history: from those who wrote it
The process of problem-based learning: what works
and why
Henk G Schmidt,1 Jerome I Rotgans2 & Elaine HJ Yew3
OBJECTIVES In this review, we portray the
process of problem-based learning (PBL) as a
cognitive endeavour whereby the learner
constructs mental models relevant to problems.
Two hypotheses are proposed to explain how
learning is driven in PBL; an activation–
elaboration hypothesis and a situational
interest hypothesis.
METHODS Research relevant to these hypoth-
eses is discussed. In addition, research studying
the effects of various support strategies used in
PBL is reviewed. Finally, we summarise a num-
ber of recent studies in which a new ‘micro-
analytical’ methodology was used to trace the
process of PBL in the natural classroom setting.
CONCLUSIONS We conclude that there is
considerable support for the idea that PBL
works because it encourages the activation of
prior knowledge in the small-group setting
and provides opportunities for elaboration on
Medical Education 2011: 45: 792–806
doi:10.1111/j.1365-2923.2011.04035.x
1
Department of Psychology, Erasmus University, Rotterdam,
the Netherlands
2
Centre for Research in Pedagogy and Practice, National Institute of
Education, Nanyang Technological University, Singapore,
Singapore
3
Centre for Educational Development, Republic Polytechnic,
Singapore, Singapore
792
that knowledge. These activities facilitate the
comprehension of new information related to
the problem and enhance its long-term
memorability. In addition, there is evidence
that problems arouse situational interest that
drives learning. Flexible scaffolding provided
by cognitively and socially congruent tutors
also seems to be reasonably effective, as
opposed to ‘hard’ scaffolding represented by,
for instance, worksheets or questions added to
problems. Small-group work protects against
dropout and encourages students to study
regularly. Initially, students do not study
much beyond the learning issues generated;
the development of personal agency in self-
study needs time to develop. The extent of
learning in PBL results from neither group
collaboration only (the social constructivist
point of view) nor individual knowledge
acquisition only; both activities contribute
equally to learning in PBL.
Correspondence: Professor Henk G Schmidt, Department of
Psychology, Erasmus University, Burgemeester Oudlaan 50,
Rotterdam 3062 PA, the Netherlands. Tel: 00 31 10 408 1749;
Fax: 00 31 10 408 9009; E-mail: schmidt@fsw.eur.nl
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
 What works and why in problem-based learning
INTRODUCTION
In this article we review current knowledge about
what works in problem-based learning (PBL) and
why it works. We will not attempt here to review the
entire literature on the topic; the database PubMed
alone presents over 5000 articles that use the term
‘problem-based learning’ in their titles or abstracts.
Nor will we make another attempt to review out-
comes of PBL schools in comparison with those
using conventional curricula. Curriculum compari-
son studies have been reviewed extensively over the
past 20 years.1–6 Here, we will focus on reviewing
studies that have examined what happens to the
learner in PBL in order to elucidate the process that
unfolds when students try to learn new material
through this approach to learning. However, we
must first establish which learning process we refer
to. In an earlier paper, we suggested that there are at
least three different perspectives on PBL in the
literature: PBL as a ‘process of inquiry’; PBL as
‘learning to learn’, and PBL as a ‘cognitive
constructivist’ approach, which defines the purpose
of PBL as helping students to construct mental
models of the world.7 Fortunately, all three per-
spectives concur on the following PBL-defining
characteristics: (i) problems are used as a trigger
for learning; (ii) students collaborate in small
groups for part of the time; (iii) learning takes place
under the guidance of a tutor; (iv) the curriculum
includes a limited number of lectures; (v) learning is
student-initiated, and (vi) the curriculum includes
ample time for self-study.8–12 As only the cognitive
constructivist approach has led to a sizable volume
of research, we will confine our review to this
interpretation.
In this paper we will first briefly describe the
process of PBL, emphasising that it is a special way
of acquiring knowledge of a domain. Secondly, we
will interpret learning in this approach in terms of
two hypotheses derived from cognitive psychology –
the activation–elaboration hypothesis and the
situational interest hypothesis – and review the
evidence supporting these. Thirdly, we will look at
research into the educational aids intended to
support learning based on problems, including: the
problems; the tutorial group; the tutor; scaffolds,
and the self-directed learning activities of the
students. Finally, we will discuss a number of
recently conducted studies in which attempts were
made to chart the learning process in PBL in the
natural classroom setting using a micro-analytical
methodology.
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
THE PROCESS OF PBL FROM A COGNITIVE
CONSTRUCTIVIST POINT OF VIEW
The following description of the process of PBL will
be brief because its constituent elements from the
perspective of the cognitive constructivist framework
have been sketched previously.7 In PBL, learners are
presented with a problem in order to activate their
prior knowledge. This prior knowledge is then built
upon further as the learners collaborate in small
groups to construct a theory or proposed mental
model to explain the problem in terms of its
underlying causal structure. As learners continue to
study related resources, their initial mental model is
further modified and refined. Moreover, as the
learners’ preconceptions are activated, they become
more easily able to identify gaps in their prior
knowledge, thus enabling better learning to take
place (the activation–elaboration hypothesis). Motiva-
tional processes support these cognitive changes.
