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PROBLEM-BASED LEARNING (PBL) For Medical Student
This is available in Acrobat 4.0 here

PBL Quick Facts:

• What is PBL? Is it a new methodology? PBL is not a new model of instruction. Plato and
Socrates required that their students think, retrieve information for themselves, search
for new ideas and debate them in a scholarly environment. However, this process
differs from the teacher-dominated approach used in most educational settings.

• Where did PBL come from? PBL was officially adopted as a pedagogical approach in
1968 at McMaster University, a Canadian medical school. (Neufeld & Barrows, 1974),
because students were unable to apply their substantial amount of basic scientific
knowledge to clinical situations.

• How Does it Work? Students in small groups investigate and analyze

problems/scenarios. Using an organizer process of; 1) identifying the FACTS in the
problem/scenario; 2) generating (un-criticized) their IDEAS about the
scenario/problem and identifying just "what is the problem?"; 3) finally identifying the
things they have to LEARN about - in order to test their hypotheses (ideas).

• Why is this an effective approach? The use of this three step inquiry-organizer helps
students become familiar with a scientist’s reasoning process, to fill the gaps in their
own knowledge base, and to use their newly acquired knowledge to refine or discard
their ideas thus generating a whole new set of LEARNING NEEDS. This model has been
successfully applied to science instruction at all grade levels.

PBL places students in small groups and provides a means by which they can investigate real
problems. According to Fincham et al. (1997), "PBL does not present a new curriculum but
rather the same curriculum through a different teaching method," (p. 419).
How is problem-based learning different from project-based learning?
Project-Based Learning: Teacher A has her class design and build a city by the end of the
semester. The task is defined for them at the beginning with the inquiry bounded. They
discuss and explore various aspects of cities, architecture, sewer and other systems etc.
Students identify what they believe are the most effective ways to build their city within the
boundaries they are given in order to complete their project.
Problem-Based Learning: Teacher B has a city designed and built by students as her final
outcome the students may not know what that outcome is. The inquiry is very open allowing
the students to discover aspects that may not have been apparent. She introduces various
scenarios/problems to her students throughout the semester. Each scenario deals with a
different aspect of the city. An example would be sewage systems. Given a scenario related to
sewage, students identify the FACTS, brainstorm IDEAS about what the problem really is and
what they think about the situation. The LEARNING NEEDS they identify for themselves may
take them into: How various systems work, alternative sewage systems, environmental issues,
the role that soil plays in waste disposal, the impact on the water supply, waste disposal
legislation, debates about the pros and cons of public/private operations, water contamination
and/or purification etc. generating new FACTS, refining IDEAS and generating new LEARNING
NEEDS. The next scenario/problem may take them in-depth into different aspects of water
purification systems, building on the knowledge they gained in the previous scenario/problem.
At the end of the semester, the city is built, and in-depth research has been done on each
piece of the city’s infrastructure.
How do I safeguard the integrity of the process? The integrity of the process depends to a
great extent on the groups themselves. Groups are kept small, approximately 5 students and a
facilitator. At the beginning of the process, group norms are set by the students in the group.
Norms include but are not limited to: Respect for everyone’s ideas – no idea is "stupid"; not
interrupting someone else while they are speaking; in other words "what should be OK in this
process and what should not be OK – the rules of the game".
IDEAS are organized and then "rephrased" into a "testable" form (hypothesis). At this point
the "problem" is also identified. The next step is to generate LEARNING NEEDS (what we need
to know) that are prioritized and then divided among the group participants for investigation.
Each group member researches their part and the next day the group meets to discuss and
share the new information. This process generates a refinement of the prior ideas/hypotheses
and generates a new set of learning needs. Assessments are given to the individuals in the
group and the resulting grades are NOT for the group as a whole - the sharing of information
becomes an imperative and because of this the group becomes a powerful force for mutual
dissemination.
What part do hands-on instructional materials and kits play in PBL? Hands-on materials and
kits are powerful tools to learn concepts and to test hypotheses in order to refine IDEAS. E.g. a
scenario/problem that has a learning need about why a seed won’t grow could utilize a kit to
test soil samples, or water samples, or a weather study could result. Teachers can anticipate
what may be needed so that materials are on hand. In addition, art or the performing arts can
be integrated as an outcome; field sketching, clay, botanical drawing, dance, plays, robot
building, etc. The process can be as creative for the teacher as for the students.
Problem-Based Learning in Science Classrooms
Students are at the center of learning when teachers implement PBL. First, a problem or
scenario is presented to stimulate student interest. Students work in small groups to
investigate the problem. With very young children, the teacher may keep the class as a large
group for fact-finding, idea generation and learning needs identification. As the process
progresses, ideas are challenged by other group members or by the teacher if necessary. The
process is cyclical and repeated several times as new information is learned and ideas have
been modified to generate new learning needs. It should be noted that solving the problem is
not the most important objective, the power of PBL is found within the learning process itself
through student-directed inquiry. Scientific facts and concepts are not taught directly, but
integrated within the scientific process. Also integrated within the process is reading, writing,
vocabulary and if desired, mathematics and a host of other disciplines.
When investigating a PBL scenario, students assume the role of scientist. Effective problems
are those that engage student interest and motivate them to probe for deeper understanding
of science concepts. Good problems ask students to formulate ideas or judgments based on
facts that may be prior knowledge, information given in the scenario, and logic. Problem-
based learning usually includes several steps.
The five-step model in the chart below identifies these steps:

1. Problem is presented and read by group member, while another acts as scribe to mark
down FACTS as identified by group.
2. Students discuss what is known (the facts).
3. Students discuss what they think and identify the broad problem
(brainstorm their ideas and formulate their hypotheses).
4. Students identify their learning needs (what they need to learn in order to prove or
disprove their ideas).
5. Students share research findings with their peers, then recycle steps 2-4

Teachers take on a minimal role when presenting PBL scenarios. They use open-ended
questions to foster student metacognitive growth. If necessary, ask questions like: What’s
going on here? What do we need to know more about? What is your evidence? A wait-time is
essential to allow the student to process the information and formulate their ideas – they
should not be rushed. As students participate in PBL over time, they become self-directed
learners who are able to ask their own questions, and identify what they need to know to
continue their learning.
Creating PBL Scenarios
Ideas for PBL scenarios can come from almost anywhere; literature, television programming,
news programs or newspapers articles. Wonderful PBL scenarios can be created by changing
traditional lessons into problem-based inquiry learning. These lessons should be aligned with
the curriculum for your grade level and embedded with desired learning outcomes. When
creating or identifying scenarios consider the following components:

• A loosely structured case or prompt embedded with links to desired learning outcomes
i.e. standards (national, state or local).
• Small group cooperative learning is best, but find the model that works best for you.
• In the example provided of a dental education case from Malmo, Sweden – the one
sentence case drives their curriculum for weeks (see schematic in Appendix).
• Use hands-on kits and instructional materials – to test hypotheses and generate new
facts based on scientific experimentation.
• Learning is very open. In the case provided, "Buzz-saw Terror" if students have an idea
that the insect is an ant and you as a teacher know it isn’t – it’s OK if they spend time
investigating ants – eventually they are going to find that ants don’t build mounds like
the one described. When they do, they’re back on track and they not only learn about
the insect that does build the mound – they also have learned about ants, which may or
may not have been a teacher-desired outcome in the first place.

We have included on this website, a variety of PBL scenarios that have been successfully implemented in
science classrooms. Feel free to use them as they are written or change them to meet the needs of
your students or your science curriculum. Some of these cases are short and can be completed
within 2-3 class sessions, other cases require 1-4 weeks. In some instances, students at different
grade levels can use the same case. The beauty of PBL is that students use their prior knowledge
when developing ideas and formulating those ideas into hypothesis that can be tested. The
advanced level of a high school student will result in a deeper, more complex investigation than
would be done by a younger student. What is PBL?

