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Clinical problem solving and diagnostic decision making: selective review of the cognitive literature

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• Clinical problem solving and diagnostic decision making: selective review of the cognitive literature - November 02, 2006
• Arthur S Elstein , professor ([email protected]) ,
• Alan Schwarz , assistant professor of clinical decision making.
• Department of Medical Education, University of Illinois College of Medicine, Chicago, IL 60612-7309, USA
• Correspondence to: A S Elstein

This is the fourth in a series of five articles

This article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving 1 , 2 , 3 and decision making. 4 , 5 , 6 , 7 , 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards.

Summary points

Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods

The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy

Final conclusions should depend both on prior belief and strength of the evidence

Conclusions reached by Bayes's theorem and clinical intuition may conflict

Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies

Evidence based medicine applies decision theory to clinical diagnosis

Problem solving

Diagnosis as selecting a hypothesis.

The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data. 1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the …

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• DOI: 10.7326/0003-4819-116-7-607_2
• Corpus ID: 68425654

Developing Clinical Problem-Solving Skills: A Guide to More Effective Diagnosis and Treatment

• H. Barrows , G. Pickell
• Published in Annals of Internal Medicine 17 June 1991

54 Citations

Clinical reasining; where do we stand on identifying and remediating difficulties, clinical skills textbooks fail evidence-based examination, assessing clinical reasoning: a method to monitor its development in a pbl curriculum, developing clinical competence, the hypothesis-oriented pediatric focused algorithm: a framework for clinical reasoning in pediatric physical therapist practice, connecting classroom, clinic, and context: clinical reasoning strategies for clinical instructors and academic faculty, clinical reasoning difficulties: a taxonomy for clinical teachers, what kind of curriculum can better address community needs problems arisen by hypothetical-deductive reasoning, developing a clinical presentation curriculum in veterinary education: a cognitive perspective, effective mode of learning: knowledge gain through problem solving exercise during medicine tutorial session, related papers.

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Medical problem solving.

Medical problem-solving skills are essential to learning how to develop an effective differential diagnosis in an efficient manner, as well as how to engage in the reflective practice of medicine. 
 Students' experience in CBI complements the clinical reasoning skills they learn through the UA COM Doctor and Patient course and through their Societies mentors.

The UA COM medical problem-solving structure applies the B-D-A ( Before-During-After)  framework as an educational strategy. Thus, CBI requires students to engage in reflection before, during and following facilitated sessions. Reflection contributes to improvement in problem-solving skills and helps medical students cultivate a habit of reflection that will serve them well as they become lifelong professional learners.

As with medical-problem solving, practice-based learning (learning through experience) requires students to engage in reflection before, during and following each learning experiences. Reflection contributes to improvement in problem-solving skills and cultivating a habit of reflection will serve medical students well as they become lifelong professional learners. 

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Problem-based, self-directed learning

• PMID: 6644989

There is an increasing concern that the curricula of many medical schools put too heavy an emphasis on memorization of facts and little stress on problem solving or self-directed study skills necessary for the practice of medicine. Problem-based, self-directed learning is a teaching-learning method specifically designed to emphasize these skills and to increase the retention of facts and their recall in the clinical situation. This approach, built on research into the problem-solving skills of physicians and principles of educational psychology, is employed by several medical schools and serves as an antidote to the many educational abuses seen in more traditional approaches.

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Problem Solving Skills Definition Medical Field

Problem-solving skills in the medical field are crucial for diagnosing diseases, formulating treatment plans, and improving patient outcomes. Understanding their significance is essential for anyone pursuing a career in medicine. These skills allow medical professionals to assess situations, recognize potential issues, and devise effective solutions that can lead to better healthcare.

Definition of Problem-Solving Skills in Medicine

In the medical field, problem-solving skills refer to the ability to identify and analyze problems or challenges that arise during medical practice and to develop strategic solutions efficiently. These skills encompass several components such as critical thinking , decision-making, analytical skills, and creativity. They involve:

• Recognizing and defining the problem or challenge
• Gathering relevant information and data
• Considering potential solutions or alternatives
• Evaluating the pros and cons of each solution
• Implementing the best solution
• Monitoring the results and making necessary adjustments

An example of problem-solving in medicine is a doctor diagnosing an illness. This involves gathering patient history, analyzing symptoms, ordering appropriate tests, interpreting the results, and finally prescribing the right treatment plan. Solving this kind of problem requires a step-by-step evaluation of the available information to arrive at an accurate diagnosis.

Importance of Problem-Solving Skills in Medical Practice

The significance of problem-solving skills in medicine cannot be overstated. These skills are vital for:

• Improving patient care and outcomes
• Enhancing the efficiency of healthcare delivery
• Reducing errors in diagnosis and treatment
• Encouraging critical and innovative thinking among healthcare professionals
• Facilitating collaboration and communication within healthcare teams

A well-honed ability to solve problems helps in creating effective patient care strategies and adapting to new medical technologies and procedures.

Medical professionals often rely on interdisciplinary teamwork where problem-solving skills are collaboratively applied.

Achieving proficiency in problem-solving within the medical field often involves the integration of multiple knowledge areas and a disciplined approach to thinking. It requires understanding not just the biological sciences but also elements of psychology, sociology , and ethics. Medical education typically incorporates simulations and real-world scenarios that are designed to cultivate problem-solving skills. Additionally, continuous professional development helps clinicians keep up with evolving medical knowledge and technologies, refining their problem-solving capabilities. Exploring the relationship between problem-solving and patient safety further illustrates the significance of these skills, as missteps in diagnosis or treatment selection can have considerable repercussions. Therefore, problem-solving is a pivotal component of a clinician's toolkit, often the difference between effective and ineffective patient care.

Importance of Problem Solving in Medical Education

In medical education, developing strong problem-solving skills is fundamental. These skills form the backbone of clinical practice and are crucial for medical students as they transition into competent healthcare professionals. Understanding the importance of these skills in medical training lays a strong foundation for your future professional life.

Role of Problem-Solving in Medical Training

Medical training is not solely about acquiring knowledge; it's about applying that knowledge effectively. Problem-solving plays a pivotal role by:

• Encouraging critical thinking and analysis.
• Improving decision-making abilities.
• Enhancing adaptability in fast-changing clinical environments.
• Facilitating effective communication and teamwork.

Without these skills, handling real-life medical scenarios could become challenging.

Critical Thinking: The ability to objectively analyze facts to form a reasoned judgment .