Situational interest is aroused by the enigmatic
nature of the problem and acts as the motivating
force that drives the learner to engage with the
literature and to continue to seek relevant informa-
tion until his or her hunger for new information
related to the problem is satisfied (the situational
interest hypothesis). These two hypotheses have been
tested in a number of studies that will be reviewed in
the next section.
EMPIRICAL EVIDENCE RELEVANT TO THE TWO
THEORETICAL CLAIMS
In this section, we will summarise the evidence
relevant to determining the mechanism by which PBL
affects learning. Firstly, we will present studies
relevant to the activation–elaboration framework.
Secondly, we will review studies that relate to the
emergence of situational interest in PBL classrooms.
The activation–elaboration hypothesis
The literature on the constructive nature of learning
and the role of elaboration through self-explana-
tion,13 discussion with peers,14 practising15 or
responding to questions16 is extensive. What needs
to be demonstrated here is that these processes are
also vital to the process of PBL. This involves the
review of a number of experiments designed to
answer the following questions:
1 Does the initial discussion of a problem lead to
the activation of previously acquired knowledge?
793
H G Schmidt et al
2 Is there evidence that having to explain the
problem leads to elaboration?
3 Do these activities facilitate the comprehension
and retention of relevant new information?
In a series of early studies that aimed to elucidate the
role of prior knowledge activation and elaboration in
the initial discussion of a problem, Schmidt and
colleagues17–19 presented students who had studied
the biological process of osmosis during high school
with either a problem unrelated to osmosis or with
the following problem: ‘A red blood cell is put in
pure water under a microscope. The cell swells and
eventually bursts. Another blood cell is added to a
solution of salt in water. It shrinks. Explain these
phenomena.’ When subsequently asked to recall
whatever they remembered about osmosis, the
students who had discussed the blood cell problem
produced almost twice as many ideas about osmosis as
the students involved in an unrelated task. This
finding suggests that the initial discussion of a
problem does indeed have a considerable effect on
the activation and elaboration of previously learned
knowledge. The authors were, however, unable to
distinguish the influence of activation from the effect
of elaboration (the students were prompted to
explain) and nor were they able to exclude the
possibility that the students simply learned from
one another in the course of providing their expla-
nations and thereby gained more knowledge.
To resolve these issues, De Grave et al.20 compared
the effects of small-group discussion of a problem
with those of individual problem analysis and direct
prompting for knowledge about osmosis. They dis-
covered that small-group discussion had a larger
positive effect than individual problem analysis; direct
prompting for knowledge had the smallest effect.
The assignment to explain leads students to further
elaborate on their prior knowledge even in the
absence of other students, but group discussion has a
considerable additional effect, suggesting that
elaboration on prior knowledge and learning from
one another (even before new information is
acquired) are potent means of facilitating
understanding of problem-relevant information.
The text comprehension studies discussed so far had
difficulty in studying effects of elaboration (through
the explanatory activities required of the students) in
isolation. To deal with this problem, van Blankenstein
et al.21 introduced a new research paradigm for study-
ing the effects of elaboration in small groups on the
learning of individual students. They taped a group
discussion about a problem and presented this video to
individual students. These students either only
794 ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
watched the video and listened to the discussion, or
were prompted to actively provide explanations them-
selves a number of times while watching the discussion.
In this way, the investigators were able to keep the
information provided by other students constant over
the conditions of the experiment (all participants
saw the same video). Subsequently, both groups
studied the same problem-related text for the same
amount of time and were tested for knowledge twice:
immediately and after 1 month. The authors found
that immediately after studying the text, the elabora-
tion group had a 28% higher score. After a month
this difference had increased to 30%.21 It seems that
elaboration in a small group not only facilitates the
processing of a study text, but also adds to its longer-
term memorability. This view is reinforced by other
reports of the long-term effects of PBL.22–24
The situational interest hypothesis
The situational interest hypothesis underlying PBL
states that problems or puzzles create a desire in
students to find out more about the topic, which
leads to increased concentration, focused attention
and a willingness to learn.25 Situational interest, as
the term implies, is not a stable or dispositional form
of interest, but is situationally aroused by an intrigu-
ing or captivating puzzle or problem. The psycho-
logical processes underlying this desire to learn can best
be explained in terms of the incongruity hypothesis
proposed by epistemic curiosity researchers (see
Loewenstein26 for a review). Humans seem to have a
natural tendency to wish to make sense of the world:
when they encounter something they do not under-
stand or something that violates their expectations,
they experience situational interest because this state
of affairs makes them aware of a knowledge gap
between what they know and what they want to know.
This phenomenon has been referred to as a cogni-
tively induced experience of (knowledge) depriva-
tion.27,28 This experience of deprivation initiates
information-seeking behaviour intended to close the
knowledge gap (i.e. learning occurs).29 As the
knowledge gap closes, through the assimilation of
new information into existing knowledge structures,
situational interest decreases until the knowledge
equilibrium is re-established.30
Studies testing the situational interest hypothesis in
the context of PBL are limited because situational
interest has only become the focus of attention
recently (but see31,32). The central assumption of this
hypothesis is that a problem presented in the context
of learning arouses situational interest because it
confronts students more extensively with what they
 What works and why in problem-based learning
still do not understand. In turn, this perception of
ignorance acts as a driving force to engage in
learning. To test this idea, Rotgans and associates
conducted a number of studies using a short rating
scale that mentions the topic to be studied and
consists of items such as ‘I want to know more about
this topic’ and ‘I think this topic is interesting’.30,33
These studies tested the level of situational interest of
students at several time-points, including on their
arrival in the classroom, after a relevant problem had
been presented and after some initial discussion
about the problem. They demonstrated that the
presentation of the problem significantly increased
the level of situational interest in the students and
this increase was maintained during the small-group
discussion.30,33
RESEARCH ON PBL SUPPORT STRATEGIES
In this section, we will review research focusing on the
means through which learning in PBL is fostered,
including: the use of problems; small-group collabo-
ration; tutors; scaffolds, and self-directed learning
(SDL).
