Which levels of education in medical sciences utilize most the Problem Based Learning?--A citation analysis study.
Hazrati, Hakimeh ; Gavgani, Vahideh Zare
Introduction
In recent years, crucial changes have taken place in the field of
clinical education. Now, the emphasis of medical education is on
applying learner-centered approaches based on problem solving and
students' active learning. (1) The aim of such methods is to
involve students in teaching-learning process in order to make learning
more effective, tangible, reflective, sel-directed, (2) and community
based (3-5). Problem Based Learning (PBL), as one of learner centered
adult-like based methods of education, tries to involve students'
persuasion and encouragement to determine their learning goals and
peer-learning and teaching (6) to increase their ability in deep
learning (7-8) and decision making. (9, 10) Since 1990, various studies
have investigated the effectiveness of PBL, (11-14) even on medical
competencies of students after their graduation, especially with regard
to their social and cognitive skills (15), to achieve basic knowledge,
critical thinking. (16) Since 2008, the PBL has gradually entered
Iranian medical education, but there are still doubts about shifting all
the curriculum to PBL or the use of PBL partially. A need for a basic
scientometric analysis of the contribution of world literature may
create evidence for this dilemma in Iran or other countries with a
similar history of implementing PBL in medical education.
Scientometrics visualizations bring in the light whether other
different countries have changed all of their medical education
curriculum to the problem-based learning or have applied PBL in some
courses beside traditional curriculum. In this study, the scientific
production of PBL in medical education during the last 10 years from
January 2003 to October 2013 in different countries has been
investigated.
Objectives
The main aim of this study was to visualize the implementation of
Problem Based Learning (PBL) at the levels of curriculum, course, or
lesson of medical education in the scientific productions indexed in Web
of Science (WoS) and PubMed and Iranian Databases of IranMedex, SID and
MagIran during 2003-2013, to create evidence on most implemented level
of education concerning PBL.
Key Words: Problem Based Learning, Evidence based education,
Scientometrics, Medical Education
Methods
A cross sectional observation and descriptive method was employed
to measure the scientific productions of PBL in medical education with
scientometrics and bibliometrics perspective. Focus question:
Which levels of medical education (curriculum, course or lesson)
mostly utilize the Problem Based Learning?
Secondary outcomes:
The proportion of articles with the primary aim of implementation
of PBL in educational levels, The leading country in producing the
articles with the mentioned primary aim The highly cited articles and
active authors in the subject.
The Share of Iranian authors and journals in producing articles
related to PBL in Medical education with the emphasis on the educational
levels of curriculum, course, and lesson.
Search Strategy:
Pub Med and ISI Web of Science / WoS (world's largest citation
database) and Iranian Databases of IranMedex, SID and MagIran were
searched in order to extract all the studies about PBL in medical
education on 24th of September 2013. The 'problem based
learning' AND 'Medical education' terms with appropriate
search strategies and phrases were searched in both the databases;
'all field' feature was applied to explore all of works in the
subject. The confounding phrase of 'problem solving' was
excluded.
Inclusion and Exclusion Criteria: only studies were eligible to
inclusion that reported use of PBL in one of three levels (curriculum,
course and lesson) of medical education without limitation in study
design.
As problem based medical education is a new educational method for
Iranian medical education, and it emerged since 2008, we limited our
search to 5 years before and after PBL was introduced into Iran's
medical education (from 2003 to 2013). Publication types on WoS may vary
from journal articles to letters, book reviews and proceeding papers or
editorials; therefore, we included only journal articles; the other
types of publications were excluded in the primary assessment of the
results of search. All the citations of conferences were excluded and
just the published articles in scientific journals were included.
Analysis:
All the selected articles from the pool of data were critically
reviewed by two experts and then categorized in three educational levels
(curriculum, course, and lesson) when their subject domain was
identified as relevant. Unrelated and duplicated titles were omitted;
discrepancy regarding the inclusion or exclusion of specific articles
between the reviewers was resolved by discussing. The analysis was done
based on scientometrics and bibliometrics indicators like number of
publication, citation counts and Journal Impact Factor, on the remaining
purely screened articles. Scientometrics is the study of quantitative
status of research through which the frequency of each country's
researchers, scientific courses, authors, impact of articles on
scientific community (6,7,8,9,10,11,12) and the authors'
contribution, subject dispersion and core journals in each course can be
determined (13). Bibliometrics is also the statistical analysis of
written publications, such as books or articles. In this study, we have
focused on the articles rather than books. The indicators which were
employed in this study are subject for both of the bibliometrics and
scientometrics analysis.