Imagine a case where a patient presents with non-specific symptoms. Through problem-solving skills, a learner can sift through potential causes, order the appropriate tests, and arrive at an accurate diagnosis.

Participating in simulation-based training enhances your problem-solving capabilities by providing a safe environment to practice complex scenarios.

Benefits of Problem-Solving in Medical Practice

The benefits of problem-solving skills in medical practice extend far beyond simple diagnosis:

• Boosts clinical confidence by equipping you with self-reliant strategies.
• Lowers the likelihood of medical errors.
• Enhances patient safety and care quality.
• Fosters a culture of continuous learning and improvement.

These skills are not innate but developed over time through meticulous practice and reflection.

Diving deeper into the importance of problem-solving in medical education reveals that integrating these skills within curricula often involves an interdisciplinary approach. Programs might include cases that require students to not only use their medical knowledge but also apply skills from ethics, sociology , and communication. Moreover, technological advancements, such as artificial intelligence in diagnostics , do not replace the need for rigorous problem-solving skills but rather complement them, enabling healthcare professionals to make more accurate, data-driven decisions. Additionally, understanding medical heuristics and avoiding cognitive biases are critical components of these problem-solving capabilities, as they guide more logical and impartial clinical decision-making processes .

Problem Solving Techniques in Medicine

Problem-solving techniques in medicine are essential for healthcare professionals to effectively address and manage diverse clinical scenarios. These techniques involve a systematic approach to diagnosing and treating patients, ensuring better healthcare outcomes.

Problem Solving Skills Examples in Medicine

Understanding problem-solving skills requires reviewing their application in medical settings. Here are some examples:

• Diagnosing a patient with multiple symptoms requires evaluating each symptom's significance and ruling out unlikely conditions.
• Formulating a treatment plan involves considering the patient's medical history, current medications, and potential drug interactions .
• Making decisions in emergency care settings, such as prioritizing care for patients in critical condition using triage protocols.
• Collaborating in multidisciplinary teams to provide holistic care solutions that address physical, social, and psychological patient needs.

In a case where a patient is experiencing chest pain, a doctor needs to perform an initial assessment to differentiate between potential causes such as heart attack , anxiety, or gastrointestinal issues. By systematically eliminating these possibilities, appropriate diagnostic tests can be ordered to confirm the diagnosis.

Conducting regular case study reviews is an effective way to enhance understanding and application of problem-solving skills.

Exercises to Develop Problem Solving Skills in Medicine

Developing problem-solving skills in medicine can be achieved through various exercises:

• Simulation Training: Engaging in real-world medical scenarios within a controlled environment helps build confidence and skills.
• Clinical Rotations: Hands-on experience during these rotations allows for practical application of learned techniques.
• Peer Discussions: Regularly discussing complex cases with peers fosters different perspectives and collaborative problem-solving.
• Reflective Practice : Journaling and reflecting on clinical experiences improve self-awareness and decision-making abilities.

Simulation-based learning is particularly effective in medical education as it provides a risk-free environment where trainees can practice complex procedures and decision-making without compromising patient safety. This method bridges the gap between theoretical knowledge and practical application. Additionally, interprofessional education involving scenarios with nursing, pharmacy , and medical students working together encourages understanding of diverse roles within a healthcare team and enhances collaborative problem-solving skills. Engaging in reflective practice further aids in understanding one's own decision-making process, promoting continuous improvement and adjustment of strategies for better patient outcomes.

How to Improve Problem Solving Skills in Medicine

Enhancing problem-solving skills in the medical field can be approached through multiple methods:

• Continuing Education: Engage in workshops and courses that focus on critical thinking and decision-making.
• Mentorship Programs: Learning from experienced practitioners helps gain insights into effective problem-solving techniques.
• Technological Tools: Utilize AI and machine learning platforms for enhanced diagnostics and patient management.
• Evidence-Based Practice : Make decisions that are informed by the latest research and clinical guidelines to ensure optimized patient care.

Regularly attending medical conferences can provide exposure to innovative problem-solving techniques and emerging technologies.

problem-solving skills - Key takeaways

• Problem-solving skills in the medical field are essential for diagnosing diseases and formulating treatment plans to improve patient outcomes.
• Problem solving in medicine involves critical thinking, decision-making, analytical skills, and creativity—key to recognizing problems, gathering information, and implementing solutions.
• Examples include diagnosing patients, formulating treatment plans, and utilizing triage protocols in emergencies.
• The importance includes improving patient care, reducing medical errors, and enhancing healthcare delivery efficiency.
• Exercises to develop these skills include simulation training, clinical rotations, peer discussions, and reflective practice.
• Improving problem-solving skills involves continuing education, mentorship, using technological tools, and adhering to evidence-based practices.

Flashcards in problem-solving skills 12

They only help in medical research advancements.

Relying solely on patient's self-diagnosis.

Focusing primarily on administrative tasks in healthcare.

Ignoring data gathering while making decisions.

Immediate prescription of medication without diagnosis.

They complement problem-solving by enabling accurate, data-driven decisions.

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• Published: 10 September 2024

Integration of 3D printing and case-based learning in clinical practice for the treatment of developmental dysplasia of the hip

• Shuo Feng 1   na1 ,
• Ying-Jin Sun 1   na1 ,
• Qi-Rui Zhu 1 ,
• Si-Feng Shi 1 ,
• Yong-Shuo Zhang 1 &
• Feng Yuan 1  

BMC Medical Education volume  24 , Article number:  986 ( 2024 ) Cite this article

Metrics details

Case-based learning (CBL) utilizing three-dimensional (3D) printed hip joint models is a problem-solving teaching method that combines the tactile and visual advantages of 3D-printed models with CBL. This study aims to investigate the impact of integrating 3D printing with CBL on learning developmental dysplasia of the hip (DDH).

We conducted a prospective study from 2022 to 2023, including 120 fourth-year clinical medical students at Xuzhou Medical University. Students were randomly allocated into two groups of 60 participants each. The CBL group received conventional CBL teaching methods, while the 3D + CBL group utilized 3D-printed models in conjunction with CBL. Post-teaching, we analyzed and compared the theoretical and practical achievements of both groups. A questionnaire was designed to assess the impact of the educational approach on orthopedic surgery learning.

The theory scores of the CBL group (62.88 ± 7.98) and 3D + CBL group (66.35 ± 8.85) were significantly different (t = 2.254, P  = 0.026); the practical skills scores of the CBL group (57.40 ± 8.80) and 3D + CBL group (63.42 ± 11.14) were significantly different (t = 3.283, P  = 0.001). The questionnaire results showed that the 3D + CBL group was greater than the CBL group in terms of hip fundamentals, ability to diagnose cases and plan treatments, interesting teaching content, willingness to communicate with the instructor and satisfaction.

