Available via license: CC BY 4.0
Content may be subject to copyright.
EYE OPENER
Case-Informed Learning in
Medical Education: A Call for
Ontological Fidelity
CORRESPONDING AUTHOR:
Dr. Anna MacLeod, Ph.D
Department of Continuing
Professional Development
and Medical Education,
Dalhousie University, C-104A,
Clinical Research Centre, 5849
University Avenue, Halifax, NS,
B3H 4H7, Canada
Anna.Macleod@dal.ca
TO CITE THIS ARTICLE:
MacLeod A, Luong V,
Cameron P, Burm S, Field S,
Kits O, Miller S, Stewart WA.
Case-Informed Learning in
Medical Education: A Call for
Ontological Fidelity. Perspectives
on Medical Education. 2023;
12(1): 120–128. DOI: https://doi.
org/10.5334/pme.47
ANNA MACLEOD
VICTORIA LUONG
PAULA CAMERON
SARAH BURM
SIMON FIELD
OLGA KITS
STEPHEN MILLER
WENDY A. STEWART
*Author affiliations can be found in the back matter of this article
ABSTRACT
Case-informed learning is an umbrella term we use to classify pedagogical approaches
that use text-based cases for learning. Examples include Problem-Based, Case-Based,
and Team-Based approaches, amongst others. We contend that the cases at the heart
of case-informed learning are philosophical artefacts that reveal traditional positivist
orientations of medical education and medicine, more broadly, through their centering
scientific knowledge and objective fact. This positivist orientation, however, leads to an
absence of the human experience of medicine in most cases.
One of the rationales for using cases is that they allow for learning in context, representing
aspects of real-life medical practice in controlled environments. Cases are, therefore,
a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation
literature, have yet to enter discussions of case-informed learning. We propose the
concept of ontological fidelity as a way to approach ontological questions (i.e., questions
regarding what we assume to be real), so that they might centre narrative and experiential
elements of medicine.
Ontological fidelity can help medical educators grapple with what information should be
included in a case by encouraging an exploration of the philosophical questions: What
is real? Which (and whose) reality do we want to simulate through cases? What are the
essential elements of a case that make it feel real? What is the clinical story we want to
reproduce in case format? In this Eye-Opener, we explore what it would mean to create
cases from a position of ontological fidelity and provide suggestions for how to do this in
everyday medical education.
121MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
Imagine you’ve been asked to write a case for an under-
graduate medical education curriculum with the direction:
“Please write a case about hypertension.” That instruction sets
into place a sequence of activity: you would likely go about
describing the condition, its presenting clinical manifestations,
relevant signs, treatment options, and prognosis. You might
turn to the literature to ensure the information included is
accurate, evidence-based, and up to date.
In contrast, imagine you received the direction: “Please
write a case that tells the story of a person with hypertension.”
The difference is subtle, but notable. The path you would
take to write this case, in telling the story of an illness and
diagnosis, brings to the fore a different focus: an attempt to
convey the essence, or lived experience, of the illness. We
believe this different orientation, though subtle, matters.
Text-based cases are, in fact, fundamental to medical
education. They are the primary mechanism through which
case-informed learning (which we will use as an umbrella
term that includes the various approaches to learning with
cases at their heart, including problem-based, case-based,
team-based and others) occurs. We contend that the way
we write and think about cases, including their format,
content, and purpose, provides not-so-subtle clues about
the types of information medicine takes to be real: fact,
evidence, procedure.
While cases as an educational device remain surprisingly
under-explored in the medical education literature, those
contributions that do exist have noted an emphasis on
the factual medical information rather than the way an
individual’s social interactions and identity can affect a
clinical encounter and health outcome [1–3]. This largely
absent patient voice in cases, we believe, is not a product
of ill-will or bad intention. On the contrary, it arises from a
desire to ensure that cases are packed full of the essentials,
meaning the information a student needs to move onto
the next stage of their education. Herein lies the challenge:
How do we determine what information is, in fact, essential
to include in a case?
The missing piece here, we contend, is a philosophical
issue, and more specifically, an ontological one. In
other words, the cases we use for education reproduce
unquestioned philosophical assumptions about the nature
of reality. The philosophy of science holds that all fields,
including medical education, are constituted through a set
of philosophical principles, including ontology (what is real),
epistemology (what we can know), methodology (how we
can know), and axiology (what we value) [4]. In its simplest
form, ontology can be defined as the science of being. In
the world of medical education, Varpio and MacLeod [4]
described ontology as what we, as a field, assume to be real.
