Eur J Dent Educ 2000; 4: 165–168 Copyright C Munksgaard 2000Printed in Denmark. All rights reserved

ISSN 1396-5883

Multidisciplinary case-based learning for undergraduatestudents

M. Therese Garvey1, Michael O’Sullivan2 and Marielle Blake1

Departments of 1Public and Child Dental Health, and 2Restorative Dentistry and Periodontology, Dublin Dental Hospital, Lincoln Place,Dublin 2, Ireland

This report describes the introduction of case-based learning intothe final-year dental programme at the Dublin Dental School.Students attended a series of one-hour sessions in groups of 8.Each group appointed a chairman for each session and a tutorfacilitated the discussion. Case details were provided during thesession with relevant diagnostic records. At weekly discussionsessions, the group findings and treatment options were con-sidered. The diagnosis and treatment plans were then discussedby clinicians involved in the treatment of the case. Following thelast session, the case-based learning programme was evaluated

THERE HAVE BEEN major clinical changes in theundergraduate dental curriculum in Trinity Col-

lege Dublin, in order to take account of the increasingdemands on undergraduate training. Curriculumevaluation and review was initiated more than 10years ago. At first, multidisciplinary small group clin-ical teaching was introduced. In 1991, further reviewsof the curriculum culminated in a decision to adopt aproblem-based learning approach (1). The introduc-tion of problem-based learning means a change of ap-proach in learning and teaching for both staff and stu-dents.

An increasing number of medical and dentalschools in North America, Australia and Europe havesuccessfully introduced problem-based learning cur-ricula which attempt to address some of the deficien-cies in the traditional curricula. The essential charac-teristics of a problem-based learning curriculum arethe use of problems as a focus for integrating learningof the basic sciences and clinical knowledge, as wellas clinical reasoning skills. In problem–based learn-ing, the problem serves as a focus for organising andcollecting information for learning and the learner isresponsible for what is learned and how it is learned(2). It is a student-centred approach. Students assumeresponsibility for their own learning and the tutors,instead of providing information to students, act asfacilitators of their learning.

165

by means of a questionnaire distributed to both tutors and stu-dents. Both students and tutors rated the sessions positively.Case-based learning was found to be a worthwhile progressionfrom problem-based learning.

Key words: case-based learning; problem-based learning;undergraduate; questionnaire.

c Munksgaard, 2000Accepted for publication 28 March 2000

In authentic problem-based learning, the problemssupport the application of problem-solving skills re-quired in clinical practice. Problem solving is an es-sential career skill and should be developed in a learn-ing environment rather than under pressure in clinicalpractice after graduation.

The presentation of case studies combined withsmall-group discussions is a common method ofteaching in business schools. Case-based learning hasbeen defined in the dental literature as an importantmethod of distilling the basic knowledge learned intexts and lectures and applying it to a patient (3). Ithas been used successfully in the dental school in To-ronto. Although problem-based learning and case-based learning share common goals, each instruc-tional design possesses unique characteristics. Inproblem-based learning, the problem drives the learn-ing. The case-based format requires students to recallpreviously-covered material to solve clinical caseswhich are based on clinical practice (4). This reportdescribes a case-based, student-centred model intro-duced to simulate decision making in general dentalpractice.

Methods

Case-based learning has been introduced on a trialbasis to the 1st term of the final dental year pro-

Garvey et al.

gramme at the Dublin Dental School. These studentswere somewhat familiar with this learning concepthaving participated in a problem-based learning cur-riculum.

Cases chosen from the dental hospital and clinicalpractice were clinically based and multifaceted. Manyof the cases selected were treated by staff membersinvolved in the programme. A total of 15 cases wereselected and streamed from less to more complex overthe course of the programme. The cases selected werenot presented with the aim of increasing factual infor-mation but rather with a view to improving the stu-dent’s diagnosis and treatment planning ability, solv-ing clinical problems by integrating knowledge fromvarious disciplines and applying it to new situations.

The class of 39 students was divided into 5 groups,4 groups of 8 and 1 group of 7. Students attendedcase-based learning sessions in groups similar toproblem-based learning. A number of clinical staffagreed to act as tutors. 10 tutors were involved in all.The role of the tutor was to facilitate rather than directthe group. Since the cases were multidisciplinary, thetutor was not an expert on every case. At the begin-ning of the programme, 1 student was appointed ineach group to liaise with the course co-ordinator. Thestudent was to report any problems and to conveyany suggestions the group might have as to how thecourse might be improved.