Conclusions

The integration of 3D printing with case-based learning has yielded positive outcomes in teaching DDH, providing valuable insights into the use of 3D-printed orthopedic models in clinical education.

Peer Review reports

Introduction

Developmental dysplasia of the hip (DDH) is a condition characterised by abnormal development of the hip joint, including dysplasia of the femoral head and acetabulum, subluxation of the hip joint, and dislocation of the hip joint [ 1 , 2 ]. Surgical intervention is a viable treatment option, but the complexity of surgery and the variability of hip joint anatomy pose challenges for both teaching and learning. Knowledge of the three-dimensional (3D) structure of the hip joint requires medical students to have certain clinical practice experience and spatial construction ability, while the traditional teaching of hip diseases mainly relies on textbooks, courseware and cadaveric specimens, which have limitations in understanding the pathological structure of the hip joint and surgical procedures [ 3 , 4 , 5 ]. 3D-printed models visually represent the local anatomical structure of the lesion and have obvious advantages in diagnosing complex diseases and facilitating simulated surgeries [ 6 , 7 , 8 ]. An increasing number of educators are turning to emerging technologies such as 3D printing to bridge the gap between theory and practice in medical education [ 5 , 8 , 9 ].

Case-based learning (CBL) is a pedagogical approach that emphasises the practical application of knowledge in a real-world context [ 10 ]. It entails presenting students with clinical cases and guiding them through the problem-solving process, thereby fostering critical thinking and problem-solving skills as well as promoting long-term retention of knowledge [ 11 , 12 ]. 3D printing and CBL have been widely used in orthopedic teaching to promote students’ understanding of orthopedic surgery and to provide new ideas for orthopedic clinical teaching [ 13 , 14 , 15 ]. The integration of 3D printing technology and CBL methods has enabled the creation of accurate 3D joint models and the simulation of surgical procedures, enhancing the understanding and visualisation of pathological structures and surgical procedures in DDH patients.

The aim of this study was to investigate the impact of the integration of 3D printing and CBL in learning about DDH and to provide insights into future teaching practices. We hypothesise that the integration of 3D-printed models with case-based learning in DDH will have positive effects on grounded theory and practical skills, increasing student interest and satisfaction.

Research design

We selected 120 fourth-year undergraduate university students enrolled in clinical programmes from January 2022 to March 2023 for the study. The students were randomly divided into a CBL group and a CBL + 3D group by a random number table with 60 students in each group. Both groups received a 6-month orthopaedic course. The 3D + CBL group received instructions on 3D-printed models combined with case-based learning (CBL), and the CBL group received only traditional CBL instruction. The content of knowledge covered in the instructions was identical in the 3D + CBL and CBL groups. All students signed an informed consent form prior to participation, making it clear that their participation was voluntary and that they could withdraw from the study at any time. We anonymized all participants’ personal information, using separate study numbers instead of any identifiable information to ensure maximum protection of patient privacy. This study was approved by the Ethics Committee of the Affiliated Hospital of Xuzhou Medical University (XYFY2023-KL146-01) and was exempt from review.

Sample size calculation

Sample size calculations were performed using G*Power software (version 3.1.9.6, Dusseldorf, Germany). The determination of the sample size relied on the main outcome indicator of the study: students’ understanding of orthopaedic surgery. A statistical power of 80% and a two-tailed ɑ = 0.05 were assumed. The necessary sample size was estimated to be 50 students per group, based on an effect size of 0.5 (Cohen’s d) derived from the data reported by Zhao et al. [ 16 ]. Considering a potential dropout rate of 20%, a total of 120 students will be recruited.

Teaching methods

A database of adult patients with hip dysplasia was established. Data on patients who underwent total hip arthroplasty for DDH in our department between 2020 and 2021 were collected. The patients had good compliance and could be followed up on time. Among them, there were two cases of Crowe type IV and one case of type III [ 17 ]. Patient data included the general condition, routine preoperative blood tests, CT imaging of the hip joint, diagnosis, treatment plan, diagnostic and therapeutic process, intraoperative photographs and postoperative X-rays. All typical cases were collected with the informed consent of the patients.

A 3D model of the hip joint was created. Preoperative images of the hip joint were imported into the 3D imaging software Mimics Research 21.0 (Materialise, Belgium), Geomagic Studio 2017 (Geomagic, USA) and Solidworks 2018 (Dassault Systemes, USA) in DICOM file format. The preoperative 3D model of the hip joint was built in an orderly manner by combining and utilising the functions of the different modules in the software. On the basis of 3D reconstruction, anatomical measurements, prosthesis design and printing can be performed (Fig.  1 and Figs.  2 ).

Anatomical measurements and prosthesis design on 3D models. Figure legends: a and b . Measurement of transverse and upper and lower acetabular diameters; c and d . Frontal and lateral views of the femur and measurement of the femoral neck stem angle

3D printed model of DDH patients. Figure legends: a , Overall view of the 3D printed model of 2 patients with DDH b , 3D printed right hip joint of DDH patient; c , d printing left hip joint of DDH patient; d , DDH patient left acetabulum e , The left femur portion of the DDH patient contained the femoral head

Comparison of pre- and postclass scores between the CBL + 3D group and CBL group. Figure legends: A&D, B&E and C&F show comparisons of the theoretical, practical, and total scores of the CBL + 3D group and the CBL group before and after class, respectively. *** indicates p  < 0.001

Group and implement teaching. Each group was divided into 6 subgroups of 10 participants, and the class was scheduled for 4 class hours. The lecturers were led by two senior orthopedic surgeons (attending physicians for 5 years) and used the same CBL teaching cases and lectures. The focus of the course was on the anatomy and pathology of DDH and options for surgical treatment. Prior to the lesson, subjects in both groups were allowed to watch instructional videos on hip anatomy and DDH surgery and to prepare for the lesson. The scenario introduced a case of adult DDH for group discussion, and only a 3D-printed model of this patient in the 3D + CBL group and a brief description were provided. Students in both groups will work in groups to search for information and discuss the development of a treatment plan based on the patient’s history, specialist examination and ancillary tests. Afterwards, the students will design a CBL case based on the surgical procedure of the target orthopedic surgery. Students will be divided into groups, and each group will be given a new case for DDH. They will need to analyse and discuss the case, develop a diagnosis and treatment plan, and present their results to the other members and the lecturers. During the discussion, students in the 3D + CBL group still received a 3D-printed model of the patient. At the end of the discussion, the lecturers commented on the results of the students’ discussions in each group, provided detailed summaries and answers to common and controversial questions, and finally emphasised the importance of deepening the students’ practical mastery of the knowledge related to the anatomy, pathology and surgical treatment of DDH.