In this manuscript, we take the position that cases are
educational artefacts, and that the ontological assumptions
of medicine are present (or not) in the purpose, structure,
and content of the cases we use for teaching. We ask
the question: what would it mean to create cases from a
position of ontological fidelity and provide suggestions for
how to do this in everyday medical education?
WHY DOES PHILOSOPHY MATTER?
Medical education, along with all related fields, is steeped
in philosophy. Yet, philosophical inquiry has yet to find its
way to the everyday practices of our medical schools. This
is despite increasing interest in integrating philosophical
ideas in the academic realm, notably within Teaching and
Learning in Medicine’s Philosophy and Medical Education
series [5], Academic Medicine’s Philosophy of Science series
[4], and the recent book Applied Philosophy for Health
Professions Education [6]. Certainly, medical education
can benefit from turning to the tools of philosophy to
address medicine’s long-standing challenges through a
fresh perspective [5]. As Veen and Cianciolo [5] remind us,
“philosophy can be seen as the fundamental approach to
pausing at times of complexity and uncertainty to ask basic
questions about seemingly obvious practices so that we
can see (and do) things in new ways” [5 p337].
Traditionally, medicine and medical education have
embraced positivist ideals around rationality, objectivity, and
neutrality [7]. Systematic practices designed to minimize
uncertainty like evidence-based medicine and critical
appraisal have historically maintained a position of privilege
within medicine and medical education [8]. However,
notions of objectivity and neutrality disguise the complex,
contradictory, and often unpredictable nature of human
activity [9]. In the context of research, the world of medical
education has benefited from constructivist perspectives
that knowledge does not exist as an objective “fact”
awaiting discovery; rather, it is a social product, a testament
to the subjectivities of its creators [10–11] (See Figure 1).
We make room for multiple ontologies in our scholarly work,
with recent contributions of critically oriented, theoretically
informed social science perspectives in our journals and
conferences [1, 12–13]. Interestingly, however, creating the
same space in our educational practices, including case-
informed learning, has not been quite as successful.
CASE-INFORMED LEARNING
Case-informed learning is one of the first pedagogical
approaches learners will encounter. This approach,
originally conceptualized and implemented as Problem-
Based Learning (PBL) by Barrows and Tamblyn in the mid
122MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
1960s [14], involves students working in small groups with
a faculty facilitator or tutor to solve a clinical “problem”
(i.e., a case) that simulates a real-life clinical situation
[15]. The goal is to “reduce fragmentation of knowledge
and acquisition of meaningless facts, to promote curiosity
and teamwork, and to present a patient rather than a
disease model” [16 p868]. In other words, as learners
collaboratively investigate the case at hand, they develop
the skills to find information and solve problems they can
subsequently apply to their professional practice [15].
Case-informed learning approaches are, in fact,
ontological artefacts. They can be traced to theories of
rationalism, which refer to the idea that opinions and
action should be based on reason and knowledge (e.g.,
mathematical knowledge) rather than on emotions or
sensory experience, and are strongly influenced by cognitive
psychology [17] as well as Dewey’s [18] encouragement of
independent and experiential learning [15]. The notion of
learning from a simulated case, or problem, can also be
credited to Dewey, as he considered context and learning
in concert with “real life” critically important.
While case-informed learning has evolved over time,
with variations like case- and team-based learning gaining
popularity, the narrative case story at the heart of the
inquiry remains consistent. As a text-based curricular
model, case-informed approaches have the potential
to embrace the stories of medical practice. In reality,
however, the “voice of medicine”—a technical, scientific,
and professional approach—has dominated illness stories,
at the expense of the patient’s “voice-of-the-life-world”:
the patient’s lived experiences of events and problems in
their life [19–20]. What we therefore see more often in
practice are the medical-centric “hospital stories,” such as
those described by Coulehan [21]:
The stories that permeate the hospital ethos don’t
usually have patients as their protagonists, and often
not even as ancillary characters that play human roles.
Rather, patients quite frequently serve as clever or
frustrating plot devices—obstacles or challenges that
impair the story’s progress; or sometimes they may
serve as positive plot devices, unexpected gifts that
facilitate the story’s successful resolution [21 p109].
Coulehan, and other scholars of narrative [22], have
encouraged us to pay attention to the work that is
accomplished through stories. Narrative medicine [23–25]
has flourished as a meaningful avenue for fostering narrative
competence: “the capacity to recognize, absorb, metabolize,
interpret, and be moved by stories of illness” [23 p1265]. By
Figure 1 Positivist and Constructivist Approaches to Case-Based Learning.
123MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
“(re)humanizing medicine” through portrayals of patients’
subjective experience of illness in medical education
research and medical humanities curriculum [26 p113],
lived experience becomes legitimized as knowledge and
provides patient agency as narrator of their own story [26].
Interestingly, though, the stories that we use for teaching
future physicians have received significantly less attention.
WHAT ABOUT THE CASE?
Despite decades of research addressing various case-
informed learning approaches, surprisingly few studies
have contested the traditional format of cases [2, 27–29].
Kenny and Beagan [30] noted that the typical construction
of cases “grants ultimate authority to the voice of the
doctor, excluding the voice of the patient. It constructs
medical observations and interpretations as incontestable
facts while devaluing patient observations as subjective
and fallible” (30 p1073). In this manner, students may be
accultured to view patients as problems to be solved, and
themselves as problem-solvers [1].
Certainly, cases educate students about more than
a particular diagnosis. The ontological (and relatedly,
axiological, i.e., what we value) foundations of medicine,
reinscribed through the case, implicitly teach students about
what they need to concern themselves with, and what they
can ignore. This, in turn, dictates not only what and how they
should think, but also what and how they should feel, and
how they ascribe and prioritize importance to these areas.
A key feature of case informed approaches consistently
described in the medical education literature is their
simulation of “real life” [3, 14, 17, 27, 31–34]. As medical
educators, we must pause to ask ourselves: what type of
practice do we hope this case will simulate?
CASE, SIMULATION, AND ONTOLOGICAL
FIDELITY
Interestingly, while we recognize that case-informed
learning is, in fact, a type of simulation, our field has not
yet made a clear connection between cases and the
concept of fidelity. In the context of simulation-based
medical education, fidelity refers to the degree of realism
we should expect, or the degree of exactness with
which the simulation reproduces reality [35–37]. Medical
educators generally focus on two types of fidelity: physical
(i.e., similarity in the look and feel of the simulator) and
functional (i.e., similarity in how the simulator responds
to manipulation or intervention) [35, 38]. Returning to our
underlying philosophical assumptions, these approaches
to fidelity draw on positivistic orientations, concerned with
objective, measurable ways these simulations align with
“real” clinical practice [37].
In another study, we brought forward the concept of
ontological fidelity as an additional type of fidelity that merits
our careful consideration [12]. In that work, we noticed
that learners engaged very differently when they practiced
procedures on a cadaver as opposed to a manikin because,
to simplify, the cadaver was real—and unmistakably so. The
cadaver had been a living person with a story and a history,
and that former life permeated the teaching sessions [12,
39]. Stated simply, then, ontological fidelity refers to the
degree to which a simulator matches what a patient is: a
real, human person. The ontological fidelity of cadavers
was their greatest strength and inspired a very different
type of practice. Despite our best efforts, no amount of
technological advancement could reproduce that realness.
Extending the concept of ontological fidelity to case-
informed learning, we believe that medicine, as a narrative
practice, is in fact constructed through story. Certainly,
there are enough true stories in medicine that we can
create a compelling, and real, case—but only if we agree to
engage in narrative practice, and only if we make space for
the human experience of medicine in our cases.
Returning to case-informed learning, we are faced with
a set of philosophical questions: What is real? Or, perhaps
more accurately, what (and whose) reality do we want to
simulate through cases? What are the essential elements
of a case that make it feel real? What is the clinical story we
want to reproduce in case format?
BRINGING ONTOLOGICAL FIDELITY TO
CASE-INFORMED LEARNING
What we currently know about case-informed learning is
that cases themselves continue to be taken-for-granted in
ways that reinforce the positivist ontological position that
objective fact, rather than patients’ stories, emotions, and
experiences should constitute the substance of the case.
We propose that attending to ontological fidelity will lead to
more meaningful cases. To do that, we encourage educators
to pause and deliberately examine their assumptions about
what is real, and how those assumptions translate into
three elements of cases: format, content, and purpose
(See Table 1).
FORMAT
The format of text-based cases remains consistently
unchallenged. While there might be variation between
institutions, we have generally come to expect cases that
are written concisely, and offer a traditional structure that
124MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
highlights the clinical focus of the case. They generally include
a description of the patient scenario where symptoms,
investigations, and treatments are listed; a set of learning
objectives and resources; and some guiding questions.
