R e v i e w a r t i c l e P r o b l e m B a s e d C u r r i c u l a a n d P r o b l e m B a s e d L e a r n i n g in P h y s i o t h e r a p y : A C r it ic a l R e v ie w A B S T R A C T : Introduction: Problem based curricula and problem based learning are used extensively to facilitate learners to become effective learners and through that, effective professional problem solvers. The basic characteristics o f the problem based curriculum and the processes o f the problem based learning are described in the literature but many variations o f problem based learning and the problem based curriculum exist. Research findings are also contradictory regarding the effectiveness o f these approaches. The aim o f this article is to discuss the theoretical foundation o f these approaches and to identify the core issues that must be addressed in order to optimize their effect on learners. M ethodology: A literature search was done by using the follow ing keywords: problem based curriculum, problem based learning, clinical decision making, clinical problem solving, clinical judgem ent, physiotherapy, medicine, health care, and health care education. Discussion: There is a lack o f research in the literature that shows evidence that the problem based curricula and problem based learning is more beneficial f o r students’ learning or mastering specific competencies than learning in a traditional curriculum. Papers on problem based curriculum and problem based learning describe the process and state the desired effects o f the teaching approaches without explicitly describing the contextual and transactional environments, as well as the internal (departm ental) environment in which the change in teaching approach took place and how it was adapted to their situation. Furthermore, no research could be fo u n d on ways to address the negative outcomes o f problem based learning. There is thus a need f o r well designed research protocols to show the best evidence o f physiotherapy educational practice. KE YW O RD S: PROBLEM BASED CURRICULA, CLINICAL DECISIO N MAKING, CLINICAL JUDGEMENT, HEALTH CARE EDUCATION. INTRODUCTION P ro b le m b ased c u rricu la and p ro b lem b ased learning h av e b ee n d ev e lo p e d as te ach in g ap p ro ach es as a resu lt o f lec­ turers striv in g to so lv e the p ro b lem s th at learn ers in the h ealth ca re field ex p e ­ rien c e in clin ical p roblem so lv in g w hen c o n fro n te d w ith p atien t care (B oshuizen a n d S c h m id t, 1995). P h y s io th e ra p y te a c h e rs a re in c lu d e d in th is g ro u p . In co m p eten ce in clinical p roblem solving is a resu lt o f le a rn e rs ’ c o n stra in e d p e r­ c e p tio n s o f th e re la tio n sh ip b etw e en k n o w led g e g ain ed d u rin g fo rm al te ac h ­ in g in p h y sio th erap y and the essen c e o f p atien t care. L earn ers ex p e rien c e th e acq u isitio n o f k n o w led g e in ‘c la s s ro o m s ’ as a p re ­ req u isite fo r th e ap p licatio n o f k n o w l­ ed g e in clin ical practice. T his im plies th at they h av e to m em o rise facts and c o n c e p ts in o rd e r to a p p ly th em in c lin ic a l p ra c tic e . It also im p lies the m e m o risatio n o f sk ills and tech n iq u es, to b e ab le to rep e at and ap p ly them in c lin ic a l p ra c tic e . W h e n le a rn e rs are co n fro n ted w ith clin ical p rac tice they assu m e th a t the k n o w led g e they h av e acq u ired is su fficien t to m ake th em s u c ­ cessfu l p ractitio n ers. T h is leads to the m isco n cep tio n th a t k n o w led g e o f facts, co n cep ts, skills and tech n iq u es is the essen c e o f p h y sio th erap y p ractice. T h e co n tin u o u s k n o w led g e ex p lo sio n ex p e rien c ed by all h ealth ca re p ro fe s­ sions leads to stifling the alread y con- te n t-cram m ed cu rricu la. T h e em p h asis on co n ten t-b ased c u rricu la is reflec te d in the a ssessm en t p rac tice o f h ealth care ed u catio n (Tow le, 1991). T his em p h asis on c o n ten t in the a ssessm en t o f learners p ro m o tes m em o risatio n o f k n o w led g e. T his is o b se rv e d by th e re se a rc h e r even in th e so -ca lle d p ro b lem b ased cu rricu la. M e m o risatio n is the lo w est fo rm o f learn in g an d takes p la ce w hen co n ten t is carefu lly p ack ag ed a n d /o r stru ctu red by the ed ucator and offered to the learner, w ho then p assiv ely ab so rb s an d sto res it in h is/h e r m em ory. T h e c o n s eq u e n ce is th a t the le arn er can o n ly rep ro d u ce w h at h as b ee n sto red , w ith o u t the co m p ete n ce o f being able to at least utilise it properly in re le v an t situ atio n s w ith w hich h e/sh e is co n fro n ted . A sse ssm e n t p rac tice in p h y sio th erap y ed u catio n th e re fo re has a C O R R E S P O N D E N C E TO: C A E k steen (B S c P hy sio ; M E d , P h D ) S en io r L ectu rer D ep a rtm en t o f P h y sio th erap y U n iv ersity o f P reto ria P . 