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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 39–49 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 condential 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 conrmation
of agreement to article publication and compliance with all applicable ethical and legal
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of third parties. This journal is a member of the Committee on Publication Ethics (COPE).
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 denition for CBL. An excellent denition
has been proposed by istlewaite et al in a review article. In their
2012 paper, a CBL denition 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 dened 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 denitions 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 dening 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 denitions 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 specic, 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 classied 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: 40teams× 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.
Denition 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 denition 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 oer a denition 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, denes CBL: “Case-based
learning is structured so that trainees explore clinically rel-
evant topics using open-ended questions with well-dened
goals.”
7
e exploring that students or trainees do factors into
other denitions. 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 denition
of CBL was oered 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 dened 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-
dent’s 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 denition 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 denition 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 denition 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 dierences (Fig. 5). In many papers, CBL is compared
and contrasted with PBL in order to dene CBL better. PBL
is also centered around a clinical case. Often the objectives are
less clearly dened 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
Reection 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 eective
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 reect 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 oered 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 diering 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
signicantly higher for PBL tract students in Obstetrics and
Gynecology and Psychiatry (P=0.02, P0.001, respectively)
and statistically not dierent for other clerkships. Clerkship
subcategory analysis demonstrated statistically signicantly
higher scores for PBL tract students in clinical performance,
knowledge and clinical reasoning, noncognitive behaviors,
and percent honors grades, with no dierence 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 specic 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
benet 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 specic 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 learner’s 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 dierent than LBL, and dicult to teach, as it is
extremely learner centered. Learning objectives are essentially
generated by the student, making faculty control over learning
dicult. At this school, the diculties in using PBL contrib-
uted to its abandonment as a stand-alone curriculum tract.
e diculties 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 dicult to initiate faculty or
teachers in teaching this way, dicult to cover a large amount
of clinical ground, and diculty in assessment. CBL, on the
other hand, has advantages of exibility in using the case and
oers the same reality base that oers relevance for the adult
health-care learner. In addition, CBL appears to be accepted
by the faculty that may be practicing clinicians and oers a
way to teach specic 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 identication 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 Kirkpatrick’s outcomes hierarchy
to assess the level of critical thinking after the CBL interven-
tion. Kirkpatrick’s 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 dicult to measure. A survey can measure hierarchy
level 1, a written test, and level 2. Behavior is more dicult
but still able to be measured. e authors measured critical
thinking in physicians, taking their Quality Improvement
course by measuring critical reection by a survey. e authors
constructed a reection survey, which asked course partici-
pants about items constructed to assess their level of reec-
tion on the cases. Least reective levels consisted of habitual
action, and most critically, reective 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 reec-
tive thinking. However, the reection 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 reections 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 “dene”, “identify”,
or “do a simple procedure”, whereas in the “extended abstract”
level, the items are “evaluate”, “predict”, “generalize”, “create”,
“reect”, 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 dierence 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 signicant 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
benet 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 dierent 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 dierent. However, ID students who scored below
the median on the pretest scored signicantly higher on the
posttest. While this study set out to compare the dierences
in SD vs ID teaching using CBL, it also compared the eects
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 benets of CBL.
In summary, CBL is dened 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) certication 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 reect 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 eective 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 diering 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 dierent 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 dierences in student
motivation for autonomous learning, which was dierent,
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 modied 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 aected 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 signicant 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
signicant 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 oces. 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 denition of CBL but were termed
dierently 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 dierent experiences. For example, several articles
described the use of an observed skills examination to evalu-
ate the learner; this examination was classied 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 dene
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 diers 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 Kirkpatrick’s
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 aected actual patients:
a few studies revealed that patient outcomes were aected posi-
tively from CBL. us, published studies of CBL spanned the
hierarchy of learning, from opinions of the activity to actual
patients aected 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 Kirkpatrick’s hierarchy of
learning and demonstrated that CBL could be shown conclu-
sively to produce deeper learning.
To repeat the denition 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 ecient 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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