Results
A total number of 468 articles were found about PBL from the Web of
Science (WOS), ; among them 158 articles were unrelated and omitted from
this study. Also, 1103 articles were retrieved from PubMed, and 325
articles were deleted due to disagreement with the objective of study.
After primary review of titles and abstracts and elimination of [begin
strikethrough]the [end strikethrough] articles which were unrelated to
medical education and levels of education, altogether from the two
databases a total number of 1088 articles were found eligible to study;
all the data from Pubmed and WoS were mixed, and the duplicated items
were eliminated; hence, analysis was done on a total number of 843
articles (Figure 1).
A total number of 114 articles from Persian/Iranian databases of
SID (11), IranMedex (54) and MagIran(49) were found; among them 30 were
duplicated articles in primary assessment of titles, and 42 unrelated
articles in the process of critical appraisal were omitted; finally, 37
articles were included in the study. The analysis of world databases and
local Persian databases is presented separately.
Of all 843 articles regarding the application of PBL in levels of
education, the biggest proportion of 338 articles (42.7%) were related
to lesson, followed by curriculum with a slight differences, 335(42.3%),
and the smallest portion was related to course level with 119 (15%)
articles. It is notable that all Iranian PBL related articles were about
lesson. This represents that the educational level of lesson is the
dominant level in the implementation of PBL, in the global publications
of the last 10 years from 2003 to 2013, (in international and local
databases). Although the level of curriculum is very close to lesson in
ranking, the level of course shows a significant interval with both of
the preceding levels of lesson and curriculum.
Furthermore, the studies related to PBL in Medical Education have
an increasing trend at 3 levels of curriculum, course and lesson, and
this progressive trend is impressive about lesson. A little downfall
occurred in curriculum and course in comparison with lesson in 2013
compared to 2012 which is the representative of more application of PBL
as a single lesson, not applying it in all the educational plan or
special educational period (Figure1).
[FIGURE 1 OMITTED]
Contribution of different fields of health and medicine to PBL
articles in Medical Education
All the articles regarding health and medical educational fields
are divided into seven fields including Medicine (Anatomy, Physiology,
Surgery, Internal Medicine, Pediatrics, Anesthesiology); Dentistry;
Pharmacology; Midwifery; Nursing; Health and Paramedicine (Radiology,
Anesthesia, Laboratory Sciences). Generally the greatest portion of
articles on PBL in Medical Education (569, 67.5%) was published in the
field of medicine followed with Nursing (192 articles out of 843).
Analysis based on the levels of education showed that, in all three
levels the field of medicine was dominant, in curriculum which is the
largest portion among other levels, the field of Dentistry ranked
second, and in the level of course the field of Nursing stood in the
second rank after Medicine (Table 1). All of 37 articles extracted from
Iranian databases were related to the implementation of PBL in level of
lesson, and the field of medicine was known as the leading field.
Statistically significant relationship was found between the fields of
education and the educational levels (P=0.0001)
The proportion of the continents in scientific production of the
PBL article in 3 levels of curriculum, course and lesson
All the scientific productions (843 articles) on the application of
PBL in Medical Education were divided into 5 continents of Asia, Africa,
America, Europe and Oceania or Australia according to geographical
affiliation. Out of 843 articles, 78 had not determined their
geographical affiliation; therefore, 765 articles with identified
affiliations were analyzed to show the continents' share in
scientific productions related to PBL in levels of curriculum, course
and lesson.