0 . B ox 667 P re to ria 0001 Tel: (012) 354-1249 Fax: (012) 3 5 4 -1 2 2 6 E -m ail: ce k ste en @ m ed ic.u p .a c.za EKSTEEN C A, B.Sc Physio; MEd, PhD'; J A SLABBERT B.Sc Hons; MEd, PhD2 1 Departm ent o f Physiotherapy, U n iversity o f the Pretoria. Asso cia te Professor, Faculty o f Education, U n iversity o f the Pretoria. SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:ceksteen@medic.up.ac.za m ajo r in flu en ce o v er le arn er c o m p e ­ ten ce in clin ical p ro b lem solving. To tak e in itiativ e fo r learn in g m ean s to co llect, analyse, o rganise, and critically e v a lu a te c o n te n t o r k n o w le d g e w ith th e p rim a ry p u r p o s e to u tilis e th e k n o w led g e in practice. T h e d isc u ssio n in th e fo rm e r p a ra ­ g rap h s im p lies th at the ex p e cted o u t­ co m es in p h y sio th erap y e d u c atio n m ust be clo sely sc ru tin ise d to e n su re th at th e m is c o n c e p tio n s o f p h y s io th e ra p y p rac tice do no t o rig in a te in the ed u catio n thereof, in sp ite o f the b est o f intentions. T h e focal p o in t in p h y sio th erap y e d u c a ­ tion should rath er be the co n stru c tio n o f new m ean in g (d eep le arn in g ) th ro u g h p ro b lem solv in g , to h elp learn ers to not o n ly m eet, bu t also to ex ceed the d em an d in g ch a lle n g es o f the fu tu re in p h y sio th erap y practice. P h y sio th erap y p rac tice alw ay s c o n ­ stitu tes a p ro b lem to be solved as a p o in t o f departure. L earn in g physiotherapy can th e re fo re n o t be seen o u t o f the co n tex t o f p ro b lem solv in g . R e sea rch ers fo u n d th a t learn ers w ho learn th ro u g h so lv in g p ro b le m s a re a c tu a lly c o n s tru c tin g k n o w led g e o r m eaning, and th at th ese learners: - h av e a b etter lo n g -term m em o ry o f that k n o w led g e; - are ca p ab le o f recallin g the k n o w l­ ed g e w ith m ore ease than learn ers w ho m aster the k n o w led g e through tran sfe re n ce and m em o risatio n ; and - ca n u tilis e th e k n o w le d g e a p p r o ­ p riately to so lv e su b seq u en t p ro b lem s (S o lo m o n , 1994). T h e m a n n er in w hich learn ers learn and th e b as is on w h ich the learn in g is fo u n d ed th e re fo re has an in flu en ce on le a rn e rs’ ab ility to so lv e p ro b lem s in p ractice. T his o u g h t to be a fu n d am e n tal consideration in physiotherapy education. A c c o rd in g to Jo n e s , J e n s e n an d R o th stein (1995), kn o w le d g e as such ca n n o t be su fficie n t in so lv in g a p ro b lem in p ra c tic e , b e c a u s e p h y s io th e ra p is ts sh o u ld , in ad d itio n to k n o w led g e, be ab le to carefu lly co n sid er all factors p ertain in g to the p ro b lem o f a p atien t b efo re m ak in g a d ecisio n on th e w ay in w h ich to so lv e it m o st effectively. T h e au th o rs (Ib id ) d escrib e th e la tte r ty p e o f d e c isio n -m a k in g as ‘w ise a c tio n ’. T his w ise actio n is o f fu n d am en tal im p o r­ tance, b ec au se it im p lies an activ ity o r p ro cess (actio n ) o f u n iq u en ess and in g e ­ nuity (a ‘w ise a c tio n ’). T h is refers to the learn in g p ro cess o f p ro b lem solv in g , w h ere th e le a rn e r co n stru cts m ean in g w hen a c h a lle n g in g p ro b lem is solved. L earn in g can th e re fo re be d escrib ed as th e c o n s tru c tio n o f m e a n in g by the le a r n e r (S la b b e rt, 1996). M e a n in g (k n o w le d g e ) has to be c o n s tru c te d (g en e ra ted th ro u g h ‘w ise a c tio n ’). T h ese tw o very d istin ctiv e asp ects are th e re­ fo re d istin g u ish e d in p ro b lem solving, n am ely a p ro cess o f ‘w ise a c tio n ’ (co n ­ stru ctio n o f m ean in g ) and the co n ten t (k n o w led g e) th at has b een co n stru cted . M a n y v a ria tio n s o f th e p ro b le m based learn in g ap p ro ach are fo u n d in the literatu re d u e to the fac t th at ed u cato rs a d a p t th e p ro b le m b a s e d le a rn in g ap p ro ach to th eir sp ecific sta ff and e n v i­ ro n m en tal circu m stan ces. T h is m ak es a co m p ariso n b etw een a p ro b lem based learn in g ap p ro ach and a co n v en tio n al cu rricu lu m very d ifficu lt (H ayes, 1998). It p ro b ab ly also ex p lain s the d ifferen ce in research o u tc o m es w hy so m e P B L a p p ro a ch es ac h ie v e b etter results than the co n v en tio n al teach in g ap p ro ach and o th ers sh o w no d iffe ren ce b etw een the tw o ap p ro ach es. A p ro b lem em erg es from th e p rev io u s d isc u ssio n n am ely a lack o f u n d ersta n d ­ ing o f w hat th e fu n d am en tal co n trib u tio n o f the p ro b lem b ased cu rricu lu m and p ro b le m b a s e d le a rn in g a re b e fo re ad d re ssin g th e d iscu ssed p ro b lem s in ph y siotherapy education. If