The patient as text: a challenge for problem-based learning

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Abstract
To explore the values and assumptions underlying problem-based learning (PBL) cases through narrative analysis, in order to consider the ways by which paper cases may affect student attitudes and values. Randomly chosen PBL cases from the first year curriculum at Dalhousie University medical school (n = 10) were coded by 3 independent reviewers attending to narrative components. The cases generally used spare, objective language, used the passive voice, eliminated agency, and employed linguistic markers to encode scepticism about patient reports. There was almost no sense of the presence of the patient as person in these cases in terms of their words, feelings, or their social and cultural context. The almost complete exclusion of the preferences and priorities of the patient was striking. The sample is small, the results only suggestive. Yet it appears that the cases used in PBL may unnecessarily, even unintentionally, encourage student detachment from the messiness of real patients' lives and emotions. Positioning a particular way of seeing - the doctor's gaze - as normative renders less visible the choices that are being made whenever an account is constructed. Including multiple voices in a case would complicate that tidy reduction of choices. Ongoing attempts to enrich the case format should be encouraged. At the same time, students may benefit from being taught the skills for critical analysis of the case itself.