America with 284 (37.12%) articles was known as the leading
continent in sharing scientific productions with all three levels of
education; in other words, they reported the use of PBL in medical
education in each three levels. In level of curriculum and Course Asia
and Europe respectively were known to have the second rank, but in the
level of lesson, Europe and Asia both stood in the second rank with
equal number of articles. The study found no statistically significant
relationship between the geographic distribution of articles and the use
of PBL in different levels of curriculum, course and lesson (P=0.93) in
medical education. (Table2)
Iran's share in scientific productions as a result of the
implementation of PBL in medical education
About 235 journals contributed in the publication of total number
of 853 articles; among them only one Iranian journal was listed with
publications in PBL on medical education, i.e. The Journal of Medical
Ethics and History of Medicine. Iran shared 6 articles in the subject
and ranked 17 among 21 countries like Singapore and Nepal, preceding the
countries Egypt, Hawaii and Korea (with 4 articles). Pakistan and
Denmark proceeded Iran with 7 and 8 articles, respectively.
The leading country, the core journal, and highly cited author were
assessed for scientometrics purpose. The most cited article in level of
lesson as well as the level of Curriculum belongs to UK with 541 and 196
citations, respectively. But regarding the course, the most cited
article is related to the field of Nursing and China with 201 citations.
(Table 4)
The core journal for PBL, in this study, was journal of Medical
Education from Wiley publication. (Table 4)
Considering more than 3 articles per author in PBL, 8 authors were
chosen as prolific/active authors in PBL in different subjects and from
different countries in PubMed and WOS (Table 5). Azer SA with 17
articles from Australia was the most prolific author in PBL, with
considerable difference with the other authors. Azer has cooperated in
scientific productions of 3 educational levels based on PBL respectively
in lesson, curriculum and course. Azer's articles in average had
17.78 citations from 2004 to 2013. Dolmans were the second active author
with 8 articles in Health and Medicine whose citation was on average
88.56 from 2008 to 2013. The least number of citations in this group
belongs to Shankar from Nepal with 4 articles whose citations were
averagely 7.5 in Medicine and Pharmacology from 2007 to 2013.
Discussion
The main aim of this study was to illustrate the share of PBL in
medical education with special emphasis on the educational levels of
curriculum, course, and lesson in the scientific productions indexed in
WoS and PubMed and Iranian databases of Iran Medex, SID, MagIran during
the years 2003-2013. The findings of the present study revealed that the
greater portion of scientific productions is related to curriculum;
therefore, it can be inferred that most of countries have implemented
PBL in their curriculum.
Analysis of extracted articles showed that Medicine has the most
citations on PBL, and Nursing, Dentistry and Pharmacology are in next
ranks. So it can be declared that PBL was applied more and in Medicine
compared to other health fields.
Among world's different continents, America has the most
scientific productions related to PBL , and Europe is the second
continent. This clearly represents that developed countries have
surpassed developing countries in implementing and presenting their use
of PBL in scholarly publishing; it also implicitly refers to change in
educational approach from traditional (lecture-based) to problem-based
method in these continents. Altogether, most scientific productions in
every three levels of curriculum, lesson and course belonged to America.
There is statistically a significant relationship between the
application of PBL and the educational levels of curriculum, course and
lesson (p=0.000). It may be inferred that the fields with more applied
lessons such as Medicine and Dentistry have entered PBL into their
educational plan. As Colliver says, if the entire educational plan is
involved, PBL's effects will be clearer, and the clinical and
educational skills will be invigorated. (17) and will merge basic and
clinical sciences; hence, learning occurs in community and will be
independent and reflexive (18).
This investigation showed that there is a gap between researches
and scientific productions related to PBL in Iran very little number of
articles are affiliated to Iran or indexed in Persian databases which
reveal that PBL is not prevalent in Iranian medical education. We infer
that PBL is implemented in Iranian medical education but not reported in
the literature. This inconsistency between the implementation and
publication may be addressed in feasibility of implementation of PBL in
developing countries like Iran that requires more educators and staff
training. (19) As Vahidi (2007) and Dianati (2012) numerated, the
students' reluctance and lack of acquaintance with team work as
basic problems and the barriers of PBL application from nursing
professors' viewpoint in Iran. (20, 21)
The trend of publication about PBL in Iran is rising and about 50%
of Iranians' scientific productions in PBL have published in the
latest year, 2013.