Problem-based Learning: PBL is any learning environment in which the problem drives the learning.
That is, before students learn some knowledge they are given a problem. The problem is posed so that
the students discover that they need to learn some new knowledge before they can solve the problem.
Some example problem-based learning environments include:
•research projects
•engineering design projects that are more than a synthesis of previously learned knowledge
The traditional and well-known "Case approach", popular with business schools, may or may not be
problem-based learning. Often the case is used to integrate previously-learned knowledge and hence
would not be, according to this definition, problem-based learning.
• What's the big deal about PBL? Posing the problem before learning tends to motivate students. They
know why they are learning the new knowledge. Learning in the context of the need-to-solve-a-problem
also tends to store the knowledge in memory patterns that facilitate later recall for solving problems.
• What skills should a student have before entering a PBL program? They should be skilled at problem
solving because that skill in needed as the students try to solve the problem.
• Does using PBL develop problem solving skills? Not without explicit interventions on the part of the
teacher. PBL offers an opportunity to develop the skills
• Is PBL an example of cooperative learning? It depends. If the PBL is an individual project, then it does not
require cooperation with others.
• Why does there seem to be so much confusion about what is and what is not PBL? Problem-based
learning, learning because you need to solve a problem, has been around for centuries. Indeed, in the
stone age, people learned skills and approaches to solve problems to survive. They just didn't say to each
other "Hey, you are using PBL." Similarly, I suggest that all research is PBL, although we don't call it that,
we call it research. In the 1960s McMaster Medical School introduced a learning environment that was a
combination of small group, cooperative, self-directed, interdependent, self-assessed PBL. Since then this
approach has been called "PBL". But PBL, as I suggested previously, can be in any form where a problem is
posed to drive the learning. To overcome the confusion, I suggest we use the awkward terminology of
small group, self-directed, self-assessed PBL when referring to learning environments similar to the
McMaster Medical school approach.
Small group, self-directed, self-assessed PBL is a use of problem-based learning which embodies
most of the principles known to improve learning. This learning environment is active, cooperative, self-
assessed, provides prompt feedback, allows a better opportunity to account for personal learning
preferences and is highly effective.
• If small group, self-directed, self-assessed PBL is so great for learning, why isn't everyone doing it?
Probably, because of fear of the unknown and resources. Using this approach requires that teachers
change. Change is not easy. This change, in particular, expects teachers to change their role from being
the center of attention and the source of all knowledge to being the coach and facilitator of the acquisition
of that knowledge. The learning becomes student-centered, not teacher-centered. For resources, the
McMaster medical school model includes a tutor/teacher with each group. The groups are tutored. Hence,
there is one teacher for every group of five or six students. This is resource intensive if you do this for only
one course. This approach is not so resource intensive ifthe whole program is changed to this format. But
what if you want to try small group, self-directed, self-assessed PBL as part of your course? or for only one
course in your departmental program? Now, one is faced with classes of 30 to 200 with only one instructor.
• How can we use this medical school model with only one instructor with large classes of 30 to 300? One
answer is to use tutorless groups. Here we provide the students with the training we give to tutors; we
empower the student groups to be autonomous and accountable, with the tutor's role being to monitor and
hold the individuals and groups accountable for their learning.

PBL and Problem Solving

Problem solving is the process used to solve a problem. Since problem-based learning starts with a
problem so be solved, students working in a PBL environment should be skilled in problem solving or
critical thinking or "thinking on your feet" (as opposed to rote recall). How is this handled? In research
programs, we usually have qualifying examinations in which we test the problem solving (thinking skills) of
the candidates before they are admitted. In the McMaster Medical school, one of five criteria for admission
is a test of the candidates problem solving skills. Regrettably, some teachers embark on PBL without either
prescreening or developing their students skill in problem solving.
Doesn't putting students in a PBL environment develop their problem solving skills? Regrettably no. Giving
students an opportunity to solve problems rarely develops their skill in problem solving.
Can you have problem solving skill development without using PBL? Sure. We have lots of examples.
Conventionally, students learn the material in Chapter 5 of a text, and then use problem solving to solve
the homework problems. Here students are using problem solving skills in a "subject-based" learning
environment compared with a problem-based learning environment.

PBL and cooperative learning

Cooperative learning is a learning environment where students work together to learn, as opposed to
competing with each other for marks.
Can you have cooperative learning without PBL? Sure. Cooperative learning can be used for subject-based
learning. Here, you ask students to work together to solve problems, discuss ideas, compare ideas about a
concept, or do any task. You do use cooperative learning when you use small group, interdependent, self-
directed PBL.
Can you have PBL without cooperative learning? Sure. Individual research or tasks in the PBL mode do not
require cooperative learning.

