Case Based Learning Versus Problem Based Learning: A ... · Case Based Learning Versus Problem Based Learning: A Direct Comparison from First Year Medical Students Perspective

Article ID: WMC001976 2046-1690

Case Based Learning Versus Problem BasedLearning: A Direct Comparison from First YearMedical Students PerspectiveCorresponding Author:Dr. Sajita Setia,Senior Resident, Dept. of Biochemistry, JIPMER - India

Submitting Author:Dr. Sajita Setia,Senior Resident, Dept. of Biochemistry, JIPMER - India

Article ID: WMC001976

Article Type: Original Articles

Submitted on:12-Jun-2011, 03:13:49 AM GMT Published on: 13-Jun-2011, 09:13:55 PM GMT

Article URL: http://www.webmedcentral.com/article_view/1976

Subject Categories:MEDICAL EDUCATION

Keywords:Case Based Learning, Medical Education, Problem Based Learning

How to cite the article:Setia S , Bobby Z , Ananthanarayanan P , Radhika M , Kavitha M , Prashanth T . CaseBased Learning Versus Problem Based Learning: A Direct Comparison from First Year Medical StudentsPerspective . WebmedCentral MEDICAL EDUCATION 2011;2(6):WMC001976

Source(s) of Funding:

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

Competing Interests:

We have no conflicts of interests to declare.

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Case Based Learning Versus Problem BasedLearning: A Direct Comparison from First YearMedical Students PerspectiveAuthor(s): Setia S , Bobby Z , Ananthanarayanan P , Radhika M , Kavitha M , Prashanth T

Abstract

Background: Case-based learning (CBL) is aneducational paradigm closely related to the problembased learning (PBL) that uses a guided inquirymethod and provides structure during small-groupdiscussions. To date, no studies have directlycompared PBL and CBL from medical students’perspective in developing countries.Aim: To compare first year medical students’ attitudesto CBL versus PBL after alternating the teachingmethods during several teaching sessions.Methods: After conducting several PBL sessions,students were introduced to CBL where the facilitatorplayed an important role during the small groupdiscussion sessions. At the end of all the CBLsessions, students filled a questionnaire form thatsought opinions on (i) rating of CBL model as a tool inunderstanding concepts’ compared with regularteaching sessions and PBL (ii) global analysis of CBLon 4-point likert scale (iii) overall remarks about CBL.Gender differences in the level of attitudes andperceptions towards the CBL program were evaluatedby logistic regression (enter method).Results: A total of 88 first year medical students tookpart in the questionnaire. Majority of the students’rated CBL in understanding concepts as “good”compared with both regular teaching sessions as wellas PBL. Majority of the students’ rated ‘‘agree’’ on a4-point likert scale for ‘‘motivation by CBL to workmore in th is sub ject ’ ’ , ‘ ‘ improvement o fproblem-solving skills using CBL”, “CBL as aworthwhile progression from PBL”, etc. Femalestudents responded more positively towards CBL thanmale students. Conclusion: Students viewed the constructs of CBLbetter than PBL.

Introduction

The last decade has witnessed a rapid expansion ofbiomedical knowledge. Trends in medical education

have shifted away from didactic teaching and towardscontextual, or problem-based learning (PBL) justifiedby studies showing superiority of PBL in improvingreasoning and communication skills1. PBL is believedto have the potential to prepare students moreeffectively for future learning because it is based onfour modern insights into learning: constructive,self-directed, collaborative and contextual2. Howeverthe growing dominance of PBL could worsen theproblems of information management in medicaleducation e.g. by discouraging teachers from refiningthe educational utility of didactic modalities, byreducing faculty time for developing reusableresources to impart factual knowledge more efficientlyetc. Hence the development of more integratedcognitive techniques for facilitating the comprehensionof complex data are required to strengthen theknowledge base of 21st century medical graduates1.In problem based learning (PBL) students use“triggers” from the problem case or scenario to definetheir own learning objectives3. They work in smallgroups in a classroom setting, apply previouslylearned information to solve the problem and identifythe knowledge and skills they lack to accurately solvethe problem4.PBL requires the ability to process and discuss ideasand learn independently, hence students who havesignificant deficiencies in communication are morelikely to be unsuccessful in a PBL program5. In India,students enter five-and-a-half year medical schoolprograms right after high school; there is nointermediate degree program. In many westerncountries however students enter medical school afterreceiving a bachelor degree, hence they are likely toposses suitable learning skills ideal for PBL. All publiceducation in India is free or very reasonable andstudents are selected through very competitive writtenentrance exams. Most public universities are entirelydependent on the government for income. Privatemedical education is however extremely expensivealthough entry is relatively easier. Students, in general,differ widely in their abilities to understand instructionsor express ideas (in oral, written, and/or graphicways); and present a range of language andcommunication skills.Case-based learning (CBL) is an educational



