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J Athl Train. 2002 Oct-Dec; 37(4 suppl): S-189–S-198.
PMCID: PMC164424

Problem-Based Learning in Entry-Level Athletic Training Professional-Education Programs: A Model for Developing Critical-Thinking and Decision-Making Skills


Objective: To establish the underlying theory and benefits and describe the implementation of a problem-based learning curriculum.

Data Sources: I searched MEDLINE, SPORT Discus, and nursing, evidence-based medicine, and educational psychology databases from 1987 through 2002 using the terms problem-based learning, physical therapy, nursing, and medicine.

Data Synthesis: In the problem-based learning process, students encounter a problem, bring to it their preconceived understanding (accurate or not), learn to identify what they need to learn to better understand the problem, engage in self-directed study, and begin to resolve the problem. Problem-based learning has its origins in medical education but is widely used in K–12 education, social sciences, health professions education, law, business administration, engineering, and aviation. An entry-level master of science degree program in athletic training based on problem-based learning and integrated clinical education is described.

Conclusions/Recommendations: Problem-based learning curricula, if implemented correctly, can facilitate the entry-level athletic training student's professional development into that of a life-long learner who bases clinical decisions and procedures on the best available evidence.

Keywords: curriculum, practice-based education, Objective Structured Clinical Examination, curriculum design, clinical practice, crew resource management

As athletic training and sports medicine professional-education programs continue to evolve, a plethora of teaching techniques has been set forth, including traditional lecture-based methods, skills-based methods (laboratory settings for teaching psychomotor skills, drill and practice, conceptualized practice, and modeling), technology-enhanced methods (electronic tools, computer simulations, Internet-based or -assisted courses, electronic assessment), individual versus group methods (self-study, cooperative learning), and inquiry-based methods (cases, projects, problems). At first glance, these methods may appear to compete directly with each other; however, understanding the science of how people learn shifts the focus from “Which technique is the best?” to “Which teaching strategies are best used to develop an instructional program?”1

“It is as important to learn the important questions as it is the important answers. It is especially important to learn the questions to which there may not be good answers.”2 The greatest challenge facing any professional-education program (eg, medicine, health professions, law, business, aviation) is to produce professionals who are capable of independent and critical thinking, who can sequentially analyze and solve dynamic problems, who possess a commitment to lifelong learning, who can rapidly understand problems in order to make critical decisions on the field and in the clinic, and who can work as part of a team.

Problem-based learning (PBL), grounded in cognitive theory and with its origins in medical education, is a useful approach for teaching students how to think critically and solve problems they will encounter. Problem-based learning has gained popularity in disciplines as diverse as K–12, university, law, business, computer science, engineering, aviation, and medical education. During the PBL process in the medical and health professions, basic science, psychomotor skills, and clinical reasoning are learned in the context of clinical practice. Four processes3 occur as the learning group is introduced to a problem: (1) hypotheses as to the cause, physical diagnosis, or management are established, (2) data pertinent to the case are obtained, (3) learning issues requiring further inquiry emerge and are assigned to group members for self-directed study, and (4) the hypotheses, data, and learning issues are reassessed, and the problem and its solution are further developed at a follow-up session. The path to the solution, unknown at the outset, develops through the PBL process.

Athletic training education, like other disciplines, will benefit from reevaluation of teaching methods in light of the fact that our cultural environment is vastly different than it was 10 years ago, thanks to the technologic revolution and the availability of information. This raises the question, “Is the way we were taught the most appropriate way to learn in today's society?” Scientific, medical, and technologic advances far surpass the ability of the human mind to integrate and assimilate all the available knowledge. Therefore, traditional teaching methods (eg, lecture format) may no longer be the most effective in today's culture, where the critical skills include problem solving and decision making. The challenges of learning for today's world require disciplined study and problem-solving skills from the earliest grades forward. My purposes are to present the learning theory and historical context for PBL, to present the benefits and elements of PBL in entry-level athletic training education, and finally, to describe a modified PBL curriculum for an entry-level athletic training master of science professional-education program. Some of the information regarding the program description is based on my experience in curriculum-program development.


Problem-based learning occurs in the context of a community of learners who share the same objective: solving the problem. Ideally, the group should consist of 5 to 7 members but can be modified to accommodate up to 14 members. Unlike the lecture format, the PBL process addresses group dynamics, including the relationships and contributions of each group member. Leadership, cooperation, communication, resource utilization, collaborative team building, and decision-making skills are crucial to group success and are developed through the PBL learning process. The active-learning process of the PBL environment allows the learner to engage the real-world problem with enthusiasm, initiative, and inherent motivation because the knowledge acquired is integrated, flexible, and immediately useful.4 The content to be learned is immediately important and relevant to the learner's life and career. The PBL process likely facilitates the development of the relationship among learning, cognitive competence, and motivation.

