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Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature

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Introduction: Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature search and review was completed. Methods: A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were “Case-based learning” and “medical education”, and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related fields of study, number of students, topics, delivery methods, and student level. Results: All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently represented field, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was 214 (7–3105). The top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed modalities in 19%. The top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent. Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of fields in healthcare, variety in student experience, curriculum implementation, and finally impact on patient care. Conclusions: CBL is a teaching tool used in a variety of medical fields using human cases to impart relevance and aid in connecting theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.
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39JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
Case-Based Learning and its Application in Medical
and Health-Care Fields: A Review of Worldwide
Literature
Susan F. McLean
Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.
ABSTRACT
INTRODUCTION: Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature
search and review was completed.
METHODS: A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were “Case-
based learning” and “medical education”, and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related
elds of study, number of students, topics, delivery methods, and student level.
RESULTS: All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently
represented eld, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was
214 (7–3105). e top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed
modalities in 19%. e top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent.
Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of
elds in healthcare, variety in student experience, curriculum implementation, and nally impact on patient care.
CONCLUSIONS: CBL is a teaching tool used in a variety of medical elds using human cases to impart relevance and aid in connecting theory to prac-
tice. e impact of CBL can reach from simple knowledge gains to changing patient care outcomes.
KEYWORDS: case-based learning, medical education, medical curriculum, graduate medical education
CITATION: McLean. 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 3949 doi:10.4137/JMECD.S20377.
TYPE: Review
RECEIVED: December 18, 2015. RESUBMITTED: March 28, 2016. ACCEPTED FOR
PUBLICATION: March 30, 2016.
ACADEMIC EDITOR: Steven R. Myers, Editor in Chief
PEER REVIEW: Four peer reviewers contributed to the peer review report. Reviewers’
reports totaled 779 words, excluding any condential comments to the academic editor.
FUNDING: Author discloses no external funding sources.
COMPETING INTERESTS: SFM has been selected as a local site primary investigator
for a study of a new tissue insert for use in surgical repair of ventral hernia. The study is
sponsored by BARD-Davol Inc.
COPYRIGHT: © the authors, publisher and licensee Libertas Academica Limited.
This is an open-access article distributed under the terms of the Creative Commons
CC-BY-NC 3.0 License.
CORRESPONDENCE: susan.mclean@ttuhsc.edu
Paper subject to independent expert single-blind peer review. All editorial decisions
made by independent academic editor. Upon submission manuscript was subject to
anti-plagiarism scanning. Prior to publication all authors have given signed conrmation
of agreement to article publication and compliance with all applicable ethical and legal
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Provenance: the author was invited to submit this paper.
Published by Libertas Academica. Learn more about this journal.
Journal name: Journal of Medical Education and Curricular Development
Journal type: Review
Year: 2016
Volume: 3
Running head verso: McLean
Running head recto: Case-based learning
Introduction
Medical and health care-related education is currently chang-
ing. Since the advent of adult education, educators have real-
ized that learners need to see the relevance and be actively
engaged in the topic under study.
1
Traditionally, students in
health care went to lectures and then transitioned into patient
care as a type of on-the-job training. Medical schools have real-
ized the importance of including clinical work early and have
termed the mixing of basic and clinical sciences as vertical
integration.
2
Other human health-related elds have also rec-
ognized the value of illustrating teaching points with actual
cases or simulated cases. Using clinical cases to aid teaching
has been termed as case-based learning (CBL).
ere is not a set denition for CBL. An excellent denition
has been proposed by istlewaite et al in a review article. In their
2012 paper, a CBL denition is “e goal of CBL is to prepare
students for clinical practice, through the use of authentic clini-
cal cases. It links theory to practice, through the application of
knowledge to the cases, using inquiry-based learning methods”.
3
Others have dened CBL by comparing CBL to a simi-
lar yet distinct clinical integration teaching method, problem-
based learning (PBL). PBL sessions typically used one patient
and had very little direction to the discussion of the case. e
learning occurred as the case unfolded, with students having
little advance preparation and often researching during the
case. Srinivasan et al compared CBL with PBL
4
and noted
that in PBL the student had little advance preparation and
very little guidance during the case discussion. However, in
CBL, both the student and faculty prepare in advance, and
there is guidance to the discussion so that important learning
points are covered. In a survey of students and faculty after
a United States medical school switched from PBL to CBL,
students reported that they enjoyed CBL better because there
were fewer unfocused tangents.
4
CBL is currently used in multiple health-care settings
around the world. In order to evaluate what is now considered
CBL, current uses of CBL, and evaluation strategies of CBL-
based curricular elements, a literature review was completed.
McLean
40 JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
is review will focus on human health-related applica-
tions of CBL-type learning. A summary of articles reviewed
is presented with respect to elds of study, delivery options for
CBL, locations of study, outcomes measurement if any, num-
ber of learners, and level of learner’s education. ese ndings
will be discussed. e rest of this review will focus on expand-
ing on the article summary by describing in more detail the
publications that reported on CBL. e review is organized
into denitions of CBL, comparison of CBL with PBL, and
the advantages of using CBL. e review will also examine
the utility and usage of CBL with respect to various elds
and levels of learner, as well as the methods of implementa-
tion of CBL in curricula. Finally, the impact of CBL training
on patient and health-care outcomes will be reviewed. One
wonders with the proliferation of articles that have CBL in the
title, whether or not there has been literature dening exactly
what CBL is, how it is used, and whether or not there are
any advantages to using CBL over other teaching strategies.
e rationale for completing this review is to assess CBL as
a discrete mode of transmitting medical and related elds of
knowledge. A systematic review of how CBL is accomplished,
including successes and failures in reports of CBL in real cur-
ricula, would aid other teachers of medical knowledge in the
future. Examining the current use of CBL would improve
the current methodology of CBL. erefore, the aims of this
review are to discover how widespread the use of CBL is glob-
ally, identify current denitions of CBL, compare CBL with
PBL, review educational levels of learners, compare meth-
ods of implementation of CBL in curricula, and review CBL
reports on outcomes of learning.
Methods
A literature search was completed using an OVID© database
search with PubMed as the database, 1946 to August 1, 2015.
e search key words were “Case Based Learning, Medical
Education”. Investigational Review Board declined to review
this project as there were no human subjects involved and this
was an article review. A total of 360 articles were retrieved.
Articles were excluded for the following reasons: unable to nd
complete article on the search engine OVID, unable to nd
English language translation, article did not really describe
CBL, article was not medically or health related, or article did
not describe human beings. Articles that originated in another
language but had English language translation were included.
After excluding the articles as described, 70 of these
articles were selected to review for location of study, description
of CBL used, human health care-related elds of study, number
of students if available, topics of study, method of delivery, and
level of student (eg, graduate or undergraduate). Students were
considered undergraduate if they were considered undergradu-
ate in their eld. For example, medical students were consid-
ered undergraduate, because they would still have to undergo
more training to become fully able to practice. If the student
was in the terminal degree, then that was considered a study of
graduate students. For example, nutrition students were listed
as graduate students. CBL encounters for both residents and
independent practitioners who were in their nal training prior
to practice were listed as graduates. Residents were listed under
graduate medical education. If a group had already graduated,
they were listed as graduates. For example, MDs who partici-
pated in a continuing medical education (CME)-type CBL
were listed as graduate type of student. Articles that did not
list the total number of students were included, as one of the
purposes of this review was to discover how widespread the
use of CBL was globally, and what types of students and types
of delivery were used. By including descriptive articles that
were not specic, the global use of CBL could attempt to be
assessed. Including locations of studies would then help decide
whether CBL was isolated from the Western countries or has
it truly spread around the world.
