An Educational Approach to Problem-Based Learning

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AN EDUCATIONAL APPROACH TO PROBLEM-BASED LEARNING

Nan-Chieh Chen Department of Internal Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

This paper provides an analysis of the educational framework of problem-based learning (PBL). As known and used, PBL finds its root in the Structuralism and Pragmatism schools of philosophy. In this paper, the three main requirements of PBL, namely learning by doing, learning in context, and focusing on the student, are discussed within the context of these two schools of thought. Given these attributes, PBL also seems ideally suited for use in learning bioethics.

Key Words: pragmatism, problem-based learning, situated learning, structuralism (Kaohsiung J Med Sci 2008;24(3 Suppl):S23–30)

In simple terms, problem-based learning (PBL) is The most important characteristic of PBL is its a curricular design and pedagogical method which emphasis on individual independence and commu- focuses on the learner, using real-life problems and nication and discussion skills among group mem- situations to stimulate students’ learning. It is usu- bers. While quantitative research has shown PBL also ally carried out in small group discussions wherein changes the characteristics of a group, the changes specialized knowledge pertaining to the problem brought about by PBL in the students who apply it is derived. This teaching method was first used in should be studied using qualitative research. If we McMaster University in Canada, and it is most widely focus too much on quantitative research on PBL, then used for teaching clinical cases in medical schools. we would not be able to explain the fundamental Reviewing papers and articles that discuss PBL, the changes in learning methods. Strictly speaking, such bulk of the research performed on PBL is quantitative. an emphasis goes against PBL’s characteristic of em- The results of these studies clearly indicate students phasizing the individual. However, well-rounded who learn by PBL show obvious differences from qualitative research must also start from theoretical those who learn by more traditional means in terms discussions, using these to clearly establish the research of learning attitude, learning motivation, and learn- category; that is the purpose of this review article. ing methods. However, quantitative research results There have been many articles written about the fail to clearly explain what causes the obvious sequence of steps in the PBL process or the principle changes, and how the use of PBL fundamentally of teaching how to write cases, but this paper pro- changes students’ learning methods and cognitive vides an analysis and discussion of the deeper level processes. of the educational framework. There have been vari- ous debates on what school of thought PBL belongs to, but most discussions suggest it belongs to one of Address correspondence and reprint requests to: two schools. One is the Structuralism school of thought, Dr Nan-Chieh Chen, Department of Internal Medicine, College of Medicine, Kaohsiung and the other is the Pragmatism school of thought. Medical University, 100 Shih-Chuan 1st Road, The ties to pragmatism came about because one Kaohsiung 807, Taiwan. of the pillars of PBL is John Dewey (1859–1952); yet E-mail: [email protected] many important theories of learning are linked to