paradigm closely related to the more common PBL.CBL’s main traits are derived from PBL e.g. a case,problem, or inquiry is used to stimulate and underpinthe acquisition of knowledge, skills, and attitudes6.However, when learners begin to explore tangents, thefacilitators use guiding questions to bring them back tothe main learning objective. Hence CBL uses a guidedinquiry method and provides more structure duringsmall-group sessions unlike PBL which is an openinquiry approach where facilitators play a minimal roleand do not guide the discussion, even when learnersexplore tangents7,8.To date, no studies have directly compared thedifferent types of small group teaching methods frommedical students’ perceptive in developing countrieslike India. In this study we evaluated several importantaspects of first year medical students’ attitudes to CBLafter alternating the teaching methods during severalwork sessions.

Methods

After conducting several work sessions related to PBLexpanding over var ious topics, f i rst yearundergraduate medical students were introduced tothe innovative CBL paradigm for few topics as anadjunct to the introductory lecture sessions.Study Unit DesignIn PBL small groups, the group focused on theprocess of discovery by students themselves tostimulate problem solving and independent learningactivities. Facilitators played a minimal role and did notguide the discussion. Learners are presented with aset of problems, they were then given time to struggleand define the problem, explore related issues andfinally come to a common consensus with respect tothe answers.In CBL, learners were presented with a clinicalproblem and had time to struggle, define, and resolvethe problem. However discovery was encouraged in aformat in which both students and facilitators sharedresponsibility for coming to closure on cardinallearning points. The main goal of the facilitator is toassist the students through the facts and to engage inanalysis and the development of possible solutions orstrategies. When learners begin to explore tangents,the facilitator used guiding questions to bring themback to the main learning objective. Students werealso encouraged to ask questions from the facilitatorduring the session.Interviewing the studentsStudent evaluations comparing CBL with traditionallecture format and PBL as well as their perceptions of

CBL model (from a pragmatic point of view) wereundertaken through a combination of Likert scales andquestionnaires. This was analyzed by the contentanalysis of the questionnaire form filled by thestudents at the end of all the CBL sessions.Students were asked to fill their demographicinformation (age and sex). The rest of the anonymousquestionnaire survey (see Appendix-1) soughtopinions on (i) rating of CBL model as a tool inunderstanding concepts’ compared with regularteaching sessions and PBL (questions 3–4) (ii) globalanalysis of CBL on 4-point likert scale (questions 5–12)and (iii) overall remarks about CBL including itsadvantages and disadvantages compared to previousPBL based discussion sessions (question 13). Genderdifferences in the level of attitudes and perceptionstowards the CBL programme were evaluated bylogistic regression (enter method) using SPSSsoftware version 13.0.

Results

We questioned a group of 88 first year studentsundertaking an undergraduate five-and-a half yearmedical degree course regarding their opinion of therecently introduced CBL model. A total of 49 studentswere male and the rest were females. Majority of thestudents’ (73.6% and 56% respectively) rated CBLmodel for a tool in understanding concepts’ as “good”compared with regular teaching model as well as PBLdiscussion sessions (Table 1). Majority of the studentsfelt that the MCQs presented were interesting andwere relevant to first year medical students (rated as‘‘strongly agree’’ on 4-point likert scale).Majority of the students’ responses rated ‘‘agree’’ on a4-point likert scale for ‘‘motivation by CBL to workmore in this subject’’, ‘‘improvement of theirproblem-solving skill using CBL, “CBL as a worthwhileprogression from PBL”, “more enjoyment with CBLcompared to PBL”, “facilitation of interaction betweenstaff and students by CBL discussion sessions”, CBLmore suited the way of learning compared to PBL and“CBL helped to improve diagnostic skills and lateralthinking” (Table 1). The overall students’ verbatimremarks directing the main advantages of the CBLover PBL model are presented in Table 2. Femalestudents viewed the constructs of CBL better thanmale students and responded more positively to CBL(Table 1). The rating of “CBL model vs. PBL as a toolin understanding concepts” as well as the rating for“more enjoyment with CBL vs. PBL” were statisticallysuperior for female students compared to malestudents (p value = 0.043 and 0.05, estimated odds



ratio = 2.18 and 2.13 respectively), Table 3.

