2013; 35: 95–100

TWELVE TIPS

Twelve tips on how to survive PBL as a medical

student
E. BATE & D.C.M. TAYLOR
The University of Liverpool School of Medicine, UK

Abstract
Background: Starting medical school can be both exciting and daunting. This is particularly the case when the style of learning is
different from that which has been experienced previously. For many students, their first experience of learning through a
problem-based learning (PBL) approach is when they commence their medical student programme.
Aim: This article provides 12 tips on how to survive PBL as a medical student.
Methods: The tips have been based on the authors’ experience of PBL and the current literature evidence base. A chronological
order was used for the tips to guide the reader, whether student or PBL facilitator, through tips for the various stages of the PBL
process.
Results: These 12 tips provide students and PBL facilitators with 12 practical tips to help them to realise the learning process and
rationale for PBL. The tips commence with surviving the initial PBL sessions and continue through the process, finishing with the
use of PBL in the clinical setting where the written scenarios are replaced by patient case histories.
Conclusion: Using a PBL approach facilitates the learning of clinical and science knowledge in context through clinical scenarios,
whilst working and learning together as a group. It is envisaged that these tips will be beneficial for PBL facilitators working with
students that are new to PBL, and for the PBL students themselves.

Introduction Although learning through PBL can be challenging,

especially initially, it is good preparation for the continuous
Problem-based learning (PBL) is incorporated, to a greater or self-motivated life-long learning, required for a career in
lesser extent, within the curriculum of many medical schools medicine, and it is hoped that these 12 tips will help both PBL
world-wide (Taylor & Miflin 2008). The original theory facilitators working with new students and students them-
formulated by Barrows, was implemented in McMaster selves, to learn to learn through PBL.
University medical school in 1969 (Spaulding 1969). The
‘McMaster philosophy’ fostered the PBL approach whereby
students work in small groups on a health problem, identifying Tip 1
their own educational needs and being responsible for the
acquisition of the knowledge required to understand the Firstly, try not to panic about PBL
scenario (Neufeld & Barrows 1974).
As mentioned above, the transition to PBL may be a daunting
The rationale for the use of PBL and andragogy in medical
prospect, particularly if previous study has taken the form of
education has been extensively studied, and is grounded in
predominantly didactic, lecture-based teaching. Some students
cognitive psychology (Schmidt 1993). The use of clinical
(and tutors) find this transition stressful; with PBL becoming a
scenarios, promotes active learning, building on epistemic
‘threshold concept’ or an area of ‘troublesome knowledge’ that
curiosity (Maudsley 1999). Activating the prior knowledge,
13

prevents commitment to PBL (Savin-Baden 2006; Kamei et al.

drawing on previous experiences, helps understand the
2012). To help overcome this, it is important to (Land et al. 2005):
20

scenario, and aids the integration of future learning within

this prior knowledge scaffold (Dewey 1938). This facilitates
deep learning in context (situated learning) (Durning &
Artino 2011), which is associated with subsequent improved
application and recall of the knowledge (Harris & Alexander
1998). PBL is a form of collaborative learning whereby PBL
groups work together throughout the whole process.
Collaborative learning has been shown to promote student
motivation to learn, reasoning skills, elaboration and deep
learning (see Bossert 1988, for an overview; also Dolmans
et al. 2005).
(a) Understand the rationale for PBL.
(b) Tolerate the initial uncertainty and persevere, engaging
with the PBL process.
(c) Have confidence in the system; PBL has been used since
1969, with increasing evidence demonstrating that
students graduating from PBL curricula are more pre-
pared for work as a doctor (Schmidt et al. 2006;
Watmough et al. 2006).
(d) Be patient and realise that different members of the PBL
group will experience PBL as a threshold concept to a