The development of these qualities and the universal applications of the PBL process are critical skills well documented in various industries such as aviation. The broad spectrum of the application of PBL in aviation ranges from the most basic concepts developed for the K–12 ages by the NASA Center for Distance Learning,5 as students are exposed to fundamental concepts of science, technology, mathematics, physics, and information retrieval to advanced aviation research and training in crew resource management (CRM), development of cognitive processes, and flight training.6,7 Crew resource management has been defined as “the process of using all available resources, both human and machine, to effectively and safely fly the airplane. Crew resource management skills include communication, leadership/followership, team building, team decision making, team problem solving, and task prioritization. Crew resource management training is distinct from technical training (basic airmanship, spins, stalls, other maneuvers, navigation, etc)” (J. D. Rodriguez, unpublished data, 2001). Technology in aviation is designed ergonomically and operationally to assist the pilot in the critical decision-making process, integrating automatization of functions with CRM (J. D. Rodriguez, unpublished data, 2001). The application to sports medicine is clear: learning of the psychomotor (technical) skills is separate from the decision-making process, yet those skills must be used in the context of the decisions to be made regarding the management of the on-field situation. Technology-assisted assessment (eg, isokinetics, arthrometers) supports the clinical decision-making process. Pediatric surgical medicine has transferred the “aviation paradigm” of CRM to the operating-room environment, recognizing that the human and technologic systems are designed to minimize and absorb the inevitable errors.8 Similarly, these concepts of CRM can be applied to the athletic health care team in the clinic and to emergency trauma management on the athletic field. Key to aviation, medicine, and athletic training is the use of all available resources, communication, and teamwork to effectively solve problems. These qualities cannot be learned in a traditional classroom environment but are integral to the success of the PBL approach.

Theoretic Foundations for Problem-Based Learning

Student-centered teaching has gained considerable attention across the disciplines in academe as faculty seek to implement approaches other than the traditional, passive lecture format.912 Active learning has been defined as environments that allow students to talk and listen, read, write, and reflect as they approach course content through problem-solving exercises, informal small groups, simulations, case studies, role playing, and other activities—all of which require students to apply what they are learning. The case-study method has been used the longest to promote clinical problem-solving skills and develop the decision-making process. These are not new concepts: more than 60 years ago, observers noted that students became active rather than passive participants in the classroom when they were engaged in real problem-solving skills.13 This collaborative learning, or “distributed cognition,” affords students the opportunity to learn from each others' insights and to clarify their thinking by articulating an idea or decision and supporting it with a clear rationale.

Research in cognition and neuroscience has continued to influence how academicians approach the learning process. Cognitive theorists such as Bruner14 contended that learning is an active process in which individuals make sense of facts through the process of conceptualization and categorization; the process of attaining a concept is viewed as a series of decisions. However, cognitive theorists are quick to point out that it is equally important to have a substantial content-knowledge emphasis.15 For this reason, students must have a knowledge base to use in solving problems. The basic science prerequisites of chemistry, biology, anatomy, physiology, physics, and statistics provide the student with the content knowledge base from which to build. Academic courses alone do not address the dilemma of “book smarts but not an ounce of common sense,” as a number of researchers have demonstrated few connections between what is learned in school and everyday problem-solving skills. Concept mapping as part of the PBL process allows students to draw the connections and interrelationships among simple and complex ideas, content, and applied knowledge to solve the problem.

Pea15 suggested several ways to facilitate knowledge transfer from the known situation to the new problem: learning must take place in the context in which the knowledge will be used, the knowledge must be functional, and concepts and skills are acquired with a purpose in mind. The purpose of this knowledge transfer is to develop decision-making skills. This approach requires teachers to move from an authoritarian, all-knowing position in the classroom to a position as collaborative colleagues, from the proverbial “sage on the stage” to the “guide at the side.” Cognitive science research1 further suggests that knowledge is organized in memory according to the conditions under which that knowledge is to be retrieved and applied. For example, the biology and chemistry knowledge required for the entry-level athletic training student to understand the inflammatory process in sufficient depth to plan an appropriate physical intervention plan differs from the breadth and depth of understanding required for the medical and pharmacologic management of inflammatory arthritis. The implications for curriculum design are clear. PBL experiences must be designed so that the knowledge students develop in the classroom can be best retrieved in the anticipated context of knowledge use: the clinical setting.