Discussion

The Problem-Based Learning (PBL) consists ofcarefully designed problems that impart the learner theacquisition of critical knowledge, problem-solvingproficiencies, self-directed learning strategies andteam participation skills leading to a constructivistapproach to learning. The problem serves as theorganizing centre and the stimulus for learning andrepresents the vehicle that develops students’ creativeand high-order thinking skills. However, the problempresented to the students at the beginning of thelearning process in PBL neither easily solves nor doesit always results in the correct answers2,5,6.A systematic review of problem-based learning (PBL)in undergraduate, pre-clinical medical education in 22years of research involving 30 unique studies recentlyshowed that PBL does not impact knowledgeacquisition; evidence for other outcomes does notprovide unequivocal support for enhanced learning9.The disadvantages of PBL have been reported to berelated its increased cost and faculty time, lower levelsof content-specific knowledge, decreased learningefficiency etc10-12.The difficulty in measuring a cognitive process such asproblem solving or clinical reasoning has beendiscussed and the evidence has led many PBLexperts to rethink the goal of teaching the process ofproblem solving, and it is no longer considered to be aprimary objective of PBL. Also the goal of tutorialhealth care scenarios is to provide a clinical context forthe acquisition of knowledge, rather than to solve theproblem10,13.Students who have significant deficiencies inexpressing ideas or communication skills are likely tobe unsuccessful in a PBL program, as PBL requiresthe ability to process and discuss ideas and learnindependently. It thus seems likely that with a guidedinquiry approach as in CBL these students might findthe problem solving exercises interesting and thismight as well improve their academic performance. Inthis study we introduced CBL model for the first time tofirst year medical students’ after conducting severalPBL related work sessions. We then tried to evaluateCBL from several important aspects of attitudes ofstudents’. CBL was enjoyed and embraced by themajority of students. Student perception indicated thatclinical reasoning, diagnostic interpretations, and theability to think logically were also improved with CBL.We also observed gender differences in the level ofattitudes and perceptions towards the CBL programme.

Overall, female students responded more positivelytowards CBL than male students. This is inconcurrence with the study by Peplow whodemonstrated that female students responded morepositively to tasks undertaken in the discussionsessions14. This study established that femalestudents in the early parts of the programmeperformed better in their examination marks comparedwith the male students. Hence female students mayperform better at a CBL style of education early in theirmedical education.

Conclusion(s)

We conclude that the innovative CBL paradigmappears to be an effective, superior and studentcentered alternative to the traditional lecture formatand PBL from medical students’ perspective indeveloping countries like India.

Reference(s)

1.Epstein R. Learning from the problems ofproblem-based learning. BMC Med Educ. 2004;4:1.2.Dolmans DH, De Grave W, Wolfhagen IH, van derVleuten CP. Problem-based learning: futurechallenges for educational practice and research. MedEduc 2005;39: 732-41.3.Wood DF. Problem based learning. BMJ 2003;326:328-30.4.Schmidt HG. Problem-based learning: rationale anddescription. Med Educ 1983;17: 11-6.5.Carrera LI, Tellez TE, D'Ottavio AE: Implementing aproblem-based learning curriculum in an Argentineanmedical school: implications for developing countries.Acad Med 2003;78:798-801.6.Schmidt HG. Assumptions underlying self-directedlearning may be false. Med Educ 2000;34:243-5.7.Distlehorst LH, Dawson E, Robbs RS, Barrows HS.Problem-based learning outcomes: the glass half-full.Acad Med 2005;80:294-9.8.Srinivasan M, Wilkes, M, Stevenson, F, Nguyen, T,Slavin, S: Comparing Problem-Based Learning withCase-Based Learning: Effects of a Major CurricularShift at Two Institutions. Acad Med. 2007;82:74–82.9.Hartling L, Spooner C, Tjosvold L and Oswald A.Problem-based learning in pre-clinical medicaleducation: 22 years of outcome research. Med Teach2010;32:28-35.10.Massey RU. Problem-based learning: a better way?Conn Med 1994;58: 753.11.Schmidt HG, Dauphinee WD, Patel VL. Comparing