Kaohsiung J Med Sci March 2008 • Vol 24 • No 3 Suppl S23 © 2008 Elsevier. All rights reserved. N.C. Chen the Structuralism school of thought. The US-born realistic “problems” or “subjects.” Small groups serve Dewey’s thinking was greatly influenced by a fellow as the basic unit in which students discuss a problem American, William James (1842–1910), a doctor by with group mates, coming up with a hypothesis and profession. As known by most, William James is the attempting to solve the problem. father of the Pragmatism school of thought, and his Yet in the whole process of finding answers and Philosophy of Action greatly influenced American liter- solutions, the roles of the participants are limited to ature, art, and theater. Due to the influence of Dewey’s that of supporter and discoverer, and throughout the thinking, some articles classify Dewey’s learning theo- learning process, the main focus is on the learner. The ries under Pragmatism. purpose of PBL is to train students to look for an- However, many articles classify PBL under the swers themselves, and through this process to develop Structuralism school of thought. Both schools em- the ability to transform abstract concepts and knowl- phasize the learner’s role in building their own knowledge into practical and workable solutions, and be edge base, and formulating their own views of the able to formulate strategies that will solve the prob- world. However, our main goal is not to determine lems. All of these goals can be achieved with the which school of thought PBL belongs to; because PBL support of a tutor. was first introduced by Barrows, Moust, Bouhuijs and Aside from what has been mentioned above, there Schmidt, aside from vague references that its theories are articles suggesting PBL learning methods can also can be linked to Dewey’s views on education, it was help students build their social and communication also influenced by Structuralism. However, they did skills [1]. One good example is Germany’s Humboldt not go into detail regarding how Dewey’s views on University of Berlin Charité School of Medicine. In the education or structuralism are related to PBL. modern era, with its emphases on patient’s needs and Although the three main requirements of PBL— the doctor-patient relationship, this medical school learning by doing, learning in context, and focusing on started its PBL program in teaching medical commu- the student—repeatedly appear in different articles, nication, with remarkable results. Unlike most schools the backgrounds of these frameworks are not suffi- which teach Medical Communication Skills as a tradi- cient. Aside from these, we can clearly see the influ- tional theoretical subject starting from the fifth semes- ences of Pragmatism and Structuralism in the practice ter, Charité’s curriculum includes the subject as a of PBL, the framework of which is actually based on required course starting from the first semester and a combination of principles from both schools. This is continuing for nine semesters. Charité thinks establish- obviously related to North American education’s em- ing relationships and communicating with patients phasis on practical labor, and the tendency to over- can best be learned by students if they do in-depth look the theoretical sources of education. Due to this, research on the subject, and simulate interacting with this article will examine the theoretical framework of patients and applying what they learned [2]. PBL, so as to help students using PBL to develop PBL’s many functions and applications are not learning methods and understand the causes of fun- limited to medical education. Other disciplines like damental changes in the cognitive process, as well as mechanical engineering, law, business administra- offering theoretical explanations for these changes. tion, information systems, and education and special education widely use PBL. The main learning methods of PBL, namely learning by doing, learning in INTRODUCTION TO PBL TEACHING context and learner as the main focus, are what cause METHODS PBL methods to be widely applied in different disciplines. However, before discussing the framework of In recent years, PBL has become the driving force PBL, we need to first discuss Situated Learning, because behind changes in teaching methods in medical edu- it is an important interim phase in the formation of cation, and has brought about a shift in the teaching PBL teaching methods, especially of important PBL paradigm, becoming synonymous with fostering views like learning by doing and learning in context, independent thinking among students. Its main prin- both of which originated from the methods of situ- ciple is “problem-solving”, structuring teaching con- ated learning. If we want to talk about PBL, then we tent based on scenarios, but not veering away from have to discuss its predecessor, Situated Learning.

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In addition, this section will discuss the significance (the tutor) to do a ‘cock-eye’ to test his physiological of problem-solving and doing, two concepts that are functions. But the tutor cannot imitate the cock-eye, PBL’s main driving forces. so he just said, ‘I cannot do a cock-eye, but patients can. We used this technique to get to the main points of the case, and this greatly helped me to remember SITUATED LEARNING the learning goals and processes of this case study.” In this example, we can clearly see the tutor’s PBL was greatly influenced by Situated Learning, role-playing and his inability to act out the patient’s which is based on the belief that the generation of illness displayed a theater-like appeal and showed knowledge, its significance and the spreading of its the whole context of the situation, which strengthened significance are the responsibilities of society and the learner’s impression of the case; his interaction culture, because every area of knowledge is strongly with his peers in diagnosing the problem enhanced linked to culture; at the same time, the transmission the process of learning by context, and also improved of knowledge and absorption of knowledge by peo- the effectiveness of learning. We may find there are ple, as well as the process of demonstrating and two different learning contexts in this example. First transferring knowledge, will result in new contexts is the context already mentioned, learning in context; and situations. Simply put, the generation of knowl- the other is learning content in context. As a result, edge and situational contexts have a complementary whenever students talk about their experiences of the relationship, and knowledge gained through situa- International PBL Workshop at Kaohsiung Medical tional contexts is truly mastered knowledge. University, the learning process in this particular case Situated learning is one of the theories of Struc- study stand out. turalism, which stresses that the learner should be Moreover, situated learning consists of three main placed in the context of the situation, and not outside axes: first is the situation, which is the location or the of it. A person will only truly learn when immersed scenario of the learner; second is the problem, which is in the situational context. Because all knowledge is the topic that is as close as possible to the real world; rooted in situational contexts, the learner should un- third is doing (or action), which is the process of learn- dergo actual application and participation to really ing how to solve or handle the problem. Based on take hold of the knowledge. In relation to this view, these, we can see the difference between situated learn- situated learning believes the learning process should ing and traditional one-way, teacher-focused learning use instructional materials and activities that reflect lies in the following: situated learning stresses the un- reality, because if instructors teach using only theo- breakable link between cognition and context, learn- ries and abstract concepts, the learner would only ing results and the learning process, and knowledge know about new concepts and outdated concepts, but and practical application [3]. would not be able to connect, internalize and apply the knowledge. A holistic learning approach should integrate situations and context; this covers the com- THE SIGNIFICANCE OF PROBLEM-SOLVING munication between the learner and his peers, and the facilitator’s guidance and support. Communication PBL is based on the belief that the accumulation of with peers and the support of facilitators will enhance internalized experiences can help achieve the purpose the purpose, content and process of learning. The of learning, and that learning starts with an intention more intense the learning by context, the better the to solve problems. Problem-solving is a common oc- results will be. currence in daily life, and all human activities have As a student who attended an international PBL the goal of solving problems and dissolving danger. workshop wrote, “The case study that left the biggest Problems can refer to big and small difficulties and impression on me was when the tutor entered the challenges encountered in our daily lives, at work, classroom, imitated a patient, and told us where he’s and even in our social interactions with people. In having problems. I and my group-mates and the other reality, problem-solving is a requirement for man’s students started to diagnose him, and after asking survival, and is also man’s instinct. The learning mo- several questions, one student requested the patient tivations behind PBL are built on this survival instinct.