the suggested ap p ro ach es d o not in flu en ce th e w ay learners th in k and act th ere w ill be no d iffe ren ce fo u n d b etw een the p ro b lem based learn in g ap p ro ach and th e co n v e n ­ tional te ach in g ap p ro ach . T h e q u estio n then is: w h at are the co re asp ect(s) o f a p ro b le m b a s e d c u r ric u lu m a n d /o r p ro b lem based learn in g th at n eed to be ad d re ssed in o rd e r to en h a n ce le a rn e rs ’ clinical p ro b lem so lv in g ab ilities? T h e aim o f this article is to discuss th e th e o re tic al fo u n d atio n o f a p roblem b ased cu rricu lu m and p ro b lem based learn in g as te ach in g ap p ro ach es, to g iv e a b e tte r u n d e rs ta n d in g o f th e w ay s in w hich learn er p otential can be o p ti­ m ised. T h is article d o es n o t aim to g iv e th e a d v a n ta g es and d isa d v a n ta g e s o f each ap p ro ach , b u t rath er d isc u sse s how they c o m p lim e n t each o th e r an d w h at the fo u n d atio n al sh o rtco m in g s are. METHODOLOGY T h e m e th o d o lo g y fo llo w e d in th is article is an an aly sis o f p rac tice , based on a literatu re review . T h e k eyw ords used in the literatu re search w ere p ro ­ b lem b ased cu rricu lu m , p ro b lem b ased learning, clinical d ecisio n m aking, cli­ n ical p ro b lem so lv in g , clin ical ju d g e ­ m ent, p h y sio th erap y , m ed icin e, health care, and h ealth care ed u c atio n . T h e data b ases used fo r th e literatu re search w ere C u rre n t C o n ten ts: C lin ic al M ed icin e, C in ah l, M E D L IN E , P U B M E D , E R IC — C u rren t In d ex to Jo u rn als in E d u catio n (C IJE ), E x e rp ta M e d ic a , an d S o cial S cie n ce s C itatio n Index. T h e referen c e lists o f rele v an t articles w ere also hand s e a rc h e d fo r re le v a n t lite r a tu r e n o t fo u n d th ro u g h the elec tro n ic datab ases. T h e co re asp ects in the literatu re p e r­ tain in g to the asp ects co v ered by the key w o rd s w ere id en tified , an aly sed , sy n th e siz ed and d escrib ed to fo rm u late a fo u n d atio n fo r c u rricu lu m d e v e lo p m e n t and te ac h in g ap p ro ach (w h ich includes assessm en t o f learners) fo r physiotherapy ed u catio n . 1. Problem-Based Curriculum B a rr (1 9 7 7 ) d es crib es a p ro b lem -so lv in g c u rric u lu m d e s ig n fo r p h y sio th erap y . In this c u rricu lu m d es ig n c o n te n t is o rg a n is e d a ro u n d s im ila r p ro b le m s aro u n d a sp ecific them e. T h e o b jectiv es (lea rn in g o u tc o m es ) are fo rm u late d and th e c o n te n t fro m basic m edical sciences (social and m edical scien ces) need ed to so lv e the p ro b lem s, is ca te g o rised u n d er the d ifferen t b asic su b jects (fo r ex am p le anatom y, physiology, p ath o lo g y ) fro m w h ich k n o w led g e is b o rro w ed to solve the problem . T h e au th o r (B arr 1977) does not d e s crib e a ch a n g e in the te a ch in g ap p ro ach to g e th er w ith the ch a n g e in th e c o m p ila tio n an d o rg a n isa tio n o f the cu rricu lu m , a lth o u g h she d escrib es c riteria on h o w th e learn ers should go ab o u t w ritin g d o w n th e an sw e r to the p ro b lem o r so lv in g th e problem . A term that is used altern ativ ely w ith the p ro b lem b ased cu rricu lu m is the in te g rate d cu rricu lu m . ‘A n in te g rate d P B L cu rricu lu m fo cu se s all learn in g o f 24 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) co n ten t, in clu d in g b asic scien ce, aro u n d h e a lth 'c a re s c en a rio s’ (S a arin en -R a h ik a and Binkley, 1998). T h e ratio n ale b eh in d the re -o rg a n i­ satio n o f the cu rricu lu m , in the fo rm o f statem en ts an d p ro b lem s, is to en ab le learn ers to in teg rate k n o w led g e in o rd er to s o lv e p ro b le m s. L e a rn e rs sh o u ld th erefo re learn to: “ ...see relatio n sh ip s b e tw e e n th e d iffe re n t e le m e n ts an d p ro cess a variety o f co n cep ts an d data. T h e m o re co m p lex the p ro b lem the m ore d ata m u st be a n a ly se d an d sy n th esized an d the g rea ter the v ariety o f the sources o f the d ata (M ay, 1977)” . A cc o rd in g to B a rr (1977) a p ro b lem based cu rricu lu m enhances: • lifelo n g learning; • th e sh arin g o f k n o w led g e w ith fellow learn ers and co llea g u es o f o th e r d isc i­ plines; • ac tiv e in v o lv e m e n t o f th e le a rn e r th ro u g h h is/h er ed u catio n (learning). H ow ever, a p o ten tial p ro b lem in a p ro b lem b ased c u rricu lu m is th at the co n ten t o f d ifferen t su b jects fro m w hich learn ers m u st o b tain k n o w led g e in ord er to so lv e a p ro b lem is alread y integrated b y th e c u r ric u lu m s p e c ia lis ts . T h e learn ers are th erefo re p rese n ted w ith, to ld o r g u id ed ‘w h ich k n o w led g e to u s e ’, to