Roles of problems in PBL
Most of the research on problems in PBL revolves
around the issue of what makes a good problem in
the views of tutors and students.34–37 The general
message from these studies is that a problem should:
(i) be authentic; (ii) be adapted to the students’ level
of prior knowledge; (iii) engage students in discus-
sion; (iv) lead to the identification of appropriate
learning issues; (v) stimulate SDL, and (vi) be
interesting. Of course, a key question concerns how
these attributes influence student learning in PBL,
such as how problems lead to the identification of
appropriate learning issues. Dolmans et al.38 investi-
gated the effectiveness of problems in a course by
comparing the learning issues identified by students
with those intended by faculty members. The
assumption behind this investigation was that an
effective problem should lead students to identify
the learning issues referred to by the problem
designers when they developed the problem. The
results of this study revealed that, on average, 64% of
the learning issues identified by students matched
those intended by faculty, with large differences
among individual problems. Interestingly, many of
the non-intended learning issues generated by
students were found to be considered relevant in
hindsight by the problem designers.38 Similar
findings were reported by Mpofu et al.39
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Soppe et al.40 investigated whether problem familiarity
had an influence on student learning. In an exper-
imental set-up, students worked with either a ‘famil-
iar’ or an ‘unfamiliar’ version of the same problem. A
measure of perceived problem quality was adminis-
tered and outcome measures, such as the number of
explanations for the problem put forward by the
students, the quality of the learning issues derived
from the discussion, the amount of time spent on self-
study and the amount of knowledge gained as
measured by a test were also obtained. The results
showed that participants in the familiar-problem
condition perceived the problem to be of higher
quality than participants in the unfamiliar-problem
condition. However, no significant differences in
learning were found. The authors40 proposed that
problems might be improved by making them more
relevant to the everyday experience of students, an
important consideration also stressed by others.41
A number of studies have taken a more holistic
perspective on the role of problems in PBL.42–45
These studies sought to determine the problem’s
influence on learning in the context of other
variables influencing learning. To this end, they
tested causal models of PBL using structural equation
modelling in which all key elements of PBL were
included. They were able to demonstrate that prob-
lem quality (defined in terms of how clear the
problem appears to students, its ability to stimulate
interest and to trigger group discussion, etc.) as
perceived by students is a major source of influence
in PBL. Problem quality influences not only the
quality of small-group discussion, but also time spent
on self-study and interest in the subject matter.
Importance of small-group collaboration
The cognitive benefits of small-group cooperation
have been discussed extensively by various
authors46,47 and need no further elaboration here.
However, we would like to focus on three other
aspects of the small-group tutorial. Firstly, the small
tutorial group provides a platform for the develop-
ment of friendships among students. Secondly, it
enables closer contacts between students and teach-
ers compared with those possible in a larger class.
Thirdly, the regularity of small-group tutorials in the
PBL environment generates peer pressure that is
useful in motivating students to be diligent in their
self-study and to meet the deadlines for work agreed
by the group. These two non-cognitive side-effects of
small-group collaboration have been found to be
advantageous in preventing dropout from school48,49
and may be a reason why students in PBL
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H G Schmidt et al
curricula tend to graduate faster than students at
conventional schools.50–52
Role of the tutor
The tutor’s role in a PBL tutorial differs from that in
a conventional tutorial. In PBL, tutors are expected
to facilitate or activate student learning and to
promote effective group functioning by encouraging
the active participation of all members, monitoring
the quality of learning and intervening when
necessary.53–56 Tutors also play active roles in the
scaffolding of student learning by providing a
framework that students can use to construct knowl-
edge on their own.57 Because it encourages students
to think more deeply and offers some modelling of
the types of questions students should be asking
themselves during problem solving, the tutor–student
relationship can be viewed as supporting a type of
cognitive apprenticeship.10,58
In view of this shift in the tutor’s role in the student-
centred PBL process, many studies have sought to
better understand how tutors contribute to student
learning in PBL. One subject of considerable debate
has centred around the importance of the tutor’s
subject matter expertise: is it sufficient for tutors to
have good facilitation skills or do they also need
substantial knowledge of the subject matter? Results
from several studies demonstrate that tutor expertise
has a significant effect on student learning out-
comes,59 whereas other studies indicate that it has no
noticeable effects.60,61 One hypothesis that may
explain this contradiction in findings is that the
subject matter expertise of the tutor impacts on
student learning more significantly when the cues and
scaffolds within the problems and resources are
insufficient to guide students in the process of
identifying what is important to study. In such situa-
tions, students are more likely to depend on their tutor
for guidance and thus a tutor who is more knowl-
edgeable in the subject matter is of more benefit.62
Another group of studies investigated the influence of
tutors’ content expertise on the tutorial process. Silver
and Wilkerson63 found that tutors with subject matter
expertise were more inclined to play a directive role in
the tutoring process, to speak more often and for
longer periods, to supply more direct answers to
questions posed by students, and to suggest more
points for discussion. They concluded that these tutor
behaviours might have a negative impact on the
development of students’ skills in active SDL and also
in collaborative learning. By contrast, Eagle et al.64
found that students with tutors who were content
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experts were able to generate more than twice as many
learning issues for SDL and that these learning issues
were almost three times more congruent with case
objectives compared with those generated by students
who were guided by non-experts. Moreover, com-
pared with the latter group, students with content-
expert tutors put in double the amount of time in self-
study. Similarly, Davis et al.59 found no significant
differences between expert-led and non-expert-led
groups in terms of teacher-directed and student-
initiated interactions, but instead demonstrated in-
creased student achievement and satisfaction in
groups led by experts. Both groups of authors59,64
suggest that the expert tutors, by virtue of their subject
knowledge expertise, were better at posing questions
at critical moments, thus positively influencing stu-
dent learning. However, although the proficiency of
content experts in using their subject matter expertise
to direct student discussion has positive effects on
student learning, their knowledge of when and how to
use this expertise to facilitate learning is more
beneficial. Thus, ideally, a tutor should be expert in
both the respective subject matter and in facilitating
student learning processes.