Correspondence: Dr. Emily Bate, School of Medicine, The University of Liverpool, Liverpool, L69 3GE, UK. Tel: 0151 794 8747; fax: 0151 795 4369;
email: e.bate@liv.ac.uk
ISSN 0142–159X print/ISSN 1466–187X online/13/020095–6 ß 2013 Informa UK Ltd. 95
DOI: 10.3109/0142159X.2013.759198
E. Bate & D. C. M. Taylor
variable extent, possibly dependent on their previous
exposures or pre-conceived understanding ( pre-liminal
variation) (Meyer & Land 2005).
Once the initial stage of liminality associated with PBL has
been left, learning through PBL should be an exciting journey,
whereby clinical scenarios are used to prompt the identifica-
tion of knowledge gaps and to guide learning in context.
Tip 2
Work with your PBL group
PBL group sessions are a core component of a PBL course and
typically a group will work together for an extended period of
time. Take the trouble to get to know the group; perhaps
consider organising a group meal or event. This helps the
group to move into the ‘performing’ stage of group develop-
ment (Tuckman & Jensen 1977).
The PBL group should not just be a study group, but should
develop into a ‘community of practice’ within which the group
members work together to achieve and learn the necessary
information required to understand the clinical scenarios as a
group of medical students, and eventually, progress to become
junior doctors (Lave & Wenger 1991).
As mentioned earlier, collaborative learning is an important
component of PBL because understanding and meaning are
socially constructed through collaboration and discussion with
others (Michaelsen et al. 2002).
Within the PBL sessions, ensure that concepts and learning
are discussed, elaborating on ideas as a group. The importance
of social interaction for learning has long been established;
Piaget described the effect of social environment on intellec-
tual development through the stimulation of learning, and
Vygotsky described the zone of proximal development as the
difference between an individual’s knowledge level and the
development level realised through interaction with others
(Vygotsky 1978; Palincsar 1998; Piaget 2001). Visschers-Pleijers
and colleagues analysed the group interactions during the PBL
sessions, aiming to learn more about the collaborative learning
processes occurring (2006). This study demonstrated that 63%
of the group time was spent on cumulative reasoning, whilst
only 10% was spent on asking explanatory questions of each
other, and 7% on handling conflict about the knowledge
(Visschers-Pleijers et al. 2006). It is at the points of cognitive
conflict or discourse that learning is thought to be occurring.
Consequently, it is important to try to ask ‘critical questions’ of
each other and to counter statements or theories to optimise
collaborative learning within the PBL sessions (Visschers-
Pleijers et al. 2006).
Tip 3
Ensure that the group activates prior knowledge
before forming the learning objectives
This is easily (and, in our experience, frequently) omitted, but
it is an essential step. Prior knowledge forms the foundation
for the construction and transformation of new knowledge
(Duffy & Cunningham 1996). Taking the time to actually
96
articulate prior knowledge aids the processing of new
information, and the subsequent retention and recall of
the information being learnt (Norman & Schmidt 1992).
For example, when working on the scenario about reproduc-
tion, take the time to discuss and draw the processes of
meiosis and mitosis recalled from an earlier educational
experience. This demonstrates how much is already known
by the group and enables the identification of the learning
objectives required, such as; how meiosis occurs in gamete
formation and how this differs between males and females.
If prior knowledge is not activated most groups form large
non-specific learning objectives (which are difficult for the
individuals to interpret), and the recall of any new information
learnt may be jeopardised (Norman & Schmidt 1992).
Tip 4
Recognise that there is no syllabus per se
Even though there may be a formal syllabus, this is only part of
the story. The syllabus is what is needed to be known to
perform as a competent foundation year doctor. Remember
though, that everything cannot be learnt at once, and that you
will be continuing to learn throughout your medical career, as
treatments develop and understanding of pathology changes.
This was acknowledged in the General Medical Council’s
(GMC’s) Tomorrow’s Doctors 2009, which encourages the
development of competent foundation doctors with the
ability to continue learning and remain up-to-date throughout
their postgraduate career (Margetson 1999; General Medical
Council 2009).
Nevertheless, at the start of each PBL module there will
seem to be a large body of new information that needs to be
studied. This can be quite daunting. First, it is important to
activate the groups’ prior knowledge (see Tip 3), and then, use
this prior knowledge to form SMART (Specific, Measurable,
Attainable, Relevant and Time-bound) learning objectives
(Garbutt 1996).
Tip 5
Work to an appropriate depth for you
What depth should I be studying to? How do I know that I am
working to the correct level? What if my PBL group is not
studying topics in sufficient detail to enable us to pass the
exams?
These are common concerns that are raised by students
when learning through PBL. It is important to work as a group.
In the feedback sessions, share learning with the group –
collaborate. This can help to demonstrate the varying depths
different group members have gone to, which should guide
the learning process, along with prompts from the facilitator.
Remember though, the depth that a student needs to study to
within each area will be individual (as each student will bring
to the group a unique ‘prior knowledge’). Each student will
have their own individual learning needs and plan at the end
of the PBL session, stemming from the groups’ shared
objectives.

