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Adv Physiol Educ 37: 356–360, 2013;

How We Teach doi:10.1152/advan.00076.2012.

Case-based learning in endocrine physiology: an approach toward


self-directed learning and the development of soft skills in medical students
Shubhada Gade1* and Suresh Chari2*
1
Department of Physiology, NKP Salve Institute of Medical Sciences and Research Center, Nagpur, India; and 2Department
of Biochemistry and Director Medical Education Unit, NKP Salve Institute of Medical Sciences and Research Center,
Nagpur, India
Submitted 13 June 2012; accepted in final form 20 August 2013

Gade S, Chari S. Case-based learning in endocrine physiology: an the recent Vision 2015 document, recommended curricular
approach toward self-directed learning and the development of soft reforms for undergraduates that included foundation courses
skills in medical students. Adv Physiol Educ 37: 356 –360, 2013; toward the orientation of students to national health scenarios,
doi:10.1152/advan.00076.2012.—The Medical Council of India, in
learning skills and communication, integration both horizontal
the recent Vision 2015 document, recommended curricular reforms for
undergraduates. Case-based learning (CBL) is one method where and vertical to bridge the gap between theory and practice, and
students are motivated toward self-directed learning and to develop an emphasis on early clinical exposure in the form of intro-
analytic and problem-solving skills. An overview of thyroid physiol- duction of case scenarios for classroom discussion/case-based
ogy was given in a didactic lecture. A paper-based case scenario of learning (CBL). This will done as a coordinated effort by pre-,
multinodular goiter was given to phase I Bachelor of Medicine, paraclinical, and clinical faculties, a student-doctor method of
Bachelor of Surgery students in two sessions. An attitude survey of clinical training, secondary clinical exposure, electives, skill
the students and teachers was done using a Likert scale ranging from development and training, and secondary hospital exposure (7).
strongly disagrees to strongly agree. A pretest and posttest were Our college, which is recognized by the Medical Council of
conducted. The students opined that CBL helped them to better their
understanding of a particular topic, gave them better retention of India, also planned to introduce a new teaching-learning
knowledge, helped them to relate clinical conditions to basic sciences, method in the form of CBL. It was first implemented in the
improved soft skills such as communication skills and group dynam- preclinical phase, and a topic from endocrine physiology was
ics, and promoted a better teacher-student relationship. There was chosen.
significant improvement in student’s performance when pre- and Conventionally, teaching of undergraduate students is done
posttest scores were compared (P ⫽ 0.018). Furthermore, faculty with the help of didactic lectures, practicals, a tutorial, and
members opined that CBL promoted self-study and problem-solving clinics, which are mostly used as passive teaching and learning
abilities of the students. In conclusion, CBL motivates students methods; however, they lack in the development of problem-
toward self-directed learning and to develop analytic and problem-
solving skills; thus, CBL could be beneficial for students’ entry into solving or reasoning skills of the students. Furthermore, there
clinical departments and, finally, in managing patients. is hardly any involvement of students in the teaching-learning
process.
case-based learning; self-directed learning; soft skills Various alternative methods are being used in many medical
colleges to reinforce didactic lectures in endocrine physiology,
MEDICAL COLLEGES in India have traditionally followed a curric- such as case-stimulated learning (16), problem-based learning
ulum overloaded with a large amount of knowledge pertaining (17), patient-centered learning (13), and multiple-format ses-
to basic sciences and clinical disciplines. Once qualified, stu- sions (5).
dents are expected to synthesize this information and apply it CBL is one method where students are motivated to learn on
to the care of patients (11). It has been reported that medical their own so as to inculcate the habit of self-learning and
graduates in India generally possesses reasonably sound integrating knowledge from different subjects to solve prob-
knowledge of medical science but they are often found defi- lems. It is a small-group method in which both students and
cient in the performance of clinical skills and problem solving, faculty members contribute to discussion, learning issues are
which form the core of clinical competence (14). Compartmen- preidentified, and preparatory readings are assigned while
talization among departments, lack of integration, poor coor- student discussion and guided inquiry around clinical problems
dination between basic sciences and clinical subjects, and are still promoted (12).
adherence to traditional didactic pedagogical methods of in- This study was undertaken with the following aims and
struction could be possible areas for improvement in the objectives:
existing curriculum. The changing needs of society, advances 1. To motivate students to adopt a problem-solving approach
in scientific knowledge, and innovations in the field have by relating basic science subjects with a clinical scenario and
prompted the Medical Council of India to adopt a needs-based to apply concepts of theory to clinical conditions through
curriculum toward self-directed learning for undergraduate self-learning.
medical education in India. The Medical Council of India, in 2. To develop soft skills such as communication skills and to
understand principles of group dynamics.
3. To motivate the peer group to adopt a new teaching-
*S. Gade and S. Chari contributed equally to this work.
Address for reprint requests and other correspondence: S. Gade, 51, New
learning methodology.
Sneh Nagar, Wardha Rd., Nagpur, Maharashtra, India (e-mail: shubhagade Thus, the study was mainly focused toward developing prob-
@gmail.com). lem-solving or reasoning skills among the students.
356 1043-4046/13 Copyright © 2013 The American Physiological Society
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How We Teach
CASE-BASED LEARNING IN ENDOCRINE PHYSIOLOGY 357