One theory of the effective tutor merges these two
qualities.65 A key idea in this theory is the concept of
‘cognitive congruence’, which is defined as the
tutor’s ability to express him or herself in the
language of the students, using the concepts they use
and explaining things in ways they can easily grasp.
Schmidt and Moust66 suggested that both subject
matter expertise and social congruence were neces-
sary conditions for cognitive congruence to emerge.
In this context, social congruence refers to interper-
sonal qualities such as the ability to communicate
informally and empathically with students, and hence
the ability to create a learning environment that
encourages the open exchange of ideas. Thus, it was
hypothesised that a tutor who is more socially
congruent and better able to use subject matter
expertise would be more cognitively congruent.
Using structural equation modelling, the authors66
demonstrated that both social congruence and
subject expertise influenced cognitive congruence,
which, in turn, influenced tutorial group functioning
and thus indirectly affected the level of student
achievement by increasing the time spent on self-
study. Social congruence directly influenced group
functioning during the problem-solving process and
the subject matter expertise of the tutor had a slight
direct positive impact on student achievement.
Hence, this study showed that effective tutoring that
results in better student achievement requires the
tutor to have both content knowledge and the ability
 What works and why in problem-based learning
to interact with students on a personal level, as well as
to utilise language students easily understand.66
Chng et al.67 hypothesised that tutors who exhibit
more cognitively congruent behaviours would influ-
ence knowledge construction and acquisition at each
learning phase in the PBL process. Thus, students
who are under the tutelage of such tutors would be
more extensively involved in the construction of
knowledge (i.e. they would recall more relevant
concepts in each PBL phase) and would ultimately
achieve better results at the end of the learning
process. Tutor behaviours were assessed by students
and the tutors were subsequently divided into three
groups according to their levels of subject matter
expertise, cognitive congruence and social congru-
ence. Student achievement at the end of the PBL
cycle was measured using an essay test. An analysis of
covariance (ANCOVA) using students’ pre-existing
grade point average (GPA) scores as the covariate
found that, contrary to the authors’ original hypoth-
esis, only the social congruence of tutors had a
significant influence on the students’ learning
process.67 This effect of social congruence was
evident in the total number of concepts recalled at
the end of the PBL phases of problem analysis, SDL
and reporting. No significant effects were found for
the subject expertise and cognitive congruence of the
tutor on any of the learning phases in the PBL
process.67 (However, in line with the findings of
Schmidt and Moust,66 all three tutor behaviours had
a significant effect on final student achievement.)
The results indicate that the social congruence of the
tutor influences the learning process more substan-
tially than cognitive congruence and subject matter
expertise, at least in this educational context. The
willingness of a tutor to establish an informal
relationship with his or her students and to display an
attitude of genuine interest therefore has significant
impact. This is possibly because socially congruent
tutors are able to create a non-threatening learning
environment and to develop strong tutor–student
relationships that support the open exchange of ideas
and questions and promote student engagement in
the learning process.