solve the pro b lem . T h ey are thus d en ied the o p p o rtu n ity to id en tify the rela tio n sh ip s b etw een facts, co n cep ts, law s an d theories th em selv es. In the latter case, th e learn ers th erefo re do no t n eed to c o n s tru c t m ean in g (do d eep learn in g ), b ec au se the k n o w led g e has alread y b een c o n stru c te d fo r them . A t th e o th e r en d , S a a rin e n -R a h ik a an d B in k ley (1 9 9 8 ) rep o rts th at in c o m ­ p le te ly in te g ra te d p ro g ra m s, stu d en ts e x p e rie n c e re la tiv e ly h ig h le v els o f stress w h ich co u ld b e attrib u ted to the u n fam iliar le arn in g m eth o d , as w ell as the v o lu m e o f c o n ten t to be learned. In the p ro b lem b as ed cu rricu lu m as a w ay in w h ich learn in g is en h an ced the le ctu rer has a d ic h o to m o u s problem . O n the one h an d s/h e m u st facilitate learn in g in the learn ers, b as ed on the p rin cip le th at they m u st be ab le to start a sk in g q u estio n s, g ath erin g in fo rm atio n / k n o w led g e an d create a solu tio n to a p ro b lem w h ich is th e b est solution for th at p articu la r p ro b lem at th a t p articu lar tim e. O n th e o th e r h an d it is v ery d ifficu lt fo r stu d en ts to g ath er relevant in fo rm atio n / k n o w led g e fro m d ifferen t fields o f study i.e. p h y sics, chem istry, o r any o f the relev an t social scien ces, w ith ­ o u t som e fo rm o f stru ctu re such as a c u r ric u lu m in w h ic h th e c o n te n t is o rg an ised in a p re-selected sequence. A cc o rd in g to B arro w s an d T am blyn (1980), S o lo m o n (1994) an d K ru sem an (1 9 9 6 ) a p ro b le m b a s e d c u r ric u lu m d esig n g o es han d in h an d w ith a ch an g e in te a c h in g a p p ro a c h . T h e le a rn e rs are p rese n ted w ith a statem en t o r a p ro ­ b le m w h ich they m u st d iscu ss o r solve. (T h is p ro b lem is the stim u lu s w h ich facilitates learn in g ). T h ro u g h d iscu ssio n o f statem en ts an d the p ro cess o f finding a so lu tio n a n d /o r so lu tio n s to the p ro ­ b lem s learners m aster the relevant subject co n ten t. B e ca u se c o n ten t fro m d ifferen t su b jects is n ee d ed to solve a pro b lem , th e sta te m e n ts o r p ro b le m s th a t the learn ers m u st d iscu ss o r altern ativ ely so lv e are fo rm u late d aro u n d selected th em es b ased on k n o w led g e fro m d iffe r­ en t su b jects su c h as anatom y, p h y sio ­ logy, p ath o lo g y an d others. In an ap p lied scien ce such as p h y sio ­ therapy, relev an t k n o w led g e fro m , for exam ple, anatom y, physiology, pathology, p h y sic s, ch e m is try , e tc e te ra , is u sed to s o lv e p ro b le m s in p h y sio th e ra p y . O b tain in g k n o w led g e co m p els learners to a c q u ir e th e re le v a n t k n o w le d g e (e.g. p h y siology, anatom y, pathology, p h y sics, ch e m istry ) an d to use it in so lv in g the p ro b lem effectively. T h e fact that learn ers w h o are ed u c ated th ro u g h a p ro b lem b ased c u rricu lu m d o no t fare as w ell in term s o f b asic k n o w led g e about basic su b jects as th e ir co u n terp arts in trad itio n al ed u c atio n can b e attrib u ted to the fact th at in th e trad itio n al te ach in g o f a n a to m y fo r in sta n c e , le a rn e rs learn an ato m y fo r the sake o f an ato m y an d not anatom y as it is relevant to physiotherapy. In a p ro b lem b ased ap p ro ach , learners learn an a to m y as rele v an t to p h y sio ­ therapy. T h eir k n o w led g e b as e o f a n a to ­ m y p er se w ill th e re fo re b e o f a d ifferen t em p h asis (S o lo m o n 1994). H ow ever, C o u lso n an d O sb o rn (1983) fo u n d that afte r 12 w eek s, an d E ise n sta d t et al (1 9 9 0 ) fo u n d th a t afte r tw o y ears, there is n o lo n g er a d iffe ren ce in k n o w led g e base o f learn ers ed u c ated in the tw o a p p ro a c h e s . T h e re s u lts o f stu d ie s co m p arin g learn ers in a P B L c u rricu lu m p ro g ra m an d learn ers in a trad itio n al c u rricu lu m w ith resp e ct to o u tc o m es are d ifficu lt to in terp ret, due to p o ten tial c o n fo u n d in g facto rs an d a lack o f valid m e asu res o f clinical and p ro fessio n al p e rfo rm a n c e ( S a a r in e n - R a h iik a an d B inkley, 1998). W h a t is h o w ev er clear fro m this d eb a te is that the d iffe ren ce in basic k n o w led g e b ase is o n e o f q u a lity o f k n o w led g e v ersu s q u a n tity o f k n o w l­ ed g e . T h e fo rm e r is o f m u c h m o re im p o rta n ce in p h y sio th erap y p ractice. It is ob v io u s that alth o u g h th e p ro b lem b ased cu rricu lu m fo cu se s on relev an t k n o w led g e (q u ality ) n eed ed in th e d if­ feren t su b jects in o rd er to so lv e the pro b lem , su ccessfu l in teg ratio n b etw e en q u ality an d q u an tity