440 MEDICAL EDUCATION 1997, 31, 440±447
Learning in a problem-based medical curriculum: students'
conceptions
Julie A Hughes Caplow,1 Joe F Donaldson,1 CarolAnne Kardash2 & Micheal Hosokawa3
1
Educational Leadership & Policy Analysis;
2
Educational and Counseling Psychology (Kardash) and
3
School of Medicine, University of Missouri-Columbia, Columbia, MO, USA
SUMMARY
The purpose of this study was to examine students'
conception of their learning in a problem-based learning
medical curriculum. A multiple case study design was
used with two units of analyses: two PBL lab groups; and
15 individual students within each lab group. Data col-
lected included weekly journals by students, video-tapes
of PBL sessions, focus group interviews with students,
two open-ended questionnaires completed by students,
and interviews with the PBL tutors. Three thematic
categories of students' conceptions of their learning
emerged: (1) awareness of PBL goals and expectations;
(2) ef®ciency and expertise; and (3) the role of the tutor.
Keywords
*Attitude; evaluation studies; *knowledge; *problem-
based learning; *students, medical
INTRODUCTION
Problem-based learning (PBL) is an instructional in-
novation in medical education ®rst adopted by
McMaster University in the mid-1960s. Since then
approximately 60 medical schools worldwide (22 in
North America) have implemented, at least in part, a
problem-based learning approach in their curricula
(Norman & Schmidt 1992). Since its initiation at
McMaster University, much research and evaluation
has been conducted on this curricular and instructional
innovation. For the most part, this research has ad-
dressed programme evaluation issues, compared stu-
dents' achievement on medical boards and clinical
performance assessments in conventional versus prob-
lem-based curricula, and examined organizational and
administrative issues (e.g. cost, types of tutors, etc.).
One area of research that has been neglected is the
underlying learning processes of PBL that produce the
Correspondence: Dr Julie A Hughes Caplow, Educational Leadership & Policy Analysis, 211 Hill Hall, University of Missouri-Columbia,
Columbia, MO 65211, USA
Ó 1997 Blackwell Science Ltd
effects that have been reported on achievement, clinical
behaviour, use of informational resources, and study
patterns. The purpose of this study was to examine
students' conceptions of their learning in a PBL cur-
riculum. Speci®cally, the following research questions
were investigated: (1) What learning processes and
strategies are employed and experienced by students in
a PBL context? (2) What dif®culties in implementing
learning strategies are being experienced by students?;
and (3) Are students satis®ed with the PBL format?
Goals of PBL
Albanese & Mitchell (1993) described PBL as ``as in-
structional method characterized by the use of patient
problems as a context for students to learn problem-
solving skills and acquire knowledge about the basic
and clinical sciences''. In their view, a central feature of
PBL that distinguishes it from other problem-oriented
instructional approaches (e.g. the case method) is the
presentation of a problem prior to students having
learned the basic science or clinical information needed
to solve the problem. Hence, the foci of learning in this
context are on the activation of prior knowledge learned
in undergraduate basic science courses and the acqui-
sition of new knowledge to address a problem rather
than simply the application of prior knowledge to that
problem.
Barrows (1986) articulated four major educational
goals of PBL. The ®rst is the structuring of knowledge
for use in clinical contexts. Inherent in this goal is the
notion that retention, recall and application of new
knowledge are enhanced as knowledge of the basic and
clinical sciences are acquired in a problem context. A
second goal of PBL is the development of clinical rea-
soning processes that include hypothesis generation,
inquiry, data analysis, problem synthesis, and decision-
making. The third goal is the development of self-di-
rected learning skills deemed critical for doctors as they
confront an expanding knowledge base and unusual or
441 ME D I C A L ED U C AT I ON 1997, 31, 440±447
unique problems in practice. The ®nal goal is to enhance
intrinsic motivation for learning. This goal is based on
the assumption that the opportunity for medical stu-
dents to work with and solve actual medical problems
early in their education is inherently motivating.
Instructional format of PBL
Problem-based learning occurs in small groups with six
to eight students and a tutor, whose role is group fa-
cilitator rather than expert or purveyor of knowledge.
There are ®ve basic elements to the PBL instructional
format: (1) encounter with the problem; (2) free in-
quiry±questioning, brainstorming and recall of know-
ledge relevant to the problem, and identi®cation of
what needs to be known to fully understand the prob-
lem; (3) identi®cation of learning issues; (4) presenta-
tion of knowledge derived from independent investi-
gation of learning issues; and (5) problem solving.