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In PBL, the constructed problems contain the pur- learner will discover the tactics and methods for pose of teaching and are used to stimulate students to solving the problem. From PBL’s viewpoint, learning learn by themselves. The theories of PBL can be traced has always been a proactive and constructive process, back to the psychological treatises on problem-solving and it is never a reactive reception of knowledge. Just by John Dewey (1910), Max Wertheimer (1945) and like Feyman said, “What I cannot create, I don’t under- Karl Duncker (1935). Among them, Dewey’s psycho- stand”. Whatever a person understands comes from logical analysis on thought and action has had the his thinking process or from his own conclusions/ biggest influence on PBL. Based on Dewey’s discus- interpretations. In other words, the learner not only sion points, Reusser simplified the problem-solving internalizes knowledge through PBL methods, but he process into a Table. also internalizes the whole problem-solving process. Based on this Table, we can clearly see that recognizing the problem is the first step towards solving the problem. Recognizing and being aware of the THE SIGNIFICANCE OF “DOING” problem are closely linked to personal experiences, because, in the process of recognizing the problem, As mentioned above, PBL was greatly influenced by one has to think back to past experiences or make Situated Learning. Although Situated Learning encoun- cognitive comparisons of existing knowledge. There- ters a topic and not necessarily a problem, students fore, we can reasonably conclude that problem-solving would have to undergo actual exercises with peers, should be directed at the problem-solver. In other known as doing (or action), to achieve the purpose of words, the learner is the main focus. Only when the learning. In PBL, topics are presented with open- learner recognizes a problem as the problem, will he ended questions, the purposes of which are to chal- be able to come up with the mechanism for solving lenge the learner’s problem-handling abilities, thus the problem. In addition, the Table shows us Dewey’s causing the learner to achieve the learning purpose discussion of problem-solving, which is actually a of the case study through problem-solving. Moreover, scaled-down model of PBL, thus showing PBL was problem-solving cannot be separated from concrete greatly influenced by Dewey’s concepts. actions such as pondering, formulating hypotheses In PBL, problem-solving actually plays two other or suggestions, evaluating, giving feedback and inter- important roles: problem-solving is the goal of learn- nalizing. Neither Situated Learning nor PBL can be ing, and is also the method of learning. The problems in removed from the domain of action. But then, what PBL case studies are the tasks the learner should re- educational significance does doing imply? In dis- solve himself. In the process of finding answers, the cussing this subject, we cannot fail to emphasize the

Table. Analysis of the complete process of thinking activities (the left column contains Dewey’s concepts, while the right column contains Reusser’s explanations) A felt difficulty Discovery of the problem: a gap in cognition, conflict, contradictions, imbalance, differentiating between motive and method; Confrontation with problem: initial awareness of the problem’s indistinctness. Its location and definition Defining the problem, analyzing the version language, meaning and motive Defining, establishing, and explaining part of the problem and the requirements of the problem. Suggestion of possible solutions Finding possible sources of the solution, reorganizing current knowledge; Formulating hypotheses; Devising a plan for solving the problem and a working plan. Development by reasoning of the Evaluating the hypotheses, engaging in critical thinking; bearings of the suggestion Synthesis of solving-steps, concretion and implementation of resolution. Further observation and experiment Evaluation, experiment and reflection; leading to its acceptance or rejection Deciding (accept or decline), communication about the solution.

Source: Reusser 2005, p164.