The traditional lecture, psychomotor competency “check-off,” case, and discussion methods may achieve the goal of imparting knowledge but fall short of producing professionals who are capable of critical thinking and independent problem solving. Furthermore, traditional, highly competitive models of education, particularly preprofessional studies (eg, medicine, law), do not foster a climate of teamwork or collaborative learning—essential skills for success in the workplace.

Benefits of Problem-Based Learning

The traditional didactic and clinical models of athletic training education may not be the best to address the expectations of students who should be able to (1) become independent and critical thinkers, (2) reason their way through patient problems, (3) recall and apply what they have been taught to the care of their patients, (4) recognize when their skills and knowledge are not adequate to the clinical task they are confronting, and (5) learn new information as they need it and as sports medicine research moves ahead, keeping contemporary in their knowledge and skills.3 The first goal of PBL is the development of clinical reasoning to apply knowledge and expertise in the context of an extensive, rich knowledge base. The second goal is the ability to “continue learning throughout the entire professional life in order to meet the unique and changing needs of patients and the problems they present, the changing problems and demands of the health care system, and to keep contemporary in medical knowledge and practice.”3

The pluralistic view of intellect points to the importance of subject-matter knowledge and the need to develop critical-thinking and decision-making skills in the educational curriculum, rather than expecting them to simply emerge from casual modeling.16 Casual modeling includes the segmentation of skills into checklists, waiting for the “teachable moment,” hoping the clinician (clinical instructor or supervisor [CIS]) will model the appropriate decision-making sequence at the precise instant that the student is ready to receive the information. Students must develop an area of knowledge depth, the ability to find information germane to the problem at hand, and the ability to evaluate the quality and relevance of available information.

The advantages of a PBL curriculum over traditional curricula include the following: students are more enthusiastic learners; students' knowledge is better retained, retrieved, and applied in clinical settings; students demonstrate a more holistic approach to patient care; PBL is more enjoyable for students and faculty as it encourages exploration, discussion, and debate; and the curriculum is inherently current and evidence based.12 However, several disadvantages to the PBL approach must also be considered: increased cost and faculty time, students' weakness in the basic sciences, and the difficulty faculty have in assessing students' knowledge content.17,18 Although the evidence is not 100% conclusive, a modified hybrid PBL curriculum incorporating characteristics of both traditional and PBL educational methods, with more structure and guidance (eg, integrate lectures, learning objectives) early in the curriculum may address these issues. This modified approach addresses the need to develop an early foundation of knowledge that can be immediately integrated into the weekly cases. For example, these lectures may include basic physics principles related to electrotherapy or the biology of the tissue-injury and tissue-healing processes. The inclusion of selected, structured content early in the first semester may ease students' anxieties and transition to a PBL curriculum. By the end of the first semester of the PBL curriculum, my students reported a greater understanding of the process and improved ability to make clinical decisions in the content area of the first semester (orthopaedic and musculoskeletal disorders).

Elements in Problem-Based Learning

The key to successful patient management is knowing where to look and how to evaluate and integrate the information from all disciplines (basic and medical sciences) into practice to solve the problem at hand. These characteristics are the hallmark of self-directed learning.

The problem-based learning approach has several requirements3:

  1. Tutor: The tutor facilitates small-group (5 to 7 students) learning and may come from the basic or clinical sciences. Tutors may also be actively practicing in the field of sports medicine and athletic training, although content expertise (while ideal) is not necessary to be a good tutor. “The skillful tutor will cause students to develop effective reasoning skills, acquire a solid knowledge base, become effective self-directed learners, take control of their own learning, and enjoy the whole process. The skillful tutor will be able to eventually fade away and allow the students to carry on the process by themselves.”19 Barrows19 noted 4 steps to assist an inexpert tutor to feel comfortable in this role: (1) state the curricular objectives so both the tutor and students know what is to be accomplished; (2) provide the learning issues the faculty feel should be identified by the students for each problem, task, or situation addressed in the group; (3) orient the tutor to the problem, task, or situation and identify its importance in the curriculum, why it was chosen, what the students should learn from it, and any difficult issues and traps it may entail; and (4) provide the tutor with an expert who can be consulted at any time and who might be able to attend a tutorial session to listen to a group's deliberations and give feedback about the group's progress.
  2. Resource Faculty (Consultants): These faculty (clinicians or academicians or both) with content expertise are available to students during self-directed study as a source for references and information from their area of expertise (basic science or clinical). The CIS often serves as a resource for the students and may provide a lecture if requested by the students (ie, student-initiated learning).
  3. Problem Simulations: The initial presentation, history, physical examination, laboratory and imaging results, and special tests of actual patient cases are addressed. Just as in real-life situations, the cases are ill structured. The students face the problems just as they would in real-life clinical situations, and the path to their solution is unknown. The students can ask any question and perform any physical examination, diagnostic procedure, or emergency intervention. Students are also allowed to ask inappropriate questions, perform inappropriate tests, and obtain the responses that would occur with an actual patient. Therefore, the ill-structured cases and problem simulations offer the same challenge to clinical reasoning as a real-life situation does. Basing cases on theoretic or imaginary groups of findings ultimately results in the collapse of a case from lack of authenticity. This is an area in which the CIS can contribute to the PBL curriculum as the problems are developed from actual cases to preserve their authenticity. The clinical instruction and supervisory roles of the CIS in a PBL curriculum are not dichotomous: separating the clinical assessment of psychomotor skills from their application in the appropriate decision-making context is impossible; thus, in this curricular model, the roles of clinical instructor and clinical supervisor are carried out by the same individual.