A central organizing principle of PBL is the use of
small tutorial groups. This instructional format is
comparable to the co-operative learning group method
in which learners co-operate in framing problems,
gathering resources and elaborating knowledge through
discussion, teaching peers, evaluating information and
sources, and answering questions (Bossert 1988;
Albanese & Mitchell 1993). Research has generally
demonstrated that this method promotes motivation to
learn, self-esteem, and a variety of cognitive abilities,
including recall, retention and problem-solving (Boss-
ert 1988).
A central argument for a PBL curriculum in medical
education is that it develops students' problem-solving
skills. This argument centres on two issues: (1) helping
students rehearse, early in their training, cognitive skills
that are associated with clinical reasoning; and (2) de-
veloping thinking processes characteristic of ``expert''
medical practice. As such, PBL responds to the im-
portance many professions are increasingly attributing
to linking early professional preparation to the contexts
and processes of professional practice (Baskett &
Marsick 1992; Curry et al. 1993).
Relevant research
One of the challenges in research on the medical school
PBL model is its multiple and overlapping theoretical
foundations. These foundations include: (1) informa-
tion processing theories, particularly those associated
with activation of prior knowledge, knowledge elabo-
ration and encoding speci®city; (2) constructivist per-
spectives of learning in which learners make meaning
and generate personal knowledge, in this case in rela-
tion to the problematic situations encountered in PBL;
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
and (3) co-operative learning. To date, research ques-
tions posed in many studies of PBL are comparable to
those that have been addressed in studying co-operative
learning in that they address the learning outcomes of
the method. What they do not address are the
``... processes that mediate and moderate the relation-
ship between [the method]... and the various [learning
process] outcomes'' (Bossert 1988).
Research on the learning outcomes of PBL appears
to be somewhat comparable, albeit more mixed, than
those found for co-operative learning. For example,
Newble & Clarke (1986) found that PBL promoted a
deep approach to study characterized by interest in the
subject matter, vocational relevance, and search for
meaning. Rankin (1992) compared the use of human
and non-human resources (e.g. the library) by students
enrolled in PBL and conventional curricula, and found
that students in a PBL curriculum used resources that
supported independent, self-directed learning processes
more than students in a conventional curriculum.
Results of studies on the thought processes promoted
by PBL have been mixed, with ®ndings such as: no
difference in diagnostic reasoning skills between stu-
dents enrolled in PBL versus conventional curricula
(Albanese & Mitchell 1993); greater recall of basic
science information among PBL students than students
in a conventional curriculum, but also greater inclusion
of irrelevant material in case analyses (Claesson &
Boshuizen 1985); and more backward reasoning links,
errors and lack of decisiveness among PBL students
(Patel et al. 1991).
More recently, researchers have begun to examine
elements of the process of PBL. Kennedy & Wilkerson
(1993) studied the types of topics selected for group
discussion and independent study in PBL. They ana-
lysed topics generated by three cases presented to the
students. Each case could have generated discussions of
basic science, clinical or psychosocial issues. Further-
more, they sought to determine whether or not the
same case would generate differential topics across PBL
groups. They found that there was consistency across
groups in the topics chosen for discussion, with basic
science issues dominating. Clinical topics were gener-
ally raised only in relation to features of a speci®c dis-
ease or treatment. Psychosocial issues were discussed
only brie¯y and not chosen as learning issues. Kennedy
& Wilkerson concluded that students may focus on
basic science issues based on general contextual cues,
such as the goals of the speci®c course and the weekly
schedule, as well as the speci®c details of the case.
Bernstein et al. (1995) used a pre- and post-survey
to assess shifts in students' attitudes after a 5-week
PBL component. The pre-test survey indicated that
442 ME D I C A L ED U C AT I ON 1997, 31, 440±447
students were concerned that learning in the PBL
format would result in knowledge gaps, reinforcement
of wrong information, and inef®cient use of time.
However, students also anticipated that PBL would be
more stimulating and enjoyable than traditional
methods, and that it would teach them how to ``learn''
rather than ``memorize.'' Although concerns about
acquiring the needed knowledge base continued to be
expressed by students on the post-survey, they noted
that PBL helped develop communication skills that are
essential for a good doctor, increased retention due to
opportunities for discussion, and facilitated thinking
about the material rather than simply memorizing it.