METHODS 12 Pre-intervention

Mean score for 20 students


Phase I Bachelor of Medicine, Bachelor of Surgery (MBBS)s Post-intervention
10
students (n ⫽ 150) from NKP Salve Institute of Medical Sciences and
Research Center (Nagpur, India) were chosen for this study. Permis- 8
sion was obtained from the Institutional Ethics Committee (approval
no. 41/2010). A meeting of teachers from the Departments of Phys- 6
iology, Medicine, and Surgery was arranged, and a case describing
multinodular goiter was designed. A facilitator training program was 4
undertaken in the department under the guidance of Chief (Head) of
the Medical Education Unit of the institute. The “facilitators” were 2
physiologists, anatomists, and physicians.
Students were informed about the new intervention, and written 0
informed consent was obtained. All steps of CBL were strictly 1 2 3 4 5 6 7
followed. An overview about thyroid gland physiology was given to Facilitator
students in a didactic lecture. Students were divided into multiple Fig. 1. Bar chart showing mean test scores along with error bars for before and
batches of 20 students each with a facilitator. A paper-based case after the intervention scenario for each group of 20 students, as obtained by the
scenario of multinodular goiter was given in two sessions 1 wk apart respective facilitator.
(APPENDIX A). Students were given enough time to study the case. They
discussed the case among themselves. During the first session, stu-
dents were asked to frame learning objectives based on the cues, and CBL helped them in relating knowledge from different subjects
a list of references (from physiology, anatomy, medicine, and surgery) (basic sciences with paraclinical and clinical subjects) and in
was given to them so as to prepare for the next session. In the next
session, more information in the form of investigative reports was
better retention of knowledge. According to 79.2% of the
provided to the students, and they were asked to solve the problem students, the small-group discussions in CBL helped them to
completely. The teacher present there only facilitated the learning improving soft skills such as communication skills, and 69.8%
process of each student, streamlined the thought process of the of the students felt that CBL improved the group dynamics.
students, and clarified controversy if there was any. An attitude survey More than 86% of the students felt that CBL would promote a
of the students was done on nine parameters using five-point Likert better teacher-student relationship (Fig. 2).
scale ranging from strongly disagrees to strongly agree. Teacher CBL was equally appreciated by faculty members. Accord-
feedback was obtained on 13 parameters by a Likert scale. To ing to 85% of the teachers, CBL is a better method of teaching
determine the effectiveness of the program, a pretest (before the first and learning, because it promotes self-study and problem-
session) and posttest (after the second session) were also conducted. solving abilities of the students. The majority (75%) of teach-
The questionnaire designed for the pre- and posttest had 20 multiple-
choice questions with a combination of recall type and higher order type ers felt that CBL would help in improving communication
based on problem-solving skills and clinical application (APPENDIX B). The skills, understanding principles of group dynamics, and facil-
questionnaire had both structured and open-ended questions. A five-point itating a better and healthy teacher-student relationship. When
Likert scale was used ranging from strongly disagree to strongly agree to asked for suggestions to make CBL better, faculty members
determine the overall rating of the program by students and teachers. A felt that training of teachers should be regularly done. Most
separate questionnaire was developed for teachers with more open-ended teachers (86%) felt that although CBL is a good teaching-
questions that could help in the better implementation of CBL in the learning method, it requires more time, faculty members, and
future. The questionnaire was validated by the Medical Education Faculty infrastructure. Some teachers (56%) found it difficult to in-
of the institute. volve shy and less interested students in the group discussion.
Statistical analysis. The objective of the study was to evaluate the
Only one teacher admitted that it was difficult to just be a
impact of the intervention, i.e., CBL, on the students. A 10-point
questionnaire was administered to the students before the intervention. facilitator as the teacher knows the subject thoroughly. Faculty
Accordingly, a score (out of 10 total) was obtained for each student. members also suggested topics that can be taught by CBL in
The same survey was again repeated after CBL, and student responses the next session and showed their willingness to be a faculty
were obtained accordingly. The method was implemented by different member for all CBL sessions in the future, as it promoted them
teachers, who measured the pre- and postintervention impact on their to revisit other subjects because CBL helps in integrating
respective tests. Average pre- and postintervention scores of all knowledge of the topic from different subjects.
students were obtained for each teacher. To assess the overall impact
of the intervention, a nonparametric Wilcoxon rank-sum test was
DISCUSSION
used. Statistical significance was tested at the 5% level, and the
analysis was carried out using the SPSS (version 18.0) package Traditionally teaching in physiology has always been
(SPSS). through didactic lectures, practicals, and tutorials. There is no
RESULTS
single method of teaching that ensures thorough understanding
of a topic among students. Our institute is affiliated with a
Of 150 students, 142 students (94.6%) were present for both Medical University of the State (Maharashtra University of
sessions. There was a significant improvement in student Health Sciences). We are provided with a curriculum from the
performance when pre- and posttest scores were compared university to be taught in a traditional manner, where the major
(P ⫽ 0.018), which provided evidence as to the effectiveness portion of physiology is taught to students with the help of
of CBL (Fig. 1). CBL was highly appreciated by the students didactic lectures. Lectures are definitely a powerful method of
(86.7%). The majority of the students (83%) were of the delivering information to a large number of students quickly.
opinion that CBL helped them in self-study and improved their However, there are many limitations, such as lectures are a
problem-solving ability, and 77.3% of the students felt that passive method of learning by students and too much informa-