o f k n o w led g e to en h a n ce the q u ality o f th e o u tc o m es is still p ro b lem atic. O f m ore im p o rta n ce is th at p ro b lem s (statem en ts) fo rm u late d in th e p ro b lem b ased c u rricu lu m sh o u ld be fo rm u late d on th e b asis o f an d in a c co rd an c e w ith th e b o d y o f k n o w led g e o f p h y sio th erap y as w ell as the m e th o d o lo g y o f the d is c i­ pline. S in ce it is the stru ctu re d isp lay e d by the b o d y o f k n o w led g e as w ell as the m e th o d o lo g y o f a d isc ip lin e th at m ak es it u n d erstan d ab le, le arn ab le an d u sab le (S ch w ab 1964), p ro b lem s fo rm u late d w ith o u t c o n s id e r in g th is w ill c a u s e d ifficu lty in d isc o v erin g th e rele v an t re la tio n sh ip b e tw e e n fac ts, c o n c e p ts, prin cip les an d law s on w h ich rea so n in g in the su b je ct d isc ip lin e (p h y sio th erap y ) is fo u n d ed . I f the p ro b lem s fo rm u late d to fac ilita te le arn in g o f p h y sio th erap y are n o t b ased o n th e b o d y o f k n o w led g e o f p h y sio th erap y as w ell as the m e th o d ­ olo g y o f th e d iscip lin e, the p ro b lem s m e n tio n e d b e fo re w ill b e p erp etu ated . In such a ca se the n ecessary co m p eten cies that le arn ers sh o u ld o b tain is n o t b ased on a co m p reh en siv e, in teg rated , h o listic co n cep tu alisatio n o f p h y sio th erap y p rac­ tice w h ich is req u ired o f p ro fessio n als. T h is c o n c ep tu alisatio n is found in the stru ctu re o f a d isc ip lin e w h ich co n sists o f tw o very sig n ific an t an d d istin ctiv e parts. A cc o rd in g to S ch w ab (1 9 6 4 ), a d isc ip lin e ’s stru ctu re c o n sists o f a body o f k n o w le d g e (c o n s tru c te d m e a n in g / k n o w n facts, p rin cip les, p ro cesses and rela tio n sh ip b etw een th em ) as w ell as SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 25 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) the w ay in w hich this b ody o f k n o w l­ e d g e c a m e in to b e in g (th e w ay in w h ic h m e a n in g is c o n s tru c te d a lso called the m ethodology o f the discipline). T h e se stru ctu res are ca lle d th e su b stan ­ tiv e and syntactical structure respectively. T he su b sta n tive stru ctu re o r b o d y o f k n o w le d g e (c o n s tr u c te d m e a n in g o r k n o w n co n ten t), c o n tain s th e co n ten t (facts, co n c ep ts, g en e ralisatio n s, p rin c i­ p les, law s, th eo ries and the in teg rated rela tio n sh ip b etw een th ese) w h ich m ay h av e a stru ctu ra l co m position, o r p rocess (p ro c e d u re , a c tio n , p ra c tic e , ro u tin e , m e th o d ) n atu re . P h y s io th e ra p y h as an essen tial p ro c ess n atu re as its s u b ­ sta n tive stru ctu re (b o d y o f k n o w le d g e ) b ec au se it c o n sists o f th e p ro cess o f ev a lu a tin g and trea tin g a p atie n t as its c o n te n t. T h e ‘s tr u c tu r a l’ k n o w le d g e u sed in p h y sio th erap y is not essen tially p h y sio th erap e u tic , b ec au se it rep resen ts th e r e le v a n t k n o w le d g e fro m o th e r d iscip lin es used in p h y sio th erap y . T he sy n tactical stru ctu re (th e w ay in w hich m ean in g is c o n stru c te d ) co n tain s the m eth o d o lo g y o f the d iscip lin e (th e scien ­ tific m e th o d o f in v estig atio n th ro u g h w h ich k n o w led g e in th e fo rm o f stru c­ tural c o n te n t o r p ro ce ss c o n te n t has been g en erated ). In the c a se o f ph y sio th erap y , it is the scien tific m e th o d o f in v e sti­ g atio n (m eth o d o lo g y ) th ro u g h w h ich the p ro ce ss o f ev a lu a tin g an d trea tin g a p atie n t (p ro cess co n ten t) is co n stru cted . A fter the la tte r is co n stru c te d , it ex ists as p ro cess c o n te n t an d can be e x e cu ted on a p atien t. T h e p ro b le m b as ed c u rric u lu m is o b v io u sly c o n c ern ed w ith the su b stan ­ tiv e stru ctu re (co n ten t) o f th e d iscip lin e. In research on the p ro b lem b ased c u r­ ricu lu m th ere is no e v id en c e th a t the p ro b lem s and the w ay in w h ich they are fo rm u late d are b ased on th e su b stan tiv e structure o f p h y siotherapy as a discipline. T his m ay be o n e o f th e rea so n s w hy th e p ro b lem b ased c u rricu lu m d o es no t fulfil th e e x p e cted o u tco m es in p h y sio ­ th erap y ed u catio n . 