Evaluating teaching effectiveness

The primary outcome measure was the improvement in knowledge scores between the pretest and posttest. Prior to the start of the course, both groups of students were asked to complete the same test papers and single-choice and multiple-choice questions before the course. At the end, the teacher assessed the students’ theoretical and practical performance and designed a questionnaire to evaluate the effectiveness of the teaching. The theoretical knowledge assessment included single-choice questions, multiple-choice questions, short-answer questions, and case analysis questions involving basic knowledge points related to hip dysplasia, diagnosis, and surgical methods, totaling 100 points. The practical assessment included history taking, medical record writing, imaging reading and choosing the surgical plan, with a total of 100 points.

At the end of the course, the two groups of students were given the same questionnaire for investigation. The questionnaire consists of 5 parts, and five aspects were scored: mastery of basic hip joint knowledge, ability to diagnose cases and formulate treatment plans, interesting teaching content, willingness to communicate with teachers, and teaching satisfaction. Students were asked to answer the questions based on these items with a total possible score of 10 and a minimum possible score of 2. Higher scores indicate higher student satisfaction. The secondary outcome measures will be surgical skill scores and surgical outcomes.

Statistical analyses

All the statistical analyses were performed using the statistical software SPSS version 26.0 (IBM Corp, Armonk, NY, USA). Independent samples t tests were used to compare continuous variables between two groups. The data are expressed as the mean and standard deviation (SD). The chi-square test was used for discontinuous variables. Differences with P  < 0.05 were considered to indicate statistical significance.

A total of 120 students were included in the experiment. The experimental group included 22 males and 38 females aged between 21 and 23 years, with an average age of 22.03 ± 0.88 years. The control group consisted of 26 males and 34 females aged 21 to 23 years, with a mean age of 21.97 ± 0.66 years; all the students were trainees. There was no significant difference in age (t = 0.468, P  = 0.641) or gender ( \(\:x\) ² = 0.556, P  = 0.456) between the two groups (Table  1 ).

Theoretical and practical performance

There was no significant difference in the performance of the two groups of students on the precourse test. The results of the postcourse assessment showed that the participants in the 3D + CBL group performed better than did those in the CBL group. The theory scores of the CBL group (62.88 ± 7.98) and 3D + CBL group (66.35 ± 8.85) were significantly different (t = 2.254, P  = 0.026); the practical skills scores of the CBL group (57.40 ± 8.80) and 3D + CBL group (63.42 ± 11.14) were significantly different (t = 3.283, P  = 0.001); and the total scores of the CBL group (120.18 ± 12.01) and 3D + CBL group (129.72 ± 14.02) were significantly different (t = 4.001, P  < 0.001) (Table  2 ). In addition, in the comparison of theory scores and total scores before and after the course, the scores of students in both groups improved, and the difference was statistically significant. However, in the practical skills test, there was no difference in the scores of the two tests in the CBL group (Fig.  3 ).

Questionnaire

After teaching, a total of 120 questionnaires were distributed to the students, and the effective recovery rate was 100%. The results showed that the 3D + CBL group was greater than the CBL group in terms of hip fundamentals, ability to diagnose cases and plan treatments, interesting teaching content, willingness to communicate with the instructor and satisfaction (Table  3 ).

Our study showed that physicians in the 3D-printed hip model combined with CBL group outperformed those in the traditional teaching group in both theoretical and clinical practice skills assessment, which mainly included understanding and mastery of imaging features, diagnosis and treatment of osteoarthritic disorders, and surgical protocols. Chen et al [ 18 ] conducted a study investigating the use of 3D printing in combination with PBL in the teaching of surgical skills for the Henle torso variant. The experimental group received traditional classroom instruction supplemented with 3D-printed models, while the control group received a 2D image of the henle trunk plus surgical video. The results showed that the experimental group performed significantly better than the control group in both theoretical knowledge and practical skills. A systematic review by Asif [ 19 ] revealed that patient-specific 3D-printed (3DP) models have been used for clinical training in the UK, especially for rarer and more complex conditions, and that 3DP models are associated with greater user satisfaction and good short-term teaching outcomes. Another study by Sun et al [ 20 ] investigated the application of 3D visualisation combined with project-based learning (PBL) in teaching about spinal disease. The study involved 106 medical students who were randomised into two groups: a group incorporating PBL instruction and a traditional lecture-based classroom group. The researchers concluded that the combination of 3D visualisation and PBL was effective in improving learning outcomes in spine surgery. Studies have shown that the use of 3D-printed models of patient joints can help surgeons better plan and perform surgery [ 21 , 22 ].

Our findings are consistent with previous studies emphasising the pedagogical benefits of incorporating 3D-printed models into surgical training [ 18 , 23 , 24 ]. The tactile and visual advantages provided by these models allow students to have physical access to anatomical structures, greatly improving their understanding of complex joint surgeries [ 25 , 26 ]. As our study demonstrates, this hands-on learning approach leads to better mastery of theoretical knowledge and practical skills. CBL is a teaching methodology that uses cases as a basis and puts empty theories into the context of specific cases for exposition. The use of 3D printing in CBL enables students to solve real-world problems [ 27 ]. In addition, the integration of 3D-printed hip models with CBL promotes active learning and critical thinking while enhancing students’ mastery of orthopedic theoretical knowledge and basic orthopedic operative skills, expanding their clinical thinking, promoting interest and motivation in orthopedic clerkships, and improving their satisfaction with traditional teaching. The interactive nature of CBL encourages students to deal with real-world surgical scenarios and develop problem-solving abilities that are critical problem-solving skills [ 28 ]. This combination of teaching methods not only improves student understanding but also contributes to improved surgical outcomes, consistent with the broader goals of medical education. The findings presented in this paper are consistent with those of previous studies exploring the integration of 3D printing and CBL in medical education. Similar positive results have been reported in studies of related areas such as spinal surgery and rare clinical conditions [ 20 ]. All of these results suggest that if the technology is extended to medical schools, it could improve teaching and learning outcomes and enhance quality to some extent.