Further, students indicated that the PBL format forced
them to be self-directed in learning about the subject
and issues.
METHOD
A PBL curriculum was implemented in the autumn
of 1993 at a medical school of a Midwestern Re-
search I university. Students admitted to the medical
school in the autumn of 1993 …n ˆ 96† were assigned
to PBL lab groups …n ˆ 8† arranged in four blocks
over the course of the academic year. Each block was
8 weeks in duration, therefore students were in four
different PBL groups during the 1993±94 academic
year. Two of the authors participated in a PBL tutor
workshop in June 1993 and one was also a tutor for a
PBL lab group during the third block. Participation
in the tutor training and the PBL lab was done so
that the researchers would have an in-depth under-
standing of the procedures and processes of the PBL
curriculum.
Students met in the PBL labs three times per week,
2 hours for the ®rst session and 3 hours for the second
and third sessions. One patient case was presented to
the labs each week. During the ®rst session of each
week, students reviewed and discussed the case and
then generated learning issues for independent investi-
gation. During the second session, the students re-
ported on the information they obtained relevant to
their learning issues and this information was applied to
the case. In some instances, the case was solved during
this second session; however, in other instances addi-
tional learning issues were determined for the third
session. At the conclusion of the second session, case-
related objectives were distributed to the students.
These objectives were developed by case writers and
provided the basis for examinations at the end of the
block. During the ®nal session, students reviewed the
facts of the case, relevant information derived from
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
independent research on learning issues, case objec-
tives, and the case solution.
A multiple case study design (Yin 1984) was used for
this research. There were two units of analyses: (1) two
PBL lab groups; and (2) individual students within
each PBL lab group. Two PBL lab groups in block
four, with a total of 16 students, were asked to parti-
cipate in the study. All but one student agreed, result-
ing in 15 individual cases. Data were collected through
(1) weekly journaling by nine of the 15 students in re-
sponse to speci®c questions on their approaches to
learning; (2) video-tapes of ®ve PBL sessions per group;
(3) two focus-group interview sessions …n ˆ 15† with
questions based on an analysis of behaviour and pro-
cesses observed in the video-tapes; (4) two open-ended
questionnaires, one regarding satisfaction with PBL
that was administered at the beginning of the block
…n ˆ 14† and the other regarding perspectives of
learning and the PBL format which was administered
during the second focus group interview sessions
…n ˆ 15†; and (5) in-depth interviews with the tutors of
both PBL labs.
In keeping with the requirements of qualitative re-
search, inductive data analysis strategies were em-
ployed, with themes and categories emerging from the
body of data, rather than being entirely decided upon
by the researchers prior to data collection. Inductive
analysis relies upon the organization of the data and the
analysis of the content in a search for themes and pat-
terns. It is generally agreed (Miles & Huberman 1984;
Lincoln & Guba 1985; Patton 1987; Merriam 1988)
that the researcher attempts to discover recurring pat-
terns in the data that allow categories to be constructed.
This categorization process, which simpli®es and or-
ganizes complex data into a meaningful form, is based
on content analysis in which coherent and important
examples, themes and patterns are identi®ed (Patton
1987). Data collection and analysis, therefore, were
conducted simultaneously.
RESULTS
The purpose of this study was to examine students'
conceptions of learning as well as their overall satis-
faction with PBL. Analysis of the data collected
through open-ended questionnaires, individual student
journals, actual and video-taped observations of PBL
sessions, and focus group interviews revealed three
major thematic categories of students' conceptions of
their learning in the PBL format: (1) awareness and
expectations; (2) ef®ciency and expertise; and (3) the
role of the tutor. In this section, students' assessments
443 ME D I C A L ED U C AT I ON 1997, 31, 440±447
of their overall satisfaction with PBL and their satis-
faction with speci®c instructional/learning strategies
used in PBL are reported followed by an explanation of
the three thematic categories.
Satisfaction with PBL
Overall, the students in this study were satis®ed with
their PBL experiences. They were asked about their
satisfaction with PBL as contributing to their learning
at the beginning of the block and then again at the end.