In order to review how CBL was used, in addition to
where it was used, the method of delivery was assessed.
Method of delivery refers to how the total educational con-
tent was delivered. Articles were reviewed for description of
exactly how material was imparted to learners. Since many
authors described their learning methods in detail, an attempt
was undertaken to classify these methods. Method of delivery
was classied as follows: live was considered a live presen-
tation of the case, this could be a description, a patient, or
a simulated patient. Computer or web based meant that the
case and content were web based. Mixed modalities meant
that more than two modalities were used during presentation.
For example, if an article described assigned reading, lectures,
small group discussions, a live case-based session, and patient
interactions, then that article would be described as mixed
modalities.
Method of evaluation of the educational intervention was
also reviewed. e multiple ways in which the interventions
were evaluated varied. A survey of how the learners viewed
the intervention was frequent. Tests of knowledge gained were
frequent, and these ranged from written, to oral, to Observed
Skills Clinical Examination (OSCE). Another way by which
CBL intervention knowledge was evaluated was review of
practice behavior in clinicians. ese multiple ways to evaluate
the introduction of CBL into a curriculum are summarized
in a table.
Results are presented in simple frequencies and percent-
ages. SPSS (Statistical Program for the Social Sciences, IBM)
version 22 was used for analysis.
Results
All continuously inhabited continents had studies on CBL
(Fig. 1). North America is represented with the most with
54.9% of articles, followed by Europe (25.4%) and Asia,
including India, Australia, and New Zealand (15.5%). South
America had 2.8% and Africa had 1%.
5–75
Level of education was undergraduation in 45 (64%)
articles and graduation in 24 (34%) articles, with one article
Case-based learning
41JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
having both levels. One study with both faculty and residents
was considered as a type of graduate education. e types
of elds of study varied (Fig. 2). e most represented eld
was medicine including traditional Chinese medicine, with
articles also on nursing, occupational therapy, allied health,
child development, and dentistry. e number of students
ranged from 7 to 3105 and the mean number of students was
214. One study reported on the use of teams of critical care
personnel, in which it was mentioned that there were three
persons per team usually. us, the number of students was
multiplied: 40teams× 3=120 in total. e total number of
students were 9884 from the 46 papers that explicitly stated
the number of students.
Methods of delivery also varied (Fig. 3). e most com-
mon method of delivery was live presentation (49%), followed
by computer or web based (20%) and then mixed modalities
(19%). Method of evaluation or outcomes was studied (Fig. 4).
Survey (36%), test (17%), and test plus survey (16%) were the
top three methods of evaluation of a CBL learning session.
Lesser in frequency was review of practice behavior (9%), test
plus OSCE (9%), and others. Review of practice behavior
could include reviewing prescription writing, or in one case
reviewing the number of adverse drug events reported sponta-
neously in Portugal.
65
Discussion and Review
CBL is used worldwide. ere was a large variety of elds
of medicine. e numbers reported included a wide range of
number of learners. Some studies were descriptive, and it was
hard to know exactly how many students were involved. is
problem was noted in another recent review.
3
CBL was used
in various educational levels, from undergraduate to graduate.
e number of students ranged from very small studies of
7 students to over 3000 students. e media used to deliver
a CBL session varied, from several live forms to paper and
pencil or internet-based media. e outcomes measurement
to review if CBL sessions were successful ranged from surveys
of participants to knowledge tests to measures of patient out-
comes. In order to further analyze the worldwide use of CBL,
the articles are reviewed below in more detail.
Denition of CBL. CBL has been used in medical elds
since at least 1912, when it was used by Dr. James Lorrain
Smith while teaching pathology in 1912 at the University
of Edinburgh.
63,68
istlewaite et al
3
pointed out in a recent
review of CBL that “ere is no international consensus as
to the denition of case-based learning (CBL) though it is
contrasted to problem based learning (PBL) in terms of struc-
ture. We conclude that CBL is a form of inquiry based learn-
ing and ts on the continuum between structured and guided
learning.” ey oer a denition of CBL: “e goal of CBL
is to prepare students for clinical practice, through the use of
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Figure 1. CBL use worldwide.
Fields of discipline (alphabetical order)
Frequency Percent
Allied health 1 1.4
Child development 1 1.4
Dentistry 5 7.1
Interdisciplinary 1 1.4
Medicine 51 72.9
Mixed 1 1.4
Nursing 3 4.3
Nutrition 1 1.4
Pharm 5 7.1
PT_OT 1 1.4
Total 70 100.0
Figure 2. Fields of study.
Mode of delivery Number Percent
Live presentation 34 49
Mixed modality 13 19
Computer or web 14 20
Live plus web 4 6
Live plus book or pocket manual 2 3
Live simulator 1 1
Live vs. self-learning 1 1
Paper 1 1
Figure 3. Mode of delivery of CBL.
McLean
42 JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
authentic clinical cases. It links theory to practice, through
the application of knowledge to the cases, using inquiry-based
learning methods.”
3
Another pathology article from Africa, describing a course
in laboratory medicine for mixed graduate medical education
(residents) and CME for clinicians, denes CBL: “Case-based
learning is structured so that trainees explore clinically rel-
evant topics using open-ended questions with well-dened
goals.”
7
e exploring that students or trainees do factors into
other denitions. In a dental education article originating in
Turkey, the authors remark: “e advantages of the case-based
method are promotion of self-directed learning, clinical rea-
soning, clinical problem solving, and decision making by pro-
viding repeated experiences in class and by enabling students
to focus on the complexity of clinical care.”
8
Another denition
of CBL was oered in a physiology education paper regarding
teaching undergraduate medical students in India: “What is
CBL? By discussing a clinical case related to the topic taught,
students evaluated their own understanding of the concept
using a high order of cognition. is process encourages active
learning and produces a more productive outcome.
13
In an
article published in 2008, regarding teaching graduate phar-
macology students, CBL was dened as “Case-based learning
(CBL) is an active-learning strategy, much like problem-based
learning, involving small groups in which the group focuses
on solving a presented problem.
45
Another study, which was
from China regarding teaching undergraduate medical stu-
dents pharmacology, describes CBL as “CBL is a long-estab-
lished pedagogical method that focuses on case study teaching
and inquiry-based learning:thus, CBL is on the continuum
between structured and guided learning.
63
It is apparent that
the denition requires at least: (1) a clinical case, (2) some
kind of inquiry on the part of the learner, which is all of the
information to be learned, is not presented at rst, (3) enough
information presented so that there is not too much time spent
learning basics, and (4) a faculty teaching and guiding the dis-
cussion, ensuring that learning objectives are met. In most
studies, CBL is not presented as free inquiry. e inquiry may
be a problem or question. Based on the fact that a problem is
expected to be solved or question answered, the information
covered cannot be completely new, or the new information
must be presented alongside the case.
A modern denition of CBL is that CBL is a form of
learning, which involves a clinical case, a problem or ques-
tion to be solved, and a stated set of learning objectives with
a measured outcome. Included in this denition is that some,
but not all, of the information is presented prior to or dur-
ing the learning intervention, and some of the information is
discovered during the problem solving or question answering.
e learner acquires some of the learning objectives during
the CBL session, whether it is live, web based, or on paper.
In contrast, if all of the information were given prior or dur-
ing the session, without the need for inquiry, then the session
would just be a lecture or reading.