the effects of problem-based and conventionalcurricula in an international sample. J Med Educ1987;62:305-15.12.Vernon DT. Attitudes and opinions of faculty tutorsabout problem-based learning. Acad Med1995;70:216-23.13. Norman, GR and Schmidt HG. The psychologicalbasis of problem-based learning: a review of theevidence. Acad Med, 1992;67:557-65.14.Peplow P. Attitudes and examination performanceof female and male medical students in an active,case-based learning programme in anatomy. MedTeach 1998;20:349–55.



Questionnaire survey content Overall(n=88)

Males(n=49)

Females(n=39)

Percentage

Percentage

Percentage

CBL vs. regular lectures1

Poor 1.1 2 0 No difference 4.4 6.1 0 Good 73.6 71.4 79.5 Excellent 20.9 20.4 20.5CBL vs. PBL2

Poor 8.8 12.2 2.6 No difference 19.8 28.5 10.8 Good 56 44.9 74.4 Excellent 15.4 14.3 12.3CBL motivates3

Strongly agree 17.6 20.4 12.8 Agree 65.9 61.2 74.4 Disagree 14.3 14.3 12.8 Strongly disagree 2.2 4.1 0

Illustrations

Illustration 1

Table 1 Content analysis of the questionnaire form (students? opinion on CBL)



Problem solving skills4

Strongly agree 20.9 16.3 23.1 Agree 64.8 65.3 69.2 Disagree 13.2 16.3 7.7 Strongly disagree 1.1 2 0Progression from PBL5

Strongly agree 14.4 18.8 7.7 Agree 64.4 56.3 74.4 Disagree 17.8 18.8 17.9 Strongly disagree 3.3 6.3 0MCQ interesting6

Strongly agree 54.9 55.1 56.4 Agree 41.8 40.8 41 Disagree 1.1 0 2.6 Strongly disagree 2.2 4.1 0Enjoyed more than PBL7

Strongly agree 14.3 10.2 20.5 Agree 47.3 42.9 51.3 Disagree 33 38.8 28.2 Strongly disagree 5.5 8.2 0Interaction facilitated8

Strongly agree 26.7 27.1 28.2 Agree 52.2 50 53.8 Disagree 16.7 16.7 17.9 Strongly disagree 4.4 6.3 0



CBL suited9

Strongly agree 10 10.4 10.3 Agree 71.1 68.8 74.4 Disagree 13.3 10.4 15.4 Strongly disagree 5.6 10.4 0Improvse skills and thinking10

Strongly agree 22.2 20.8 25.6 Agree 65.6 66.7 64.1 Disagree 8.9 10.4 7.7 Strongly disagree 3.3 2.1 2.6

1Rating of CBL model as a tool in understanding concepts’ compared with regular teaching model2Rating of CBL model as a tool in understanding concepts’ compared with PBL student discussion sessions3Case based learning motivates me to work more in this subject (4-point likert scale)4I have improved my problem-solving skill using Case based learning (4-point likert scale)5Case based learning is a worthwhile progression from problem based learning (4-point likert scale)6The MCQs presented were interesting and were relevant to first year medical students (4-point likert scale)7I enjoyed case based learning more than problem based learning (4-point likert scale)8The discussionsessions facilitated interaction between staff and students (4-point likert scale)9Case based learning suitedthe way I learn compared to problem based learning (4-point likert scale)10Case based learning helped to improve my diagnostic skills and lateral thinking (4-point likert scale)



“CBL is an interesting way of learning. We can be benefited due to better knowledgeof the teacher”.“CBL is better than PBL since we will get better information without any confusion”.“CBL helps in clearing doubts, PBL helps in self analysis”.“In CBL, answering skill is developed and proper guidance is there”.“In CBL guidance is there, concepts are built, easily assess where we are wrong,interesting and disciplined”.“In PBL, quality of discussion depends on other group members as well. CBL isuniformly good”.“CBL makes progression in understanding and I can spot out the weakness area. I donot find any disadvantage of CBL”.“In PBL, only the students who are confident talking in the class gain more”.“In PBL we were deviating from the topic and we never found a solution. In CBL weget guidance and hence it is more advantageous over PBL”.“In PBL students get deviated and tend to talk about things other than the subject, thisis prevented in CBL. However in CBL, our freedom is reduced”.“In CBL answers are discussed by faculty, in PBL sometimes confusion occurs likesome students say wrong answers”.