Our use of small group, self-directed PBL

Our experience has been with small group, self-directed, self-assessed PBL in tutorless groups. In the
chemical engineering program, we use PBL as part of two courses: one topic or problem in a junior
level course; and five topics in a senior level course (Woods, 1991). The students concurrently are taking
five to seven required courses presented in the conventional format. Both PBL courses have about 30 to 50
students with one instructor. Hence, we use five to ten tutorless groups with five students per group.
Before the students they have received about 50 hours of workshop style training in the processing skills.
The outcomes for the PBL activity are the Chemical Engineering subject knowledge (process safety and
engineering economics), lifetime learning skills and chairperson skills. Each problem is studied for about
one week. Before the first PBL activity, the students have workshopsintroducing them to this PBL approach
to learning and workshops on managing change. The students are required to submit journal reports
frequently that make explicit their progress and activities within the PBL tutorless groups. The elaboration
is done by having three meetings: a goals meeting, a teach meeting and an elaboration/feedback meeting.
Student-generated learning issues are validated by the instructor during the goals meeting. The students'
assessment of the partial PBL learning environment, as measured by the Course Perceptions Questionnaire
(Knapper, 1994 and Ramsden, 1983), is d= +1 more positive than the responses from a control group of
engineering students in a conventional program (N=47).
At McMaster University, the theme school program was created. This is a program for interdisciplinary
learning that students from all disciplines may elect to take on overload. Based on the research expertise
at McMaster, one of the theme schools is on new materials and their impact on society. This school
has five 3-credit courses, three 2-credit seminar courses and two 6-credit research internships. Enrolment
is limited and by application. About 35 students were admitted in both the first and second year since it
was started. Students are from English, biology, physical education, nursing chemistry, mathematics and
engineering. The 3-credit courses use the small group self-directed problem-based format. For each
course has two instructors and 1 teaching assistant. The first course is sophomore level. In each 13-week
course the tutorless student groups handle 2 to 3 cases or problems. Concurrently they are taking 5 to 7
required courses in their major area. Except for the nursing program, all the other courses the students
take are presented in the conventional lecture format. The students have received no formal training in
the processing skills before they enroled in the theme school. Our approach has been to develop these
skills concurrently. We have five explicit, 1½ h workshops that are given during the second semester of
their sophomore year. The topics are understanding PBL and its expectations, managing change, problem
solving, group skills and self-directed-interdependent small group learning. The student evaluations of the
program have identified the importance of these explicit workshops and have recommended that these be
given before the students encounter their first case problem. Currently, this program does not explicitly
include the development of processing skills as valued outcomes nor are these skills formally assessed. I
believe that the program would be strengthened if it did. The students are not required to do extensive
journal writing. However, their written reports must demonstrate that they have synthesized information
and material learned from other members of their group. Student's assessment of the PBL learning
Problem-base learning is learning centered around a problem. The term "centered" means that the theme,
unit or mastery of content is replaced as the main focus of learning.Students' abilities to solve the
problem, present solutions and revise solutions when presented with additional information become the
goals. Centering around a problem emphasizes the students "doing" rather than mastery of discreet
pieces of information or skills.
Problem centered tasks are tasks in which there is a problem to solve, one about which students care and
which often, but not nesessarily always, they will have had a hand in formulating. By engaging students in
the conceptualization of a problem, they are invited to exercise the best of their analytic and speculative
abilities. When the problem is one that is genuinely meaningful to them, they are much more likely to
become stakeholders in the problem rather than people who simply execute the purposes of another-
which, incidentally, was Plate's definition of a slave (Eisner, 1994, p82).

Apppropriate problems should be relevant, real, complex and amenable to definite

solutions(Norton/Wiburg1998). Problems should also be solved in a social context. Working together
allows learners to solve problems at a level not yet possible when working alone (Vygotsky, 1978).
Content is taught because it is necessary and related to the problem's solution. Good problem situations
share some common characteristics:

• students should make a testable prediction of its outcome

• should work well with a range of equipment (not just high-end)
• complex enough to elicit several problem solving approaches
• solving benefits from group efforts
• should be relevant to the problem solvers
• should be ill-defined

Ill-defined problems are those that require more knowledge than is initially available in order for
understanding and decisions about actions for resolution to occur (Stepien, Gallagher, and Workman
(1993). There is no single right way to solve an ill-defined problem and as new information is introduced
the problem changes.
In designing problem-based learning tasks, there are four basic steps to consider:

• presenting the problem

• building a knowledge base
• supporting learners' problem solving
• testing and revising solutions

Presenting the Problem

In presenting the problem, the problem should be recognized and understood. This is where learner
motivation to solve the problem is stimulated with significant emphasis attached to its relevancy to the
learner.