S26 Kaohsiung J Med Sci March 2008 • Vol 24 • No 3 Suppl An educational approach to PBL results of doing and their practical applications, and views and sentiments will be strengthened while how these are used to discuss the significance of doing. solving the case, because his personal experiences Pragmatism is different from the philosophy of and knowledge are drawn into the process; in short, Idealism, which emphasizes and validates the exis- the case study will highlight the problem-solver’s tence of the absolute mind, but Pragmatism is based strong individual beliefs. Aside from these, the meth- on the belief that absolute mind is the premise for ods for solving the problem will come in different a discussion of the rationale of individual reality, and styles and approaches, displaying diversity and plu- proposes that man cannot rely on this absolute help ralism. to return to the world of individual reality. However, Having elaborated on the topics of Situated Learn- it is also different from the general Materialism view ing, Problem-solving and Doing, we can now have a that denies the value of the absolute mind. Rather, clear idea of PBL’s outline and the genesis and devel- Pragmatism is based on the belief that, with the help opment of its three main concepts, learning by doing, of abstract cognition, man can still reside in individual learning by context, and learner as the focus. How- reality, and abstract concepts can merge with individ- ever, learning is a form of cognitive process, so if we ual reality. Thus, Pragmatism is not inconsistent with want to discuss the basic framework of PBL, we have the existence of an absolute mind. We can see from to discuss how PBL practitioners view the process of this that Pragmatism does not emphasize absolute gaining and accumulating knowledge. truth, but rather a pluralistic truth, wherein experiences which have unambiguous and functional value are considered truths. Simply put, it emphasizes the EPISTEMOLOGICAL FOUNDATION OF PBL effectiveness of truths. Under Pragmatism, as long as a line of thought is As mentioned above, PBL combines the educational able to produce practical results, then it can be recog- theories of Pragmatism and Structuralism. Hence, nized, believed and applied. In other words, to know before discussing PBL’s epistemological foundation, whether a concept or hypothesis is true or not, one we first have to separately discuss the epistemologi- has to check if it has utility (utilizable), and if the utility cal foundations of both schools of thought, and then is appropriate, suitable to the needs of everyday liv- do a comparison to remove any ambiguity regarding ing, and if it can be seamlessly integrated with expe- the sources of PBL’s epistemology. riences [4]. These arguments explain that actions form the basis for determining whether a line of thought Educational epistemology of Pragmatism or idea can produce practical results, and at the same Pragmatism is based on the idea that growth and time, whether in the act of doing the actions connect progress are the results of integrating internalized the mental concepts to the doer’s experiences. experiences and outside information. Then, through In the cognitive process, the process of accepting a repeated independent filtering process, experiences new ideas or new events is considered to be an em- and information are internalized as transformed expe- bedding process. This means that, in the process of riences. From the pragmatists’ viewpoint, experiences accepting new ideas and new events, we will use our that have undergone transformation become knowl- existing experiences and knowledge as the bases for edge. Cognition—absorbing experiences, transforming forming new interpretations, digesting and recreating experiences—is an unending process. Man’s experi- information, and then embedding them in our men- ences are combined and integrated into a structure, tal repository to create new truths. Simply put, prag- and the absorbed experiences undergo a continuous matists believe new truths are the improved results process of being destroyed and rebuilt. of combining old truths and new experiences; and The philosophy of Pragmatism was actually actions serve as the moving force in the combination greatly influenced by Darwin’s Theory of Evolution, and improvement processes. which states that, in the process of adapting to the In the process of solving problems, doing plays a environment, man needs to use his old experiences similar role, because actions connect information about as the bases for solving problems. In light of this, if he the problem at hand and the problem-solver’s exist- encounters a similar problem in the future, he would ing knowledge and concepts. The problem-solver’s naturally attempt to solve the problem on the basis of

