Discussion When assessing the feasibility and implications of incorporating PBL into the curriculum, we need to first understand

students perceptions towards PBL and their readiness for that style of learning. To do so, we need an understanding of their current curriculum and its gaps in addressing the learning needs of students. What do students think about PBL and SDL? What was their readiness? Why is this important? because students may have pre-conceived notions about what PBL and SDL is all about will this affect how they approach the sessions? this will influence how they approach the project by measuring their understandings before and after, we get a good idea of how their ideas change What was their outlook on small group learning? Perceptions about fellow classmates? Why is this important? Because PBL depends on functioning as a group and learning from each other.. need to trust classmates these perceptions may influence how sessions run Measuring perceptions is important because it could be compared with perceptions after PBL is incorporated We need to know where the students are coming from to know where PBL can take them
Understanding Problem-Based Learning and Self-Directed Learning As problem-based learning (PBL) is still considered a non-traditional learning style and one that is not currently a focus within the curriculum for medical students in Guyana, it was important to elicit the students understanding of what PBL encompassed. Students generally identified PBL as a process of group discussion based on clinical scenarios. After completing the three-week pilot project, students identified more specific components of PBL such as using ones own interests and gaps in knowledge to guide learning. This demonstrates that students developed a deeper understanding of PBL after only three tutorial sessions. This is significant because to maximize effectiveness of the group process, students should have a concrete understanding of the goals of PBL and how its approach differs from didactic learning. Without this understanding, students may enter into their tutorials expecting to be taught by their tutor, and the ability of PBL to foster self-directed learning may be missed. If PBL is being incorporated into an existing medical curriculum, it is important for all participating members to have a clear understanding of both the benefits and shortfalls of PBL and why it is being adopted by the institution. Similarly to understanding the foundation of problem-based learning, awareness of self-directed learning (SDL) is another integral component to being able to incorporate this method into a curriculum. Students understood SDL as a self-motivated and independent process, using ones preferred learning styles. It was viewed as a manageable and comfortable way to learn. It is apparent that students currently use SDL as a way to supplement and enhance their learning within the didactic curriculum, by reading extra resources about a specific topic on their own time. Students familiarity with using SDL is a factor that would facilitate integration of PBL into the permanent curriculum. Integrating PBL would allow the students to move from using SDL as a learning supplement to using it as a primary mode of life-long learning.

Readiness for small-group learning Prior to the PBL project, we asked about medical students perceptions of working with their classmates. For students to prosper in a team-based learning environment, it is important for them to trust each other, collaborate, and appreciate the value of learning from their peers. Interestingly, the students expressed mixed feelings about working with and learning from their peers, which we believe may be partly due to their existing didactic curriculum. Without the opportunity to collaborate and problemsolve with their peers on a regular basis, students may be unable to develop highly positive professional impressions of each other. However, students acknowledged that working in groups improves efficiency on health-care teams and would help them to think positively about these interactions in the future. Evidently, there was a desire among students to enhance these team-based, collaborative experiences during their undergraduate medical education. Implementing PBL into the curriculum would address these desires. The surgical clerks descriptions of small group learning both before and after the PBL pilot project demonstrated an overall positive change in attitude. Some of the most common positive terms used were: willing, effective, and optimistic. The negative terms included skeptical, distracting, and unsure. However, the number of negative words used to describe small group learning greatly decreased following the PBL pilot. This demonstrates that overall, students had a positive impression of PBL during the pilot project. Tutor feedback and moving forward In follow-up discussion with the local tutors (surgical staff), several strengths of the PBL pilot project were identified including: (1) it encouraged interaction between both students and tutors and helped to break barriers; (2) students learned to take on more responsibility; (3) a process of self-realization occurred through the learning process; and (4) it was a targeted way to discuss a topic which met the needs of students. Some of the challenges identified by the tutors were as follows: (1) staff members faced a lack of time and incentive to prepare for/facilitate the sessions due to excessive workloads and difficulty scheduling; (2) some students lost interest in the tutorial because it did not involve an evaluation component; (3) there was a need for increased clarity on the roles of students and tutors in the group process; and (4) self-directed learning was a challenge for the students because they are used to didactic teaching. In conclusion, the PBL pilot project received positive feedback from both the surgical clerks and participating staff at GPHC. Students learned from the PBL sessions, felt that its method was equal if not superior to didactic teaching, and developed more positive impressions of small-group learning. They acknowledged that team-working skills are important to develop and would help them become better clinicians in the future. The surgical clerks at GPHC seemed ready and willing to take on PBL as a component of their learning. The staff tutors also advocated that PBL be incorporated into the curriculum. They offered several suggestions on moving forward with the program: (1) educating all faculty and students on the purpose of PBL and the evidence supporting it as a learning methodology; (2) including an evaluation component to tutorial sessions; and (3) training more tutors and creating a case bank. Permanent implementation of PBL into the surgical clerkship rotation would be the first step, with the involvement of other faculties being a possibility in the future.