Comparison of CBL and PBL. CBL is not the rst and
only method of inquiry-based education. PBL is similar, with
distinct dierences (Fig. 5). In many papers, CBL is compared
and contrasted with PBL in order to dene CBL better. PBL
is also centered around a clinical case. Often the objectives are
less clearly dened at the outset of the learning session, and
Outcome
Frequency Percent Cumulative percent
Behavior change 1 1.4 1.4
Descriptive 2 2.9 4.3
Evaluation of radiology
discussions
1 1.4 5.7
Focus group 1 1.4 7.1
Formal evaluations and survey 1 1.4 8.6
Oral and written 1 1.4 10.0
Reection essay plus survey 1 1.4 11.4
Review of practice behavior 6 8.5 20.0
Simulation plus survey 1 1.4 21.4
Survey 25 35.7 5 7.1
Survey plus web metrics 1 1.4 58.6
Test 12 17.1 75.7
Test OSCE 6 8.6 84.3
Test plus survey 11 15.7 100.0
Total 70 100.0
Figure 4. Method of evaluation.
Case-based learning
43JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
learning occurs in the course of solving the problem. ere is a
teacher, but the teacher is less intrusive with the guidance than
in CBL. One comparison of CBL to PBL was described in an
article on Turkish dental school education: “… CBL is eective
for students who have already acquired foundational knowl-
edge, whereas PBL invites the student to learn foundational
knowledge as part of researching the clinical case.” Study, of
postgraduate education in an American Obstetrics and Gyne-
cology residency, describes CBL as “CBL is a variant of PBL
and involves a case vignette that is designed to reect the edu-
cational objectives of a particular topic.
54
In an overview of
CBL and PBL in a dental education article from the United
States, the authors note that the main focus of PBL is on the
cases and CBL is more exible in its use of clinical material.
16
e authors quote Donner and Bickley,
70
stating that PBL is
… a form of education in which information is mastered in
the same context in which it will be used … PBL is seen as a
student-driven process in which the student sets the pace, and
the role of the teacher becomes one of guide, facilitator, and
resource … (p294).” e authors note that where PBL has the
student as the driver, in CBL the teachers are the drivers of
education, guiding and directing the learning much more than
in PBL.
16
e authors also note that there has not been conclu-
sive evidence that PBL is better than traditional lecture-based
learning (LBL) and has been noted to cover less material, some
say 80% of a curriculum.
71
It is apparent that PBL has been
used to aid case-related teaching in medical elds.
Two studies highlight the advantages and disadvantages
of CBL compared with PBL. Both studies report on major
curriculum shifts at three major medical schools. e rst
study, published in 2005, reported on the performance out-
comes during the third-year clerkship rotations at Southern
Illinois University (SIU).
19
At SIU, during the 1994–2002
school years, there was both a standard (STND) and PBL
learning tract oered for the preclinical years, years 1–2. Dur-
ing the PBL tract, basics of medicine were taught in small
group tutoring sessions using PBL modules and standardized
patients. In addition, there was a weekly live clinical session.
e two tracts were compared over all those years with respect
to United States Medical Licensing Exam© (USMLE) test
performance on Steps 1 and 2, and also overall grades and
subcategories on the six third-year clerkships. So the two
tracks had diering years 1–2 and the same year 3. Results
noted that the PBL track had more women and older students,
so these variables were set out as covariates analyzing other
scores. Comparing the PBL versus STND tracks, USMLE
scores were statistically equal over the years 1994–2002. PBL
was 204.90±21.05 and STND was 205.09±23.07 (P, 0.92);
Step 2 scores were PBL 210.17±21.83, STND 201.32±23.25
(P, 0.15). Clerkship overall scores were overall statistically
signicantly higher for PBL tract students in Obstetrics and
Gynecology and Psychiatry (P=0.02, P0.001, respectively)
and statistically not dierent for other clerkships. Clerkship
subcategory analysis demonstrated statistically signicantly
higher scores for PBL tract students in clinical performance,
knowledge and clinical reasoning, noncognitive behaviors,
and percent honors grades, with no dierence in the percent-
age of remediations. e school decided to switch to a single-
tract curriculum after 2002. e problems noted with the
PBL curriculum involved recruiting PBL faculty and faculty
Figure 5. Differences in CBL and PBL.
PBL CBL
Item
Goals Designed so that students may learn problem-
solving, information gathering, clinical reasoning,
collaboration. Focus is usually how to go about solving
the problem presented, not as much what the content
of the problem. This is process learning activity.
Designed so that students can learn about clinical cases:
diagnosis, management. Problem solving is often required
but may be aided.
Focus Problem solving.
Clinical based knowledge. How to solve specic problems
in the profession, or manage/identify problems or diseases.
Advanced study Little advanced study. Information is often
researched during the case.
Advanced study required. Students have been shown to
benet from having baseline knowledge imparted prior to
case based learning.
Role of learner Active participation. Expected to ask questions,
explore the topic during the session.
Expected to participate, have done advanced preparation,
ask some questions directly related to cases.
Role of teacher
Provide case, information as requested. Expected to
not interfere with student interest, even if not directly
applied to case. Expected to observe, not too much
guidance. Expected to impart the method of problem
solving or information gathering.
Provide case or cases. Expected to guide discussion or
if written or online, guide content so that specic learn-
ing objectives are met. Keeps discussion on tract without
allowing much tangential discussion. Ensures that correct
answers are known.
Amount of content Usually one case per session, since the focus is on
the process.
Can be one to many. Usually more than one case.
Learning objectives Loosely followed if at all. Discrete learning objectives.
Outcomes The process is the outcome. Measured outcomes to see if objectives are met.
McLean
44 JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
acceptance of student interactions, and also assessment issues.
Faculty had to be trained to teach in PBL, which was time
consuming and interfered with the process of learning by stu-
dents. In addition, some faculty felt that the teachers should
determine the learners needs and not vice versa. e PBL
assessment tools were novel and not immediately accepted
by the faculty.
19
Other schools noted similar problems with
PBL: it is dierent than LBL, and dicult to teach, as it is
extremely learner centered. Learning objectives are essentially
generated by the student, making faculty control over learning
dicult. At this school, the diculties in using PBL contrib-
uted to its abandonment as a stand-alone curriculum tract.
e diculties in using PBL were associated with
changes in other medical schools. Two medical schools in
the United States, namely, University of California, Los
Angeles, and University of California, Davis, changed from a
PBL method to a CBL method for teaching a course entitled
Doctoring, which was a small group faculty led course given
over years 1–3 in both schools.
4
Both schools had a typical
PBL approach, with little student advance preparation, little
faculty direction during the session, and a topic that was ini-
tially unknown to the student. After the shift in curriculum
to CBL, there were still small group sessions, but the students
were expected to do some advance reading, and the faculty
members were instructed to guide or direct the problem
solving. Since in both schools the students and faculty had
some experience with PBL before the shift, a survey was used
to assess student and faculty experiences and perceptions of
the two methods. Both students and faculty preferred CBL
(89% of students and 84% of faculty favored CBL). Reasons
for preference of CBL over PBL were as follows: fewer
unfocused tangents (59% favoring CBL, odds ratio [OR] 4.10,
P=0.01), less busywork (80% favoring CBL, OR 3.97 and
P=0.01), and more opportunities for clinical skills application
(52%,OR 25.6, P=0.002).
