Abstract

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Background: Case-based learning (CBL) is an educational paradigm closely related to the problem based learning (PBL) that uses a guided inquiry method and provides structure during small-group discussions. To date, no studies have directly compared PBL and CBL from medical students’ perspective in developing countries.
Aim: To compare first year medical students’ attitudes to CBL versus PBL after alternating the teaching methods during several teaching sessions.
Methods: After conducting several PBL sessions, students were introduced to CBL where the facilitator played an important role during the small group discussion sessions. At the end of all the CBL sessions, students filled a questionnaire form that sought opinions on (i) rating of CBL model as a tool in understanding concepts’ compared with regular teaching sessions and PBL (ii) global analysis of CBL on 4-point likert scale (iii) overall remarks about CBL. Gender differences in the level of attitudes and perceptions towards the CBL program were evaluated by logistic regression (enter method).
Results: A total of 88 first year medical students took part in the questionnaire. Majority of the students’ rated CBL in understanding concepts as “good” compared with both regular teaching sessions as well as PBL. Majority of the students’ rated ‘‘agree’’ on a 4-point likert scale for ‘‘motivation by CBL to work more in this subject’’, ‘‘improvement of problem-solving skills using CBL”, “CBL as a worthwhile progression from PBL”, etc. Female students responded more positively towards CBL than male students.
Conclusion: Students viewed the constructs of CBL better than PBL.

Introduction

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The last decade has witnessed a rapid expansion of biomedical knowledge. Trends in medical education have shifted away from didactic teaching and towards contextual, or problem-based learning (PBL) justified by studies showing superiority of PBL in improving reasoning and communication skills1. PBL is believed to have the potential to prepare students more effectively for future learning because it is based on four modern insights into learning: constructive, self-directed, collaborative and contextual2. However the growing dominance of PBL could worsen the problems of information management in medical education e.g. by discouraging teachers from refining the educational utility of didactic modalities, by reducing faculty time for developing reusable resources to impart factual knowledge more efficiently etc. Hence the development of more integrated cognitive techniques for facilitating the comprehension of complex data are required to strengthen the knowledge base of 21st century medical graduates1.
In problem based learning (PBL) students use “triggers” from the problem case or scenario to define their own learning objectives3. They work in small groups in a classroom setting, apply previously learned information to solve the problem and identify the knowledge and skills they lack to accurately solve the problem4.
PBL requires the ability to process and discuss ideas and learn independently, hence students who have significant deficiencies in communication are more likely to be unsuccessful in a PBL program5. In India, students enter five-and-a-half year medical school programs right after high school; there is no intermediate degree program. In many western countries however students enter medical school after receiving a bachelor degree, hence they are likely to posses suitable learning skills ideal for PBL. All public education in India is free or very reasonable and students are selected through very competitive written entrance exams. Most public universities are entirely dependent on the government for income. Private medical education is however extremely expensive although entry is relatively easier. Students, in general, differ widely in their abilities to understand instructions or express ideas (in oral, written, and/or graphic ways); and present a range of language and communication skills.
Case-based learning (CBL) is an educational paradigm closely related to the more common PBL. CBL’s main traits are derived from PBL e.g. a case, problem, or inquiry is used to stimulate and underpin the acquisition of knowledge, skills, and attitudes6. However, when learners begin to explore tangents, the facilitators use guiding questions to bring them back to the main learning objective. Hence CBL uses a guided inquiry method and provides more structure during small-group sessions unlike PBL which is an open inquiry approach where facilitators play a minimal role and do not guide the discussion, even when learners explore tangents7,8.
To date, no studies have directly compared the different types of small group teaching methods from medical students’ perceptive in developing countries like India. In this study we evaluated several important aspects of first year medical students’ attitudes to CBL after alternating the teaching methods during several work sessions.

Methods

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After conducting several work sessions related to PBL expanding over various topics, first year undergraduate medical students were introduced to the innovative CBL paradigm for few topics as an adjunct to the introductory lecture sessions.
Study Unit Design
In PBL small groups, the group focused on the process of discovery by students themselves to stimulate problem solving and independent learning activities. Facilitators played a minimal role and did not guide the discussion. Learners are presented with a set of problems, they were then given time to struggle and define the problem, explore related issues and finally come to a common consensus with respect to the answers.
In CBL, learners were presented with a clinical problem and had time to struggle, define, and resolve the problem. However discovery was encouraged in a format in which both students and facilitators shared responsibility for coming to closure on cardinal learning points. The main goal of the facilitator is to assist the students through the facts and to engage in analysis and the development of possible solutions or strategies. When learners begin to explore tangents, the facilitator used guiding questions to bring them back to the main learning objective. Students were also encouraged to ask questions from the facilitator during the session.
Interviewing the students
Student evaluations comparing CBL with traditional lecture format and PBL as well as their perceptions of CBL model (from a pragmatic point of view) were undertaken through a combination of Likert scales and questionnaires. This was analyzed by the content analysis of the questionnaire form filled by the students at the end of all the CBL sessions.
Students were asked to fill their demographic information (age and sex). The rest of the anonymous questionnaire survey (see Appendix-1) sought opinions on (i) rating of CBL model as a tool in understanding concepts’ compared with regular teaching sessions and PBL (questions 3–4) (ii) global analysis of CBL on 4-point likert scale (questions 5–12) and (iii) overall remarks about CBL including its advantages and disadvantages compared to previous PBL based discussion sessions (question 13). Gender differences in the level of attitudes and perceptions towards the CBL programme were evaluated by logistic regression (enter method) using SPSS software version 13.0.

