Table 3. A joint display of the results from the exploratory sequential mixed method
Qualitative study phase   Quantitative study phase
Discussion topics at FGD Themes identified by the thematic analysis Specific phrases at FGDs for each theme   Category the question number % total score in each category* Item-total correlation†
Outcome of PBL Effective learning - Ability of summarizing my idea and speaking precisely would not be improved by learning from a lecture; however, that was improved at PBL. I believe that such an ability is useful after becoming a doctor. Learning effects of PBL Q1-6 68.9% (2445/3550) n = 119          r=.836 n=112 p<.001
- I could learn beyond my self-learning at each session of the group discussions. It seems to be a better way to learn huge volumes of medical knowledge.      
- At Mie University, the general knowledge is learned in lectures, and the symptomology of individual diseases are learned in PBL tutorials.    
- The discussion sometimes kept on going even if I did not understand the discussion.      
Cognitive thinking - PBL-tutorials made me understand how the knowledge of basic medical science is applied to clinical practice. We did not know the importance of basic medical science and knowledge so much for clinical practice.      
- At a PBL-tutorial, the sequence goes in a reverse direction of the contents of textbooks. It is same as the diagnosis of real patients. I could learn a way of thinking which is needed in a clinical setting.        
Application of PBL outcome Social skills - I got to feel that it was easy to have a discussion with my classmates even if my opinion might be wrong through the PBL program.   Social interaction       during and after PBL  Q7-12               57.7% (2047/3550) n = 119          r = .882 n = 112 p < .001
- I gained the ability to explain after considering other’s level of understanding.        
- I always worried about saying something wrong about my learning achievements. Every time I honestly hoped that the tutorial would be finished as soon as possible.        
Social interaction - I thought about how to get along well with others every time at a tutorial. I think such ability was trained at tutorials, but I really disliked it.    
- The good atmosphere motivates students to communicate freely. If a few members talk too much, the group may not work well.        
Continuing learning - I became to summarize clinical information effectively. The PBL program was a good pre-clinical training.                       
Clinical practice - If I join clinical rotations without such learning, I may have a lot of trouble at a hospital. Application of PBL       experiences to clinical clerkship               Q13-17 63.4% (1886/2975)          n = 119 r = .868 n = 112   p < .001
Challenges of PBL / Suggestion for PBL Learning resources - Since many students use the same textbook, the contents of group work overlapped. There is no meaning to discussing together.   Satisfaction with         PBL                 Q18-24*                                         67.9% (2826/4165)             n = 119 r = .674 n = 112 p < .001
- I learned about searching PubMed and looked for more sources. Because I had read only textbooks, the source of information expanded.        
- It is hard to understand physical examinations on paper. I recommend that more visual materials should be provided.        
Assessments - Too many assessment items disturb student’s proper assessment.        
- Peer assessment tends to be done with bias by the preconception of each student.        
Student’s learning behaviors - I made a copy of an easy text as part of my portfolio. Everyone is copying the contents.    
- Students who benefit most from group learning are           those who do not study by themselves before group work.      
- Since we are passive, there is little feedback from the tutor.      
Quality of tutors - Some tutors are not specialized physicians. In such cases, the tutor was less involved in the activities. I hoped the tutor would be more active.    
- If tutors improve their facilitation skills, PBL would be completely different. Tutor training should be required.      
- Some tutors are very enthusiastic. Such tutors understand the scenario and know the teaching points properly. But some may not well understand the scenario. The standardization of tutors’ teaching skills may be challenge for better PBL tutorials.      
Quality of case-scenarios - Since the same scenarios are used every year, some students get the information from senior students. They deal with tutorials without learning anything.    
Innovation of learning strategy - Someone should play the role of the patient indicated in the scenario. A tutor can make a good reaction like an actual patient.    
- It might be nice to have a preparatory lecture at the beginning of the PBL tutorials. If I received a summary lecture, it could be effective.        
- We should put more emphasis on patient's complaints than laboratory data.        
Reflection of student perspectives - The purpose of PBL was not clearly indicated to students.    
- PBL works well in Canada, but we need to modify it for Japanese students. The condition of PBL tutorials should be changed so that we can talk comfortably.        
Limitations of the application - There was a gap in knowledge between learning at PBL and clinical practice.        
- We should learn more about the process of patient care.

*A total score of responses to all questions in each category was counted and expressed as % total score of the maximum value. Deficit values at each question were 1 in Q2, 1 in Q3, 1 in Q5, 1 in Q6, 1 in Q7, and 3 in Q12. †An item-total correlation was analyzed between the total scores of responses to all questions in each category and all categories. The results were expressed as a correlation coefficient and p-value. The score at Q24 was reversely counted in data analysis as it was a negative question.

Int J Med Educ. 2022; 13:322-334; doi: 10.5116/ijme.6399.dee1