2 . Problem Based Learning (PBL) W ith p r o b le m b a s e d le a rn in g , the e m p h a sis m o v es fro m c u rric u lu m to learner. T h is rela tio n sh ip b etw een the p ro b lem b ased c u rricu lu m an d p ro b lem b a s e d le a rn in g is in d ic a te d by th e f o llo w in g q u o ta tio n fro m S o lo m o n (1994): “P B L is an ed u c atio n al p ro cess w h ere le a rn in g is c e n tre d a ro u n d p ro b lem s as o p p o se d to d isc re te su b je ct-rela te d co u rse s.” B oth B a rro w s (1 9 8 0 ) an d S ch m id t (1983) d e s crib e p ro b lem based learn in g as an ed u c atio n al ap p ro ach w h ich w as d ev e lo p e d to o v erc o m e p ro b lem s th at w ere e x p e rien c ed by m ed ical students in p ra c tic e . P ro b le m b a s e d le a rn in g w o u ld , ac co rd in g to th e au th o rs, en a b le learn ers to o b tain an in te g rate d su b ject k n o w led g e (b o d y o f k n o w led g e ) rela ted to the p ro b lem , as w ell as to d ev e lo p and en h a n ce p ro b lem so lv in g com petency. T h e p ro cess o f p ro b lem b ased le arn ­ in g as an ed u c atio n al a p p ro a ch can be d iv id e d in to fo u r steps, nam ely: i) c h a lle n g in g th e le a rn e rs (d iv id e d into sm all g ro u p s) w ith a p ro b lem o r statem en t; ii) sm all g ro u p d isc u ssio n by the le arn ­ ers; iii) se lf-stu d y by th e le arn ers o f the c o n te n t th a t they h av e to m aster; and iv) e x c h a n g e o f in fo rm a tio n a m o n g learn ers in the sm all group. T h e learn ers are ch a lle n g ed w ith a sta te m en t o r p ro b lem w h ich they h av e to reaso n , ex p lain o r solve. T h e statem en t o r p ro b lem is fo rm u late d in such a w ay th a t it d irects the le a rn e rs’ learning. S ch m id t (1 9 8 3 ), K ru sem a n (1996) and B a rro w s an d T am blyn (1 9 8 0 ) all d e scrib e seven steps by w h ich learners w o rk in sm a ll g ro u p s to s o lv e th e p ro b le m o r d e b a te th e sta te m e n t. A su m m ary o f the p ro ce ss th a t the learn ers m u st go th ro u g h in sm all g ro u p s, is m en tio n ed briefly: i) the e x p lan a tio n o f te rm in o lo g y and c o n c ep ts that they d o n o t u n d erstan d ; ii) d efin in g the p ro b lem (d u rin g this step the learn ers sh o u ld m ak e a list o f th e p h en o m en a w h ich n eed to be ex p lain ed ); iii) an aly sis o f th e p ro b lem in th a t the le arn ers d efin e as m any d iffe ren t ex p lan a tio n s fo r the p h en o m en a as p o ssib le by u sing p rev io u s k n o w l­ ed g e and c o m m o n sense; iv) th e d ra w in g -u p o f a s y s te m a tic re p re se n ta tio n o f the ex p lan a tio n s th a t are d ed u c ed fro m step 3 in o rd er to d e s crib e th e in fo rm atio n th ro u g h w h ich th e p h en o m en a are e x p lain e d in a c o m p re h en siv e p ro cess; v) fo rm u latio n o f learn in g o b jectiv es; vi) th e c o llec tio n an d assim ilatio n o f in f o rm a tio n d u r in g a s e lf-s tu d y p erio d o u tsid e th e g roup; and v ii)th e sh arin g an d in te g ratio n (sy n tax is an d te stin g ) o f th e n ew ly g ain ed k n o w led g e. T h e p u rp o se o f th e p rec ed in g steps is to h elp th e learn ers beco m e self-directed. S c h m id t (1 9 8 3 ) d e s c rib e s th re e fac to rs w h ich fa c ilita te learn in g th ro u g h th e p rec ed in g p ro cess o f p ro b lem b ased learn in g , nam ely: • d u rin g th e p ro ce ss th ro u g h w h ich k n o w led g e is o b ta in ed th e p re-k n o w l- ed g e w h ich the learn ers alread y h av e is ac tiv a te d (actu alised ). A cco rd in g to S c h m id t (1 9 8 3 ) le a rn in g is a restru c tu rin g p ro ce ss w h ich en ab les the le arn er to p ro cess new k n o w led g e a b o u t a p articu la r to p ic on the basis o f h is/h e r p re-k n o w led g e , in an ea sie r w ay; • th e g re a te r th e sim ila rity betw een the situ atio n th at is sk etch ed in the ‘p ro b le m ’ and reality, th e b etter th e le a r n e r ’s su ccess w o u ld be in th e e x e cu tio n o f th e learn in g action. T his is k n o w n as c o d in g -sp e cific ity ; and •. new k n o w led g e is b etter u n d ersto o d , p ro c e s se d an d re c a lle d i f learn ers h av e th e o p p o rtu n ity to elab o rate on th e k n o w led g e they h av e m astered, o r to e x p lain to fello w gro u p m e m ­ bers w h at they h av e learn ed . L earn ers are g iv en the o p p o rtu n ity d u rin g th e im p le m e n ta tio n o f p ro b le m b as ed le arn in g to ex p lain to th e ir p e e r gro u p w h at they h av e learn ed , to ed u c ate the gro u p there-in, to answ er questions a b o u t it an d /o r to d iscu ss a p articu la r topic, to w rite su m m aries ab o u t it an d to fo rm u late h y p o th eses a b o u t a g iv en p ro b lem a n d /o r to ev a lu a te it critically. A cc o rd in g to S o lo m o n (1994) le a rn ­ in g is also fac ilita te d by: • p ro v id in g a co n tex t in w h ich k n o w l­ ed g e can be recalled ; and • stim u la tin g learn ers to ex p a n d th eir k n o w led g e. 26 SA J o u r n a l o f Ph ysioth era p y 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) B arro w s and T am b ly n (1 9 8 0 ) em p h a ­ sise fu rth e rm o re th a t an a tm o sp h e re w h ic h e n h a n c e s le a rn in g in th e gro u p s should b e estab lish ed an d th a t c o -o