Some studies on tutors move away from investigating
the tutor’s role in influencing student achievement
alone and instead focus on the student learning
process and issues such as how and when a tutor
should intervene in the event of difficult incidents in
tutorial groups.68,69 Hmelo-Silver and Barrows70
describe in detail how ‘collaborative knowledge
building’ is facilitated. By analysing the discourse that
took place between five medical students and their
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
facilitator as they worked on a problem over 5 hours
in two sessions, these authors demonstrate how the
facilitator can support knowledge building through
the use of open-ended questions that serve as
scaffolds for students.70
The use of scaffolds in PBL
From the descriptions above, it is clear that the role of
the tutor as a scaffold to facilitate meaningful learn-
ing is one that is generally agreed upon. Although
Kirschner et al.71 suggest that PBL is a minimally
guided approach and is therefore less effective and
efficient in helping students learn, others argue that
PBL provides extensive guidance and scaffolding to
help students learn.72,73
The metaphor of scaffolding refers to the temporary
support provided for learners to help them complete
a task they would otherwise not be able to complete on
their own.74 Although scaffolds can take multiple
forms, Saye and Brush75 suggest that most scaffolds
can be classified as either ‘soft’ or ‘hard’. Soft scaffolds
are dynamic and refer to tutor actions that support
specific learner needs, as described in the section on
the role of the tutor in PBL.75–77 By contrast, hard
scaffolds are static supports that can be developed in
advance based on typically expected learner difficul-
ties associated with a task.75 Such scaffolds can take
the form of computer- or paper-based cognitive tools,
such as worksheets.78 In line with the metaphor,
scaffolds should gradually be withdrawn or fade from
use as the learner becomes increasingly responsible
for his or her own learning.79 For example, although
novices in a PBL environment may be supported
initially with some resources that scaffold their
learning, as their expertise increases, these students
should be provided with fewer resources. In this
way, students develop as independent learners
through a form of flexible scaffolding.73
Studies investigating the use and impact of hard
scaffolds in the PBL context are rather limited. A
study by Simons and Klein80 examined the impact of
hard scaffolds on the learning outcomes of middle-
school learners during the implementation of a PBL
unit. Students were subjected to one of three exper-
imental conditions, including one in which no
scaffolding was provided, one in which optional
scaffolding was provided, and one in which students
were required to use all the scaffolds provided.
Results showed that students in the optional-
and compulsory-scaffold conditions performed
significantly better than students in the no-scaffold
condition. In addition, those in the compulsory-
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H G Schmidt et al
scaffold condition produced better organised
project notebooks containing a higher percentage of
relevant entries. The PBL environment described in
this study was one with very little consistent teacher
support (soft scaffolding), in which students gener-
ally performed poorly. Simons and Klein80 therefore
concluded that hard scaffolds seem to enhance
student performance, especially under circumstances
of limited teacher support.
Another study investigating the effect of worksheets
as a scaffolding tool on student achievement in a PBL
environment was carried out by Choo et al.81 Forty-
eight teams (241 students) were randomly assigned to
one of two experimental groups; students in one
group were provided with a worksheet and students
in the other group were not. No statistically signifi-
cant difference emerged between the two groups in
terms of their post-lesson concept recall tests. The
findings of Choo et al.81 therefore suggest that
scaffolds such as worksheets may not play a significant
role in enhancing student learning within this PBL
context. Furthermore, results from a survey adminis-
tered to the students in this study indicated that the
strongest factor to impact on their learning was the
tutor, followed by the tutorial group; the worksheet
was rated as having the lowest influence.81 Two other
experiments have examined the effect of hard scaf-
folds in the form of questions provided as guidelines
for self-study in addition to the problem.82,83 In one
of these,82 the presence or absence of the scaffolds
did not matter; in the other,83 scaffolding was even
detrimental to achievement.
In conclusion, the effects of scaffolding in PBL are
rather inconclusive and more research is needed
here. Problem-based learning was originally devel-
oped in medical schools for use with relatively mature
and motivated learners, a context in which hard
scaffolds may have been of limited value. However, in
view of the increasing implementation of PBL by
educators of students at different levels of education
and in various disciplines,84,85 research to shed
further light on the role of scaffolding to support
student performance in PBL is necessary.
Self-directed learning
Dolmans et al.86 examined the relationship between
student-generated learning issues and self-study. As in
an earlier study,38 they found considerable overlap
between the learning issues identified by students
and the faculty-intended objectives, but increasing
this match by improving problem quality did not
result in more self-study time. Therefore, they con-
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cluded that the learning issues produced during
group discussion may not represent the only factors
on which students base their decisions of what to
study during self-study.86 Other factors may be
involved, such as tutor suggestions, content covered
in previous courses, literature found during self-study
and the nature of the learning resources available.
Interestingly, first-year students tended to focus on
the learning issues agreed upon more than older
students.86 It appears that students become more self-
directed as the years of study progress. A similar
finding was reported by van den Hurk et al.,87 who
found that students in their first year of study
adhered strictly to the learning issues, whereas in
later years students pursued their personal learning
interests to a larger extent. In addition, students who
tended to study beyond the agreed learning issues
spent more time on individual study and performed
better on achievement tests.
As SDL is considered to be a key element in PBL,
helping students develop the ability to regulate their
own learning is an important priority. Some studies
have demonstrated outcomes that can be considered
to result from the emphasis on SDL in PBL. Students
in a PBL curriculum have, for instance, been shown
to borrow more books from the library than students
in conventional curriculum schools.88–90 These find-
ings suggest that PBL students are more independent
learners and take more personal responsibility for
their learning.
CHARTING PBL IN THE CLASSROOM
A micro-analytical approach to studying learning
processes in PBL
Any attempt to study PBL as it occurs in its natural
habitat – the PBL classroom – or to survey the
underlying mechanisms of learning during PBL must
seek new approaches to measurement. Convention-
ally, motivation and learning data are collected at the
end of a course. These responses provide an
‘averaged’ impression of how motivated students
were during the course or how much they learned.
Although such a measurement approach is useful
when the focus of interest is students’ overall moti-
vation or learning, this type of measurement may
hide important contextual variations during learning.
The alternative approach involves carrying out
detailed classroom observation: a learning event is
videotaped and subsequently transcribed. Although
this measurement approach tends to provide more
detail on what is happening in a classroom, the
 What works and why in problem-based learning
resulting qualitative dataset usually poses consider-
able technical and interpretational challenges.
