A traveller had lost her way, so she asked a passer by whether he could tell her how to reach her destination. "Yes", he replied, "But I would not start from here".
The teaching programmes of some health care training schools seem to be about as helpful as this man's advice. In stead of starting where the students are interested and motivated, with the real problems of ordinary patients, they overwhelm the students with endless and apparently irrelevant facts, facts and yet more facts. This is suffocating to their interest and motivation.

Gradually this old fashioned pattern is becoming less popular and many established medical schools have abandoned it for a completely opposite pattern, which shifts the emphasis to the problems which students will meet in their practice.
The idea to focus teaching on real problems is not new. An electronics teacher called Shoemaker was teaching radio technicians about electronics in Georgetown during the Second World War. He became tired of teaching formally about valves, condensers, ammeters and much else. He decided instead to provide students with radios, which did not work, and then told them that their tasks was to figure out how to make the radios work. And if they were interested and puzzled about a transformer or a condenser, he told them that there were books and he would happily talk to them about it. He was amazed at how more rapidly these students became effective and efficient radio technicians than with those whom he had taught previously through lectures. He called this "learning in a functional context", and this is how more and more medical schools are developing new teaching programmes.
This kind of learning is now called Problem Based Learning (PBL) most of the time.

PBL has been adopted, indeed welcomed, as the method to win the interest of health care students; in just the same way mechanics learn to repair technical problems by presenting them real problems from practice.
In PBL a carefully designed problem is given to students who are divided in small groups. The problem is almost always a patient about whom some facts are given. Each group then discuss the problem, notes what information is given, and then debates what further information is needed, what questions have to be answered in order to understand the problem better. The members of the group guided; not dominated by their tutor, than agree what questions each will study. The tutor encourages them when they set about reading, seeking the help of other staff members, or looking for useful books and journals in the library. When the group reassembles, they each bring the results of their study and so they together learn much around the original problem.

Working in small groups is not the method of traditional teaching programmes when the students wait to receive a lecture, do not organise their own learning, and are basically passive. In PBL students are active, they direct their learning and are not dependent on lecture after lecture.

It has been shown by educational research workers that students learn very little when they listen to a lecture, more when the lecturer uses pictures and diagrams, and most of all when they are given things to do as part of this learning. This principle of learning can be summed up by the old Chines proverb:
Hear and forget....see and remember.....do and understand.

PBL is an educational approach that tries to make the learning of students as active as possible, the "do and understand" of this proverb.

PBL and Community oriented, or Community based Medical Education

PBL is a method-but it is not the end in itself. It must be used in the education of health workers which is based on relevant health problems of unchallengeable relevance. The WHO stresses that PBL used in this way is a very valuable approach. PBL then becomes the servant of community oriented medical education.
Sometimes new ideas and innovations in education are called community-based or problem based, as were the two are the same. They are not. The overriding goal of community based is to ensure that the doctor and other health care workers focuses on the community-its needs, its structure, its health education and promotion, its service, and much else. There is inevitable less emphasis on high technology and sophisticated tertiary curative medicine. PBL is an educational tool in which relevant problems in the community can be brought to the students in order to give them an opportunity to study these problems in a self directed way. But PBL is a method which can be used also in curative medicine and other disciplines like management, engineering and law. Than problems from these fields are offered to students to study in a self directed way.

PBL, Leprosy and Tuberculosis

There are so many reasons, apart from purely educational reasons, to support PBL in TB and Leprosy training. The incidence and prevalence of leprosy are changing in different countries. MDT has had a dramatic effect and leprosy is no longer the disease as it was 20 years ago. Teaching and learning must reflect these developments. The students must be prepared for today's problems. Sometimes leprosy is combined with another disease, or leprosy is just one of the possible diseases that present in small clinics or dispensaries. TB now appears in all possible forms as the result of the HIV infection and is a massive international health care problem. It can mimic so many diseases.
Traditional discipline oriented education would not be very effective in such circumstances. But to equip students to confront difficult problems, whether in diagnosis and treatment, in complications of the disease or due to treatment, in community impact or education, and in health service organisation, whether in a small clinic or in a region of a country, PBL is admirable. The student who has learned through PBL has already met the unknown, tackled the unexpected and been prepared for the unfamiliar. A student should be well aware of the curative, social, economic and managerial problems of TB and leprosy.