This study showed that there is no significant relationship between
the average count of citations and the mean of cited items. It means
that having more articles does not represent receiving more citations
and author's reputation. For example, Azer has most articles in all
3 levels, she is the fifth out of eight active authors considering the
mean of citations, but Dolmans' cooperation, as the second author,
was half of Azer's article and almost 5 times more than Azer's
citations (Table 4). The mean range of the publication of Azer's
articles' in years was older than Dolmans', and it cannot be
concluded that the number of citations increases as timepasses. This can
be considered as the weak point of scientometric indications and the
shortage of using citations in the length of a period to judge about the
efficacy of an article; In other words, getting 14 citation does not
mean the author's or article's efficiency. Therefore, there is
a need to use other such as the number of downloads, reference, marking,
tweeting and bookmarking as used in Altmetrics in order to determine
efficiency, effectiveness, and validity.
This article suggests that Medical Education in Iran should enter
PBL into the curriculum of practical fields of Medicine, Dentistry and
Nursing. And a mixed/hybrid method can be used in theoretical fields. As
Armstrong says, education will be more effective if different models are
applied. (22)
This study also suggests rigorous research studies on the
utilization of PBL in medical education in Iran to fill the evidence
gap.
Limitations
Scientific production on medical education may be scattered in
various international databases such as CINHAL, EMBASE, Psychinfo, Web
of Science, and Medline (/PubMed) as well as national databases of every
country and gray literatures. Also publication types may vary from an
editorial, letter, book chapter, proceedings, to articles .We just
selected Pubmed and Web of Sciences due to limitations in access to
other databases, and only articles published in journals indexed in the
mentioned databases; this can be known as access or publication bias,
especially in systematic reviews and limitation for this study.
Therefore, more studies may be conducted to figure out the more visible
depiction of scientific production in international databases.
Acknowledgements
This paper is based on a research project approved and founded by
the Educational Development Center (EDC) of Tabriz University of Medical
Sciences (Iran). We declare there is no conflict of interest financially
and ethically with this research.
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Hakimeh Hazrati Medical Education Research Center, Education
Development Center (EDC), Tabriz University of Medical Sciences, Tabriz,
Iran-tabriz, hakimeh.hazrati@gmail.com
Vahideh Zare Gavgani Health Services Management Research Center,
National Public Health Management Center (NPMC), Tabriz University of
Medical Sciences, Tabriz, Iran, vgavgani@yahoo.com
Running title: PBL in medical education
Caption: Figure 1: Trend of PBL articles in different levels of
education 2003-2013
Table 1. Distribution of PBL articles by field and education level
Field Curriculum Course N Lesson N Total P
N (%) (%) (%)
Medicine 262 66 241 569 P=0.0001
(46%) (11.6%) (42.4%)
Nursing 33 18 54 192
(31.4%) (17.2%) (51.4%)
Dentistry 38 7 19 188
(59.3%) (10.9%) (29.7%)
Pharmacology 11 24 18 42
(20.8%) (45.2%) (34%)
Health 11 5 14 59
(36.6%) (16.7%) (46.7%)
Para medicine 3 4 9 16
(19%) (25.0%) (56.3%)
Midwifery 3 0 3 6
(50.0%) (50.0%)
TOTAL 335 119 338 843
(42.3)% (15.0)% (42.7)% (100.0%)
Table 2. Distribution of PBL articles by educational level and
continent
Educational America Europe Asia Africa
Level N (%) N (%) N (%) N (%)
Curriculum 107 (33.5%) 80 (25%) 88 (27.6%) 25 (7.8%)
Course 45 (%40.5) 32 (28.8%) 20 (18%) 4 (3.6%)
lesson 132 (39.4%) 80 (23.9%) 80 (23.9%) 13 (3.8%)
TOTAL 284 (%37.1) 192 (25%) 188 (24.6) 42 (5.5)
Educational Australia Total P
Level (%) N (%)
Curriculum 19 (2.8%) 319 (41.7) P=.093
Course 10 (9%) 111 (14.5%)
lesson 30 (8.9%) 335 (43.8%)
TOTAL 59 (7.7%) 765 (100%)
Table 3: Highly cited articles and journals publishing scientific
productions on PBL based on educational levels
Title Author Country Field
ABC of learning and teaching Wood, DF UK Medicine
in Medical--Problem based
learning
Problem-based learning: future Dolmans Netherlands Medicine
challenges for educational
practice and research
Psychiatr The effectiveness of McParland UK. Psychiatry
problem-based learning M
compared to traditional
teaching in undergraduate
psychiatry.