Kaohsiung J Med Sci March 2008 • Vol 24 • No 3 Suppl S27 N.C. Chen his previous experiences first. Once the existing ex- interactions. The level of significance of an element periences proved insufficient to solve the problem, or should be determined based on the element’s role in if he encounters a more complicated and difficult sit- the whole structure. Besides, the relationships among uation, man would have to transform and enrich his structures can be complementary, independent, sub- experiences, and use them to face the new environ- ordinate, encompassing, excluding, or transforming. ment and situation. Pragmatism contains the idea that Moreover, the significance of a structure is defined by education is a continuous cycle of reconstructing ex- its interactions with other structures. periences, so as to increase the significance of these Generally speaking, structuralists believe that experiences, helping to strengthen man’s ability to man’s existence has an opposing relationship with control/take charge of his experiences. the outside environment. Man derives needed infor- Besides these, pragmatists consider learning as mation from the external environment, and at the same a step-by-step process of increasing knowledge, and time, man’s actions and behaviors need to undergo cognition lines up old concepts alongside new changes to adapt to the external environment. When knowledge; strictly speaking, the changes have an a new element from the outside enters a structure overall effect. In this basic concept, Dewey carefully and establishes relationships with the structure’s ele- expounded on his views on epistemology. His epis- ments, the whole relationship context and the entire temological concepts are deeply saturated with con- structure will undergo adjustments to accommodate cepts of pragmatism, for he believed all knowledge the inclusion of the new element. At this point, all of comes from action, and emphasized reflection in the elements which make up the structure will create action. At the same time, Dewey’s educational back- new relationships, causing a change in the funda- ground was greatly influenced by German idealism; mental nature of the whole structure in response to thus, his epistemology contains traces of metaphysics. the change in its environment. Dewey’s epistemology does not deny the exis- Structuralism contains the idea the learner pos- tence of an object; that is why he admitted experiences sesses the ability to construct knowledge, and that he have corresponding objects. In experiences, there is himself must construct knowledge. In his quest to a main object, with the body and soul on opposite understand, predict or control his environment, man sides, but these are human efforts. Experiences per se needs to establish his own worldview. Knowledge is are continuous, and all of the elements are related; built on the learner’s existing understanding of the strictly speaking, dualism does not exist. In other world; understanding happens in the process of inter- words, discussions on objectivity and dualism merely acting with the environment. During this interaction, represent an experience of self-awareness, not the man will discover and produce cognitive conflicts. existence of an entity. Experiences of self-awareness These cognitive conflicts arise from comparisons of can guide actions, and at the same time become part old and new experiences, which can stimulate learn- of the actions. Action results in experience, and expe- ing and create understanding or comprehension. We rience becomes knowledge after the process of self- have to carry out comparisons with other people awareness. We can see from this that Dewey’s (comparisons with other structures), share our un- epistemology, or Pragmatism’s epistemology, cannot derstanding of knowledge, and revalidate new infor- be separated from the domain of experience. mation based on acquired experiences, to build knowledge. Educational epistemology of Structuralism The fundamental thought of Structuralism, just like COMPARISONS AND QUESTIONS its name, proposes that existence is the result of a suc- cessive combination of many elements. From Struc- Both Pragmatism and Structuralism contain the idea turalism’s point of view, an independent element man’s cognitive process uses old experiences as bases does not have any significance. Every element is and that after accepting new information from the always connected to one or more similar elements, external environment it reorganizes and produces or to one or more different elements; the significance a new model of foundational experience. This type of of these elements is based on these connections and integration and change is necessary for survival. Both