Another guide can be the resources provided by the
university. These can range from the plenary sessions, to
anatomy dissection or demonstration classes. It is important to
identify the resources that are meaningful to you; there is little
point forcing yourself to read a book or resource that you do
not understand. Instead, start with a resource at your level of
understanding and progress to the more in-depth resources.
Try not to simply rote learn the information needed just to ‘tick
off the objective’. Aim to understand the principles, for
example, the physiology, so that the pathology then makes
sense to you. This will enable you to identify why, for
example, the symptoms described in the scenario may be
occurring.
Tip 6
Use PBL to help develop a learning approach that is
best for you and study using different resources
Have the confidence to learn from different resources, not only
textbooks and lectures, but journal articles, the Internet,
patients, experience and each other. Appraise your sources
critically and cross-reference them. Some sources may explain
ideas more clearly than others and may be more up-to-date.
In addition to utilising a variety of resources, it is important
to develop learning techniques that are best for you, e.g.
highlighting information, drawing quick mind-maps, writing
notes or practising questions on the topic, remembering that
the time is finite and that the most efficient and effective way of
learning for you is the best way. A warning though, the way
that works best for you for examinations which only test recall
may not serve you well as a medical student.
Students on a PBL course often have a more flexible
timetable. Ensure that you do not leave your PBL learning until
the night before the next session. Try to work steadily on the
objectives throughout the week, gradually building on your
understanding, using a variety of resources. Entwistle
(Entwistle et al. 1979) described three approaches to learning;
deep, strategic and superficial. Revising facts the night before
the PBL sessions to recite would be considered superficial
learning, whilst deep learning is where a thorough in-depth
understanding of the topic and its processes is achieved.
Strategic learning, meanwhile, is learning what is perceived to
be necessary to pass the exams.
Although it is acknowledged that a strategic approach to
learning is sometimes required, especially during the one-
week run up to the final examinations, the PBL process aims to
foster deep learning approaches whereby knowledge is
understood and learned in context, and is therefore retained
and easily retrievable.
Tip 7
Encourage equal participation from all group mem-
bers and ask questions of each other
Ensure that the group utilises the PBL sessions, to share their
learning, but also to learn from each other within the group.
These sessions provide a safe learning environment in which to
Surviving PBL as a medical student
question each other’s ideas and concepts, aiming to resolve any
confusion or queries together. To facilitate this, listen to each
other, maintain confidentiality and share experiences. You are
not competing in the PBL setting and the more you actually put
into the session the more you get out of it.
Try to engage the entire group through the use of open
questions, such as ‘what does everyone else think?’ Another
method is to ensure that every person in the group writes on the
board/flipchart at least once in each session. Setting ground
rules as you begin to work with every new PBL group has been
identified as a method to help groups to function successfully
(Hitchcock & Anderson 1997). This set of agreed ground rules
can subsequently be referred to in order to help the group work
effectively together. As a group, it is the responsibility of
everyone, including the tutor, to address any issues that could
lead to the group being dysfunctional as soon as possible,
otherwise student learning can be jeopardised.
The ability to lead and promote good teamwork within a
group is not only essential as a PBL student, but also when
working in a multi-disciplinary team as doctors (General
Medical Council 2009).
Tip 8
Respect differing viewpoints expressed by other
members of the group
Pooling of resources and information learnt facilitates discus-
sion enabling the investigation of different views. Remember
that there may be no correct answer. Medicine is rarely certain
and there are often many valid possible answers. Some
members of the group will find this easier to accept than
others, which was expressed by Perry in his scheme for
intellectual and ethical development (Kloss 1994; Perry 1999).
In this scheme, students progress through four main categories
of knowledge:
(1) Dualism – there is one right solution to a problem, and
that is what is learnt from the teacher.
(2) Multiplicity – there is an appreciation that there are
many different solutions to a problem and that views of
peers are acceptable, but the teacher is still correct.
(3) Relativism – the merits of the different opinions can be
weighed up and information from peers and teachers is
accepted and compared.
(4) Commitment – the knowledge learnt from multiple
sources can be appraised and amalgamated, alongside
personal experience, which can then be applied to
everyday problems.
This can be related to within the PBL group setting, as
gradually a greater range of resources are used by the group,
as opposed to the one ‘correct’ textbook. Different members of
the group may find it easier than others to reflect critically on
the different views expressed and appreciate the lack of one