Medical Simulation-based Steadman USA Medicine
training is superior to RH
problem-based learning for the
acquisition of critical
assessment and management
skills.
General competencies of Prince KJ Netherlands Medicine
problem-based learning (PBL)
and non-PBL graduates.
A comparison of the effects of Tiwari A China Nursing
problem-based learning and
lecturing on the development
of students' critical thinking
Problem-based learning Hoffman, K UK Medicine
outcomes: Ten years of
experience at the University
of Missouri-UK School of
Medical
Experience-based learning: a Dornan, T Medicine
model linking the processes
and outcomes of medical
students' workplace learning
First year medical student Moffat, KJ UK Medicine
stress and coping in a
problem-based learning
Faculty development for Farmer EA. South Dentistry
problem-based learning. Australia
Title Type Journal IIF Date
ABC of learning and teaching lesson BMJ 17.215 2003
in Medical -Problem based
learning
Problem-based learning: future lesson Med Edu 2.639 2005
challenges for educational
practice and research
Psychiatr The effectiveness of lesson Med Educ 2.639 2004
problem-based learning
compared to traditional
teaching in undergraduate
psychiatry.
Medical Simulation-based lesson Critcal 6.124 2006
training is superior to Care
problem-based learning for the Medical
acquisition of critical
assessment and management
skills.
General competencies of lesson Med Edu 2.639 2005
problem-based learning (PBL)
and non-PBL graduates.
A comparison of the effects of Course Med Edu 2.639 2006
problem-based learning and
lecturing on the development
of students' critical thinking
Problem-based learning Curriculum Academic 3.292 2006
outcomes: Ten years of Medical
experience at the University
of Missouri-UK School of
Medical
Experience-based learning: a Curriculum Med Edu 2.639 2007
model linking the processes
and outcomes of medical
students' workplace learning
First year medical student Curriculum Med Edu 2.639 2004
stress and coping in a
problem-based learning
Faculty development for Curriculum Eur J 1.01 2004
problem-based learning. Dent
Educ
Title citation
ABC of learning and teaching 541
in Medical -Problem based
learning
Problem-based learning: future 439
challenges for educational
practice and research
Psychiatr The effectiveness of 419
problem-based learning
compared to traditional
teaching in undergraduate
psychiatry.
Medical Simulation-based 256
training is superior to
problem-based learning for the
acquisition of critical
assessment and management
skills.
General competencies of 206
problem-based learning (PBL)
and non-PBL graduates.
A comparison of the effects of 201
problem-based learning and
lecturing on the development
of students' critical thinking
Problem-based learning 196
outcomes: Ten years of
experience at the University
of Missouri-UK School of
Medical
Experience-based learning: a 175
model linking the processes
and outcomes of medical
students' workplace learning
First year medical student 171
stress and coping in a
problem-based learning
Faculty development for 147
problem-based learning.
Table 4. The most cited authors and their cooperation in
problem based learning with emphasis on educational level
row Author N of Country Subject
papers
1 Azer SA 17 Australia Medicine
Dentistry
2 Dolmans DH 8 Netherlands Health,
Medicine
3 McLean M 7 South Africa Medicine
4 Papinczak T 7 Australia Medicine
5 Jacobs J 6 USA Medicine
6 Watmough S 4 UK Medicine
7 Williams B 4 USA Nursing
8 Shankar PR 4 Nepal Medicine
Pharmacology
row Level < Year> Citation
1 lesson =8 2004-2013 17.76
Curriculum =6
Course =3
2 lesson =5 2005-2013 88.57
Curriculum =3
3 lesson =1 2003-2007 17.57
Curriculum=6
4 lesson =3 2007-2011 26.57
Curriculum=3
Course =1
5 lesson =3 2003-2008 16.4
Curriculum =3
6 2006 22.25
7 lesson =3 2004-2013 19.75
Curriculum =1
8 lesson =3 2007-2014 7.5
Curriculum=1