A CBL teaching method that incorporates 3D-printed models can have implications for traditional teaching and learning. This interactive learning method can be used as a complementary tool to enhance traditional classroom instruction, especially in understanding complex medical and surgical concepts [ 5 , 8 , 29 ]. Students’ engagement and interest can be increased through the combination of visual and tactile use of 3D-printed models and dynamic learning experience in the CBL teaching method. At the same time, instructors can introduce active learning and critical thinking into the traditional classroom, guiding students to analyse problems and explore solutions in a more holistic manner and improving overall teaching and learning outcomes [ 26 ]. There are many advantages to using triple 3D-printed models as an alternative to actual anatomical specimens in medical education. First, 3D models provide more vivid and clearer visualisations, helping students understand human structures in a more intuitive way [ 25 ]. Second, compared to actual anatomical specimens, 3D models are not limited by time and place, simplifying the teaching process. Educators can also customise different scenarios and content to meet the learning needs and teaching goals of different students, which is especially applicable in personalised case teaching, helping to discuss personalised treatment plans. In contrast, the use of real anatomical specimens involves ethical issues and difficulties, especially for rare lesion specimens from patients with DDH [ 30 ]. Moreover, anatomical specimens may deteriorate, rot or deform over time, making maintenance difficult. In summary, the use of 3D-printed models helps to compensate for the scarcity of anatomical specimens, avoids ethical issues, improves teaching efficiency, and promotes research innovation. This alternative method provides new possibilities and opportunities for medical education and research.

Limitations of the study include the following: ① The sample size and scope limitations include the fact that the study included only 120 students, which may limit the generalizability of the results. In addition, all participants were from the same educational institution, which may have biased their geographical and educational backgrounds. ② Study design: Although randomised grouping was used, it was not clear whether there was a blinded design, i.e., whether the raters and the participants were aware of the group to which they were assigned, which may have affected the objectivity of the results. ③ Validation of the assessment tool: The study used a self-administered questionnaire to conduct the assessment, and the degree of standardisation and validation was not specified. The degree of standardisation and validation was not described in detail, which may have affected the accuracy and reliability of the results. ④ Unknown long-term effects: This study focused mainly on teaching and learning effects in the short term and failed to assess long-term learning outcomes and skill retention. Future research needs to delve deeper into the use of different types of 3D-printed models in orthopedic education and expand beyond the current focus on DDH to other orthopedic areas, such as knee disorders and spinal disorders, to explore the effectiveness of CBL teaching methods that incorporate 3D printing. Future research will also require long-term follow-up studies to assess the lasting impact of the teaching approach on students’ clinical skills and knowledge retention. These studies will provide new insights and innovations to the field of orthopaedic education.

The combination of 3D printing and case-based learning has yielded positive results in treating DDH, providing valuable insights into the use of 3D-printed orthopedic molds in clinical teaching.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Case-Based Learning

Project-Based Learning

Three-Dimensional

developmental dysplasia of the Hip

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The authors received financial support from the Jiangsu Hospital Association Hospital Management Innovation Research Project (JSYGY-3-2023-215), Jiangsu Province Education Science Planning Project (D/2021/01/105), Jiangsu Provincial Department of Science and Technology (BE2022708), Jiangsu Commission of Health (ZD2022064) and Jiangsu Provincial Traditional Chinese Medicine Science and Technology Development Plan (MS2021102).

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Shuo Feng and Ying-Jin Sun contributed equally to this work.

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Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, No. 99, Huaihai West Road, 221002, Xuzhou , Jiangsu, P.R. China

Shuo Feng, Ying-Jin Sun, Qi-Rui Zhu, Si-Feng Shi, Yong-Shuo Zhang & Feng Yuan

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F.S. and S.YJ. wrote the main manuscript text and analysed the data. Z.QR. and S.SF. prepared the figures and tables. Z.YS. was responsible for collecting and collating data. Y.F. was responsible for the research design and article evaluation.

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Correspondence to Shuo Feng or Feng Yuan .

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Feng, S., Sun, YJ., Zhu, QR. et al. Integration of 3D printing and case-based learning in clinical practice for the treatment of developmental dysplasia of the hip. BMC Med Educ 24 , 986 (2024). https://doi.org/10.1186/s12909-024-05934-w

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DOI : https://doi.org/10.1186/s12909-024-05934-w

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Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review

Joan carles trullàs.

1 Medical Education Cathedra, School of Medicine, University of Vic-Central University of Catalonia, Vic, Barcelona, Spain

2 Internal Medicine Service, Hospital de Olot i Comarcal de La Garrotxa, Olot, Girona, Spain

3 The Tissue Repair and Regeneration Laboratory (TR2Lab), University of Vic-Central University of Catalonia, Vic, Barcelona, Spain

Carles Blay

4 Catalan Institute of Health (ICS) – Catalunya Central, Barcelona, Spain

Elisabet Sarri

Ramon pujol, associated data.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Problem-based learning (PBL) is a pedagogical approach that shifts the role of the teacher to the student (student-centered) and is based on self-directed learning. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness of the method is still under discussion. The author’s purpose was to appraise available international evidence concerning to the effectiveness and usefulness of PBL methodology in undergraduate medical teaching programs.

The authors applied the Arksey and O’Malley framework to undertake a scoping review. The search was carried out in February 2021 in PubMed and Web of Science including all publications in English and Spanish with no limits on publication date, study design or country of origin.

The literature search identified one hundred and twenty-four publications eligible for this review. Despite the fact that this review included many studies, their design was heterogeneous and only a few provided a high scientific evidence methodology (randomized design and/or systematic reviews with meta-analysis). Furthermore, most were single-center experiences with small sample size and there were no large multi-center studies. PBL methodology obtained a high level of satisfaction, especially among students. It was more effective than other more traditional (or lecture-based methods) at improving social and communication skills, problem-solving and self-learning skills. Knowledge retention and academic performance weren’t worse (and in many studies were better) than with traditional methods. PBL was not universally widespread, probably because requires greater human resources and continuous training for its implementation.

PBL is an effective and satisfactory methodology for medical education. It is likely that through PBL medical students will not only acquire knowledge but also other competencies that are needed in medical professionalism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-022-03154-8.