4
In summary, these two reports
indicate that while a case-oriented learning session can pre-
pare students for both tests of knowledge and also clinical rea-
soning, PBL has the problems of dicult to initiate faculty or
teachers in teaching this way, dicult to cover a large amount
of clinical ground, and diculty in assessment. CBL, on the
other hand, has advantages of exibility in using the case and
oers the same reality base that oers relevance for the adult
health-care learner. In addition, CBL appears to be accepted
by the faculty that may be practicing clinicians and oers a
way to teach specic learning objectives. ese advantages
of CBL led to it being the preferred method of case-related
learning at these two large medical schools.
Advantages of CBL and deeper learning. Another
touted advantage of CBL is deeper learning. at is, learning
that goes beyond simple identication of correct answers and
is more aligned with either evidence of critical thinking or
changes in behavior and generalizability of learning to new
cases. Several articles described this aspect of CBL. One
article was set at a tertiary care hospital, the Mayo Clinic,
and was a teaching model for quality improvement to pre-
vent patient adverse events.
33
e students were clinicians,
and the course was a continuing education or postgraduate
course. e authors in the Quality Improvement, Informa-
tion Technology, and Medical Education departments cre-
ated an online CBL module with three cases representing
the most common type of patient adverse events in internal
medicine. e authors use Kirkpatricks outcomes hierarchy
to assess the level of critical thinking after the CBL interven-
tion. Kirkpatricks outcomes hierarchy is based on four levels:
the rst, reaction of learner to educational intervention, the
second, actual learning: acquiring knowledge or skills, the
third, behavior or generalizing lessons learned to actual prac-
tice, and the fourth, results that would be patient outcomes.
72
e authors note that as one moves up this hierarchy, learning
is more dicult to measure. A survey can measure hierarchy
level 1, a written test, and level 2. Behavior is more dicult
but still able to be measured. e authors measured critical
thinking in physicians, taking their Quality Improvement
course by measuring critical reection by a survey. e authors
constructed a reection survey, which asked course partici-
pants about items constructed to assess their level of reec-
tion on the cases. Least reective levels consisted of habitual
action, and most critically, reective items asked physicians
if they would change the way they do things based on the
cases. e results of their intervention showed that physicians
had the lowest scores in reaching the higher levels of reec-
tive thinking. However, the reection scores were shown to
be associated with physicians’ perceptions of case relevance
(P=0.01) and event generalizability (P=0.001). is study
was the rst to evaluate physician’s reections after a CBL
module on adverse events. e assumption is that deeper
learning will be more likely to lead to behavioral changes.
Another attempt to measure deeper learning was reported
from a dental school in Turkey.
8
e authors compared a CBL
course with an older LBL course from the previous year by
using “SOLO” taxonomy, developed by Biggs and Collis.
73
SOLO taxonomy rates the learning outcomes from prestruc-
tural through extended abstract. For example, in unistructural,
the second item of SOLO, items could be “dene”, “identify,
or “do a simple procedure”, whereas in the “extended abstract
level, the items are “evaluate”, “predict, “generalize”, “create”,
“reect, or “hypothesize” in higher mental order tasks.
8
A post-
test was used to measure the responses on the test. e test
questions were assigned to SOLO categories. In the rst three
categories of SOLO taxonomy questions, there was no statisti-
cal dierence in scores between LBL and CBL groups. In the
last two or higher categories of questions based on SOLO tax-
onomy, there was a statistically signicant increase in the scores
for relational and extended types of questions for the CBL
group (P = 0.014 and 0.026, respectively). is review shows a
benet in higher level learning using a CBL program. Again,
the assumption is that by inducing higher order mental tasks,
deeper learning will occur and behavioral change will follow.
Case-based learning
45JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
Two other studies discussed the levels of thinking and
preparation for practice. One study compared students in
interdisciplinary (ID) versus single-discipline students (SD;
clinical anatomy) in a Graduate School for Health Sciences
in Missouri, U.S. e two groups had slightly dierent cases.
e ID group had complex ID cases and answered multiple
choice questions about the cases. e SD group had cases in
their discipline and answered multiple choice cases around
the case. e assessment tool was the Watson-Glaser Critical
inking Appraisal. e mean scores of both groups were not
statistically dierent. However, ID students who scored below
the median on the pretest scored signicantly higher on the
posttest. While this study set out to compare the dierences
in SD vs ID teaching using CBL, it also compared the eects
of an ID course on critical thinking and it appears to be syn-
ergistic with improving scores for students who started below
the median on testing. is is important in education pro-
grams, because while mean scores may not rise, if less students
are scoring lower, then less students will fail the course and
have to repeat.
e second paper that attempted to measure higher
learning outcomes queried dental school graduates who had
completed a CBL course during their dental school training.
22
e survey was designed to assess the CBL curriculum with
respect to actual job requirements of practicing dentists. e
graduates spanned 16 years, from 1990 to 2006, and the survey
was conducted in 2007–2008. e response rate was 41%.
e ndings were that the CBL course was associated with
positive correlations in “research competence, “interdis-
ciplinary thinking, “practical dental skills”, “team work,
and “independent learning/working”. Other items including
“problem-solving skills”, “psycho-social competence”, and
business competence” were not scored as highly with respon-
dents. is article measured self-reported competencies and
not the competencies as assessed by independent observers.
However, it does attempt to link CBL with the actual practice
with which it was attempting to teach, which is one of the
generally accepted benets of CBL.
In summary, CBL is dened as an inquiry structured
learning experience utilizing live or simulated patient cases
to solve, or examine a clinical problem, with the guidance of
a teacher and stated learning objectives. Advantages of using
CBL include more focusing on learning objectives compared
with PBL, exibility on the use of the case, and ability to
induce a deeper level of learning by inducing more critical
thinking skills.
Uses of CBL with respect to various elds and various
levels in health-care training. CBL is used to impart knowledge
in various elds in health care and various elds of medicine. e
ndings in this review showed that articles demonstrated the
use of CBL in medicine,
2,4–7,9,10,12–14,18–21,24–26,30,33,34,36,37,39–44,
46,48–62,64–67
dentistry,
8,15,16,22,23,28
pharmacology,
11,27,29,35,45,63
occupational and physical therapy,
31
nursing,
5,21,38,47,51
allied
health elds,
32
and child development.
17
Eighteen elds of medicine were seen in this review, from
internal medicine and surgery to palliative medicine and criti-
cal care (Fig. 2, “elds of study”). Several articles highlight
ID care or interprofessional care. A 2011 article in critical
care medicine demonstrated the utility of both simulators and
CBL on behaviors in critical situations of critical care teams of
physicians and nurses.
5
Palliative care
21
and primary care
51,59
articles also reported on using a CBL course for learning
with physicians and nurses. An article from the United Arab
Emirates discussed how CBL better prepared participants for
critical situations as well as basic primary care.
59
CBL is also used in various levels, including undergrad-
uate education in the professions, graduate education, and
postgraduate education. One eld that uses CBL for all lev-
els is surgery. Several articles describe surgical undergraduate
medical education. One article describes using a paper and
pencil plus live review sessions on improving student knowl-
edge as tested by a standardized test in surgery.
6
Another
paper from Germany describes initiation of a CBL curricu-
lum for medical students and lists the pitfalls in establishing
this curriculum.
26
A third undergraduate paper in a medical
school course in surgery describes utilizing CBL and a more
structured curriculum to aid in knowledge gains. A study
utilizing both surgical simulators for laparoscopic proce-
dural skills and CBL for clinical knowledge and reasoning
demonstrates learning enhancement using CBL in surgical
residents, or graduate surgical training.