Building a Knowledge Base

Content knowledge, skills and experience needed to solve the problem should be developed in this step.
Various information resources, simulations and multimedia/hypermedia applications could all be used to
build prerequisite knowledge and skills.

Supporting Learners' Problem Solving

This step allows the students time and resources to develop their own solutions to the problem. Teachers
should assume the role as peer experts and resource facilitators. Teachers should also plan for adequate
time and a proper environment whith which to problem solve.

Testing and Revising Solutions

Activities should be planned to permit learners to obtain feedback for their solutions, to encounter new
examples of how the problem might be solved, and to encounter new information which may cue solution
revisions.
environment in the Theme school, as measured by the Course Perceptions Questionnaire is d = +2 more
positive than their assessment of their "home" departments. Their responses for their home department
were consistent with the responses from a control group of students in a conventional program that has
enrolment limited and is by application.
In Civil Engineering, Fred Hall uses small group, self-directed, self-assessed PBL in a junior level course; in
Geography, Caroline Eyles and Fred Hall use this approach for a senior level project course.
In summary, these are examples of the use of small group self-directed PBL where tutorless groups of five
to six students function effectively. The class sizes are in the range 30 to 50 with one or two instructors.
The students concurrently take conventional courses. In these examples, the students work in tutorless
groups of about 5 to 6 students.
Problem Based Learning

If asked, most educators would agree that one essential goal of education is the development of students who are
effective problem solvers for the Information Literacy Age. Most reports, such as the national SCANS (Survey of
Necessary and Comprehensive Skills) and Goals 2000 documents, recommend such instruction. Most school goal
statements allude to the need for critical thinking and problem solving skills. Recent California Frameworks in
Mathematics and Science reflect consensus on this educational goal. But often such instruction in problem solving takes
the approach of teaching models to students to apply to neat case studies rather than the messy problems of a real world.

Research indicates that critical thinking and problem solving skills are not typically addressed in the classroom. A number
of studies indicate that in the typical classroom, 85% of teacher questions are at the recall or simple comprehension level.
Questions that elicit synthesis and evaluative skills of thinking are rarely asked. The media portrays teachers as asking
such simple, mindless questions in movies such as "Ferris Bueller's Day Off" and "Dead Poet's Society".

In Problem Based Learning (PBL) environments, students act as professionals and confront problems as they occur - with
fuzzy edges, insufficient information, and a need to determine the best solution possible by a given date. This is the
manner in which engineers, doctors, and, yes, even teachers, approach problem solving, unlike many classrooms where
teachers are the "sage on the stage" and guide students to neat solutions to contrived problems.

What is Problem Based Learning?

Problem Based Learning is a curriculum development and delivery system that recognizes the need to develop problem
solving skills as well as the necessity of helping students to acquire necessary knowledge and skills. Indeed, the first
application of PBL was in medical schools which rigorously test the knowledge base of graduates. PBL utilizes real world
problems, not hypothetical case studies with neat, convergent outcomes. It is in the process of struggling with actual
problems that students learn both content and critical thinking skills.

Problem based learning thus has several distinct characteristics which may be identified and utilized in designing such
curriculum. These are:

1. Reliance on problems to drive the curriculum - the problems do not test skills; they assist in development of the
skills themselves.
2. The problems are truly ill-structured - there is not meant to be one solution, and as new information is gathered
in a reiterative process, perception of the problem, and thus the solution, changes.
3. Students solve the problems - teachers are coaches and facilitators.
4. Students are only given guidelines for how to approach problems - there is no one formula for student
approaches to the problem.
5. Authentic, performance based assessment - is a seamless part and end of the instruction.