‘correct answer’. It is important to discuss differences of
opinion thoroughly within the group as it is this ‘discourse’ that
stimulates deeper reflection on ideas and subsequent learning
across Vygotsky’s ‘zone of proximal development’ (Vygotsky
1978; Palincsar 1998).
97
E. Bate & D. C. M. Taylor
Tip 9
Ensure that all curriculum themes (e.g. anatomy,
physiology, pathology, public health, psychology and
ethics) identified by the scenario are studied and
applied
The PBL scenarios are based on clinical situations.
When considering the learning objectives required to under-
stand the scenario, ensure that all aspects of the ‘patient’
are considered, for example, in a scenario about a diabetic
patient:
Think about the structure and function of the
pancreas. What is diabetes and what is the aetiology
of diabetes? How do you manage and treat it, and
how is diabetes managed by different health profes-
sionals? What are the implications socially and
psychologically for patients diagnosed with, and
living with diabetes? What could be the impact on
family and social life of being diagnosed with
diabetes? Is it an important public health issue, and
how has its prevalence varied over the past 10 years?
The list continues.
Similarly, when discussing the learning outcomes in the
feedback sessions, try to integrate the different themes.
Integrating the information learnt in this way, helps the
formation of an organised knowledge network that can be
easily retrieved and activated by future similar situations.
This ‘situated learning’ with the formation of ‘schemas’
or ‘illness scripts’ (Collard et al. 2009) has been shown
to significantly improve the amount of structured
knowledge learnt by 38–40% compared to the students
using non-schema-based learning approaches (Blissett
et al. 2012).
Tip 10
Do not use notes during the PBL sessions, but do
use the board/flipchart to help explain concepts in
your own words
The ability to recall knowledge and express it coherently is
good preparation for the challenges to be faced as a doctor
since questions will be posed not only by other healthcare
professionals, but also by patients. This is not always easy, but
explaining complex ideas and concepts to your peers reaffirms
and challenges your own knowledge and is good preparation
for your future career.
Working without notes also demonstrates and tests the
level of understanding attained, as opposed to reading ability.
By using the board to explain diagrams and concepts, this
focuses the group’s attention, and facilitates the discussion
(Taylor & Miflin 2008). This also negates the need for notes, as
different members of the group can help the person writing on
the board. Through conversation and debate group members
fill in each other’s knowledge gaps, without having to read the
information from personal notes.
98
Tip 11
Reflect and evaluate yourself and each other giving
constructive feedback to your peers and tutor at the
end of each session
In doing this, the group’s PBL process improves session by
session. An increasing evidence base demonstrates that PBL’s
andragogical processes are not sufficient alone to promote
deep learning, but need to occur with concurrent peer, and
self-evaluation, and formative assessment (Rushton 2005;
Papinczak et al. 2008).
Dolmans et al. described two of the main problems
occurring within PBL as; dysfunctional tutorial groups and
tutors being too directive (2005). Problems occurring within
PBL groups leading to them being dysfunctional can range
from; groups that are cynical about the PBL process causing
the lack of engagement and adherence to the PBL steps, to,
group members not preparing sufficiently for the sessions
(Dolmans et al. 2005). One of the main methods for addressing
these issues is through the group evaluation at the end of every
PBL session, where all members are encouraged to participate.
Questions to consider during the evaluation include: What
went well/not so well in the session? Did the group work
together with everyone participating? Was time well managed?
Did the learning objectives formed help the group to under-
stand the scenario? How could the group improve on any of
the above issues for further sessions? (Holen 2000).
In addition to this, reflection on your own learning and
knowledge is vital as part of the learning process. As identified
earlier, Dewey described the importance of recognition of
prior experience in the formation of new learning (1938),
which was later expanded by Kolb in his experiential learning
cycle. In this cycle (Kolb, 1984), prior knowledge or experi-
ence (concrete experience) is reflected upon through self-
evaluation and peer feedback (reflective observation), from
which theoretical studies are undertaken (abstract conceptua-
lisation) followed by the implementation of what has been
learnt (active experimental isolation), which then forms the
new concrete experience to recommence the cycle (Maudsley
& Strivens 2000).
The ability to provide and respond to peer feedback, in
addition to reflecting on your own learning, are essential
components for the development of the self-directed, life-long
learning and self-efficacy required for a professional career
(Papinczak et al. 2007a, b).
Tip 12
Apply the skills that you learn within PBL to other
situations
PBL is not just a process to be used purely during the set PBL
sessions; remember to use and apply the skills that you learn
from PBL. The process of recognising knowledge gaps,
revisiting current understanding and identifying new learning
objectives are important skills for continued professional
development.