The Role of the Tutor in Problem-Based Learning

The tutor functions on a metacognitive level, which has been defined by Barrows3,19 as,

thinking: pondering, deliberating, or reflecting on the problem or situation; reviewing what is known and remembered about the kind of problem confronted; creating hypotheses; making decisions about what observations, questions or probes need to be made; questioning the meaning of new information obtained from inquiry.

Barrows further identified the role of the tutor as a guide to facilitate student independence and critical thinking, keep the process moving in the right sequence, probe the student's knowledge depth, be sure all students are involved in the group process, and engage in educational diagnosis of each student (errors in reasoning, difficulties in understanding the information and concepts). The tutor is responsible for several tasks critical to the group's success: keeping the learning process moving and taking each phase in the right sequence (eg, students should explore the causes of a problem before moving to inquiry to gain more information); probing the student's knowledge deeply with “why” questions challenging ideas, terms, definitions, explanations, and comments; being sure that all students are involved in the group; offering educational diagnoses (eg, reasoning difficulties, problems understanding the information and concepts, or problems finding the appropriate information); and modulating the challenge of the problem at hand (ie, the task should not be so easy that the students are bored, nor should they be faced with a problem that is far too complex or overwhelming).19 These skills are not used in traditional, didactic education and must be learned by the tutor. Tutorial and facilitation styles vary and may have a profound impact on the outcome20 and the group's ability to continue the process on its own.

The skilled tutor asks probing questions to determine whether the students' discussion has reached the depth and breadth of the topic as determined by the instructor's learning objectives and anticipated learning outcomes for that problem. The tutor may assist the students in organizing the information and moving to the next level of understanding without directing where the group discussion should go. For example, the group may have identified the neural structures (receptors, nerve types, pathways, fiber types, diameter, etc) involved in pain transmission but not linked those concepts to electrotherapy-setting selections. The tutor may say, “Given what you know about the nervous system, how does this relate to what you will do clinically to achieve your goal of pain relief?” With each passing week, students “discover” and learn new information in the context of solving a case; the tutor can provide cues to the students if they begin to draw incorrect conclusions. The tutor also focuses the group on the task at hand if the discussion moves toward themes that are “nice to know” but not essential to the case. As students gain more experience with PBL, the tutor becomes less necessary to the success of the group.

One of the dangers the tutor must guard against is the students' temptation to believe they have solved the problem when they have only achieved a superficial understanding of it. The problem should be designed with sufficient depth and breadth so that students must uncover the deeper, underlying basic science principles responsible for the clinical presentation or intervention problem. Didactic education and fact memorization keeps the learning at the superficial level. It is only when the student develops the connections among facts, principles, and clinical presentation that critical-thinking, analysis, and decision-making skills begin to manifest. The final discussion period of the week is designed to deepen these connections and to facilitate the transfer of the knowledge gained during the week to new situations later in the semester. The cases encountered in the PBL curriculum begin to provide students with a deeper understanding of interrelationship between the basic and clinical sciences. Rather than memorizing facts, students learn to draw connections and think critically about a cluster of findings, much in the same way they will encounter problems in the field. Concept mapping21 is a useful process for students to discover the connections from superficial to deep areas of knowledge and understanding. The tutor can determine if the students have achieved the depth of inquiry by comparing the concept map to the list of anticipated learning issues developed as the problem was designed (Figure).

Fig. 1
Sample concept map for acute shoulder injury: exploring the neuroscience branch.