20
In this study, scores
in both procedural ratings during surgery for residents and
also knowledge scores when presented with complications
from surgery both rated higher in the CBL-enhanced course.
Graduate use of CBL in surgery is frequent. CME courses are
taught in trauma, which features lectures, skill stations, and
simulation-based CBL.
74
Advanced Trauma Life Support
(ATLS) certication is required for all surgeons who prac-
tice in a designated trauma center in the United States.
74
In
addition, the American College of Surgeons publishes a self-
assessment course entitled “SESAP” or Surgical Education
and Self-Assessment Program, which is a web or CD-ROM
course that is largely case based, with commentaries.
75
ese
two courses are widely available and are constantly revised
to reect new advances in patient care research. e use of
CBL programs was employed in undergraduate and graduate
including postgraduate elds in this review.
Use of CBL in rural and underserved areas. One practi-
cal use of CBL is to use CBL to enhance knowledge in rural or
underserved areas. An excellent example of CBL is the Project
Extension for Community Healthcare Outcomes (ECHO)
program in Arizona and Utah states, United States.
10,12
is
program was based on the Project ECHO program initially
devised at the University of New Mexico Health Sciences
Center in 2003.
10
In Arizona and Utah, the CDC helped fund
a program to teach primary care providers and also provide
access to specialist to treat hepatitis C virus (HCV)-infected
patients. e primary aim was to increase treatment, as new
McLean
46 JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
drugs have become available, which are highly eective in
treating HCV. e program works by recruiting primary
care physician to participate. An initial teaching session is
held on site at the health-care clinic in the rural or under-
served area. en, the provider teams are asked to participate
in “tele ECHO” clinics in which participants present cases
and have experts in HCV treatment comment. ere are
also educational sessions. Ninety providers participated, with
66% or 73% being primary care providers in rural or com-
munity health centers and not at universities. Over one and
a half years, 280 patients were enrolled with 46.1% starting
treatment. Other patients were likely not able to be treated, as
their laboratory values indicated advanced liver disease. e
percentage starting treatment was more than twice as many
as expected to receive treatment prior to the project, based
on historical controls. In addition to showing how CBL can
impact rural medical care, this study is an example of learning
assessment measured in patient outcomes.
A second CBL project was used in the United Arab
Emirates to train rural practitioner’s vital aspects of primary
and emergency care using a CBL project.
60
e learners
were able to provide feedback to the teachers as to the top-
ics needed. is demonstrates the potential for interaction
between teachers and learners using CBL, as it is a practi-
cal way to teach active practitioners. A third demonstration of
using CBL in rural areas is in a report on teaching laboratory
medicine in Africa.
7
In Sub-Saharan Africa, there is low trust
in laboratory medicine services due in part to lower the qual-
ity of laboratories. is problem directly impacts patient care.
Multiple international agencies are assisting the clinical labo-
ratories in Sub-Saharan Africa in order to improve the quality
of service. According to this report, the quality problem has
led to decreased trust in laboratory medicine in the region.
e course, given at Addis Ababa University in Ethiopia, was
initiated to provide knowledge and also increase trust in labo-
ratory medicine. e participants were 21 residents (gradu-
ate medical education), 3 faculty members, and 4 laboratory
workers. e course was structured with both lectures and
cases. Students were given homework for the diering cases.
e assessments were both knowledge gains and also surveys
of satisfaction for the course. Ratings on the survey were by
ratings on a Likert scale of 1 (least valuable) to 5(most valu-
able). Regarding the methods of delivery, the CBL sessions
were rated highest with 85% of learners rating them as most
valuable. In all, 81% rated case discussions as most valuable.
Lectures received the most valuable rating by 65%. On the
12 question pre-/posttest, the mean score rose and also the
number of questions answered correctly by the majority of
learners.
7
ese reports from three continents demonstrate
that CBL is a practical way to impart knowledge in a diverse
range of topics to clinicians who may be remote from a medi-
cal university.
Delivery of CBL: implementation and media. As illus-
trated in the above examples of use of CBL in rural settings,
CBL use is varied as to the delivery method and implementa-
tion. Several articles demonstrate the importance of prepara-
tion for use in CBL. As many practitioners and students in
all elds likely have more experience with LBL, participating
in a course with CBL requires a dierent strategy and mind-
set in order to reach learning objectives. Preparation of both
students and teachers in a CBL format is also very impor-
tant for success. Two studies highlight the preparation and
implementation of CBL: one not as successful as the other.
In a qualitative study of introducing a new CBL format series
to undergraduate medical students based in Sweden, the
authors found that preparation of both students and faculty
was likely inadequate for complete success. is study, held
at the Karolinska Institutet, described the implementation of
a CBL format for learning surgery during a semester course.
All LBL classes were replaced with CBL sessions. e authors
noted that at this time, there were organizational obstacles
to starting a CBL course: lack of time and funds for faculty
training. As such, faculty training was delayed and decreased.
e study was a survey of ve students and ve faculty, who
were picked from larger pools. ere was a lot of criticism
by students that the CBL needed more structure, or that the
faculty often turned the CBL session more into a lecture ses-
sion. e faculty described problems with getting the students
to engage, and also with the lack of preparation for teach-
ing in that format. Still, the overall impression was that CBL
could increase interactive learning for this level of student.
26
is study demonstrates how lack of adequate preparation can
impact a CBL experience for both faculty and students.
Another article demonstrated the dierences in student
motivation for autonomous learning, which was dierent,
depending on how CBL was introduced. In a study of child
development students in Sweden, there were four group meth-
ods to compare how students learned, depending on how CBL
was introduced. e four groups were as follows: (1) LLL or
all lecture, (2) CCCC or all CBL, (3) LCLC in which lecture
and CBL were alternated in each session after the introduc-
tion, and (4) LLCC, in which there were three sessions with
all lectures, two mixed lecture plus CBL, and two CBL only
lectures to nish. ere was a knowledge pretest and post-
test to assess what the authors call prior knowledge (pretest)
and achievement (posttest). Student motivation for learning
was assessed by means of a modied Academic Self-Regulation
Scale.
76
e results were that achievement scores and also
autonomous motivation were both the highest in the LLCC
group, or the group in which CBL was introduced after LBL.
e authors conclude that students are more prepared for
CBL after some foundational knowledge is imparted. ese
two articles demonstrate that both teacher and student prepa-
ration is necessary for a successful CBL learning encounter.
Use of CBL to impact patients and measurement of
results. As described earlier, the Kirkland model of learning
and assessment of outcomes includes assessment of the results
of the training as its nal method of assessing an intervention.
Case-based learning
47JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
In other words, how did the training impact patient care or
its surrogate marker? Four recent studies illustrated how CBL
can impact patient care.
10,12,40,54,69
e rst, already described,
is the Project ECHO for HCV treatment, which resulted in
46.1% of patients in the areas aected being started on treat-
ment, and a large proportion of those treated being started on
the newer antivirals. e second study was a study on practices
by primary care physicians on treating diabetic patients. In
this study, 122 primary care physicians (Family and Internal
Medicine) at 18 sites were divided into three groups to enhance
diabetes care. Group A received surveys and no intervention
and served as a control group; group B received Internet-based
software with three cases in a virtual patient encounter. e
cases had simulated time and could include laboratory and
medication orders and follow-up visits. After the cases, the
physicians received feedback in the form of what an expert
would do. Group C received the same CBL as group B with the
addition of 60 minutes of verbal feedback and instruction from
a physician opinion leader. e authors were able to obtain
clinical data for the results. e results were that group B had
a signicant decline in hemoglobin A1C measures, the most
common means of assessing glucose control over time in dia-
betics, while groups A and C did not. Groups B and C had a
signicant decline in prescribing metformin in patients with
contraindications also. is demonstrates favorable clinical
results using a CBL intervention.