In the subsequent sections, we present a series of
studies on motivation and learning in PBL using an
approach we refer to as micro-analytical measure-
ment.33,91 In this micro-analytical measurement
approach, a short questionnaire or a short knowledge
test is re-administered several times at critical points
during the course of a learning event. These repeated
measurements are subsequently related to one
another and to final outcomes of learning. Adminis-
tering a measure several times over a learning event
may provide insights into what actually happens
during learning. From this, inferences can be made
about the mechanisms underlying PBL.
Interest is a driving force in PBL but is consumed
over the course of learning
In a study by Rotgans and Schmidt,33 a micro-
analytical measurement approach was applied to
investigate how students’ situational interest develops
during PBL. Five short measures of situational inter-
est were administered over the course of a 1-day PBL
session. The first two measures were administered,
respectively, immediately before and after the pre-
sentation of the problem to determine whether the
problem would trigger students’ interest. The third
measurement was conducted after the discussion of
the problem and the generation of learning issues.
The fourth administration took place after self-study
to determine whether SDL activities had an effect on
situational interest. The fifth and last measurement
took place after the final discussion. The results of
the study showed that once the problem had been
presented, students’ situational interest increased
significantly. However, as the learning event pro-
gressed, situational interest decreased: it seemed as if
the initial increase in situational interest created by
the problem was slowly consumed over the course
of the learning event. The authors used the situa-
tional interest hypothesis to explain this phenome-
non. The experience of being confronted with a
problem that contains unknowns that need to be
known triggers awareness of knowledge deprivation
in the form of a knowledge gap that must be bridged
by the finding of information about the unknowns.
Knowledge acquired during self-study closes this gap.
As situational interest is an indicator of the existence
of such a gap, its decrease over time provides
empirical support for this hypothesis. This study also
showed that situational interest predicted students’
academic achievement with considerable accuracy,
demonstrating that it drives learning.33
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
In a follow-up study, Rotgans et al. (unpublished data)
applied the same micro-analytical measurement
approach to determine students’ situational interest
in both PBL and direct instruction (DI). In a quasi-
experiment study involving several classes of primary
school pupils, the authors ensured that all factors
were kept constant, except for the instructional
approach. For instance, situational interest measures
were administered at the same time-points to both
groups, the same teacher was present, the same
learning resources were available and the same
amount of time was allocated in both groups. The
results of this study revealed that the PBL group was
consistently more interested than the DI group on all
but two measurement occasions (Rotgans et al.,
unpublished data). Fig. 1 shows an overview.
The first of these differences in interest occurred at
the start of the session, just before the PBL group
read the problem and the DI group was presented
with some examples to demonstrate the application
of the topic to a real-life context. This was to be
expected because this time-point gave a measure of
students’ situational interest before the treatment
took place. Students in both conditions showed
‘equally little interest in the topic’. However, when
students in the PBL group were presented with the
problem, their situational interest increased signifi-
cantly. After the problem had been presented, the
level of situational interest in the PBL group
decreased significantly, as in the study by Rotgans
and Schmidt.33 In the DI group, situational interest
decreased significantly from the start when the group
was presented with some examples (instead of the
problem). This outcome demonstrates that the DI
group did not experience the positive surge in
situational interest generated by the problem and the
corresponding feeling of knowledge deprivation.
Their interest decreased immediately from the onset.
However, the DI group showed one significant
increase during self-study, which occurred when this
group was given the opportunity to engage in
independent group discussion to discuss some real-
life applications of the topic. At this time-point there
was no difference in situational interest between the
PBL and DI groups (Rotgans et al., unpublished
data).
Overall, applying a micro-analytical approach to
the study of student interest in PBL revealed the
underlying situational interest processes, which
would have been difficult to achieve with conven-
tional survey measures or classroom observations. In
the following study the micro-analytical measurement
approach was applied to measure how students’
799
H G Schmidt et al

DI group PBL group

4.00
Identification
of learning 3.80
Presentation goals Self-study
of the 3.72 3.67 Presentation Elaboration
problem of findings 3.63 of what was
learned

Level of situational interest

3.52 3.54
3.50 Students
were
informed 3.28
about the
topic
Assignment
3.17 List of
learning
3.00 objectives Elaboration
Presentation
and group
2.86 Discussion of what was
of examples assignment 2.79 learned 2.82
2.95 activity

Lesson 1 (1 hour) Lesson 2 (1.5 hours) Lesson 3 (1 hour)

2.50
SI1 SI2 SI3 SI4 SI5 SI6
Points at which situational interest was measured

Figure 1 Mean levels of situational interest (SI) over the learning event in the direct instruction (DI) and problem-based
learning (PBL) groups and description of learning activities. (Based on Fig. 1 in Rotgans et al., unpublished data)

knowledge construction develops during the learning in pre- and post-tests, were analysed using structural
process. equation modelling. Results demonstrated that only
the hypothesised model had a good fit with the data
Cumulative process of learning in PBL obtained.92 Fig. 2 shows an overview.