Although each case is unique in terms of the names and
conditions of the patients represented, the framework for
the case, itself, is reproduced again and again. Students
can begin to find this rather boring, contributing to what
has been referred to as “PBL fatigue” [40]. Additionally,
these similarly structured cases present each simulated
clinical encounter as more or less “the same,” detracting
from the uniqueness and complexity of each patient,
and deviating from the ways that spoken speech may
be experienced in clinical encounters with patients and
colleagues (e.g., during oral case handovers). Further, text-
dense documents may pose barriers to accessibility for
learners with diverse learning profiles, including those with
learning differences such as dyslexia.
The reproduction of a standardized case format appears
to be a long-standing practice. For example, in 1993, Good
and Good observed, “No explicit attention is paid to how
cases are constructed (with minimal social and personal
characteristics and great physiological detail) and how
sufferers are reconstructed as cases….” [41 p94].
Were we to reimagine case format to attend to ontological
fidelity, we might reconsider the prescribed approach to
structuring cases. While templates are undoubtedly helpful
in terms of attending to all the details that need to be
included, templates also serve to reinforce the expectation
that all cases look the same, and relatedly, can be managed
in the same way. The order of information might be changed
so that each case, and the related activities it inspires/
requires, is unique. Sometimes cases may feature stories
from patients (which could be written or video), and in others
they might include reflective comments from practitioners.
Guiding questions, rather than being designed to draw out
specific bits of information, might be reoriented to inspire
higher level discussion, critical thinking, and empathy.
CONTENT
Case-informed approaches are frequently described as
a “patient-centred” pedagogical approach [14, 16, 27,
42–47]. Each case features a patient—how could they be
anything else?
We believe, however, that simply having a named
patient in each case does not offer the patient perspectives
necessary for ontological fidelity. The patient in an educa-
tional case is often written as a narrative device: a two-
TRADITIONAL CASES WAYS TO ENHANCE ONTOLOGICAL FIDELITY
Format Description Typical format promotes biomedical/clinical focus. Less prescriptive format may encourage space to consider
patient’s unique context and experience.
Example Headings include: Learning Objectives, Preparation Tasks,
Resources, Case Description, Physical Exam, Laboratory
Findings, Questions to Consider, Other Information
Additional/alternative headings could include: Patient
Context, Practitioner’s Perspective, Illness Experience,
Critical Thinking/Reflective Discussion Questions
Content Description Content includes mostly objective, decontextualized
fact. The disease, rather than the patient, is the
protagonist of the case.
Content integrates factual biomedical information with
patient, family, and practitioner experiences. The patient is the
protagonist of the case, with family members, caregivers, and
healthcare workers actively contributing to the patient’s story.
Example Case Title: A case of leukemia
Case information: symptoms at presentation,
progression of symptoms, test results, interventions
(e.g., medications, surgeries, etc.), broad outcome
(e.g., full recovery, death)
Narrative devices: The case information is presented
in the passive voice (e.g., the patient was given a
transfusion; counseling was provided)
Case Title: A case of a woman diagnosed with leukemia
Case information: symptoms and experience of symptoms
are described simultaneously; details of how tests and inter-
ventions were negotiated between practitioners and patients
are provided; outcomes are placed within a specific context.
Narrative devices: The story is written in the active voice,
and multiple “characters” actively speak in the case.
Purpose Description The case aims to impart essential information. The case
promotes succinct answers rather than active discussion.
The case integrates narrative devices and probing
questions that aim to inspire rich conversation.
Example Questions are biomedically focused (e.g., What is a
haemopoietic stem cell transplant? What are the
general principles of cytotoxic chemotherapy?)
The case resolves suddenly and neatly (e.g., “The
patient died peacefully in her sleep, 2 years after her
diagnosis.”)
Questions integrate critical questions about the patient’s
experience (e.g., Why might the patient refuse treatment
at this stage? How might the patient’s background
influence her current experience with leukemia?)
The messy experience of recovery, or death and dying
during the end of life, are described realistically.
Table 1 Examples of how Attending to Ontological Fidelity can Enhance the Format, Content, and Purpose of Cases in Case-Informed Learning.
125MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
dimensional vehicle for relaying biomedical or clinical
information. They are presented as a list of symptoms
assigned a name and, in some instances, a job. Rarely do we
hear from a patient in their own voice in cases [2]. Rarely do
we learn about, or even consider, the emotional elements
of the case in question. Rarely do cases engage with the
magnitude of the diagnosis for individual patients and
what life will look like for those who have been diagnosed,
particularly as they wade through lengthy weeks and
months of testing and appointments, which does not
equate to a paragraph or two on paper. Rarely do cases
address the social realities of a diagnosis: that an illness is
experienced differently depending on social location of the
patient. Instead, cases are generally flat, tidy, and orderly—
lacking the contours of a patient’s embodied experience,
agency, and humanness. While this flatness does not arise
from any ill intent, it is consequential.