There has always been enormous interest in identifying the best learning methods. In the mid-twentieth century, US educator Edgar Dale proposed which actions would lead to deeper learning than others and published the well-known (and at the same time controversial) “Cone of Experience or Cone of Dale”. At the apex of the cone are oral representations (verbal descriptions, written descriptions, etc.) and at the base is direct experience (based on a person carrying out the activity that they aim to learn), which represents the greatest depth of our learning. In other words, each level of the cone corresponds to various learning methods. At the base are the most effective, participative methods (what we do and what we say) and at the apex are the least effective, abstract methods (what we read and what we hear) [ 1 ]. In 1990, psychologist George Miller proposed a framework pyramid to assess clinical competence. At the lowest level of the pyramid is knowledge (knows), followed by the competence (knows how), execution (shows how) and finally the action (does) [ 2 ]. Both Miller’s pyramid and Dale’s cone propose a very efficient way of training and, at the same time, of evaluation. Miller suggested that the learning curve passes through various levels, from the acquisition of theoretical knowledge to knowing how to put this knowledge into practice and demonstrate it. Dale stated that to remember a high percentage of the acquired knowledge, a theatrical representation should be carried out or real experiences should be simulated. It is difficult to situate methodologies such as problem-based learning (PBL), case-based learning (CBL) and team-based learning (TBL) in the context of these learning frameworks.

In the last 50 years, various university education models have emerged and have attempted to reconcile teaching with learning, according to the principle that students should lead their own learning process. Perhaps one of the most successful models is PBL that came out of the English-speaking environment. There are many descriptions of PBL in the literature, but in practice there is great variability in what people understand by this methodology. The original conception of PBL as an educational strategy in medicine was initiated at McMaster University (Canada) in 1969, leaving aside the traditional methodology (which is often based on lectures) and introducing student-centered learning. The new formulation of medical education proposed by McMaster did not separate the basic sciences from the clinical sciences, and partially abandoned theoretical classes, which were taught after the presentation of the problem. In its original version, PBL is a methodology in which the starting point is a problem or a problematic situation. The situation enables students to develop a hypothesis and identify learning needs so that they can better understand the problem and meet the established learning objectives [ 3 , 4 ]. PBL is taught using small groups (usually around 8–10 students) with a tutor. The aim of the group sessions is to identify a problem or scenario, define the key concepts identified, brainstorm ideas and discuss key learning objectives, research these and share this information with each other at subsequent sessions. Tutors are used to guide students, so they stay on track with the learning objectives of the task. Contemporary medical education also employs other small group learning methods including CBL and TBL. Characteristics common to the pedagogy of both CBL and TBL include the use of an authentic clinical case, active small-group learning, activation of existing knowledge and application of newly acquired knowledge. In CBL students are encouraged to engage in peer learning and apply new knowledge to these authentic clinical problems under the guidance of a facilitator. CBL encourages a structured and critical approach to clinical problem-solving, and, in contrast to PBL, is designed to allow the facilitator to correct and redirect students [ 5 ]. On the other hand, TBL offers a student-centered, instructional approach for large classes of students who are divided into small teams of typically five to seven students to solve clinically relevant problems. The overall similarities between PBL and TBL relate to the use of professionally relevant problems and small group learning, while the main difference relates to one teacher facilitating interactions between multiple self-managed teams in TBL, whereas each small group in PBL is facilitated by one teacher. Further differences are related to mandatory pre-reading assignments in TBL, testing of prior knowledge in TBL and activating prior knowledge in PBL, teacher-initiated clarifying of concepts that students struggled with in TBL versus students-generated issues that need further study in PBL, inter-team discussions in TBL and structured feedback and problems with related questions in TBL [ 6 ].

In the present study we have focused on PBL methodology, and, as attractive as the method may seem, we should consider whether it is really useful and effective as a learning method. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness (in terms of academic performance and/or skill improvement) of the method is still under discussion. This is due partly to the methodological difficulty in comparing PBL with traditional curricula based on lectures. To our knowledge, there is no systematic scoping review in the literature that has analyzed these aspects.

The main motivation for carrying out this research and writing this article was scientific but also professional interest. We believe that reviewing the state of the art of this methodology once it was already underway in our young Faculty of Medicine, could allow us to know if we were on the right track and if we should implement changes in the training of future doctors.

The primary goal of this study was to appraise available international evidence concerning to the effectiveness and usefulness of PBL methodology in undergraduate medical teaching programs. As the intention was to synthesize the scattered evidence available, the option was to conduct a scoping review. A scoping study tends to address broader topics where many different study designs might be applicable. Scoping studies may be particularly relevant to disciplines, such as medical education, in which the paucity of randomized controlled trials makes it difficult for researchers to undertake systematic reviews [ 7 , 8 ]. Even though the scoping review methodology is not widely used in medical education, it is well established for synthesizing heterogeneous research evidence [ 9 ].

The specific aims were: 1) to determine the effectiveness of PBL in academic performance (learning and retention of knowledge) in medical education; 2) to determine the effectiveness of PBL in other skills (social and communication skills, problem solving or self-learning) in medical education; 3) to know the level of satisfaction perceived by the medical students (and/or tutors) when they are taught with the PBL methodology (or when they teach in case of tutors).

This review was guided by Arksey and O’Malley’s methodological framework for conducting scoping reviews. The five main stages of the framework are: (1) identifying the research question; (2) ascertaining relevant studies; (3) determining study selection; (4) charting the data; and (5) collating, summarizing and reporting the results [ 7 ]. We reported our process according to the PRISMA Extension for Scoping Reviews [ 10 ].

Stage 1: Identifying the research question

With the goals of the study established, the four members of the research team established the research questions. The primary research question was “What is the effectiveness of PBL methodology for learning in undergraduate medicine?” and the secondary question “What is the perception and satisfaction of medical students and tutors in relation to PBL methodology?”.

Stage 2: Identifying relevant studies

After the research questions and a search strategy were defined, the searches were conducted in PubMed and Web of Science using the MeSH terms “problem-based learning” and “Medicine” (the Boolean operator “AND” was applied to the search terms). No limits were set on language, publication date, study design or country of origin. The search was carried out on 14th February 2021. Citations were uploaded to the reference manager software Mendeley Desktop (version 1.19.8) for title and abstract screening, and data characterization.

Stage 3: Study selection

The searching strategy in our scoping study generated a total of 2399 references. The literature search and screening of title, abstract and full text for suitability was performed independently by one author (JCT) based on predetermined inclusion criteria. The inclusion criteria were: 1) PBL methodology was the major research topic; 2) participants were undergraduate medical students or tutors; 3) the main outcome was academic performance (learning and knowledge retention); 4) the secondary outcomes were one of the following: social and communication skills, problem solving or self-learning and/or student/tutor satisfaction; 5) all types of studies were included including descriptive papers, qualitative, quantitative and mixed studies methods, perspectives, opinion, commentary pieces and editorials. Exclusion criteria were studies including other types of participants such as postgraduate medical students, residents and other health non-medical specialties such as pharmacy, veterinary, dentistry or nursing. Studies published in languages other than Spanish and English were also excluded. Situations in which uncertainty arose, all authors (CB, ES, RP) discussed the publication together to reach a final consensus. The outcomes of the search results and screening are presented in Fig.  1 . One-hundred and twenty-four articles met the inclusion criteria and were included in the final analysis.