Fourteen of the 15 students responded to the initial
question and all 15 responded to the question pre-
sented at the end of the block. At the beginning of the
block, nine students indicated that they were ``very
satis®ed'', four were ``somewhat satis®ed'', and one
indicated that he was ``not satis®ed''. The students who
cited that they were ``very satis®ed'' identi®ed the fol-
lowing aspects of PBL as contributing to their learning:
(1) the ability to see the relevance of material being
learned …n ˆ 7†;
(2) learning the clinical aspects of medicine …n ˆ 4†;
(3) the interactions between students and the chance
to be the ``teacher'' …n ˆ 3†;
(4) in-depth researching of concepts related to a clin-
ical case …n ˆ 3†;
(5) the opportunity to do independent research
…n ˆ 5†;
(6) group discussion …n ˆ 6†;
(7) a more interesting way to learn because of the op-
portunity to integrate and apply basic science issues
to patient situations …n ˆ 4†; and
(8) the opportunity to take an active role which helped
to maintain interest …n ˆ 3†.
Those that were ``somewhat satis®ed'' indicated
similar aspects as contributing to their learning; such as
the use of cases that give a clinical picture of basic
sciences and reinforces basic science concepts, inde-
pendent research, learning from peers, and learning
diagnostic skills. The one student who was not satis®ed
indicated that looking up information in references was
an aspect of PBL that contributed to his learning.
At the end of the block, students were asked again
about their overall satisfaction with PBL. In addition,
they were asked to respond to a series of questions re-
garding their level of satisfaction with speci®c elements
of the PBL format. Twelve students indicated that they
were ``very satis®ed'' with the PBL format, two were
``somewhat satis®ed'', and one continued to be ``not
satis®ed''.
Students were also asked to respond to two open-
ended questions that asked them to identify aspects of
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
PBL that both contributed to their learning and was a
hindrance to their learning. The majority of those
aspects cited corresponded to the major instructional/
learning strategies of PBL (e.g. small group tutorials,
use of tutors, patient cases, etc). The aspects identi®ed
with the greatest frequency as contributing to learning
were: (1) the tutor …n ˆ 10†; (2) the group …n ˆ 9†; (3)
course materials and cases …n ˆ 8†; and (4) indepen-
dent research …n ˆ 6†. Those identi®ed as hindering
learning with greatest frequency were: (1) the tutor
…n ˆ 6†; (2) some aspect of the group …n ˆ 4†; (3) lack
of prior knowledge …n ˆ 8†; and (4) the sequence of
topic dif®culty …n ˆ 3†.
Theme 1: Awareness of PBL goals
and expectations
As mentioned earlier, PBL has four major goals or ex-
pectations for learning: (1) the structuring of know-
ledge for use in clinical contexts; (2) the development
of clinical reasoning skills; (3) the development of self-
directed learning skills; and (4) the enhancement of
intrinsic motivation. Students' general awareness of the
expectations for learning within a PBL format was de-
rived from three data sources: (1) the focus group in-
terview responses; (2) responses to an open-ended
question on expectations for learning (``What do you
think are the expectations for your learning in PBL?'');
and (3) weekly journal responses. Students seemed to
be most aware of two of the four expectations for
learning using a PBL approach: the structuring of
knowledge for use in clinical contexts; and the devel-
opment of self-directed learning skills. Their awareness
of the ®rst expectation was re¯ected in overt comments
about how PBL helped them to acquire, retain, elabo-
rate and apply basic science knowledge, whereas ex-
pectations about self-directed learning were imbedded
in comments about the process. Only one student
noted that the development of clinical reasoning skills
was an expectation for learning. And, although students
discussed how their experience in PBL motivated them
to learn more about issues and become more self-di-
rected, no-one cited increased motivation as an actual
expectation for their learning.
A central expectation of PBL is that grounding the
acquisition of basic science information in a patient
case context facilitates recall and retention (Norman &
Schmidt 1992). Generally, students seemed aware of
this expectation citing three instructional strategies of
PBL: (1) the use of patient cases; (2) group discussions;
and (3) independent research, when discussing how
they were able to establish the relevance of basic science
information, understand rather than just memorize the
444 ME D I C A L ED U C AT I ON 1997, 31, 440±447
material, and retain the basic science information. For
example, students commented:
`Knowledge and facts attained while working on an
actual case is retained longer. I felt that because I
have looked up the information on my own and also
have discussed the material with classmates.'
`The participation of other group members reaf®rms
my hypotheses or explanation. I personally remem-
ber things better in the context of case discussion.'
`The clinical associations in PBL stimulates active
learning and improves long-term retention of facts'.