Reimagining case content to attend to ontological fidelity
might mean attending not only to the relevant clinical
information, but also to the other human dimensions of a
clinical encounter. The patient voice has historically been
excluded, in part, due to epistemic injustice: patients are
often stereotyped as unreliable sources of information
and are therefore denied the capacity to contribute to
knowledge generation [48]. The narrative nature of any
patient-physician interaction would be made more present
by inviting real patients (as well as physicians and other
health care providers) to share everyday clinical stories in
the case writing process.
We would hear voices—of clinicians, of patients, and of
others relevant to the scenario at hand. The words used,
the feelings expressed, and the reactions described would
be authentic, and the story might not follow a neat or
logical timeline—it might even be a bit messy! There may
even be room for cases to become progressively messier
as learners move through the curriculum and gain skill,
knowledge, and confidence, working toward fostering
comfort with uncertainty and ambiguity that characterizes
human experience, including medical practice.
PURPOSE
Despite our best efforts to write cases that lead to rich
conversation and inspire deep thinking, the cases that
commonly structure our curriculum aim primarily to impart
essential information. Consequently, cases often come to
serve as a type of checklist.
The ritualized purpose of a case invokes a set of
prescribed small-group learning practices that students
have come to expect, and—motivated by a workload that
is intense and stressful [49]—these are often approached
with a ‘let’s get this done’ attitude [2]. Translated into
how we approach cases, this means that they are often
anticipated to be succinct with limited detail [33]; they
simplify complex ideas into easy-to-memorize steps or
categories; and they focus on streamlining material that
might be assessed on an upcoming exam.
Likewise, cases are expected to unfold in a routine
way. Whether negative (ending with the patient’s death,
perhaps) or positive (ending with the patient recovering
and thriving, for example), learners generally expect the
cases to conclude with a concrete resolution. However,
if the purpose of cases is to provide a mechanism for
students to learn in context, cases ought to simulate the
context of real-life medical practice [14, 17, 30], which is
multi-layered and complex [50]. One might expect that
cases would be somewhat convoluted, in order to inspire
reaction and rich conversation.
If we were to reimagine cases to attend to ontological
fidelity, we might reorient cases so that they make space
for the stories that constitute medical practice. Cases might
present a complicated situation, or one that moves away
from the routine and might not be easily resolved. This
could foster deeper thinking, introspection, and analysis of
the types of challenges they will face moving forward in
practice.
ONTOLOGICAL FIDELITY IN “REAL LIFE”
Without a doubt, evidence-based scientific and clinical
approaches must be present in cases—but these are
certainly not the only things that matter. While the
integration of a philosophical perspective to cases may
seem complicated, in reality, cases already exist as an
artefact of our ontological orientation in the field of
medicine. Our job is simply to reflect on what we want to
represent as real and important.
We believe that, like all education strategies that
attempt to simulate future real-life scenarios, cases
should attend to the question of fidelity. But, rather than
physical or functional fidelity, it is ontological fidelity that
lies at the heart of every case. Perhaps the simplest way
to provide ontological fidelity—to make the cases feel real
to students—is to base these cases on real people and
communicate that to students. However, as any reader of
literature or movie-goer can attest, we do not need stories
to be true in order for them to feel real. When cases are
thoughtfully constructed, they convey universal truths
in ways that we recognize to be deeply rooted in reality.
In this manner, just as the students in our previous study
engaged differently with cadavers compared to manikins
because of their realness [12], creating cases that feel
authentic may change the way students engage with case-
informed learning.
126MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
The cases we use for medical education reproduce
unquestioned philosophical assumptions about the nature
of reality. Cases that stick to a prescribed formula help
to reinforce a narrow construction of what tutorials and
cases should look like and what they can do. As we focus
on the idea of ontological fidelity, we encourage educators
to broaden their ideas about what cases not only could be,
but also what they should be. This means re-examining
case format, content, and purpose, but also involves a
concerted effort to authentically integrate the “lifeworld,”
including story, patient voice, emotion, culture, and
experience. We encourage educational administrators
and case writers to consider what might be gained by
approaching case writing progressively and collaboratively,
while attuning to ontological questions relating to the
nature of reality. Consulting with, and even inviting real
patients, physicians, and other health care providers to
share everyday clinical stories in the case writing process
would be a good way forward.
FUNDING INFORMATION
This study was funded by a grant from the Social Sciences
and Humanities Research Council [Grant number: 435-
2020-0827].