40
e third was a study to
institute chlamydia screening in oces. While the interven-
tion did not globally increase chlamydia screening, the impact
was that there was less of a decay on chlamydia screening
in the intervention groups.
54
e last study demonstrated a
CBL study in Portugal, which demonstrated an increase in
reporting of adverse drug events after a CBL intervention in a
study population of over 4000 physicians.
69
ese four articles
describe the use of CBL to impart medical knowledge and the
use of patient outcomes to assess that learned knowledge. is
is the ultimate test of learning for health-care practitioners:
knowledge that improves patient care.
Limitations of this Review
is review was an attempt to classify a term, case-based
learning, which is used frequently. In reviewing articles, this
term was used as a search term. It is possible that articles writ-
ten which would t the denition of CBL but were termed
dierently by the individuals writing that article might have
been missed. In addition, foreign language articles were not
retrieved if there was not an English translation. ere may
be additional articles that would be instructional in other
languages. e higher number of articles retrieved from
North America may be biased by using a United States data-
base. In an attempt to describe the various articles, which
were termed case-based learning, the methods of delivery and
evaluation were described in terms familiar to medical person-
nel. In the learning situation, these terms might be describing
slightly dierent experiences. For example, several articles
described the use of an observed skills examination to evalu-
ate the learner; this examination was classied as “observed
skills clinical examination or OSCE”. ese OSCEs might
have been more, or less, stringent. In defense of the search
strategy, since the objective of the article was to write about
what is currently considered case-based learning, this item was
used as the search term. In order to classify and further dene
what exactly is CBL and how it is used, putting into discrete
categories the described methods of delivery and evaluation
was necessary, or else the review would reduce to a listing of
separate articles without being able to provide a meaningful
commentary.
Conclusions
CBL is a tool that involves matching clinical cases in health
care-related elds to a body of knowledge in that eld, in order
to improve clinical performance, attitudes, or teamwork. is
type of learning has been shown to enhance clinical knowledge,
improve teamwork, improve clinical skills, improve practice
behavior, and improve patient outcomes. CBL advantages
include providing relevance to the adult learner, allowing the
teacher more input into the direction of learning, and induc-
ing learning on a deeper level. Learners or students in health
care-related elds will one day need to interact with patients,
and so education that relates to patient is particularly relevant.
Relevance is an important concept in adult education. CBL
was found to be used in all continents. Even limiting the search
to English and English translations, articles were found on all
continuously inhabited continents. is nding demonstrates
that the use of CBL is not isolated to Western countries, but is
used worldwide. In addition, based on the number and variety
of elds of medicine and health care reported, CBL is used
across multiple elds.
In reviewing the worldwide use of CBL, several con-
stants became apparent. One is that this involves a case as a
stimulant for learning. e second is that advance preparation
of the learner is necessary. e third is that a set of learning
objectives must be adhered to. A comparison with PBL across
several articles revealed that most teachers who use CBL, in
contrast to PBL, need to get through a list of learning objec-
tives, and in so doing, must provide enhanced guidance to the
learning session. at adherence to learning objectives was
evident in most articles. ere were varied methods of delivery,
depending on the learning situation. at is one of the practi-
cal aspects of learning sessions termed case-based learning or
CBL. e teachers used cases within their realm of teaching
and adapted a CBL approach to their situation; for example,
live CBL might be used with medical students, video cases
might be used with practitioners. CBL diers from PBL in
that it can cover a larger amount of topics because of the stated
learning objectives, and guidance from the teacher or facilita-
tor who does not allow unguided tangents, which may delay
covering the stated objectives. Contrasting CBL with CBL,
in PBL, the focus is on the process of learning as much as the
McLean
48 JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2016:3
topic, whereas in CBL, the learning objectives are stated at the
outset, and both learners and teachers try to adhere to these.
Because there are stated objectives at the outset of the learning
experience in CBL, these objectives can be tested to see if they
are met. ese tests of knowledge were explored as methods of
evaluation, which varied.
e methods of evaluation ran the range of Kirkpatricks
hierarchy of learning. One of the important aspects of CBL
which was explored was that perhaps CBL could induce learning
on a deeper level. And so going up the hierarchy of learning,
some evaluations were simple surveys of the learners/and or the
teachers on how they liked the CBL intervention. Some were
tests of knowledge or skills learned. A few studies evaluated
practice behavior; that is, going beyond knowledge learned into
what behaviors that knowledge induced. e last hierarchy was
how the knowledge learned from CBL aected actual patients:
a few studies revealed that patient outcomes were aected posi-
tively from CBL. us, published studies of CBL spanned the
hierarchy of learning, from opinions of the activity to actual
patients aected by the learning of practitioners.
In summary, CBL was found to be practiced worldwide,
by various practitioners, in various elds. CBL delivery was
found to be varied to the situation. Methods of evaluation
for CBL included all the steps on Kirkpatricks hierarchy of
learning and demonstrated that CBL could be shown conclu-
sively to produce deeper learning.
To repeat the denition included earlier in this review,
CBL is a form of learning that involves a clinical case, a prob-
lem or question requiring student thought, a set of learning
objectives, information given prior and during the learning
intervention, and a measured outcome.
CBL imparts relevance to medical and related curricula,
is shown to tie theory to practice, and induce deeper learning.
CBL is practical and ecient as a mode of teaching for adult
learners. CBL is certain to become part of every medical and
health profession’s curriculum.
Author Contributions
Conceived the concepts: SFM. Analyzed the data: SFM.
Wrote the rst draft of the manuscript: SFM. Made critical
revisions: SFM. e author reviewed and approved of the nal
manuscript.
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... [17] Medical educators have realized the importance of mixing of basic and clinical sciences as vertical integration. [18] Some educators have introduced teaching-learning strategies that illustrate teaching points with simulated or clinical case scenarios early in basic science courses. CCPS approach has received much attention in medical education worldwide as it is student-centered and exposes students to real-world clinical case scenarios which are required to be solved by deep understanding of concepts, thinking critically, linking theory to practice, interrelating, and justifying answers, and applying gained knowledge to diagnose. ...
... [19,20] A CCPS approach involves a clinical case, set of questions or problem to be solved, and a defined set of session learning objectives with a measured outcome. [18] In this approach, some information is provided prior to the session, some presented during the learning intervention, and some information is unearthed during students' active peer interaction and question answering session. This would encourage students to self-identify their learning needs, promotes their interest, and motivates them to get actively involved in peer discussion. ...
... Clinical case-based teaching-learning approach provides an opportunity to students to critically evaluate their ideas, bridge theory and practice, acquire greater knowledge, and apply gained knowledge to find solution to clinical-related problems. [11,18,21] The current study results support these facts as most of the students expressed that CCPS improved their critical thinking ability, problem-solving skills, and knowledge on the topic. ...
... The theoretical part consisted of explaining why and the methodology of the study, as well as the uniform definitions of the SDHs [18,19,39,41,42]. The practical part consisted of solving 18 practical cases that professionals could encounter in their primary care practice, and a checklist was used to minimize the time burden on health care providers in deciding whether to record or not. ...