Students' appreciation for PBL's ability to facilitate
the acquisition of basic science information was medi-
ated by concerns about end-of block examinations. At
the middle of each case (end of the second session),
students are given a list of learning objectives for the
case which provide the basis for end of block examin-
ations. Therefore, the students were constantly aware
of the need to acquire information as de®ned by the
objectives. Often, the learning issues identi®ed via the
case did match these objectives. Students were aware
that they had to depend on other students to provide
accurate information needed for end-of-block exams
(e.g. `It's tough to know what's important on the test')
and/or that a mismatch could occur between learning
issues and case objectives (e.g. `It's dif®cult to trust
other students to provide the needed information').
A second expectation for learning within a PBL for-
mat is the development of self-directed learning skills.
Three instructional strategies used in PBL ± (1) inde-
pendent investigation of learning issues; (2) ``teaching''
the group; and (3) group discussion ± were discussed by
students in relation to the development of self-directed
learning skills. This awareness of the expectation that
they develop self-directed learning skills were re¯ected
in the following comments:
`The best part has been learning to use the library
and faculty resources in independent learning.'
`I enjoy becoming an ``expert'' on a topic, reporting
back to the group and having other students criti-
cally evaluate my information.'
`Group discussions and presentations [of learning
issues] helps looking at information from different
viewpoints.'
`Group discussions provide a good time to clear up
small questions and misunderstandings.'
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
Theme 2: Ef®ciency and expertise
As data emerged from informal observations of the
groups and their discussions prior to and during video-
taping, initial journal responses, and responses to the
®rst focus group interviews, it became apparent that
issues related to the use of personal time were of im-
portance to the students. This led to the inclusion of
questions for the journals, focus group interviews, and
focus group questionnaires regarding preferred ways to
investigate learning issues. At the beginning of the
block, students agreed to divide the identi®ed learning
issues for independent investigation rather than having
all students investigating all learning issues. Each stu-
dent prepared handouts for the others on the learning
issues that she or he investigated. In general, this was
the approach used in prior blocks and students seemed
satis®ed, despite concerns about the reliance on peers
for accurate and in-depth information.
A central issue for students regarding the ``dividing-
up'' of learning issues was balancing the ef®cient use of
their time against developing expertise on speci®c
learning issues. A second issue was the reliance on other
students to provide needed and accurate information.
This did not seem to be a major concern as students
indicated, in general, that the delegation of responsi-
bility to one's peers engendered by the small groups
resulted in group norms and pressures to thoroughly
and accurately research learning issues, and to provide
well-prepared handouts as resources. Nonetheless,
students appeared to struggle to balance the opportu-
nity to develop expertise on one topic within limited
time frames against: (1) the recognition that they were
accountable for all of the information identi®ed in the
learning issues and objectives presented with the case;
and/or (2) personal preferences for developing a broad
knowledge base on their own. This struggle was evi-
denced by the following comments:
`Investigating one learning issue allows in-depth
knowledge, the other way [investigating all learning
issues] does not allow me to become expert on a
subject.'
`I learn more about the case in general and the sci-
ence intended to be learned through the case when I
study multiple issues rather than just one.'
`I learn more broad background of the science being
covered and build a knowledge base of understand-
ing which is more pro®table in the long run rather
than being an expert in one speci®c topic that may or
may not be important.'
445 ME D I C A L ED U C AT I ON 1997, 31, 440±447
`I store handouts in a notebook until test time, in-
vestigating each issue on my own would be too time
consuming.'
`It's too time consuming to investigate all issues.'
Theme 3: Role of the tutor
As mentioned above, students indicated almost uni-
formly that the tutor role was a critical factor in their
learning. This ®nding was underscored by 14 of the 15
students indicating that a tutor was essential to PBL,
with several noting that PBL would be chaotic or di-
sastrous without one. Although students felt that the
tutor was a critical factor, they differed in their con-
ceptualizations and expectations of the role. Based on
students' responses to open-ended questions, focus
group interviews and journal entries, three content roles
for tutors were identi®ed: (1) facilitative expertise ± the
tutor's knowledge of, and ability to facilitate, group
work; (2) knowledge expertise ± the basic science or
medical craft knowledge possessed by tutors; and (3)
clinical reasoning expertise ± tutor knowledge of med-
ical problem-solving and/or critical reasoning skills.