(Adapted from Stepien, W.J. and Gallagher, S.A. 1993. "Problem-based Learning: As Authentic as it Gets." Educational
Leadership. 50(7) 25-8 and Barrows, H. (1985) Designing a Problem Based Curriculum for the Pre-Clinical Years.
Problem Based Learning assists students to solve problems by the process of continually encountering the type of ill-
structured problems confronted by adults or practicing professionals. As with information literacy, PBL develops students
who can:

• Clearly define a problem

• Develop alternative hypotheses
• Access, evaluate, and utilize data from a variety of sources
• Alter hypotheses given new information
• Develop clearly stated solutions that fit the problem and its inherent conditions, based upon information and
clearly explicated reasoning

Students with such ingrained skill are well prepared for occupations which rarely have a supervisor who has time,
inclination, or knowledge to tell the worker what to do. They are also well prepared for the explosion of knowledge which
gluts the world today.
Stages in Problem Based Learning
In the PBL curriculum, one may note three distinct phases of operation by students. Whether gathering knowledge
through a variety of sources on the Internet, through print sources, or by speaking with experts, these stages explicated
below are characteristic of PBL. Each step in the process is "hot linked" to a sample lesson developed by a SCORE
Teacher on Assignment.
Stage 1: Encountering and Defining the Problem
Students are confronted with a real world scenario through authentic looking correspondence. Students may be asked to
present to the Ancient World Architectural Review Board regarding their perspective about how and why great ancient
monuments were built. They may ask some basic questions such as :

• What do I know already about this problem or question?

• What do I need to know to effectively address this problem or question?
• What resources can I access to determine a proposed solution or hypothesis?

At this point, a very focused Problem Statement is needed, though that statement will be altered as new information is
accessed and understood.
Stage 2: Accessing, Evaluating and Utilizing information
Once they have clearly defined the problem, students might access print, human, or electronic information resources. In
the case of the Southern Illinois Medical School, professors may be interviewed or medical texts examined. In the case of
a city plan, calls to human resources such as the town manager or staff engineers might be of use. The Internet can be a
focal point of research when a problem is constructed with that purpose. In the case of the sample problem, students may
find a rich diversity of perspectives and resources preparatory to phase 3. Part of any problem is evaluation of the
resource. How current is it? How credible and accurate is it? Is there any reason to suspect bias in the source? When
utilizing the information, students must carefully appraise the worth of the sources they have accessed. If evaluating sites
which theorize about these monuments and how and why they were built, students must carefully note and evaluate the
accuracy and credibility of information posted at that site.
Stage 3: Synthesis and Performance
In this stage, students construct a solution to the problem. Students may create a multi-media production, a presentation
to a body such as the U.N. Commission on Human Rights or the Ancient World Architectural Review Board, or a more
traditional written paper focused around an essential question. In all cases, the students must re-organize the information
is new ways. This is unlike an assignment which asks them to " make a report about the Palestinians and Israelis." This
latter leads to use of the Internet as if it were a giant cyberspace encyclopedia. An assignment which asks students to
propose a solution to the conflict between the Palestinian people and the Israelis involves a question which forces re-
organization of information and consideration of perspectives.
Problems in Implementation
Cultural change is required to implement PBL. Students trained in the more traditional model of teaching, which features
the teacher as "sage on the stage" and disseminator of knowledge, will experience culture shock of a sort. Students will
wish to know expectations for a high grade. Though constructing a rubric with a teacher may allay fears, there is initial
suspicion of the new approach.
Students must also learn to be part of the group. As with real life tasks, one person cannot conduct all research and make
the entire presentation of the problem solution. Complaints about "hitchhikers" (those in the group who do not pull their
own weight) will be heard from hard working students and their parents.
Teachers also experience major adjustments. More preliminary work must be done to design the problem and to ensure
that there are enough materials available (in print, online, and through human resources) for this resource's ravenous
approach. They must learn to construct problems that assist students to learn appropriate skills and knowledge. And they
must learn to facilitate, rather than direct, student learning.
The Rewards
Though change from a teacher-centered to a problem and project based environment causes discomfort, those that have
made the transition speak of new energy and enthusiasm for their classes. Students praise challenging tasks that prepare
them for learning. For more information, see the Problem Based Learning online resources below:

• The University of Delaware has numerous articles about PBL including teaching art, science, and other
courses. A good teacher resource. http://www.udel.edu/pbl/
• Howard Barrows, Southern Illinois School of Medicine (A medically focused analysis of PBL.)
http://www.pbli.org
• Illinois Math and Science Academy (Includes K-12 applications in various disciplines.) http://www.imsa.edu/

If you have further questions about PBL, please email Bob Benoit of the Butte County Office of Education at
[email protected]. Bob has directed a PBL project which included six high schools and 30 teachers over the
last four years.