p e ra tio n , m u tu a l su p p o rt o f o n e another, jo in t resp o n sib ility fo r gro u p fu n ctio n in g an d also critical ev a lu a tio n o f fello w g ro u p m e m b ers sh o u ld ch a ra c ­ terise th e fu n ctio n in g o f th e gro u p s in o rd er to o p tim ise learning. T h e fa c ilita tio n o f th e le a r n e r s ’ rea so n in g pro cess d u rin g th e so lu tio n o f th e p ro b lem is d ea lt w ith b y a fac ilita to r (educator or tutor). T he ed ucator (or tutor) m ay en co u ra g e learn ers d u rin g the e x e ­ cu tio n o f th e learn in g action, o r m ay in te rru p t the p ro cess to fo c u s th e ir a tte n ­ tio n o n a p articu la r asp ect, o r to re-direct the d iscu ssio n . T h e w ay in w h ich fa c i­ litatin g learn in g is d es crib ed in p ro b lem b ased learn in g m ak es it clea r th a t the ed u c a to r o r tu to r co n tro ls th e process. F a c ilita tin g th e le a rn e rs th ro u g h th e fra m ew o rk o f a c h a lle n g in g p ro b lem so th at the learn ers rem a in in a co n tin u o u s re la tio n sh ip w ith the learn in g ta sk is not the p rim a ry aim. A cc o rd in g to B a rro w s (1983) and S o lo m o n (1994) p ro b lem -b a sed le a rn ­ ing, as an ed u c atio n al m e th o d w ith in the p ro b lem o rien ted o r p ro b lem b ased cu rricu lu m , h as as a re su lt th at learners: i) a re m o re k n o w le d g e a b le in th e so lv in g o f pro b lem s; ii) b e c o m e lifelo n g learn ers; iii) d ev e lo p g o o d in terp erso n al skills; iv) d ev e lo p a p p lica tio n (and in teg ratio n ) o f c o g n itiv e , c o m m u n ic a tio n an d m a n ip u la tiv e co m p ete n cies in p ra c ­ tice; v) h av e b etter lo n g term m em o ry o f th e ac q u ired k n o w led g e; vi) are m o re m o tiv ate d to learn an d also p re fe r th e p ro b lem b ased learn in g ap p ro a ch to the trad itio n al w ay o f ed u c atin g ; and v ii)u se m o re h y p o th e sis-d ed u c tiv e re a ­ so n in g in th e so lu tio n o f p ro b lem s th an learn ers w h o are e d u c ated in tra d itio n a l w ay s an d w h o rea so n deductively. H o w ev er, P atel e t al (1 9 9 1 ) found e m p ir ic a lly th a t le a rn e rs w h o w ere ed u c ated by m ean s o f p ro b lem b ased learn in g in th e ir p articu la r e n v iro n m en t and sy stem m a k e s u b stan tia lly m o re m istak es in the e x p lan a tio n o f clin ical d iag n o stic fin d in g s th an learn ers w ho are ed u c ated in a trad itio n al cu rricu lu m . T h e rea so n fo r this p ro b ab ly lies in the fact that problem based learning enhances back w ard -reaso n in g (hypothetico-deduc- tiv e re a s o n in g ) to th e d e trim e n t o f th e m a s te rin g o f fo rw a rd -re a s o n in g (in d u ctiv e rea so n in g ) and fo rm a tio n o f so p h istica te d k n o w led g e w h ich is n ec es­ sary fo r m ak in g a d ia g n o sis an d w h ich is ch a racteristic o f e x p e rt clin ician s. T h ere is also co n c ern th a t th e ac h ie v em e n t o f learn ers (sh o rt-te rm rec all o f facts) w h o fo llo w ed th e p ro b lem b ased le a rn ­ ing ap p ro ach is o ften lo w er than th a t o f learn ers w h o w ere ed u c ated in the trad itio n al ap p ro ach , w h ere th e e m p h a ­ sis is o n b asic k n o w led g e. L o n g term rete n tio n o f facts is b etter in learn ers w h o are e d u c ated through a p ro b lem b as ed ap p ro ach . O n th e o th e r han d , s o m e r e s e a rc h e rs in d ic a te d th a t th e d if fe r e n c e in u ltim a te a c h ie v e m e n t b etw e en learn ers w h o are ed u c ated in th e trad itio n al w ay an d th o se w h o are ed u c a te d th ro u g h th e p ro b lem b as ed learn in g ap p ro a ch is n o t v ery sig n ifican t (N o rm a n an d S ch m id t 1992; K ru sem an 1996). T h e fac t o f the m a tte r is th a t p ro b lem based learning does not fulfil the expected o u tco m es o f p h y sio th erap y ed u c atio n in rela tio n to th e d em an d s o f th e future. R e flec tio n o n p ro b lem b as ed learning, as d escrib ed in th is p arag rap h , in d icates th a t th e es sen c e o f p ro b lem based le a rn ­ in g is situ ated in th e le a rn in g process. A ch a racteristic fea tu re o f th is learn in g sh o u ld b e th a t learn ers are ab le to act ‘w is e ly ’. T h e re can b e no d o u b t that ‘w ise a c tio n ’ has to b e in itiated . T h is can o n ly b e d o n e th ro u g h a c h a lle n g in g p ro b lem w h ich d em an d s ‘w ise a c tio n ’ to be ta k en . H o w e v e r, th e p ro b le m o b v io u sly n ee d s to d em an d n o t ju s t any ‘w ise a c tio n ’, b u t a p a rtic u la r ‘w ise a c tio n ’ w h ich w ill re su lt in th e b est solution to th e pro b lem . T his refers to the learn in g p ro ce ss (co n stru c tio n o f m e an ­ in g ) w h ich has to h av e its p articu la r co m p ete n cies d eterm in e d b y th e s y n ta c ­ tic a l stru