Results

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We questioned a group of 88 first year students undertaking an undergraduate five-and-a half year medical degree course regarding their opinion of the recently introduced CBL model. A total of 49 students were male and the rest were females. Majority of the students’ (73.6% and 56% respectively) rated CBL model for a tool in understanding concepts’ as “good” compared with regular teaching model as well as PBL discussion sessions (Table 1). Majority of the students felt that the MCQs presented were interesting and were relevant to first year medical students (rated as ‘‘strongly agree’’ on 4-point likert scale).
Majority of the students’ responses rated ‘‘agree’’ on a 4-point likert scale for ‘‘motivation by CBL to work more in this subject’’, ‘‘improvement of their problem-solving skill using CBL, “CBL as a worthwhile progression from PBL”, “more enjoyment with CBL compared to PBL”, “facilitation of interaction between staff and students by CBL discussion sessions”, CBL more suited the way of learning compared to PBL and “CBL helped to improve diagnostic skills and lateral thinking” (Table 1). The overall students’ verbatim remarks directing the main advantages of the CBL over PBL model are presented in Table 2. Female students viewed the constructs of CBL better than male students and responded more positively to CBL (Table 1). The rating of “CBL model vs. PBL as a tool in understanding concepts” as well as the rating for “more enjoyment with CBL vs. PBL” were statistically superior for female students compared to male students (p value = 0.043 and 0.05, estimated odds ratio = 2.18 and 2.13 respectively), Table 3.

Discussion

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The Problem-Based Learning (PBL) consists of carefully designed problems that impart the learner the acquisition of critical knowledge, problem-solving proficiencies, self-directed learning strategies and team participation skills leading to a constructivist approach to learning. The problem serves as the organizing centre and the stimulus for learning and represents the vehicle that develops students’ creative and high-order thinking skills. However, the problem presented to the students at the beginning of the learning process in PBL neither easily solves nor does it always results in the correct answers2,5,6.
A systematic review of problem-based learning (PBL) in undergraduate, pre-clinical medical education in 22 years of research involving 30 unique studies recently showed that PBL does not impact knowledge acquisition; evidence for other outcomes does not provide unequivocal support for enhanced learning9. The disadvantages of PBL have been reported to be related its increased cost and faculty time, lower levels of content-specific knowledge, decreased learning efficiency etc10-12.
The difficulty in measuring a cognitive process such as problem solving or clinical reasoning has been discussed and the evidence has led many PBL experts to rethink the goal of teaching the process of problem solving, and it is no longer considered to be a primary objective of PBL. Also the goal of tutorial health care scenarios is to provide a clinical context for the acquisition of knowledge, rather than to solve the problem10,13.
Students who have significant deficiencies in expressing ideas or communication skills are likely to be unsuccessful in a PBL program, as PBL requires the ability to process and discuss ideas and learn independently. It thus seems likely that with a guided inquiry approach as in CBL these students might find the problem solving exercises interesting and this might as well improve their academic performance. In this study we introduced CBL model for the first time to first year medical students’ after conducting several PBL related work sessions. We then tried to evaluate CBL from several important aspects of attitudes of students’. CBL was enjoyed and embraced by the majority of students. Student perception indicated that clinical reasoning, diagnostic interpretations, and the ability to think logically were also improved with CBL.
We also observed gender differences in the level of attitudes and perceptions towards the CBL programme. Overall, female students responded more positively towards CBL than male students. This is in concurrence with the study by Peplow who demonstrated that female students responded more positively to tasks undertaken in the discussion sessions14. This study established that female students in the early parts of the programme performed better in their examination marks compared with the male students. Hence female students may perform better at a CBL style of education early in their medical education.

Conclusion(s)

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We conclude that the innovative CBL paradigm appears to be an effective, superior and student centered alternative to the traditional lecture format and PBL from medical students’ perspective in developing countries like India.

Reference(s)

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Source(s) of Funding

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There was no source of funding for the work described in the study

Competing Interests

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We have no conflicts of interests to declare.

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