The idea that learning is cumulative and that new This model showed that students’ prior knowledge
learning depends on what has been learned previ- significantly influenced learning in the first PBL phase
ously is generally accepted by most educationalists. (problem analysis), which then strongly influenced
However, most of the evidence for this has come from learning at the end of the SDL phase. Similarly,
experiments in psychology laboratories, particularly learning at the end of the SDL phase significantly
in the field of text comprehension. Yew and impacted on learning at the end of the reporting
Schmidt92 argue that learning outcomes in PBL can phase. Finally, students’ learning achievements were
only reflect collaborative processes because social significantly influenced by learning at the end of the
constructivism suggests that knowledge is constructed reporting phase. By contrast, results from the alter-
through collaborative interactions and co-construc- native hypotheses tested indicated that collaborative
tions.93,94 By contrast, it is also possible to infer that small-group learning or self-directed study alone were
the individual SDL phase more significantly influ- insufficient to account for learning in PBL. These
ences student learning in PBL as studies on self- findings also demonstrate that the sequential nature
regulated learning have demonstrated that the use of of learning in PBL (from the problem analysis phase to
self-regulated learning strategies strongly impacts on SDL to the reporting phase) is essential in influencing
students’ academic outcomes.95 student learning outcomes.92

Yew and Schmidt92 therefore tested the hypothesis

that PBL is cumulative and that learning in PBL DISCUSSION
involves both collaborative and self-directed learning.
They also tested three alternative hypotheses: (i) only We have sketched a picture of PBL that emphasises its
the collaborative learning phases influence learning cognitive constructive nature. We have reviewed
in PBL; (ii) only the self-directed study phase influ- empirical evidence supporting six propositions. The
ences learning in PBL, and (iii) both collaborative first is that the initial discussion of a problem in a
learning and self-directed study influence learning in small group of students leads to the activation of
PBL, but not in a cumulative process. The units of prior knowledge. This prior knowledge is elaborated
analysis used as an indicator of student learning at upon to collaboratively construct a tentative theory
the end of each PBL phase were the relevant concepts explaining the phenomena described in the problem.
recalled by 218 students at the end of each learning The cognitive constructions that result from this
phase. These concepts, together with students’ results exercise in the minds of these students subsequently

800 ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806

0.45 Concepts recalled 0.75
Prior knowledge after problem
analysis phase
Presentation Self-
of the directed
problem learning
Figure 2 Path model for the hypothetical model of relationships among different phases of problem-based learning. Numbers
indicate standardised regression weights. (Based on Fig. 1 in Yew & Schmidt92; reproduced here with permission)
facilitate the comprehension of new information and
its long-term survival.96
Next, problems drive learning by generating situa-
tional interest. We have demonstrated that the
introduction of a problem in the learning situation
leads to an increase in situational interest in the topic
at hand, and that this situational interest is largely
maintained over the course of learning (although to
some extent it seems to be ‘satisfied’ by the new
knowledge acquired and diminishes over time). A
higher level of situational interest, in turn, relates to
higher levels of achievement.33
Thirdly, as well as providing cognitive benefits, small-
group tutorials contribute to students’ feelings of
being ‘at home’ in their class, both socially and
academically, and these protect against dropout. In
addition, as these groups are focused on interaction
in which students are expected to explain subject
matter to one another, free riders are discouraged
and students are encouraged to study regularly. This
may be a reason why PBL curricula tend to have
higher graduation rates.97
Fourthly, tutors’ subject matter knowledge, ability to
relate to students and ability to be cognitively congru-
ent with students all contribute to learning in PBL.
Findings in this area suggest that good tutors provide
flexible scaffolding by supporting student learning
on a ‘just-in-time’ basis. Experiences with so-called
‘hard’ scaffolds, such as those generated when work-
sheets or additional questions are supplied, were more
equivocal; the few studies conducted in this area
suggest limited effects and one even showed hard
scaffolds to be detrimental to learning.81,83
Fifthly, students in the PBL classroom have been
shown to be more ardent users of library resources
ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
What works and why in problem-based learning
0.33
Concepts recalled 0.77 Concepts recalled 0.28
after self-directed after reporting Achievement
learning phase phase
Reporting of
findings
than students in conventional programmes, which
suggests that these students are more self-directed in
their learning. However, students need time to
develop this propensity. One study showed that
students at the beginning of PBL do not study much
beyond the learning issues generated in the small
group.87 Real personal agency appears to require
time to develop, but when it does, it has surplus value
over learning driven solely by external stimuli.
Finally, the extent of learning in PBL does not result
from either group collaboration (the social
constructivist point of view), or individual knowledge
acquisition in isolation: both activities contribute
equally to learning in PBL.
In summary, PBL seems to have fairly strong effects on
learning and achievement compared with conditions
in which learning is not driven by the presentation of
problems. The studies reviewed generally showed
learning gains in PBL students that extended beyond
those in students in control conditions in which
problems were not the focus of attention or in which
students were not encouraged to elaborate on their
prior knowledge. These findings seem to be at variance
with the findings of curriculum comparison studies
that generally do not report PBL to have effects
superior to those of forms of conventional training.2 It
seems that although effects are found at the micro
level, these do not translate into visible effects at the
curriculum level. This then raises the question of why
this is so. What might explain this apparent paradox?
We can offer only some tentative hypotheses. The first
is a ‘compensation’ hypothesis. There is some evi-
dence that students who study under less favourable
circumstances tend to compensate by working
harder.98,99 This would imply that although students
profit more from PBL, they compensate for this
801
H G Schmidt et al
additional support by working less hard. This is
unlikely because students in PBL curricula tend to
spend more time on individual learning than those
in more conventional environments.