COMPETING INTERESTS
The authors have no competing interests to declare.
AUTHOR AFFILIATIONS
Anna MacLeod orcid.org/0000-0002-0939-7767
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada
Victoria Luong orcid.org/0000-0001-9174-1207
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada
Paula Cameron orcid.org/0000-0001-5621-6829
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada
Sarah Burm orcid.org/0000-0002-0767-2278
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada
Simon Field orcid.org/0000-0001-6969-3763
Department of Emergency Medicine, Dalhousie University, Halifax,
Nova Scotia, Canada
Olga Kits orcid.org/0000-0002-2444-7881
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada
Stephen Miller orcid.org/0000-0001-6024-5665
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada;
Department of Emergency Medicine, Dalhousie University, Halifax,
Nova Scotia, Canada
Wendy A. Stewart orcid.org/0000-0002-5811-8373
Department of Continuing Professional Development and Medical
Education, Dalhousie University, Halifax, Nova Scotia, Canada;
Department of Pediatrics, Dalhousie University, Halifax, Nova
Scotia, Canada
REFERENCES
1. Cavanagh A, Vanstone M, Ritz S. Problems of problem-
based learning: towards transformative critical pedagogy in
medical education. Perspect Med Educ. 2019; 8(1): 38–42.
DOI: https://doi.org/10.1007/S40037-018-0489-7
2. MacLeod A. Six ways problem-based learning cases can
sabotage patient-centered medical education. Acad
Med. 2011; 86(7): 818–825. DOI: https://doi.org/10.1097/
ACM.0b013e31821db670
3. Servant-Miklos VFC, Norman GR, Schmidt HG. A short
intellectual history of problem-based learning. In: Moallem
M, Hung W, Dabbagh N, editors. The Wiley Handbook of
Problem-Based Learning. MA. 2019; pp. 3–24. DOI: https://doi.
org/10.1002/9781119173243.ch1
4. Varpio L, Macleod A. Philosophy of science series: harnessing
the multidisciplinary edge effect by exploring paradigms,
ontologies, epistemologies, axiologies, and methodologies.
Acad Med. 2020; 95(5): 686–689. DOI: https://doi.
org/10.1097/ACM.0000000000003142
5. Veen M, Cianciolo AT. Problems no one looked for:
philosophical expeditions into medical education. Teach
Learn Med. 2020; 32(3): 337–344. DOI: https://doi.org/10.108
0/10401334.2020.1748634
6. Brown MEL, Veen M, Finn GM. (2022). Applied philosophy
for health professions education: a journey towards mutual
understanding. Singapore: Springer. 2022; 676 p. DOI: https://
doi.org/10.1007/978-981-19-1512-3
7. Mykhalovskiy E, Weir L. The problem of evidence-based
medicine: Directions for social science. Soc Sci Med.
2004; 59(5): 1059–69. DOI: https://doi.org/10.1016/j.
socscimed.2003.12.002
8. Bluhm R, Borgerson K. Evidence-based medicine. In: Gifford
F, editor. Handbook of the philosophy of science series:
philosophy of medicine. Oxford: Elsevier. 2011; pp. 203–238.
DOI: https://doi.org/10.1016/B978-0-444-51787-6.50008-8
9. Greenhalgh T, Fisman D, Cane DJ, Oliver M, Macintyre CR.
Adapt or die: how the pandemic made the shift from EBM to
EBM+ more urgent. BMJ. 2022; 27: 253–260. DOI: https://doi.
org/10.1136/bmjebm-2022-111952
127MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
10. Mann K, MacLeod A. Constructivism: learning theories and
approaches to research. In: Cleland J, Durning SJ, editors.
Researching medical education. West Sussex: Wiley. 2015;
pp. 49–66. DOI: https://doi.org/10.1002/9781118838983.ch6
11. Rees CE, Crampton PES, Monrouxe LV. Re-visioning
academic medicine through a constructionist lens. Acad
Med. 2020; 95(6): 846–850. DOI: https://doi.org/10.1097/
ACM.0000000000003109
12. MacLeod A, Luong V, Cameron P, Kovacs G, Fredeen M,
Patrick L, Kits O, Tummons J. The lifecycle of a clinical
cadaver: a practice-based ethnography. Teach Learn Med.
2022; 1–17. DOI: https://doi.org/10.1080/10401334.2022.20
92111
13. Paradis E, Nimmon L, Wondimagegn D, Whitehead CR.
Critical theory: broadening our thinking to explore the
structural factors at play in health professions education.