Students discussed expectations of tutors related to the
®rst two content roles of tutors most often, yet there
was suf®cient mention of clinical reasoning expertise for
it to be included as a distinct role category.
An interesting paradox in the comments of several
students was the distinction they made between their
individual learning and group functioning as these re-
lated to tutor role. This distinction was re¯ected in
students' comments about a process dimension of the
tutor role. This process dimension was de®ned by the
researchers as the extent to which tutors used the in-
herent power they possessed as tutors. This power was
derived from the authority of their formal positions as
staff members, as evaluators of students' performance
(25% of student grades are assigned by the tutors), and
from the knowledge authority in the basic sciences or
medicine. The perceived exercise of power manifested
itself in several ways in the student data. Comments
were made about the extent of control exercised by
tutors, the extent to which the tutors participated in
group dynamics, the development of dependency rela-
tionships with tutors, students performing to tutors'
expectations, and tutors directing the group and its
work rather than serving as non-directive guides.
Therefore, students' perspectives on the tutor role
seemed to re¯ect complex, and often seemingly con-
tradictory, expectations for the tutor role when the in-
teractions between multiple role contents and the
power dimension were considered. For example, many
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
students indicated that, to optimize learning in the
group context, they preferred tutors who were not di-
rective in their roles as facilitators, minimally chal-
lenging and non-judgmental in their roles as knowledge
experts, and not directive in their roles as coaches or
models of clinical reasoning. Yet these students also
indicated that, in their experience, the tutors who were
moderately to highly directive, judgmental and con-
trolling in their roles challenged them to be better
prepared for group sessions ± thereby contributing to
the depth and breadth of their individual learning.
DISCUSSION
Overall, the students who participated in this study
indicated that they were satis®ed with PBL. They in-
dicated that the PBL format facilitated their learning of
basic science information by enabling them to establish
the relevance of new learning and by providing them
with the opportunity to integrate and apply basic sci-
ence concepts in the context of patient cases. This
®nding supports the research of Bernstein et al. (1995)
who found that students expressed more favourable
attitudes about PBL after experiencing it, speci®cally
that they felt PBL enhanced retention and thinking
about the material rather than just memorizing it. In
addition, the students indicated that PBL fosters in-
dependent and self-directed learning. Based on the data
collected, self-directed learning and motivation may be
related. Students indicated a sense of obligation to
pursue in-depth knowledge about their learning issues
and objectives for two major reasons: (1) to expand
their own knowledge base; and (2) to ful®l their re-
sponsibilities to other group members by teaching them
the material. Hence, the motivation was both intrinsic
(to increase knowledge base) and extrinsic (obligation
to other group members).
Data analysis did not reveal an overt awareness by
students about development of clinical reasoning skills.
Coles (1990) posited that the clinical reasoning argu-
ments for PBL ``... are in part naive, largely inaccurate,
and overall misleading educationally''. Instead, he
proposed that a more competent theory for PBL is a
contextual-learning theory, a theory that focuses on
elaborated learning and knowledge and which is sup-
ported by the results of this study. The theory suggests
that three elements are essential to PBL instruction:
(1) the clinical context of cases/problems that provide
an appropriate context for learning; (2) the presentation
of appropriately structured and organized information
(although he questions whether having students at-
tempt to discover this structure is as ¯awed as the
446 ME D I C A L ED U C AT I ON 1997, 31, 440±447
conventional lecture and textbook system); and (3) an
active learning process. Coles argued that this model is
more congruent with PBL practice than models pro-
posed in earlier prescriptive literature. In his opinion,
PBL has only fortuitously embodied the problem-
solving/reasoning model rather than being primarily
de®ned and supported by it.
The results of this study indicate that students'
awareness of expectations for learning related to the
major goals of PBL are most clearly articulated when
instructional strategies are directly linked to the goals.
Students appeared to be able to re¯ect on and ex-
amine their learning strategies when there was a clear
association between the PBL goals and instructional
strategies employed to accomplish these goals. There
are four major instructional strategies used in a PBL
format: (1) the use of patient cases; (2) a co-operative
group format for discussion and problem solving; (3)
independent research by students of identi®ed learning
issues; and (3) ``teaching'' by students. In this study,
students referred to all these strategies when discuss-
ing the two expectations of PBL about which they
seemed most aware: (1) structuring of knowledge for
use in a clinical context; and (2) the development of
self-directed learning skills. However, the other two
major goals of PBL (developing clinical reasoning
skills and increasing motivation) may be implicit to the
process and, therefore, not as well articulated or linked
to speci®c instructional strategies used in PBL. Al-
though increased motivation was cited by many stu-
dents as part of their experience with PBL, it was not
discussed in the context of speci®c instructional/
learning strategies and was mentioned only in general
and personal terms. This may indicate that students
are aware that motivation is a key goal in PBL but are
unclear about what aspect of PBL leads to increased
motivation.