Study flow PRISMA diagram. Details the review process through the different stages of the review; includes the number of records identified, included and excluded

Stage 4: Charting the data

A data extraction table was developed by the research team. Data extracted from each of the 124 publications included general publication details (year, author, and country), sample size, study population, design/methodology, main and secondary outcomes and relevant results and/or conclusions. We compiled all data into a single spreadsheet in Microsoft Excel for coding and analysis. The characteristics and the study subject of the 124 articles included in this review are summarized in Tables ​ Tables1 1 and ​ and2. 2 . The detailed results of the Microsoft Excel file is also available in Additional file 1 .

Characteristics of the 124 publications included in the scoping review

a The number of publications of each country appears in parentheses.

b Including: Bahrain, Iran, South Korea, Pakistan, Philippines, Singapore, Sri Lanka, Taiwan and Vietnam.

c Including: Belgium, Georgia, Netherlands and Sweden.

d Forty-eight studies included secondary outcomes: including student satisfaction (24), tutor satisfaction (9), knowledge retention (5), social and/or communication skills (5), reasoning (1) and other outcomes (4)

Study design according to main and secondary outcomes and continents

a Sample size was available in 99 studies. Results are expressed in median and [range]

Stage 5: Collating, summarizing and reporting the results

As indicated in the search strategy (Fig.  1 ) this review resulted in the inclusion of 124 publications. Publication years of the final sample ranged from 1990 to 2020, the majority of the publications (51, 41%) were identified for the years 2010–2020 and the years in which there were more publications were 2001, 2009 and 2015. Countries from the six continents were represented in this review. Most of the publications were from Asia (especially China and Saudi Arabia) and North America followed by Europe, and few studies were from Africa, Oceania and South America. The country with more publications was the United States of America ( n  = 27). The most frequent designs of the selected studies were surveys or questionnaires ( n  = 45) and comparative studies ( n  = 48, only 16 were randomized) with traditional or lecture-based learning methodologies (in two studies the comparison was with simulation) and the most frequently measured outcomes were academic performance followed by student satisfaction (48 studies measured more than one outcome). The few studies with the highest level of scientific evidence (systematic review and meta-analysis and randomized studies) were conducted mostly in Asian countries (Tables  1 and ​ and2). 2 ). The study subject was specified in 81 publications finding a high variability but at the same time great representability of almost all disciplines of the medical studies.

The sample size was available in 99 publications and the median [range] of the participants was 132 [14–2061]. According to study population, there were more participants in the students’ focused studies (median 134 and range 16–2061) in comparison with the tutors’ studies (median 53 and range 14–494).

Finally, after reviewing in detail the measured outcomes (main and secondary) according to the study design (Table ​ (Table2 2 and Additional file 1 ) we present a narrative overview and a synthesis of the main findings.

Main outcome: academic performance (learning and knowledge retention)

Seventy-one of the 124 publications had learning and/or knowledge retention as a measured outcome, most of them ( n  = 45) were comparative studies with traditional or lecture-based learning and 16 were randomized. These studies were varied in their methodology, were performed in different geographic zones, and normally analyzed the experience of just one education center. Most studies ( n  = 49) reported superiority of PBL in learning and knowledge acquisition [ 11 – 59 ] but there was no difference between traditional and PBL curriculums in another 19 studies [ 60 – 78 ]. Only three studies reported that PBL was less effective [ 79 – 81 ], two of them were randomized (in one case favoring simulation-based learning [ 80 ] and another favoring lectures [ 81 ]) and the remaining study was based on tutors’ opinion rather than real academic performance [ 79 ]. It is noteworthy that the four systematic reviews and meta-analysis included in this scoping review, all carried out in China, found that PBL was more effective than lecture-based learning in improving knowledge and other skills (clinical, problem-solving, self-learning and collaborative) [ 40 , 51 , 53 , 58 ]. Another relevant example of the superiority of the PBL method over the traditional method is the experience reported by Hoffman et al. from the University of Missouri-Columbia. The authors analyzed the impact of implementing the PBL methodology in its Faculty of Medicine and revealed an improvement in the academic results that lasted for over a decade [ 31 ].

Secondary outcomes

Social and communication skills.

We found five studies in this scoping review that focused on these outcomes and all of them described that a curriculum centered on PBL seems to instill more confidence in social and communication skills among students. Students perceived PBL positively for teamwork, communication skills and interpersonal relations [ 44 , 45 , 67 , 75 , 82 ].

Student satisfaction

Sixty publications analyzed student satisfaction with PBL methodology. The most frequent methodology were surveys or questionnaires (30 studies) followed by comparative studies with traditional or lecture-based methodology (19 studies, 7 of them were randomized). Almost all the studies (51) have shown that PBL is generally well-received [ 11 , 13 , 18 – 22 , 26 , 29 , 34 , 37 , 39 , 41 , 42 , 46 , 50 , 56 , 58 , 63 , 64 , 66 , 78 , 82 – 110 ] but in 9 studies the overall satisfaction scores for the PBL program were neutral [ 76 , 111 – 116 ] or negative [ 117 , 118 ]. Some factors that have been identified as key components for PBL to be successful include: a small group size, the use of scenarios of realistic cases and good management of group dynamics. Despite a mostly positive assessment of the PBL methodology by the students, there were some negative aspects that could be criticized or improved. These include unclear communication of the learning methodology, objectives and assessment method; bad management and organization of the sessions; tutors having little experience of the method; and a lack of standardization in the implementation of the method by the tutors.

Tutor satisfaction

There are only 15 publications that analyze the satisfaction of tutors, most of them surveys or questionnaires [ 85 , 88 , 92 , 98 , 108 , 110 , 119 ]. In comparison with the satisfaction of the students, here the results are more neutral [ 112 , 113 , 115 , 120 , 121 ] and even unfavorable to the PBL methodology in two publications [ 117 , 122 ]. PBL teaching was favored by tutors when the institutions train them in the subject, when there was administrative support and adequate infrastructure and coordination [ 123 ]. In some experiences, the PBL modules created an unacceptable toll of anxiety, unhappiness and strained relations.