Acad Med. 2020; 95(6): 842–845. DOI: https://doi.
org/10.1097/ACM.0000000000003108
14. Barrows HS, Tamblyn RM. Problem-based learning, an
approach to medical education. NY: Springer. 1980; 228 p.
15. Schmidt HG. Foundations of Problem-Based Learning—some
explanatory notes. Med Educ. 1993; 27: 422–432. DOI:
https://doi.org/10.1111/j.1365-2923.1993.tb00296.x
16. Stephenson A, Higgs R, Sugarman J. Teaching professional
development in medical schools. Lancet. 2001; 357: 867–
870. DOI: https://doi.org/10.1016/S0140-6736(00)04201-X
17. Norman GR, Schmidt HG. The psychological basis of
problem-based learning: a review of the evidence.
Acad Med. 1992; 67(9): 557–565. DOI: https://doi.
org/10.1097/00001888-199209000-00002
18. Dewey J. The quest for certainty: a study of the relation of
knowledge and action. Oxford: Balch and Co. 1929; 318 p.
19. Barry CA, Stevenson FA, Britten N, Barber N, Bradley
CP. Giving voice to the lifeworld. More humane, more
effective medical care? A qualitative study of doctor-
patient communication in general practice. Soc Sci Med.
2001; 53(4): 487–505. DOI: https://doi.org/10.1016/S0277-
9536(00)00351-8
20. Mishler EG. The discourse of medicine: dialectics of medical
interviews. NJ: Ablex Publishing Corporation. 1984; 212 p.
21. Coulehan J. You say self-interest, I say altruism. In: Wear
D, Aultman JM, editors. Professionalism in medicine: critical
perspectives. OH: Springer. 2006; pp. 103–128. DOI: https://
doi.org/10.1007/0-387-32727-4_6
22. Clandinin DJ, Cave MT, Berendonk C. Narrative inquiry: a
relational research methodology for medical education.
Med Educ. 2017; 51(1): 89–96. DOI: https://doi.org/10.1111/
medu.13136
23. Charon R. What to do with stories: the sciences of narrative
medicine. Can Fam Physician. 2007; 53(8): 1265–1267.
24. Frank AW. The wounded storyteller: body, illness, and ethics.
IL: University of Chicago Press. 2013; 280 p.
25. Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine
as a medical education tool: a systematic review. Med Teach.
2019; 41(7): 802–810. DOI: https://doi.org/10.1080/014215
9X.2019.1584274
26. Woods A. Beyond the wounded storyteller: rethinking
narrativity, illness and embodied self-experience. In: Carel
H, Cooper R, editors. Health, illness and disease. Durham:
Routledge. 2014; pp. 125–140.
27. McLean SF. Case-Based Learning and its application in
medical and health-care fields: A review of worldwide
literature. J Med Educ Curric. 2016; 3: 1–11. DOI: https://doi.
org/10.4137/JMECD.S20377
28. Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM,
MacDougall C, Matthews P, Purkis J, Clay D. The
effectiveness of case-based learning in health professional
education. A BEME systematic review: BEME Guide No. 23.
Med Teach. 2012; 34(6): 421–444. DOI: https://doi.org/10.310
9/0142159X.2012.680939
29. To MJ, MacLeod A, Hwang SW. Homelessness in the medical
curriculum: an analysis of case-based learning content from
one Canadian medical school. Teach Learn Med. 2016; 28(1):
35–40. DOI: https://doi.org/10.1080/10401334.2015.1108198
30. Kenny NP, Beagan BL. The patient as text: a challenge
for problem-based learning. Med Educ. 2004; 38(10):
1071–1079. DOI: https://doi.org/10.1111/j.1365-
2929.2004.01956.x
31. Boud D, Feletti G. The challenge of problem-based learning.
London: Routledge. 1997; 336 p.
32. Donner RS, Bickley H. Problem-based learning in American
medical education: an overview. Bull Med Libr Assoc. 1993;
81(3): 294–298.
33. Lohfeld L, Neville A, Norman G. PBL in undergraduate
medical education: a qualitative study of the views of
Canadian residents. Adv Health Sci Educ. 2005; 10: 189–214.
DOI: https://doi.org/10.1007/s10459-005-1293-9
34. Servant-Miklos VFC. The Harvard connection: how the case
method spawned problem-based learning at McMaster
University. Health Prof Educ. 2019; 5(3): 163–171. DOI:
https://doi.org/10.1016/j.hpe.2018.07.004
35. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA.