IMPLICATIONS
There are two major implications based on the results
of this study. First, implementation of a curriculum
innovation, such as PBL, requires overt attempts to
socialize students to the goals of PBL. This may be
accomplished, in part, by articulating the relationship
between speci®c instructional strategies used to ac-
complish speci®c PBL goals. When the expectations are
tacit, incomplete socialization may result. Students'
experiences with the various instructional strategies of
PBL (e.g. use of patient cases as an impetus for learn-
ing, identi®cation of learning issues for independent
investigation, co-operative group format) have the po-
Students' conceptions of learning in PBL J A Hughes Caplow et al.
Ó 1997 Blackwell Science Ltd
tential for generating normative expectations from
which students re¯ect on their own learning. Our
®ndings indicate that students re¯ected on aspects of
their learning where the instructional strategy was
clearly linked to a goal of PBL. For example, they were
able to discuss how they acquired and retained infor-
mation in the context of a patient case. Conversely,
students' responses re¯ected either lack of clarity or
ambiguity in relation to the major goals of PBL for
which there are tacit or unde®ned links to instructional
strategies. For example, there is no speci®c strategy to
foster motivation; rather, it is assumed that students
will be intrinsically motivated by learning in the context
of patient cases. In addition, students showed little re-
¯ection on how or if reasoning processes were being
developed. This may be due to, as Coles (1990)
pointed out, ambiguity about the instructional strate-
gies that are linked to the goal of development of rea-
soning processes.
Although the development of clinical reasoning pro-
cesses is not overtly associated with a speci®c instruc-
tional strategy, it may be associated implicitly with the
role of the tutor. Research on the tutor role in PBL has
focused almost exclusively on differences in student
outcomes, satisfaction and verbal interactions in rela-
tion to tutor behaviour and tutor knowledge expertise,
which has been de®ned primarily in terms of basic
science expertise (Moust et al. 1989; Silver & Wilkerson
1991; Davis et al. 1992). However, some studies (Gij-
selaers & Schmidt 1990; Schmidt et al. 1993) have
highlighted the importance of tutor facilitation exper-
tise in helping individuals and groups direct their own
work, and monitor and criticize their own thinking.
In this study, students identi®ed tutors as being both
a help and a hindrance to their learning and revealed
diverse experiences and variability in tutor expecta-
tions. Indeed, the tutors of the two PBL lab groups
identi®ed different de®nitions and roles for tutors. One
tutor maintained that a signi®cant role of the tutor was
to help students develop reasoning skills by modelling
those skills in his own approach to the case and by
being directive in leading students through steps in the
reasoning process in their analyses of the patient case.
The second tutor maintained that it was beyond the
scope of the tutor to foster clinical reasoning in the PBL
labs; rather, reasoning skills were to be developed in the
context of clinical experiences which occurred later in
medical education. The results of this study suggest
that further research is needed to re®ne and identify
more subtle distinctions about tutor expertise and role
process dimensions, particularly in relation to the de-
velopment of students' reasoning processes.
447 M E D I C A L ED U C AT I ON 1997, 31, 440±447
CONCLUSION
The results of this study have raised more questions
than answers. Yet, by employing a qualitative approach,
concepts and relationships between these concepts have
been posited, issues have been identi®ed, and further
topics for research have been suggested. Research on
PBL instruction differs little in its history and focus
from that conducted on collaborative group learning
(Bossert 1988). Most research has focused on out-
comes, leaving the PBL process and the mediating
variables within the process relatively underexplored.
More research is needed on process dimensions, such
as the socialization of students to an educational in-
novation and mediating variables such as tutor behav-
iours and roles. Such efforts are required to add sub-
stance to the debate about PBL's theoretical foundation
and to sharpen our understanding of the processes and
dynamics embedded within the ``black box'' called
Problem-Based Learning.
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Received 29 October 1996; accepted for publication 18 March 1997