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Background Social determinants of health may be more important than medical or lifestyle choices in influencing people's health. Even so, there is a deficit in recording these in patients' computerized medical histories. The Spanish administration and the World Health Organization are promoting the recording of diagnoses in computerized clinical histories with the aim of benefiting the individual, the professional, and the community. In most cases, professionals tend to record only clinical diagnoses despite evidence in the literature documenting that addressing the social determinants of health can lead to improvements in health and reductions in social disparities in disease. Objective This study aims to develop and evaluate the effectiveness of a mixed intervention (face-to-face-digital) aimed at improving the quantity and quality of the records of the social determinants of health in computerized medical records at primary care clinics. Methods A quasi-experimental, nonrandomized, controlled, multicenter study with 2 parallel study arms was conducted in the area of Central Catalonia (Spain) with primary care professionals of the Institut Català de la Salut (ICS), working from September 23, 2019, to March 31, 2020. All interested professionals were accepted. In total, 22 basic health areas were involved in the study. In Spain and Catalonia, the International Classification of Diseases is used, in which there is a coding of the social determinants of health. Five social determinants were selected by a physician, a nurse, and a social worker; these professionals had experience in primary care and were experts in community health. The choice was made taking into account the ease of use, benefit, and existing terminology. The intervention, based on the integration of a checklist, was integrated as part of the usual multidisciplinary clinical workflow in primary care consultations to influence the recording of these determinants in the patient's computerized medical record. Results After 6 months of implementing the intervention, the volume and quantity of records of 5 social determinants of health were compared, and a significant increase in the median number of pre- and postintervention diagnoses was observed (P≤.001). There was also an increase in the diversity of selected social determinants. Using the linear regression model, the significant mean increase of the experimental group with respect to the control group was estimated with a coefficient of 8.18 (95% CI 5.11-11.26). Conclusions The intervention described in this study is an effective tool for coding the social determinants of health designed by a multidisciplinary team to be incorporated into the workflow of primary care practices. The effectiveness of its usability and the description of the intervention described here should be generalizable to any environment. Trial Registration ClinicalTrials.gov NCT04151056; https://clinicaltrials.gov/ct2/show/NCT04151056
... That is, learning that goes beyond simple identification of correct answers and is more aligned with either evidence of critical thinking or changes in behavior and generalizability of learning to new cases. 18 By discussing a clinical case, students evaluated their own understanding of the concept using a high order of cognition. This process encourages active learning and produces a more productive outcome. ...
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Introduction: COVID-19 pandemic has caused an impact on various sectors of life, including the education sector. During the COVID-19 pandemic, education from various levels could only be carried out online by utilizing various on-line media. In Health professional education context, one of the learning activities that must be shifted in online format was interprofessional education (IPE) program. This study aimed to evaluate students' collaborative knowledge construction to evaluate the effectiveness of online interprofessional case-based learning (CBL) activities. Methods: This interventional study using quantitative and qualitative method involved a total of 476 students; consisted of 204 medical students, 39 midwifery students and 233 nursing students; who took part online interprofessional CBL. All students were divided into 34 mixed profession groups with 14 students each. To evaluate students' collaborative knowledge construction during CBL, data were collected using the Maastricht Peer Activity Rating Scale (MPARS). Qualitative data exploring students' perception regarding online IPE activity and their online CBL process were collected using Focus Group Discussion (FGD). Quantitative data were analysed using statistical tests, and the qualitative data were analysed using thematic analysis. Results: Students' scores for constructive, collaborative, and motivational activities evaluated using MPARS were considered as average to high. However, nursing students scored the lowest compared to the other two fellow professions: medical and midwifery students, on all items of the MPARS. Medical students had the highest MPARS scores. Several themes could be explored during the FGD. Discussion: This study revealed that students could engage in collaborative knowledge construction in interprofessional education implementing online interprofessional CBL. However, students thought that offline collaborative practice will better improve team bonding which is considered as prominent aspect for collaboration. This thought gives idea to the implementation of hybrid online offline learning for IPE.
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Among the various systems taught in the preclinical phases, the nervous system is more challenging to learn than other systems. In this report, a novel teaching methodology, 'real-life scenario (RLS) blended teaching' is described and its effectiveness in facilitating inquisitive learning in undergraduate medical students was evaluated. This mixed-method study was conducted among three groups (Group-1; n=83, Group-2; n=85, and Group-3; n=79) of undergraduate medical students (18-20 years) in the neurology and behavioral sciences module. RLS was presented to students in the form of demonstrations, role-plays, videos, and group activities. Group-1 students underwent traditional teaching-learning sessions. Group-2 students underwent RLS blended sessions and were provided with multiple mini-assignments in a vignette format. Group-3 students received RLS blended sessions, multiple mini-assignments, peer discussions, multiple formative assessments, and facilitator feedback sessions. The student performances on different exams were compared in terms of their Group, and their perceptions of RLS were documented. Students exposed to RLS sessions blended with multiple assignments, peer discussions, multiple formative assignments, and facilitator feedback sessions performed well in the final summative assessments (67.87%) compared to those exposed to RLS sessions and assignments (50.21%) or exposed to traditional teaching alone (50.34%). RLS sessions increased students' curiosity and motivated them to learn the subject well. RLS sessions stimulated student interest and facilitated their learning. RLS along with effective use of multiple assignments, formative assessments and/or feedback sessions significantly improved student learning. This demonstrates the effectiveness of this active method in teaching various subjects with appropriate modifications.
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To describe a 4-day laboratory medicine course for clinicians given at Addis Ababa University, Ethiopia, designed to improve the use of laboratory-based diagnoses. Each day was dedicated to one of the following topics: hematology, blood bank/transfusion medicine and coagulation, chemistry, and microbiology. The course included lectures, case-based learning, laboratory tours, and interactive computer case-based homework. The same 12-question knowledge quiz was given before and after the course. Twenty-eight participants took the quiz before and 21 after completing the course. The average score was 5.28 (range, 2-10) for the initial quiz and 8.09 (range, 4-11) for the second quiz (P = .0001). Two of 12 and 8 of 12 questions were answered correctly by more than 60% of trainees on the initial and second quiz, respectively. Knowledge and awareness of the role of the laboratory increased after participation in the course. Understanding of laboratory medicine principles by clinicians will likely improve use of laboratory services and build capacity in Africa. Copyright© by the American Society for Clinical Pathology.
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Hepatitis C virus (HCV) infection is the leading reason for liver transplantation and a common cause of hepatocellular carcinoma, the most rapidly increasing cause of cancer-related deaths in the United States. Of the approximately 3 million persons living with HCV infection in the United States, an estimated 38% are linked to care, 11% are treated, and 6% achieve cure. Recent development of highly effective and well-tolerated medications, such as sofosbuvir and simeprevir, to treat chronic HCV infection shows promise in curbing rising HCV-related morbidity and mortality, with the potential to cure >90% of patients. To fully benefit from these new treatments, improvement in linkage to care and treatment is urgently needed.* Lack of provider expertise in HCV treatment and limited access to specialists are well-documented barriers to HCV treatment. In September 2012, CDC funded programs in Utah and Arizona to improve access to primary care providers with the capacity to manage and treat HCV infection. Both programs were modeled on the Extension for Community Healthcare Outcomes (Project ECHO), developed by the University of New Mexico's Health Sciences Center in 2003 to build primary care capacity to treat diseases among rural, underserved populations through videoconferencing and case-based learning in "teleECHO" clinics. To assess the effectiveness of these programs in improving primary care provider capacity and increasing the number of patients initiating treatment, process and patient outcome data for each state program were analyzed. In both states, Project ECHO was successfully implemented, training 66 primary care clinicians, predominantly from rural settings. Nearly all (93%) of the clinicians had no prior experience in care and treatment of HCV infection. In both states combined, 129 (46%) of HCV-infected patients seen in teleECHO clinics received antiviral treatment, more than doubling the proportion of patients expected to receive treatment. These findings demonstrate Project ECHO's ability to expand primary care capacity to treat HCV infection, notably among underserved populations.