Other skills (problem solving and self-learning)

The effectiveness of the PBL methodology has also been explored in other outcomes such as the ability to solve problems and to self-directed learning. All studies have shown that PBL is more effective than lecture-based learning in problem-solving and self-learning skills [ 18 , 24 , 40 , 48 , 67 , 75 , 93 , 104 , 124 ]. One single study found a poor accuracy of the students’ self-assessment when compared to their own performance [ 125 ]. In addition, there are studies that support PBL methodology for integration between basic and clinical sciences [ 126 ].

Finally, other publications have reported the experience of some faculties in the implementation of the PBL methodology. Different experiences have demonstrated that it is both possible and feasible to shift from a traditional curriculum to a PBL program, recognizing that PBL methodology is complex to plan and structure, needs a large number of human and material resources, requiring an immense teacher effort [ 28 , 31 , 94 , 127 – 133 ]. In addition, and despite its cost implication, a PBL curriculum can be successfully implemented in resource-constrained settings [ 134 , 135 ].

We conducted this scoping review to explore the effectiveness and satisfaction of PBL methodology for teaching in undergraduate medicine and, to our knowledge, it is the only study of its kind (systematic scoping review) that has been carried out in the last years. Similarly, Vernon et al. conducted a meta-analysis of articles published between 1970 and 1992 and their results generally supported the superiority of the PBL approach over more traditional methods of medical education [ 136 ]. PBL methodology is implemented in medical studies on the six continents but there is more experience (or at least more publications) from Asian countries and North America. Despite its apparent difficulties on implementation, a PBL curriculum can be successfully implemented in resource-constrained settings [ 134 , 135 ]. Although it is true that the few studies with the highest level of scientific evidence (randomized studies and meta-analysis) were carried out mainly in Asian countries (and some in North America and Europe), there were no significant differences in the main results according to geographical origin.

In this scoping review we have included a large number of publications that, despite their heterogeneity, tend to show favorable results for the usefulness of the PBL methodology in teaching and learning medicine. The results tend to be especially favorable to PBL methodology when it is compared with traditional or lecture-based teaching methods, but when compared with simulation it is not so clear. There are two studies that show neutral [ 71 ] or superior [ 80 ] results to simulation for the acquisition of specific clinical skills. It seems important to highlight that the four meta-analysis included in this review, which included a high number of participants, show results that are clearly favorable to the PBL methodology in terms of knowledge, clinical skills, problem-solving, self-learning and satisfaction [ 40 , 51 , 53 , 58 ].

Regarding the level of satisfaction described in the surveys or questionnaires, the overall satisfaction rate was higher in the PBL students when compared with traditional learning students. Students work in small groups, allowing and promoting teamwork and facilitating social and communication skills. As sessions are more attractive and dynamic than traditional classes, this could lead to a greater degree of motivation for learning.

These satisfaction results are not so favorable when tutors are asked and this may be due to different reasons; first, some studies are from the 90s, when the methodology was not yet fully implemented; second, the number of tutors included in these studies is low; and third, and perhaps most importantly, the complaints are not usually due to the methodology itself, but rather due to lack of administrative support, and/or work overload. PBL methodology implies more human and material resources. The lack of experience in guided self-learning by lecturers requires more training. Some teachers may not feel comfortable with the method and therefore do not apply it correctly.

Despite how effective and/or attractive the PBL methodology may seem, some (not many) authors are clearly detractors and have published opinion articles with fierce criticism to this methodology. Some of the arguments against are as follows: clinical problem solving is the wrong task for preclinical medical students, self-directed learning interpreted as self-teaching is not appropriate in undergraduate medical education, relegation to the role of facilitators is a misuse of the faculty, small-group experience is inherently variable and sometimes dysfunctional, etc. [ 137 ].

In light of the results found in our study, we believe that PBL is an adequate methodology for the training of future doctors and reinforces the idea that the PBL should have an important weight in the curriculum of our medical school. It is likely that training through PBL, the doctors of the future will not only have great knowledge but may also acquire greater capacity for communication, problem solving and self-learning, all of which are characteristics that are required in medical professionalism. For this purpose, Koh et al. analyzed the effect that PBL during medical school had on physician competencies after graduation, finding a positive effect mainly in social and cognitive dimensions [ 138 ].

Despite its defects and limitations, we must not abandon this methodology and, in any case, perhaps PBL should evolve, adapt, and improve to enhance its strengths and improve its weaknesses. It is likely that the new generations, trained in schools using new technologies and methodologies far from lectures, will feel more comfortable (either as students or as tutors) with methodologies more like PBL (small groups and work focused on problems or projects). It would be interesting to examine the implementation of technologies and even social media into PBL sessions, an issue that has been poorly explorer [ 139 ].

Limitations

Scoping reviews are not without limitations. Our review includes 124 articles from the 2399 initially identified and despite our efforts to be as comprehensive as possible, we may have missed some (probably few) articles. Even though this review includes many studies, their design is very heterogeneous, only a few include a large sample size and high scientific evidence methodology. Furthermore, most are single-center experiences and there are no large multi-center studies. Finally, the frequency of the PBL sessions (from once or twice a year to the whole curriculum) was not considered, in part, because most of the revised studies did not specify this information. This factor could affect the efficiency of PBL and the perceptions of students and tutors about PBL. However, the adoption of a scoping review methodology was effective in terms of summarizing the research findings, identifying limitations in studies’ methodologies and findings and provided a more rigorous vision of the international state of the art.

Conclusions

This systematic scoping review provides a broad overview of the efficacy of PBL methodology in undergraduate medicine teaching from different countries and institutions. PBL is not a new teaching method given that it has already been 50 years since it was implemented in medicine courses. It is a method that shifts the leading role from teachers to students and is based on guided self-learning. If it is applied properly, the degree of satisfaction is high, especially for students. PBL is more effective than traditional methods (based mainly on lectures) at improving social and communication skills, problem-solving and self-learning skills, and has no worse results (and in many studies better results) in relation to academic performance. Despite that, its use is not universally widespread, probably because it requires greater human resources and continuous training for its implementation. In any case, more comparative and randomized studies and/or other systematic reviews and meta-analysis are required to determine which educational strategies could be most suitable for the training of future doctors.

Acknowledgements

Not applicable

Abbreviations

Authors’ contributions

JCT had the idea for the article, performed the literature search and data analysis and drafted the first version of the manuscript. CB, ES and RP contributed to the data analysis and suggested revisions to the manuscript. All authors read and approved the final manuscript.

No funding was received for conducting this study.

Declarations

Not applicable for a literature review.

All authors declare that they have no conflict of interest.

Publisher’s Note

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