Illustration 2

Table 2 Few general verbatim remarks of students directing the advantages of CBL over PBL



Questionnaire surveycontent

Regressioncoefficient (β)

Standarderror

P-value Estimated odds ratio

CBL vs. regular lectures1 -0.17 0.53 0.74 0.84

CBL vs. PBL2 0.78 0.38 0.04 2.18

CBL motivates3 -0.47 0.43 0.27 0.62

Problem solving skills4 0.64 0.54 0.08 1.7

Progression from PBL5 -0.53 0.45 0.24 0.56

MCQ interesting6 -0.05 0.43 0.9 0.94

Enjoyed more than PBL7 0.76 0.39 0.05 2.13

Interaction facilitated8 0.34 0.36 0.86 0.44

CBL suited9 0.12 0.51 0.81 1.13

Improve skills and thinking10 0.31 0.46 0.49 1.37

1Rating of CBL model as a tool in understanding concepts’ compared with regular teaching model2Rating of CBL model as a tool in understanding concepts’ compared with PBL student discussion sessions3Case based learning motivates me to work more in this subject (4-point likert scale)4I have improved my problem-solving skill using Case based learning (4-point likert scale)5Case based learning is a worthwhile progression from problem based learning (4-point likert scale)6The MCQs presented were interesting and were relevant to first year medical students (4-point likert scale)7I enjoyed case based learning more than problem based learning (4-point likert scale)8The discussion sessions facilitated interaction between staff and students (4-point likert scale)9Case based learning suited the way I learn compared to problem based learning (4-point likert scale)10Case based learning helped to improve my diagnostic skills and lateral thinking (4-point likert scale)

Illustration 3

Table 3 Logistic regression analysis (enter method) to study gender differences in students' attitudes towards CBL



Questionnaire surveyWe appreciate your honest opinionsThe responses will be treated anonymously and confidentially

The first set of questions relate to your demographic information1. What is your age?2. Gender? Female Male

The remaining questions relate to your opinions on case based learning (CBL)3. How would you rate CBL model as a tool in understanding concepts’ compared with regular teaching sessions?

a) Poorb) No differencec) Goodd) Excellent

4. How would you rate CBL model as a tool in understanding concepts’ compared with PBL student discussionsessions that were used in previous sessions?a) Poorb) No differencec) Goodd) Excellent

‘Case based learning’ global analysis on 4-point likert scale

5. Case based learning motivates me to work more in this subject.a) Strongly agreeb) Agreec) Disagreed) Strongly disagree

6. I have improved my problem-solving skill using Case based learninga) Strongly agreeb) Agreec) Disagreed) Strongly disagree

Illustration 4

Appendix-1



7. Case based learning is a worthwhile progression from problem based learninga) Strongly agreeb) Agreec) Disagreed) Strongly disagree

8. The MCQs presented were interesting and were relevant to first year medical studentsa) Strongly agreeb) Agreec) Disagreed) Strongly disagree

9. I enjoyed case based learning more than problem based learninga) Strongly agreeb) Agreec) Disagreed) Strongly disagree

10. The discussion sessions facilitated interaction between staff and studentsa) Strongly agreeb) Agreec) Disagreed) Strongly disagree

11. Case based learning suited the way I learn compared to problem based learninga) Strongly agreeb) Agreec) Disagreed) Strongly disagree



12. Case based learning helped to improve my diagnostic skills and lateral thinkinga) Strongly agreeb) Agreec) Disagreed) Strongly disagree

Please give your remarks about this model of CBL. Also please list advantages and disadvantages of CBLcompared to previous PBL based discussion sessions.



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Case Based Learning Versus Problem Based Learning: A ... · Case Based Learning Versus Problem Based Learning: A Direct Comparison from First Year Medical Students Perspective