Educational Strategies Viewpoint: Leaving the “Empty Glass” of Problem-Based Learning Behind: New Assumptions and a Revised Model for Case Study in Preclinical Medical Education

The popularity of problem-based learning (PBL) reflects medical educators’ recognition that case study can enhance the preclinical medical school curriculum. However, the PBL method itself has features, particularly its reliance on small-group work with tutor–facilitators, that are expensive to implement and that limit the potential educational value of case study. The author systematically analyzes specific aspects of the PBL methodology and concludes that the PBL approach misuses the faculty, tends to compromise the authenticity of cases, and results in an unnecessarily varied and impoverished educational experience for students. Approaches to case study with different assumptions need to be devised. A model is proposed that shifts the goal of case study from development of problem-solving skills to development of ideas that allow meaningful engagement in sophisticated discussions of medicine. In this model, the method shifts from self-directed learning to independent study guided by the expertise of the faculty. One possible approach to case study based on this model is briefly described. It consists of reading published cases from the medical literature, with analysis and discussion of the cases led by faculty experts in largegroup format. The approach immerses students in an authentic, state-of-the-art discussion of medicine and is easily incorporated into any curriculum structure at limited cost. The author argues that, contrary to the claims of proponents, the glass is “mostly empty” for PBL and that we can generate the higher-level discussion that case study merits only by moving away from PBL’s extraneous assumptions. Acad Med. 2007; 82:479–485. Recently in this journal, Distlehorst and colleagues1 reported their experience comparing a problem-based learning (PBL) track with a parallel standard curriculum track at Southern Illinois University School of Medicine (SIUSM) and concluded that for PBL, the glass was “half full.” This optimistic conclusion was based on the outstanding performances of PBL-track students in some clerkships (notably psychiatry) and the lack of evidence that students choosing the PBL track were disadvantaged in any measurable way. PBL has dominated the discussion of curriculum for several decades, and reports such as Distlehorst et al’s abound. These studies, with their confounded results (in this case by, among other things, the profile characteristics of the self-selected PBL students), their weak effects,2 and their futile preoccupation with “outcomes,”3 distract attention from a long-overdue inquiry into the philosophical foundations of PBL and analysis of the question of whether the PBL method can even theoretically maximize the potential of case study. This is especially important given the costs and difficult logistics of