Tutor training is essential to the success of a PBL curriculum.12,19 Options for learning effective tutorial skills include faculty colleagues who have experience and success in the tutorial process, PBL tutor-training courses offered by institutions (eg, Southern Illinois University Medical School), analysis of videotape tutorial sessions, and in-depth understanding of the tutorial process. The tutor's skills are also further refined based on the group's constructive feedback at the end of each weekly case-summary discussion. Once trained, the CIS can facilitate groups and laboratory sessions in his or her area of expertise for short periods (2 to 3 sessions, typically lasting a week): for example, the field management of the athlete with suspected spinal trauma. The CIS works closely with the course coordinator in debriefing sessions after the tutorial sessions to determine whether underlying learning objectives were met, the progression of the case, and methodologic issues related to improving tutorial skills. This represents an investment of the university in the clinical setting and provides a unique opportunity for clinicians to be involved in the curriculum and to interact closely with the students.


The PBL entry-level athletic training master's degree curriculum spans 4 semesters, with clinical education commencing during the first semester and progressing in complexity and intensity during the curriculum (Table (Table1).1). Because the program offers a master of science degree, students are required to complete a research thesis, selecting from the research themes and agendas of the faculty. The entry-level professional-education requirements are the same, so this model can be used for either undergraduate or graduate curricula. From the outset of the program, students are challenged to support their assessment findings and intervention plans (field management, therapeutic modalities, and exercise) with evidence from the literature. Throughout the curriculum, students are encouraged to practice evidence-based medicine.22

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Table 1. Sample Problem-Based Learning Curriculum Structure*

Evidence-based medicine is a method for evaluating the validity of research in clinical medicine and applying the results to patient care. It integrates clinical expertise with the best available clinical research because neither expertise nor research on their own merits are sufficient to guarantee optimal care.23 First, traditional sources of information (textbooks) are often out of date, contain errors, are ineffective, are too overwhelming in their volume, or are lacking in validity for practical use. Second, with novice students, disparity among assessment skills, judgment, and clinical knowledge is great. Third, reimbursement often depends on the ability to produce evidence and justification for a particular treatment approach or intervention.22 Problem-based learning and the practice of evidence-based medicine (as applied to the health professions, including athletic training) share a number of features, including identifying the problem or area of uncertainty, formulating relevant and clinically focused questions, finding and appraising the evidence, assessing the clinical importance of the evidence, assessing the clinical application of the recommendations or conclusions of the research, assessing the outcomes of the clinical actions taken, and summarizing and storing information for future reference.24

The athletic training curriculum follows a modified PBL format to provide students with guidance through appropriate readings and learning objectives. This offers needed structure to the students' learning experience, particularly early in the first semester of the program. Unlike the passive lecture format, which disengages the students from the learning process, the active learning environment in the PBL curriculum requires that students become actively involved, assuming responsibility for their learning. For many students, the transition from a passive to active learning environment is initially uncomfortable, as they must begin to decide for themselves what is important to know to solve the problem.

Based on feedback from students after the first year of the curriculum, several well-placed lectures dealing with basic concepts (eg, tissue healing, organization of the nervous system) presented early in the semester may be beneficial. Students must have a foundation of factual knowledge (gained by the basic science prerequisites for the professional-education program and lectures given early in the program) in order to develop problem-solving ability and to transfer the knowledge to new situations. To complete the circle, the students' ability to acquire organized skills and facts (through drill and practice, modeling, electronic simulations, etc) is enhanced when those skills are connected to meaningful problem-solving activities and students understand why, when, and how those skills are relevant. The key for success with a modified approach (lecture and PBL format in the same curriculum) is to facilitate the transfer of concepts in a meaningful way from one problem to another. Needham and Begg25 compared problem solving with rote memorization and found that not only were the students in the problem-solving group better able to transfer and apply concepts to new problems, but feedback about the correct solution was also important for successful transfer. Using a modified approach allows the curriculum to draw on the best aspects of both the traditional and PBL approaches to achieve the goals of student learning.

When designing a PBL curriculum, ideally all instructional faculty of the basic and clinical sciences will reach a consensus on the content sequence and location in the curriculum. Specific learning objectives and reading assignments are provided to the students to assist them in developing and focusing their resources. Course work in cadaver anatomy and physiology is coordinated with assessment, treatment (field management, therapeutic modalities, manual therapy, therapeutic exercise), reconditioning, injury prevention, practice issues, and clinical-skills development. The subject matter revolves around the cases and the information necessary for each case. The weekly content is spread across the courses with the same underlying theme. Students participate first in a small-group discussion to begin to address the problem, followed by the laboratory session the next day. For example, the first week of the semester focuses on tissue response to injury in the case of an acute onset of shoulder pain. The cadaver anatomy and physiology course content focuses on introductory anatomical, physiologic, and biomechanical concepts, including movement definition, basic arthrology, palpation, injury response, pain transmission, scapulohumeral biomechanics, torque, force couples, and the anatomy of the shoulder complex. The assessment course introduces the basic concepts of history and physical examination, the screening examination, shoulder-complex examination (manual muscle testing, goniometry, and special tests), and functional examination. The therapeutic modalities and exercise course introduces the modalities used for inflammation and acute pain, principles of therapeutic exercise, and specific manual and exercise interventions for the case. Athletic taping and bracing techniques, functional progression of exercise and return to performance, and in-depth practice and assessment of the techniques learned in the earlier laboratories are further practiced and reinforced in the clinical-skills courses using drill and practice, simulations, and computer-based models. Students are introduced to the profession of athletic training, scope of practice, and evidence-based medicine in the practice issues course.