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Objective: To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH). Methods: Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively. Results: Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations. Conclusion: Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.
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Background: Spontaneous reporting of adverse drug reactions (ADRs) is the method most widely used by pharmacovigilance systems, with the principal limitation being the physician's underreporting. Objective: This study sought to evaluate the results of workshop and telephone-interview interventions designed to improve the quantity and relevance of ADR reporting by physicians. Methods: A cluster-randomized controlled trial was conducted on 6579 physicians in northern Portugal in 2008. Following randomization, we allocated 1034 physicians to a telephone-interview intervention, 438 to a workshop intervention and the remaining 5107 to the control group. At the workshop, a real clinical case was presented and participants were then asked to report on it by completing the relevant form. In the telephone intervention, participants were asked (i) whether they had ever had any suspicion of ADRs; (ii) whether they had experienced any difficulties in reporting; (iii) whether they remembered the different methods that could be used for reporting purposes; and (iv) whether they attached importance to the individual physician's role in reporting. We followed up physicians to assess ADR reporting rates to the Northern Pharmacovigilance Centre. In terms of relevance, adverse reactions were classified as serious or unexpected. Statistical analysis was performed on an intention-to-treat basis, and generalized linear mixed models were applied using the penalized quasi-likelihood method. The physicians studied were followed up over a period of 20 months. Results: Two hundred physicians underwent the educational intervention. Comparison with the control group showed that the workshop intervention increased the spontaneous ADR reporting rate by an average of 4-fold (relative risk [RR] 3.97; 95% CI 3.86, 4.08; p<0.001) across the 20 months post-intervention. Telephone interviews, in contrast, proved less efficient since they led to no significant difference (p = 0.052) vis-a-vis the control group in ADR reporting (RR 1.02; 95% CI 1.00, 1.04). The effects of the interventions on the reporting rate of serious and high-causality ADRs indicated that the RRs associated with workshops were 6.84 (95% CI 6.69, 6.98; p < 0.001) for serious ADRs and 3.58 (95% CI 3.51, 3.66; p<0.001) for high-causality ADRs. Conclusions: Whereas telephone interventions only increased spontaneous reporting in the first 4 months of follow-up, workshops significantly increased both the quantity and relevance of spontaneous ADR reporting for more than 1 year.
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BACKGROUND: Inconsistencies in adherence to evidence-based medicine practice guidelines and quality indicators for inflammatory bowel disease (IBD) have been a recognized limitation in the quality of care afforded to IBD patients. We designed an Objective Structured Clinical Examination (OSCE) to assess many of the core competencies and to provide GI fellows with a simulated, case-based learning experience in the management of IBD patients. To supplement this experience, we provided GI fellows with an easily accessible educational resource in the form of a pocket-sized guide to highlight key evidence-based concepts in IBD education stressed in the OSCE. We assessed the utility of the NYU Gastroenterology Fellowship Training Program Pocket Guide's usefulness, functionality, utilization, and the GI fellows' satisfaction with this educational resource.METHODS: The NYU Gastroenterology Fellowship Training Program's OSCE course included 4 real life IBD clinical scenarios. Five New York City GI training programs and 12 second-year GI fellows participated. Following the OSCE, each fellow was given a pocket guide entitled "NYU Gastroenterology Fellowship Training Program Pocket Guide: Key Concepts in Managing Patients with Inflammatory Bowel Disease." In addition, the pocket guide was given to the remaining 8 NYU GI fellows who did not participate in the OSCE. The white coat pocket-sized guide is comprised of 5 front and back laminated pages, with approximately 2 pages devoted to each OSCE case. Three months following the distribution of the pocket guide, 20 fellows were invited to participate in an online survey about the pocket guide in general as an education tool, and about its specific elements, and the fellows' answers were collected.RESULTS: Sixteen of 20 (80%) fellows responded to the survey. Nearly 94% (15/16) of responders found the pocket guide to be a useful supplement to their fellowship IBD training, and 100% agreed that the guide would have been a useful reference tool to have at the start of GI fellowship training. Fifty percent (8/16) of fellows reported consulting the IBD pocket guide for the care of 20% or more of their IBD patients. Nearly 70% (11/16) would have found the pocket guide most useful as a smartphone application instead of a pocket-sized laminated guide. When assessing the usefulness of the specific key concepts detailed in the guide, the majority of fellows (>=50%, >=8/16) agreed that the information improved their care of IBD patients.CONCLUSIONS: This IBD pocket guide serves as an educational resource that fulfills physicians' need to easy access to evidence-based medicine and quality indicators to help guide clinical decision-making in the care of IBD patients. The majority of GI fellow participants agreed that the care for their IBD patients improved with the use of the guide as a resource. The large majority of fellows found the guide to be a useful and vital educational tool to aid in the employment of evidence-based medicine when caring for their IBD patients. Most would have preferred a smartphone application instead of a physical pocket guide.(C) Crohn's & Colitis Foundation of America, Inc.
Article
Objective: To investigate the impact of three different training formats in occupational medicine (OM) on perceptions and performance of undergraduate students. Methods: A comparative study which included all fourth-year medical students was conducted over a three-year period. The year group in 2010 (211 students) received paper case studies followed by one small group session. The format used in 2011 actively engaged 188 students in the learning process by adding collaborative work and group discussions to the written information. In 2012, the approach comprised no longer constructed text cases but 212 students encountered real patients. Students' perceptions were obtained by questionnaire. Their learning performance was assessed through review of written reports and score on oral presentations. Statistical differences in ratings were analyzed using Fisher's exact and Kruskal-Wallis tests. Results: All three formats were found to equally achieve the stated learning objectives. The year groups with incorporation of active learning strategies and patient contacts had significant better test performance compared to those receiving only written case studies. Real patient students gave statistically significant higher rates for relevance, authenticity and appropriate difficulty level of the training than did students who discussed written case studies. Conclusion: Both approaches with augmented interaction in 2011 and 2012, improved performance and satisfaction among students. However, students valued the use of real patients higher than paper-form cases.
Article
The Medical Council of India, in the recent Vision 2015 document, recommended curricular reforms for undergraduates. Case-based learning (CBL) is one method where students are motivated toward self-directed learning and to develop analytic and problem-solving skills. An overview of thyroid physiology was given in a didactic lecture. A paper-based case scenario of multinodular goiter was given to phase I Bachelor of Medicine, Bachelor of Surgery students in two sessions. An attitude survey of the students and teachers was done using a Likert scale ranging from strongly disagrees to strongly agree. A pretest and posttest were conducted. The students opined that CBL helped them to better their understanding of a particular topic, gave them better retention of knowledge, helped them to relate clinical conditions to basic sciences, improved soft skills such as communication skills and group dynamics, and promoted a better teacher-student relationship. There was significant improvement in student's performance when pre- and posttest scores were compared (P = 0.018). Furthermore, faculty members opined that CBL promoted self-study and problem-solving abilities of the students. In conclusion, CBL motivates students toward self-directed learning and to develop analytic and problem-solving skills; thus, CBL could be beneficial for students' entry into clinical departments and, finally, in managing patients.
Article
In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.