A second hypothesis, more parsimonious with the
micro-level finding reviewed in this article, has been
proposed recently. This hypothesis assumes that
differential dropout and study duration mask the
effects of PBL at the curriculum level. It takes as its
starting point the observation that PBL curricula
tend to show less dropout and shorter study duration
than conventional schools.52,97 Comparisons
between PBL and conventional schools may there-
fore be biased against PBL; effects of PBL become
hidden by differential attrition and differential study
duration. To test this hypothesis, Schmidt and
colleagues (unpublished data) re-analysed 104 cur-
riculum comparisons among schools for which
dropout rates and study duration information were
available. By correcting for differences on these
variables, they were able to demonstrate robust
effects of PBL on both knowledge attainment and
diagnostic performance. It seems that micro-level
effects of PBL do replicate at the curriculum
level.
Given that well over 5000 studies referring to PBL are
represented in PubMed, what interesting avenues
remain for further research? We will confine
ourselves to two suggestions here. The tutorial group,
vital to the inner workings of PBL, remains in many
respects a black box. For instance, differences in
epistemological beliefs among students have been
shown to influence achievement (i.e. students who
believe that learning is knowledge construction
perform better than other students100). Why is this
so? Are groups that are heterogeneous in terms of
prior knowledge more successful than homogeneous
groups, as some studies seem to suggest?101 Despite
the importance in the small group of elaboration on
what one already knows, students tend to avoid
elaboration on the incorrect assumption that every-
body in the group already knows what the individual
knows. Would it help if tutors explicitly prompted for
further elaboration? Tutors were shown to be more
effective when they were able to explain things in a
simple way. What does this imply? Do cognitively
congruent tutors explain more items in the tutorial
group? What would happen if tutors were instructed
to explicitly provide scaffolds whenever their group
reached a dead end in their discussion?
The second suggestion refers to long-term memory for
what has been learned. Some literature implies that
802 ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 792–806
PBL has a particular effect on the long-term
memorability of learned material, even if initially no
effects are found.22–24 If this is true, there may be
several reasons for it. For instance, as the problem that
originally drove the learning will be stored in the
memory along with the material learned, it is possible
that such a problem acts as a cue for the retrieval of
the knowledge acquired and thus increases its
accessibility at a later stage.102 A related explanation
may be that students in PBL organise knowledge in
memory differently in a manner that facilitates its
later retrieval. Studies of possible differences in
knowledge organisation that affect the use of that
knowledge in new contexts – the transfer issue – are
virtually non-existent in education research,103 but
are sorely needed.
In the Introduction to this paper, we suggested that
different authors tend to define the ultimate goals
of PBL in different ways. This paper took as its point of
departure cognitive psychology and well-known prin-
ciples of constructivist learning, with an emphasis on
how people acquire knowledge. However, a point of
view particularly prevalent in many medical schools
tends to define PBL as a process of inquiry.104,105 From
this perspective, the ultimate objective of PBL is to help
students develop the ‘inquiry’ or ‘problem-solving’
skills of an expert by imitating his or her thinking
processes. Working on a problem is seen as a simula-
tion of what the doctor does, particularly in its
emphasis on data gathering and interpretation. In this
view of PBL, the role of knowledge acquisition is
somewhat vague. Although most of its proponents
acknowledge that knowledge is needed to fill gaps in
the student’s knowledge base, from this perspective
PBL is clearly focused on the acquisition of problem-
solving skills. This perspective is attractive to
medical educators because professionals in the field
seem to think that their expertise is indeed partly based
on the possession of such elusive skills. However, thirty
years of research in this domain have made it clear that
it is unlikely that problem-solving skills can be learned
through education, or even that such things as
problem-solving skills, independent of subject matter
knowledge, exist.106 If this is true, it indicates that there
are no shortcuts to acquiring expertise in medicine;
that there are no domain-independent problem-
solving skills the acquisition of which could compen-
sate to some extent for lack of knowledge acquisition.
The cognitive constructivist perspective on PBL incor-
porates this view that clinical reasoning is knowledge-
based. It sees learning in the field of medicine as a
series of attempts to construct mental models of the
underlying mechanisms of disease in terms of how it is
produced, the conditions under which it appears, and
 What works and why in problem-based learning
its consequences in terms of observable signs and
symptoms in patients. These mental models of disease,
or ‘illness scripts’, are the cognitive tools that doctors
use when they engage in clinical reasoning.107 The task
of medical education is to help students develop these
cognitive structures. Problem-based learning may be a
useful way of doing so.
Contributors: HS initiated and coordinated the writing of
this review. He provided the conceptual outline and final
plan of the manuscript. JR contributed sections on
situational interest research and the micro-analytical
approach. He also reviewed the role of problems in
problem-based learning (PBL). EY reviewed studies on the
role of the tutor, scaffolds used in PBL and research on the
cumulative nature of learning. All authors contributed to
the critical revision of the paper and approved the final
manuscript for submission.
Acknowledgements: none.
Funding: none.
Conflicts of interest: none.
Ethical approval: not applicable.
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Received 7 March 2011; editorial comments to authors 11 March
2011; accepted for publication 5 April 2011