In the second year, the PBL approach must be integrated into courses taught by faculty from other departments who are not familiar with PBL. Conceivably the content (exercise physiology and pathophysiology) could be linked with common cases used in both courses. Despite the challenges, multidisciplinary groups are beneficial in that students are exposed to philosophies, skills, practice issues, and decision-making pathways in other disciplines. Lary et al,9 in a pilot project to test a model of rural health assessment, designed a multidisciplinary education model consisting of students in physical therapy, physician assistant, and dental hygiene programs. Phase I involved discipline-specific content and problems and team concepts; phase II consisted of working in multidisciplinary groups to solve a PBL case; and phase III had students working in small groups on real patients. Overwhelmingly, more than 90% of the students evaluating the program reported enhanced problem-solving skills, improvements in working in groups, and an enhanced knowledge of the other disciplines.

The process begins during the first discussion session, when the students are introduced to the case and read the problem (this often happens on Friday so students have the weekend for independent study and preparation for the upcoming week) (Table (Table2).2). During the first discussion session, students brainstorm to identify hypotheses and possible solutions; data, including information obtained from the patient or test results, diagrams, pictures, radiographs, models, answers to any questions they might pose; learning issues, including areas of knowledge deficit, what students need to know about the case, what further information is necessary to interpret data or make decisions regarding the hypotheses; and an action plan, including tasks that need to be completed to solve the problem (Table (Table3).3). The students then identify and assign essential issues for each group member to research.

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Table 2. Sample Curriculum Schedule, Semester 1
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Table 3. Sample Case-Planning Worksheet

The second discussion session begins with a case summary (in the style of grand rounds), evaluation of resources used by the students in independent study, reevaluation of the hypotheses and data in light of the new information, addition or deletion of hypotheses, and carrying the problem through to the intervention. The final discussion session of the week focuses on reviewing the relationships between the clinical findings and basic sciences. Concept mapping may be used during this session to graphically represent those relationships. Students are asked to evaluate the performance of the group, each individual, and the tutor and to offer positive suggestions for improvement. As the students move through the semester, their reactions vary from excitement over the novelty of the experience to a sense of being overwhelmed at the volume of knowledge available, and finally, to a sense of the possible: the work is difficult, but they are learning principles and more clinically applicable material over a wider range of topics.

The faculty—both academic and clinical—design the problem around the basic and clinical sciences in an integrated fashion. They have structured and designed the case to reach the desired depth of knowledge. Case-planning worksheets clearly demonstrate where each of the competencies is addressed in the curriculum and are included in the documentation for the accrediting agencies. All educational competencies have been cross-referenced with multiple exposures in the classroom, laboratory setting, clinical-skills courses, and finally, the open clinical setting. The curriculum is revised at the conclusion of each semester as part of an ongoing curriculum assessment: cases are modified and revised after the students work through the problems. Additional anticipated learning issues and difficult areas are identified and included in the problem description for the following year.

For example, the basic sciences focus on introductory anatomy concepts (as reflected by the anatomy learning objectives provided the students), basic organization of the nervous system, introduction to pain theories, acute tissue injury (biology and clinical presentation), and anatomy of the shoulder complex via cadaver dissection, while the clinical sciences focus on introductory assessment principles and shoulder assessment. After the first tutorial (assessment), the students participate in the assessment laboratory, where they learn the techniques highlighted in the discussion. The tutor and the students also have learning objectives for the laboratory sessions. At the second session, one student summarizes the case as if presenting at grand rounds, and the discussion moves toward intervention methods.

Integrated Development of Clinical Skills

Considerable discussion has focused on the notion of assessing “learning across time” and each of the cognitive, psychomotor, and affective competencies and the clinical proficiencies described by the National Athletic Trainers' Association competencies document.26 Although decision making and skill application are mentioned in the preface, the clinical proficiencies are, for the most part, listed as technical abilities (locate, identify, apply, select settings, etc). However, clinical proficiency is more than technical ability or a prescribed amount of knowledge. It is the combination of knowledge; understanding of the basic sciences, skills, and attitudes; understanding of factors influencing the current clinical situation; and the ability to think critically to make appropriate decisions. For example, a fourth grader can learn the psychomotor task of performing a Lachman test: hand placement, direction of pull, position of the body part, etc. However, the fourth grader would likely be unable to demonstrate clinical competency in the broader sense.