Each group met in a pre-assigned seminar roomequipped with a table, chairs, an X-ray viewer and flipchart. At the start of each session, the group elected achairman. The tutor provided each student with acopy of the case details and relevant diagnostic rec-ords such as study models, radiographs, clinicalphotographs and pathology reports (haematology,microbiology, etc.) where appropriate. Each groupworked as a team and was expected to diagnose thecase and identify solutions to the clinical problems,understanding the advantages and limitations of thetreatment plans selected. Students were encouragedto base their treatment planning on research and toutilise evidence-based dentistry. One case was evalu-ated per week and all students were provided withidentical information and case details. Each 60–90-minsession concluded with the chairman summarisingthe relevant details. Students were then free to re-search any unfamiliar concepts for the remainder ofthe 3-h period allocated. At the end of each week, theclass of 39 students attended an hour-long discussionsession.

The purpose of this session was to give studentsan opportunity to discuss the case with the cliniciansinvolved in the selection and treatment of the case.

166

Each chairman presented the group’s findings and thetreatment options. Following these student presen-tations, the case was discussed by all the cliniciansinvolved in the treatment of the case. The diagnosisand treatment plans, together with the advantagesand disadvantages, were outlined and where possible,completed cases were presented. This session pro-vided uniform feedback. Students were encouraged tobase clinical decisions on sound research and wherepossible on evidence-based dentistry in an effort toprescribe more efficient and effective treatments.

A questionnaire was designed to evaluate the case-based learning programme. The questionnaire com-prised a total of 10 statements. Questions 1–4 relatedto the cases and organisation of the course, and ques-tions 5–10 related to the value of case-based learningas a method of learning. Positive statements wereused in the questionnaire design to enable the use ofcomposite mean comparisons. In addition to answer-ing the questionnaire, students were encouraged tomake any suggestions they felt might enhance thecourse. The questionnaire was distributed to 37 finalyear students at the end of the case-based learningmodule. 2 students who participated in an Erasmusexchange programme were excluded, as they did notattend all the sessions. 8 tutors completed a slightlymodified questionnaire (the authors were not in-cluded). The students and tutors could agree or dis-agree with each statement. The scoring was based ona scale of 1–5, 1 representing strong disagreement and5 strong agreement.

Results

There was a 100% response rate to the questionnairesdistributed to both students and tutors. The scoringbreakdown of the individual questions is outlined inTables 1, 2. The composite mean score of the class ob-tained by averaging students’ individual mean scoreswas 4.16 out of a possible 5 (Table 1). The compositemean score of the tutors was 4.37 (Table 2). A high %of students and tutors responded with marks of 4 or5 to each question. Greater than 90% of studentsfound case-based learning to be ‘‘interesting and in-volving several disciplines’’ and ‘‘relevant’’, awardinga grade of 4 or 5. However 37.8% of students awardeda mark of 3 or less to Question 3 ‘‘The course was wellorganised‘‘. There was also a discrepancy between theopinion of students and tutors on Question 9, with35.1% of students scoring 3 or less while 100% of tu-tors felt ‘‘The discussion sessions facilitated interac-tion between staff and students’’ awarding a score of4 or 5.

Case-based learning

TABLE 1. Student evaluation of case-based learning programme (nΩ37)

Questions % «–––» % Classstrongly strongly meandisagree agree

1 2 3 4 5

1. The cases presented were interesting and involved several disciplines 0 0 8.1 37.9 54 4.462. The cases presented were relevant to final-year dental students 0 2.7 5.4 27 64.8 4.463. The course was well organised 2.7 2.7 32.4 35.1 27 3.874. The cases facilitated active discussion at the seminars 0 2.7 27 46 24.3 3.925. Case-based learning is a worthwhile progression from 2.7 2.7 5.4 19 70.2 4.51

problem-based learning6. Case-based learning helped to improve my diagnostic skills and 0 0 16.3 43.2 40.5 4.24

lateral thinking7. Case-based learning improved my ability to treatment plan 0 5.4 19 43.2 32.4 4.028. This teaching method is a useful preparation in clinical problem 0 0 10.8 46 43.2 4.32

solving9. The discussion sessions facilitated interaction between staff and 2.7 0 32.4 40.5 24.3 3.83

students10. I enjoyed case-based learning 0 0 21.6 46 32.4 4.10

composite mean 4.16

TABLE 2. Tutor evaluation of case-based learning programme (nΩ8)

