Problem-Based Learning: Assumed and assigned roles in Medical education

Based on an ethnographic study in which seven medical students enrolled in problem-based learning medical education were observed and interviewed during clinical practice. It became clear that clinical practice requires medical students to assume two distinctly different roles depending on the specifics of the situations in which they find themselves. While they are sometimes expected to contribute to the treatment of patients on a par with the doctors, at other times they are perceived as students who are still in the process of becoming doctors. Adapting to the demands of these roles requires students to be able to switch between two different ways of thinking about the nature of the different responsibilities that follow from these roles. As students they are responsible for learning whereas the role of doctor requires them to feel responsibility for the treatment of patients.
The aim of this paper is to explore how a problem-based learning curriculum assumes students’ to adapt to various roles and how students experience these roles during clinical practice.
An ethnographic study was conducted at Aalborg University Hospital involving 200 hours of participant observation and 10 hours of semi-structured interviews. The fieldnotes and interviews were analysed thematically.
The findings illustrate how a problem-based learning curriculum influences medical students’ abilities to handle the responsibilities for learning as well as treatment of patients allowing them to assume the role of medical student and doctor at various times depending on the context.
Keywords: Medical education, professional identity, transition, work-based learning, preparedness Type of contribution: PBL research
Introduction
PBL originated in medical education to enable a smoother transition of medical students into clinical practice and prepare them better for the work as doctor (Boud & Felitti, 1998).
In PBL, students work in collaborative groups to identify what they need to learn in order to solve an authentic problem (Dolmans, De Grave, Wolfhagen & Van Der Vleuten, 2005). They engage in self-directed learning and apply their prior knowledge to the problem and reflect on what they have learned (Hmelo-Silver, 2004). The intention of PBL include helping students develop flexible

knowledge, problem-solving skills, self-directed learning skills, collaboration skills, and intrinsic motivation (Hmelo-Silver, 2004).
The medical education at Aalborg University is based on a combination of PBL and clinical practice and the signature pedagogy of this medical education can be defined as learning for work, learning at work and learning from work, with an emphasis on observation, social interaction and supervision in an authentic environment (Billet, 1994).
The purpose of this paper is to explore how a problem-based learning curriculum assumes students’ to adapt to various roles and how students experience these roles during clinical practice.
Method
Because of my specific concern with how PBL supports medical students in changing between different roles, learning environments, and social groups in their everyday work life. Data was produced using participant observations and semi-structured interviews. I carried out the observations to capture students’ social acting in the clinical practice and go beyond what they say to what they do.
A thematic analysis of the fieldnotes from the participant observations and the semi-structured interview was conducted to identify and analyse themes and categories.
Results
Below an example from the results of one medical student are presented illustrating three main themes: “Role as a doctor” and “Role as a student” & “The role of problem-based learning”.
Role as a student:
“The morning conference is about to start, and the doctors are busy preparing their presentation of the ward cases. I am seated with the medical students, along the wall as we are told. Even though, there are several empty seats around the table in the conference room, no one of us are invited to take a seat at the table and join the discussions. I got this strange feeling of “us and them”, because of the way the room is furnished and the missing interaction between the doctors represented at the conference and the medical students”. (Maria, 5th year graduate medical student)
In this situation, the medical students are not encouraged to contribute to the discussion of the ward cases. It becomes clear that the medical students are attending to the conference as learners and not as an integrated part of the professional community and they are assigned the role as students. In the situation described above the medical students’ primary responsibility is to acquire new knowledge and develop the ability to self-directed learning, problem-solving which is supposed to support their ability to handle other demanding situations.

Role as a doctor:
“Her supervisor askes her if she is prepared to carry out the consultation on her own, which she accepts. Shortly after we leave the office and walk down the aisle toward the patient who is waiting for a consultation according to the cancer treatment. She is obviously nervous, she blush and speak in a faltering voice to the patient. [...] on her own in the examining room, responsible for asking the right questions, acting and thinking like a doctor.”
(Maria, 5th year graduate medical student)
In this situation the medical student is assigned the role as doctor. In a demanding situation like this, the ability to employ the acquired knowledge and problem-solving skills, self-directed learning skills, collaboration and communication skills, becomes important.
The role of problem-based learning:
“Maria is told to update the patient’s medication list by her supervisor. At first, she hesitates to assume the task, but the supervisor encourages her to try and she finally agree. [...] While watching her sitting by the computer searching for information about medicine, I ask her where she acquired the knowledge to solve a case like this? By reading plenty of patients’ records, but primarily it is the case-work at the university and the clinical practice, that has prepared me and developed that kind of thinking about what is important and how to get one's priorities right.”
(Maria, 5th year graduate medical student)
In this situation the medical student rapidly adapt to the requirements of the task and are expected to switch role from student to doctor in a few seconds. She emphasize that PBL case-work at the university and case-work in the clinical practice, has developed the ability to adapt to the requirements of demanding situations and switch between different ways of thinking.
Conclusion
The findings indicate that PBL competencies such as problem-solving, self-directed learning, ability to reflect on what they learned, collaboration, and communication skills influence the abilities of medical students to adapt to the requirements of the roles they are expected to assume in the clinical setting. This leads us to the conclusion that the PBL curriculum in medical education has an important and meaningful role to play in supporting the medical students’ ability to handle the responsibilities for learning as well as treatment of patients allowing them to assume the role of medical student and doctor at various times depending on the context.