In decision making, several features distinguish psychomotor competencies from clinical competencies. Psychomotor competency is based on understanding how and why a decision will lead to successful results, what other factors may be involved, what other physical examination techniques should be employed, and having the ability to solve the problems presented by the clinical situation. Clinical competency is a broad, far-reaching combination of skills, knowledge, and decision-making skills. For example, competence as a clinician includes the broad range of knowledge and understanding upon which the assessment and subsequent intervention are based, including competence in patient and athlete assessment, management, tissue healing, processes that would promote or inhibit wound healing, and factors involved with functional return to competition. Mere technical skill does not necessarily translate to the skills needed to be a reflective practitioner. Thus, the notion of “learning across time” must mean more than documenting that the skill has been taught 3 times during the training curriculum. Assessment of skill attainment occurs first in the context of psychomotor proficiency and then progresses to appropriate use in a clinical or field setting. To that end, the curriculum design should move from assessing isolated psychomotor clinical skills to a contextual evaluation of decision making to select the appropriate group of skills relative to the situation. It is impossible to predict every situation that the sports medicine clinician will experience on the athletic field; however, highly developed critical-analysis and problem-solving skills enable the clinician to make good field decisions.

Beginning with the first semester, students are introduced to the clinical proficiencies and skills in the appropriate laboratory session (assessment or intervention) and are provided a psychomotor checklist breaking the skill into its component parts, including “fatal flaws,” which, if present, result in automatic failure for that skill. The first assessment of clinical skills in the curriculum occurs in a closed laboratory environment. Students have the opportunity in the corequisite clinical-skills courses to further refine the clinical skills in a progressively open environment and place them in the context of field practice. During the first year, the students are closely supervised by the clinical CIS during the laboratory sessions and on the field in an open, applied environment. The CIS is familiar with the progression of the curriculum and seeks to design clinical experiences in concert with the student's progress in the classroom. Because the students have learned the didactic and clinical information in an integrated fashion, once they are placed in the clinical environment, they are judged on their critical-thinking and analysis skills against the benchmark of a practicing certified athletic trainer. During the closely supervised clinical-skills courses, students are also socialized into the profession with the assessment of professional abilities, including interpersonal skills, commitment to learning, communication skills, effective use of time and resources, use of constructive feedback, problem solving, professionalism, responsibility, critical thinking, and stress management.27

The Objective Structured Clinical Examination (OSCE) used in medical and physical therapy education has been adopted as an assessment tool in the clinical-skills courses. The OSCE, or standardized patient,28,29 requires students to interact with a simulated patient or situation who presents with a standard history and physical examination or with a standardized scenario. The clinical examination focuses on 6 areas of clinical competence: (1) detailed and relevant history; (2) physical examination; (3) identification, performance, and interpretation of the appropriate tests and measures (special tests, diagnostic tests, physical performance, radiographs, etc); (4) identification of the problem and working diagnosis; and (5) management. The OSCE is completed with a checklist or rating scale for each station. The grading forms have been tailored to each station according to a standardized blueprint, including (1) test situation presented to the examinee, (2) diagnosis or nature of the problem, (3) level of student to be assessed, (4) time allowed, (5) objectives to be tested, (6) task examinee is asked to perform, (7) data to be observed and how they are to be observed and recorded, (8) scoring method, and (9) strategies for making decisions.28 The OSCE represents a higher-level assessment, as the skills are now evaluated in the context of a complete examination. The final stage of assessment occurs in the context of the students' clinical experiences. Results of the basic-skills laboratory examinations, OSCE, and field assessment span the continuum of assessment from psychomotor skill assessment to assessment of clinical decision making.

Assessment of Student Learning

Assessment in a PBL environment occurs in the context of the students' abilities to revise and improve their thinking and to see progress and revise any errors in understanding. The tutor identifies problems that need to be remedied.

Written and practical examinations fall short in assessing whether the student has learned to think critically or ask the important questions. These examinations often focus on the student's ability to memorize facts rather than assessing learning and understanding. The ability to think independently and clinically must be fostered throughout the curriculum, recognizing that it is a process, not an outcome, and contains both rational and emotive elements. Brookfield30 identified 4 components of critical thinking: (1) identifying and challenging assumptions, (2) challenging the importance of context, (3) attempts to imagine and explore the alternatives, and (4) imagining and exploring the alternatives leads to reflective skepticism. Clearly the PBL curriculum addresses each of these components. Assessment in a PBL curriculum must be ongoing in order to make the students' thinking, misconceptions, and development evident to the teacher, who continuously monitors their progress.

