Cased-based Learning From Two Perspectives: Learner and Teacher

by Madison Parker, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Who enjoys being proved wrong or having to learn the hard way? The rhetorical answer is no one! However, in the last couple of months, it has happened to me time and time again. I recently graduated from pharmacy school. I matched for a PGY-1 pharmacy residency at the medical center associated with my alma mater. Wanting to be a well-rounded pharmacist and a successful preceptor, I decided to participate in an elective academia rotation. I quickly learned how different things are on the “other side.” As a student, I never understood the time commitment and detail that went into teaching a class and developing cases.

As a student, I did not enjoy the “case-based approach.” I did not understand why we were going to school if we were essentially just teaching ourselves. What I didn’t realize at the time was how much I was learning and growing as a health professional by grappling with cases. Hindsight always seems to be 20/20! Case-based learning made me dig far deeper than typical lectures ever did during pharmacy school. I was no longer just memorizing a drug side effect to regurgitate it back on a multiple-choice test. It was challenging, and it made me think well beyond “the right answer.” I had to learn how to pivot when a treatment was contraindicated or what to do next if a patient suffered a side effect.  Essentially, I learned how to contingency plans to better take care of my future patients.

I have also learned about Bloom’s Taxonomy during my teaching experience and the “cognitive skills” that case-based learning requires. Lectures rely on regurgitating information and the goal is to have students “remember” and “understand” whereas case-based learning requires the student to “analyze,” “evaluate,” and “create.”¹

During case-based learning, the student is provided a detailed clinical case or scenario that they need to work through and discuss. This typically involves a small group rather than a large lecture hall. Case-based learning, like typical lectures, should still include learning objectives, but the teacher won’t always disclose all of the objectives before the case discussion occurs.¹ This non-disclosure allows the learner to think for themselves. Case-based teaching dates back to the early 1900s. Dr. James Lorrain, a professor at the University of Edinburgh, was thought to be the first teacher to use case-based teaching during his pathology course. 

One study surveyed health professional students about their opinions toward case-based learning. There were 520 students invited to participate. These students were from various professional schools including medicine, pharmacy, nursing, and social work.  Students were required to work through the cases as teams during the course. Students were given a nine-item survey that asked about their satisfaction with small-group, case-based learning format using a 7-point semantic differential scale. The students were asked to rank each point from 1-to 5 where 1 indicated ‘strongly disagree’ and 5 indicated ‘strongly agree.’ Ratings were reported as a mean: e-learning discussions (3.54 ± 0.99), small group learning experiences (3.94 ± 0.88), and panel discussions (3.76 ± 0.91). Based on student satisfaction scores, one can infer that case-based learning can be challenging but also rewarding for the learner.³

Another study examined medical students in their pre-clinical years from 2015-2018 at Stanford who chose to enroll in an optional case-based learning course. This course was led by a facilitator and involved a small group of students who would discuss a prospective patient case. At the end of the course, the medical students were asked to participate in a pre-and post-intervention study reflecting on their clinical skills. The control sample included medical students who did not participate in the course. Non-participants were encouraged to participate in pre-and post-intervention surveys as well. A 14 item survey was given to assess participants’ self-reported skills including the ability to report, interpret, manage, educate, and course-specific skills and objectives. A 5-point Likert scale was utilized with 1 indicating ‘strongly disagree’ whereas 5 indicated ‘strongly agree.’ Two surveys were administered; the first survey was completed within two weeks before the first session of the optional course, and the second survey was completed within 2 weeks after the final session. The difference between the post-intervention score and pre-intervention score was calculated. The intervention group resulted in a more positive change in the following categories: understanding how clinicians arrive at a diagnosis, using a step-by-step approach in a longitudinal primary care setting, and how to ultimately share information with their patients.⁴

There are many benefits associated with case-based teaching. It challenges health professional students to use their problem-solving skills before encountering real patients in their clinical years. This in turn allows students to practice and sharpen their skills so that they know how to grapple with real problems and challenges using the same resources that practitioners use when faced with the unknown.⁴ As a future preceptor, I am a big fan of case-based teaching!

In my opinion, cases should be created by experts in the field of practice. Cases should be constructed in a way that they spark students’ interest when hearing about “the real world.” Case-based learning should be facilitated, but by whom? In my experience, it doesn’t have be an expert in the field, just someone with a general knowledge of the subject matter. However, it is helpful for facilitators to have a guide created by the case author.  The case guide should clearly state the objectives the students should acheive and give “tips for success” in the written matters.

In summary, case-based teaching is effective and encourages higher order thinking. It is particularly effectives in health professions education, giving students a chance to practice in a safe environment where “no harm” will arise from a poorly conceived or ill-informed decision. Case-based learning should be extensively used in every health-related curriculum as the benefits and positive results are well established.

References:

1. Armstrong, P. Bloom’s Taxonomy. Vanderbilt University Center for Teaching. 2010.
2. McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. Journal of Medical Education and Curricular Development. 2016;3:JMECD.S20377.
3. Curran VR, Sharpe D, Forristall J, Flynn K. Student satisfaction and perceptions of small group process in case-based interprofessional learning. Medical Teacher. 2008;30(4):431-433.
4. Waliany S, Caceres W, Merrell SB, Thadaney S, Johnstone N, Osterberg L. Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC Med Educ. 2019;19(1):31.