ctu re (m eth o d o lo g y ) o f p h y sio ­ th erap y as a d iscip lin e. T h a t w h ich is r e v e a le d h e re is th e f u n d a m e n ta lly im p o rta n t re la tio n sh ip b etw e en p ro b lem b a s e d le a rn in g an d th e d ic h o to m o u s stru ctu re o f a d iscip lin e: the sy n tactical stru ctu re n ee d s to b e im p lem e n te d to d isc o v e r o r c o n s tru c t th e su b stan tiv e stru ctu re (S ch w ab , 1964) - w h ich is ex a ctly th e in te n tio n o f p ro b lem b ased learning. T h e o u tc o m e o f p ro b le m b a s e d learn in g h as the sam e sh o rtco m in g s as th a t o f th e p ro b lem b ased cu rricu lu m . T h e sh o rtc o m in g s in p ro b le m b as ed learn in g , h o w ever, are situ ated in the nature o f th e p ro b lem and th e d em a n d in g crite ria to w h ich a p ro b lem fo rm u late d b y th e le c tu re r u sin g th e P B L ap p ro ach sh o u ld ad h e re to in o rd er to co m p e l le arn ers to im p le m e n t th e p a r tic u la r learning p ro c ess unique to p h y siotherapy as a d iscip lin e. T h is co n stitu tes th a t the sy n tactical stru ctu re o f ph y sio th erap y , w h ich h as alre ad y b ee n es tab lish ed , is n o t to b e d istin g u ish e d from the ec le ctic co m b in atio n o f m an y th eo ries attem p tin g to q u alify p h y sio th erap y as a u n iq u e d iscipline. It is th e re fo re th e c o n c e iv a b le ab sen ce o f a d escrip tio n o f th e s y n ta c ­ tica l stru ctu re o f p h y sio th erap y as a d is c ip lin e w h ic h is th e b a s ic s h o rt­ co m in g giv in g rise to th e u n sa tisfac to ry o u tc o m e o f p h y s io th e ra p y e d u c a tio n , an d w h ich n ee d s to b e ad d ressed . CONCLUSION T h e p r o b le m b a s e d c u r r ic u lu m an d p ro b lem b ased le arn in g g o h an d in han d . W h ereas th e p ro b lem b as ed c u rricu lu m sh o u ld b e b a s e d o n th e s u b s ta n tiv e stru ctu re o f p h y sio th erap y as a d is c i­ pline, p roblem b ased learning e m p h asises th e in itiatio n an d th e p ro ce ss o f clin ical p ro b lem solv in g . T h e la tte r is ca lle d the sy n tactical stru ctu re o f th e d iscip lin e. T h is a p p ro a c h c la im s to e n h a n c e a le a rn e r’s ab ility to cre ate a stru ctu re in w h ich k n o w led g e can b e rec alle d and w h ich serv es as b asis fo r th e g en e ratio n o f n ew k n o w led g e (research in p h y sio ­ therapy). T he process learners use to solve a p ro b lem is a sim ila r p ro cess u sed to generate new know ledge in physiotherapy. To le arn effectiv ely a le arn er should n o t o n ly b e ab le to b e a v ersa tile learner, b u t also b e ab le to co n tro l his learn in g p ro c e s s (b e a m e ta - le a r n e r ) an d to a d a p t h is/h e r le arn in g strateg y to acq u ire th e r e le v a n t c o g n itiv e , p s y c h o m o to r a n d c o m m u n ic a tiv e c o m p e te n c ie s to c o m p le te th e le a rn in g task (S la b b ert SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 4 27 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 1988). T h e o u tco m es o f p ro b lem b ased learn in g th a t w ere m e n tio n e d serv e as an in d ic atio n o f th e resu lt o f p ro b lem b ased le a rn in g as a te a c h in g a p p ro a c h o n le a rn e rs ’ p erso n a l c o m p e te n c e to act professionally. P ap ers on p ro b lem b ased c u rricu lu m an d p ro b le m b ased learn in g d escrib e th e p ro ce ss o f h ow to so lv e a p ro b lem an d th e (d esired ) effects o f the te ac h in g ap p ro a ch es w ith o u t ex p licitly d es crib in g h o w it w as ad ap ted to the c o n te x tu a l an d tran sa ctio n al e n v iro n ­ m en ts, as w ell as th e in te rn al (d ep a rt­ m en tal) en v iro n m en t in w h ich th e te a c h ­ in g ap p ro ach to o k p lace. It is th e re fo re difficult to co m p are the results o f p roblem b ased learn in g ap p ro ach es w h ich w ere ap p lied in v ario u s cen tres. F u rth erm o re, n o rese arch c o u ld b e fo u n d o n w ays to ad d ress th e n e g a tiv e o u tc o m es o f p ro b lem b ased le arn in g ph y sio th erap y . T h ere is th u s a n ee d fo r w ell d esig n ed rese arch p ro to co ls to show th e b es t e v i­ d en ce o f p ro b lem b as ed c u rricu lu m and p ro b lem b as ed le arn in g as ed u c atio n al a p p ro a ch es in ph y sio th erap y . REFERENCES B a rr J S 1977 A P ro b le m -so lv in g C u rricu lu m D esign. Physical T herapy 57(3): 262-264 B arrow s H S 1980 P roblem b ased learning: A n A pproach to M edical E ducation. N ew York B arrow s H S 1983 P ro b le m -b a se d , S elf­ d irec te d learning. Journal o f the A m erican M edical A sso c ia tio n 250(22): 3077-3079 B arrow s H S, T am blyn R M 1980 Problem - b a se d le a rn in g : an a p p ro a c h to m ed ic al education. V olum e 1. 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