Reconsidering fidelity in simulation-based training. Acad
Med. 2014; 89(3): 387–392. DOI: https://doi.org/10.1097/
ACM.0000000000000130
36. Paige JB, Morin KH. Simulation fidelity and cueing:
a systematic review of the literature. Clin Simul Nurs.
2013; 9(11): e481–e489. DOI: https://doi.org/10.1016/j.
ecns.2013.01.001
37. Schuwirth LW, van der Vleuten CP. The use of clinical
simulations in assessment. Med Educ. 2003; 37: 65–71. DOI:
https://doi.org/10.1046/j.1365-2923.37.s1.8.x
38. Tun JK, Alinier G, Tang J, Kneebone RL. Redefining
simulation fidelity for healthcare education. Simul
128MacLeod et al. Perspectives on Medical Education DOI: 10.5334/pme.47
TO CITE THIS ARTICLE:
MacLeod A, Luong V, Cameron P, Burm S, Field S, Kits O, Miller S, Stewart WA. Case-Informed Learning in Medical Education: A Call for
Ontological Fidelity. Perspectives on Medical Education. 2023; 12(1): 120–128. DOI: https://doi.org/10.5334/pme.47
Submitted: 27 October 2022 Accepted: 30 March 2023 Published: 12 April 2023
COPYRIGHT:
© 2023 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source
are credited. See http://creativecommons.org/licenses/by/4.0/.
Perspectives on Medical Education is a peer-reviewed open access journal published by Ubiquity Press.
Gaming. 2015; 46(2): 159–174. DOI: https://doi.
org/10.1177/1046878115576103
39. MacLeod A, Luong V, Cameron P, Kovacs G, Patrick L,
Tummons J, Kits O. When I say…human. Med Educ.
2021; 55(9): 993–994. DOI: https://doi.org/10.1111/
medu.14537
40. MacPherson R, Jones A, Whitehouse CR, O’Neill PA.
Small group learning in the final year of a medical
degree: a quantitative and qualitative evaluation.
Med Teach. 2001; 23(5): 494–502. DOI: https://doi.
org/10.1080/01421590120042973
41. Good B, Good M. Learning medicine: the construction
of medical knowledge at Harvard Medical School. In:
Lindenbaum S, Locke M, editors. Knowledge, power and
practice: the anthropology of medicine and everyday life. CA:
University of California Press. 1993; pp. 81–107.
42. Chan WP, Hsu CY, Hong C-Y, Pong Chan W, Yi Hsu C, Ye
Hong C. Innovative “Case-Based Integrated Teaching” in
an undergraduate medical curriculum: development and
teachers’ and students’ responses. Ann Acad Med. 2008; 37:
952–956. DOI: https://doi.org/10.47102/annals-acadmedsg.
V37N11p952
43. Droege M. The role of reflective practice in pharmacy.
Educ Health. 2003; 16(1): 68–74. DOI: https://doi.
org/10.1080/1357628031000066778
44. Leung WC. Why is evidence from ethnographic and discourse
research needed in medical education: the case of problem-
based learning. Med Teach. 2002; 24(2): 169–172. DOI:
https://doi.org/10.1080/01421590220125268
45. Richards PS, Inglehart MR. An interdisciplinary approach
to case-based teaching: does it create patient-centered
and culturally sensitive providers? J Dent Educ. 2006;
70(3): 284–291. DOI: https://doi.org/10.1002/j.0022-
0337.2006.70.3.tb04084.x
46. Sullivan AM, Krupat E, Dienstag JL, McSparron JI, Pelletier
SR, Fazio SB, Fleenor TJ, Dalrymple JL, Hundert EM,
Schwartzstein RM. The Harvard Medical School Pathways
curriculum: a comprehensive curricular evaluation. Med
Teach. 2022; 1–9. Advance online publication. DOI: https://
doi.org/10.1080/0142159X.2022.2081142
47. Utting MR, Campbell F, Rayner C, Whitehouse CR, Dornan
TL. Consultation skills of medical students before and after
changes in curriculum. J R Soc Med. 2000; 93(5): 247–253.
DOI: https://doi.org/10.1177/014107680009300509
48. Fricker M. Epistemic injustice: power and the
ethics of knowing. Oxford: Oxford University Press.
2007; 208 p. DOI: https://doi.org/10.1093/acprof:o
so/9780198237907.001.0001
49. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors
facing medical students in the millennial generation. Med
Educ Online. 2018; 23(1): 1–11. DOI: https://doi.org/10.1080/
10872981.2018.1530558
50. Morris D. Illness and culture in the postmodern age. CA:
University of California Press. 2000; 356 p.