S28 Kaohsiung J Med Sci March 2008 • Vol 24 • No 3 Suppl An educational approach to PBL philosophies contain the idea the initial needs of cog- rather, it is proactive, but also reactive learning. For nition and survival instincts and related and cogni- example, the learner is usually under pressure from his tive activities cannot exist outside of daily living. At peers to proactively seek related materials to solve the the same time, both philosophies agree the individual problem. This type of proactive and reactive learning possesses the ability to proactively construct his cog- method has not yet been thoroughly researched, and nitive world. The individual also has the ability to could be a topic for future research. evaluate whether new information is worthy of being included as an element of his cognitive world. Re- garding how new information is interpreted and un- POSSIBLE INTEGRATION OF PBL derstood, the individual has to confirm the new TEACHING METHODS AND MEDICAL information based on his existing experiences. ETHICS COURSES Based on this comparison, these two philosophies certainly have similarities in their epistemologies, In this concluding section, we must mention the in- especially in their beliefs that cognition is based on teresting subject of whether PBL methods and human existing experiences and that, after absorbing new in- medical ethics courses can be integrated, as brought formation, the experiences are reorganized, produc- up in the IPWK Communication Conference. Regret- ing new experiential models. Simply put: learning is tably, this subject was not thoroughly discussed. As a relearning process. previously discussed, PBL’s main requirements are: What PBL does is to take the common points of learning by doing, learning in context, and learner as Pragmatism and Structuralism, and use them in its the main focus. These concepts are structured on the teaching methods. From the comparison above, we premise that knowledge should be transformed into can see that PBL acquires its cognitive theories from something the student can apply in daily life, or the similarities between these two educational episte- knowledge that can be applied in actual clinical ses- mologies; this is the source of the disagreements sions, not merely piece-by-piece or conceptual knowl- among many documents written about the subject. edge. This is the reason why PBL can be widely used After comparing and validating the concepts of these in medical schools. two kinds of epistemology, we discovered that, in In reality, ethical reasoning happens in actual reality, the educational theories of PBL and Prag- interpersonal relationships; what is discussed is the matism are more aligned, because Pragmatism and issue that actually happened between people. Every PBL both originated from North America, and be- person’s definition and interpretation of his rela- cause the application of PBL methods is strongly tional context with another will vary according to the linked to Pragmatism’s popularity in North America. person’s culture, thinking, educational background, However, we cannot dismiss those who say PBL is financial status, and even occupational background. the product of Structuralism: owing to the influences Hence, the ethical discussions that arise from inter- of technological integration and globalization, it would personal relationships are diverse. I believe ethical be acceptable if PBL used some of the educational the- reasoning happens in the context of interpersonal ories of Structuralism. In terms of application though, relationships, so we must apply the technique of I think it is more appropriate to classify PBL under learning by doing in teaching ethics. Moreover, inter- Pragmatism. personal relationships have a dynamic nature, which Now the question is, do these two schools of means that they change over time, so ethical discus- thought encompass all of PBL’s learning methods? sions that arise from interpersonal relationships are I think this is worth studying and evaluating. In terms also evolving. of the learner’s learning methods, both Pragmatism For a topic that is constantly evolving, if we don’t and Structuralism emphasize the subject’s independ- learn in context, then the knowledge gained would ence, and his proactive way of acquiring knowledge. likely not be useful and would not help us associate We need to discuss this topic because in the PBL pro- the concepts; it might even be considered an out- cess, the learner expands his learning horizon by dated doctrine. Abstract reasoning concepts would interacting and discussing with his peers in a small be of little help to students who have to face many group. The learning method is not always proactive; kinds of interpersonal ethical issues. The aim of ethics

Kaohsiung J Med Sci March 2008 • Vol 24 • No 3 Suppl S29 N.C. Chen classes is not to teach students about doctrinal right have rendered the diagnoses of PBL cases as tempo- and wrong, but to enable students to learn how to rary and appropriate to the present situation. Basically, face and resolve often complex and intertwined ethi- the PBL case questions used in clinical medicine classes cal issues. Aside from these, a person’s interpretation are, to some extent, open questions. This situation is of an interpersonal relationship reflects his personal the same as dealing with ethical questions, for which lifestyle; thus, we can see the person’s characteristics there are no standard answers! in interpersonal relationships. Teaching on ethical reasoning should give importance to the learner’s individual thinking. These individual thinking styles ACKNOWLEDGMENTS can be stimulated and reasoned out in small group discussions, thus leading to a diverse understanding I would like to thank Professor Keh-Min Liu for his and interpretation of ethical issues, as well as the constructive suggestions for this paper and Professor learner’s individual beliefs. Based on these, ethical J. Chen for her support in translation. discussions should be focused on the learner. Ethical discussions using PBL are necessary and appropriate. Some might suggest PBL should not be REFERENCES used to teach a subject that has no correct answers and no standard answers, such as ethics. However, 1. Burger W, Kiessling C. Psychosoziale aspekte im reform- with the advances in medical technology, changes in studiengang medizin der Charité. Abschlussbericht für die Carl-Gustav-Carus-Stiftung. Berlin 2004:3–4. the concepts and definitions of diseases have led to the 2. Terzioglu P, Jonitz B, Schwantes U, et al. Kommunikative present state of clinical medicine, in which medical und soziale kompetenzen: vermittlung muss im medi- professionals are used to facing the challenge of having zinstudium beginnen. Deutsches Ärzteblatt 2003:458–61. no correct or standard answers. What sample cases 3. Reusser, K. Problemorientiertes lernen- tiefenstruktur, gestaltungsformen, wirkung. Beiträge zur Lehrerbildung present is limited to certain situations and medical 2005;23:159–82. conditions. As such, problems cannot encompass all 4. James W. Pragmatism: A New Name for Some Old Ways of aspects, and the rapid advances in medical technology Thinking (1907). F.Q. Publishing 2007.

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