Questions % «–––» % Classstrongly strongly meandisagree agree

1 2 3 4 5

1. The cases presented were interesting and involved several disciplines 0 0 0 50 50 4.52. The cases presented were relevant to final-year dental students 0 0 0 50 50 4.53. The course was well organised 0 0 12.5 37.5 50 4.374. The cases facilitated active discussion at the seminars 0 12.5 12.5 50 25 3.875. Case-based learning is a worthwhile progression from 0 0 12.5 25 62.5 4.5

problem-based learning6. Case-based learning helped to improve the students’ diagnostic 0 0 0 62.5 37.5 4.37

skills and lateral thinking7. Case-based learning improved the students’ ability to treatment plan 0 0 25 37.5 37.5 4.128. This teaching method is a useful preparation in clinical problem 0 0 0 37.5 62.5 4.62

solving9. The discussion sessions facilitated interaction between staff and 0 0 0 50 50 4.7

students10. I enjoyed case-based learning 0 0 12.5 37.5 50 4.37

composite mean 4.37

Discussion

The results of the evaluation revealed that case-basedlearning was well received by both students and tu-tors. The majority of students agreed that case-basedlearning was a worthwhile progression from problem-based learning and that the cases were relevant to fi-nal-year students. Students commented that theywere unhappy to change tutors during the course andwished to be assigned the same tutor for the entirecourse. This may in part account for the high negativestudent response to Question 3, ‘‘the course is wellorganised‘‘.

167

A case-based learning model in orthodontics hasbeen described in the literature (5). At the end of thecourse, the students completed a 10-item ques-tionnaire. 100% of students agreed/strongly agreedthat the case analysis seminars ‘‘were more interestingand challenging than lectures‘‘. Although it is ac-cepted that case-based learning is not as useful as ex-tensive clinical experience, it is a worthwhile ap-proach in developing diagnostic skills and clinicaljudgement (3, 5).

Improvement in the areas of diagnosis, lateralthinking and treatment planning were commentedupon favourably. The cases were selected to reflect a

Garvey et al.

variety of clinical scenarios and received a high ap-proval rating.

It is important that students learn the skills of treat-ment planning through an interdisciplinary approachand not within the confines of speciality departments(6). The aim was to combine previously-acquiredknowledge from different areas of dentistry and solvemultidisciplinary clinical problems. Due to the limi-tations of time in the undergraduate dental curricu-lum, students will be exposed to a small portion ofthe spectrum of clinical problems. Case-based learn-ing can in some way counteract this shortfall.

Conclusion

Case-based learning is a natural progression fromproblem-based learning in a clinical discipline. It is inkeeping with the ethos of the Dublin Dental School thatstudents assume responsibility for their own learningand that staff, instead of providing information to stu-dents, act as guides and facilitators of their learning.The discussion session facilitated debate between thetutors and students on the advantages and disadvan-tages of selected treatment plans. Students were ex-posed to the expert opinions of tutors in various discip-lines, and learned that experienced clinicians did notalways agree on every treatment plan. Case-basedlearning requires creativity, facilitator skills, a reducedfocus on traditional lecture presentations and a dedi-cation to encouraging students to use reasoning anddecision-making skills. Enthusiastic colleagues whoare willing to supply cases with records and devote thenecessary time to discussion are an essential compo-

168

nent of any case-based learning programme. Case-based learning was well received by tutors and stu-dents. However, actual learning as defined by examina-tion performance was not evaluated.

Acknowledgements

The authors would like to acknowledge their col-leagues in the Dublin Dental School who participatedand facilitated in the implementation of case-basedlearning.

References

1. Kelly M, Shanley DB, McCartan B, Toner M, McCreary C.Curricular adaptation towards problem-based learning indental education. Eur J Dent Educ 1997: 1: 108–113.

2. Norman GR. Problem-solving skills, solving problems andproblem-based learning. Med Educ 1988: 22: 279–286.

3. Oesterle LJ, Shellhart WC. Assessing the use of CD-ROMtechnology in case-based learning. Eur J Dent Educ 1998: 2:160–164.

4. Kassebaum DK, Averback RE, Fryer GE. Student preferencefor case-based versus lecture instructional format, J DentEduc 1991: 55: 781–784.

5. Engel FE, Hendricson WD. A case-based learning model inorthodontics. J Dent Educ 1994: 58: 762–767.

6. Moskona D, Kaplan I, Leibovich P, Notzer N, Begleiter A. A3-year programme in oral diagnosis and treatment planning.A model using an interdisciplinary teaching team. Eur JDent Educ 1999: 3: 27–30.

Address:M. T. GarveyDepartment of Public and Child Dental HealthDublin Dental HospitalLincoln Place, Dublin 2Ireland