The traditional, multiple-choice examination format focuses on students' ability to memorize facts. If structured in the context of solving a problem and requiring synthesis of information and prioritization of options,31 written examinations may also provide opportunities for clinical decision making. In a modified PBL curriculum, it is most effective to provide students with the data about a particular case and then ask questions relating to anatomy and physiology; assessment; signs, symptoms, and mechanisms; field intervention; rehabilitation; and prevention for that case. As the examination progresses, additional data may be provided to further develop the case. Because all the courses are corequisite and emphasize different aspects of the same case, single examinations with questions from all the courses are given at 3 points in the semester. Questions from each course are identified and tallied separately.

Just as student assessment in a PBL curriculum can be problematic, students learn early that their old study strategies are ineffective. Straight memorization, reading, and highlighting texts with an arbitrary content sequence are not effective in helping students learn concepts or group information in an interrelated and meaningful way. With some instruction, students learn to group information in a structured manner so that interrelationships among ideas become apparent. The concept-mapping method20 and Kiewra's32 matrix-representation system present methods for students to organize information in a meaningful way from generalities to specifics. During the final summary discussion of the week, students amass all the basic science and clinical aspects of the case and reconsider the evidence and context of the material covered. With the tutor's assistance, students develop a concept map (see Figure), beginning with the superficial knowledge of the case and its presentation. Founded in cognitive science, concept mapping demonstrates true competence in an area of inquiry (the case) as students demonstrate factual foundations (ie, basic sciences), understand those facts in the context of the conceptual framework developed by the map, and organize the new knowledge in meaningful ways that facilitate retrieval and clinical application. Daley et al21 suggested 6 steps in creating a concept map:

  1. Select the topic, reading, or case for which you want to develop a map.
  2. Identify the most general concepts first and place them at the top of the map.
  3. Identify more specific concepts that are related to the general concepts.
  4. Tie the general and specific concepts together with linking words in some fashion that has meaning for the learner.
  5. Look for cross-linkages between the more general and more specific concepts.
  6. Discuss, share, think about, and revise the map.

As students gain more experience and familiarity with concept mapping, the maps become more complex, providing graphic representations of their progress during the preceding week.

Challenges in Implementing a Problem-Based Learning Curriculum

Designing and implementing a PBL curriculum is easiest for new programs, which have the luxury of being able to assign content and teaching methods across the curriculum. Each major area (ours was divided into musculoskeletal/orthopaedics, neurologic/spine/head trauma, cardiovascular, thoracoabdominal, and internal medicine content blocks) should be carefully designed to integrate both the basic science (anatomy, physiology, pathophysiology, and biomechanics) and clinical science components. Typically in a 16-week semester, 13 to 14 cases are developed to address the interrelated nature of the biological, physical, and clinical concepts illustrated by each case. In that sense, the cases become the curriculum. The resistance to a PBL curriculum may come from our colleagues in the basic sciences who fear that knowledge of the basic sciences will be reduced, thus undermining the scientific foundation of the profession. Most curricula will have to integrate their courses with other disciplines (eg, basic sciences, other departments) and faculty who may not share the enthusiasm or commitment for PBL. Therefore, it may be more feasible to integrate the PBL approach into modules or blocks within a semester.

The PBL process is introduced to the students during the application process, when they are invited to the campus for group interviews to provide the faculty with the opportunity to observe how they function in a group setting. Also, applicants gain a notion of what to expect in a PBL curriculum. Before the semester starts, the students participate in a week-long orientation session during which they are provided with more materials about the PBL process,33 experience the PBL process for the first time, and are taught essential skills required on the first day of their clinical experience.


Problem-based learning, grounded in cognitive theory and medical education, is a useful approach in teaching students how to think critically and solve problems they will encounter in the athletic training professional environment. Students who participate in PBL curricula generally find less of a dichotomy between the didactic and clinical settings. Athletic training education programs, particularly start-up programs, should consider integrating PBL into portions of their curricula. The modified PBL is the most feasible option, given academic environment and manpower restrictions. Although evidence to support PBL as superior to traditional methods is lacking, students and faculty report that the PBL process is more immediately relevant, interesting, and motivating than the traditional lecture format. The formal preparation of sports medicine professionals should foster the development of critical thinking, rational decision making, the ability to be a team player, and the curiosity to seek new knowledge to solve any problems that present themselves. Selecting the appropriate educational approach, based on the current understanding of how people learn and use information will allow the right questions to be asked and answered.


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Articles from Journal of Athletic Training are provided here courtesy of National Athletic Trainers Association