] who reported that PBL produced clear benefits for students such as increased autonomous learning, critical thinking, problem solving and communication. It has been also mentioned that students were of the opinion that refining their problem solving capabilities which helps in enhancing the communication skills and interpersonal relations [55,56]. Woltering et al. [37], have found that motivation; subjective learning gains and satisfaction were achieved higher by the blended PBL students compared with the students learning by standard PBL.
In the present study, 48.3% of the participants agreed that PBL enhanced their ability to find the information needed using internet and library. Similar findings reported by Barman [57] in relation to the perception on learning resources: 50.9% of students were found to have felt that enough learning resources were available in the faculty for PBL sessions. In this study the learning resources obtained were mostly from the library and internet. The findings may reflect that the faculty need to review and upgrade the learning resources, review and renew the PBL triggers, providing guidelines for searching resource materials and brief the students and facilitators about the philosophy and principles of PBL. Students learn most effectively when using a variety of information resources. Therefore, provision of adequate resources meeting the needs of different learning styles is important [31,58,59]. The extensiveness of different learning resources used is also an indicator of students self directed learning skill. The diversity of information sources influences the breadth and depth of discussion [60]. Learners are challenged to the look for the relevant resources through a variety of investigative means including the search for books and online material. By doing this, students become able to acquire an integrative body of knowledge as well as acquire skills of problemsolving, self-directed learning, necessary for personal growth and development [61].

Conclusion
This study shows that the acceptance of PBL among the surveyed medical students is low. The findings of the study suggest that more rigorous and practical training should be given to tutors and students to understand the philosophy of PBL. A combination of teacher center lectures with the PBL sessions at the beginning of the program and then progressively moving towards more student-driven PBL may possibly be a way to make students more receptive to this new learning method.