More importantly, possessing the knowledge and skills to
enable you to fill these knowledge gaps and collaborate with
others, are essential skills required for practice as a doctor.
Finally, for every new patient, there is a ‘scenario’ from
which you need to recognise what you already know and do
not know, liaise with colleagues, perform necessary investi-
gations, and then assimilate and apply the additional informa-
tion, to (hopefully) enable you to arrive at a diagnosis and
management plan for the patient.
Conclusion
PBL is increasingly being used in medical education world-
wide. With enthusiasm and perseverance from both the
students and facilitators, the PBL process can be a stimulating
way for students to learn medicine in a clinical context. In
doing so, new knowledge can be readily recalled in the clinical
setting.
Learning through PBL can be challenging, especially
initially, with many students experiencing the PBL process
itself as a ‘threshold concept’ causing them to enter a state of
liminality (Savin-Baden 2006; Land et al. 2008). It is at this
stage that these simple ‘12 tips’ will hopefully help to guide the
student and facilitator to undertake PBL successfully.
In time, most students appreciate the skills acquired from
learning through PBL, and continue to utilise these skills
throughout their postgraduate medical career.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
Notes on contributors
EMILY BATE is an Academic Education Foundation doctor at the University
of Liverpool and co-chair of the Junior ASME committee. Her research
interests are in student involvement in medical education and PBL.
D.C.M. TAYLOR is a senior tutor and deputy director of Medical Studies at
Liverpool Medical School where he was instrumental in introducing
problem-based learning. His research interests include learning theory,
communities of practice and professionalism.
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