Advances in Physiology Education • doi:10.1152/advan.00076.2012 • http://advan.physiology.org


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How We Teach
358 CASE-BASED LEARNING IN ENDOCRINE PHYSIOLOGY

90
Strongly disagree
80 Disagree

Number of responses
70 Neither agree or disagree
60 Agree

50 Strongly agree

Fig. 2. Bar chart showing student responses (in 40


numbers) to different attitudinal questions on the 30
Likert scale. CBL, case-based learning.
20

10

0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9

Advantages of CBL Soft skill Teacher student relations


development

tion is given without application or a problem-solving ap- According to previous study (13) teaching endocrine phys-
proach. iology in a patient-centered learning curriculum, students are
There has always been a need for an alternative to the better equipped to analyze clinical problems, find and apply
traditional didactic format of lectures in medical education (2, appropriate basic science knowledge, and present their patients
6). Hence, we thought of adopting a judicious mixture of compared with students from a traditional curriculum.
didactic lectures and CBL sessions as a pilot project in our In a comparative study (12) between problem-based learning
institute so as to retain the lectures and supplement them with and CBL, both students and faculty members preferred the
a new teaching learning methodology, which will give a CBL method, as it offers more opportunities for problem-
problem-solving approach. solving skills within a session. In a similar type of study carried
As medical teachers, we provide students a large amount of out in India, the majority of students reported CBL as a more
information, but, at same time, it is necessary to ensure that it suitable way of learning compared with problem-based learn-
should be used to establish and optimize students’ understand- ing and that CBL helped to improve their diagnostic skills and
ing. lateral thinking (10).
What is CBL? By discussing a clinical case related to the The teachers who were facilitators in the CBL project
topic taught, students evaluated their own understanding of admitted that with this exposure to a new teaching-learning
the concept using a high order of cognition. This process process, their knowledge about the new teaching-learning
encourages active learning and produces a more productive method has increased and they are now ready to experiment
outcome (4, 8). with new methods of teaching (theory or practical), assess-
Why use CBL? (1) ment, and evaluation. Thus, we recommend the incorporation
1. To provide students with a relevant opportunity to see of this new teaching-learning method for a few systems in
theory in practice. physiology, which can be experimented further in other depart-
2. To require students to analyze data to reach a conclusion. ments.
3. To develop analytic, communicative, and collaborative Summary. The present teaching-learning intervention in the
skills along with the content knowledge. form of CBL was an attempt toward making students respon-
4. To provide an opportunity for students to put themselves sible for their own learning and narrow down the gaps between
in the decision maker’s shoes. students and teachers. Both believe that a proper balance of
The results of this study indicate that the learning of students faculty time and available space would lead to a successful
is significantly enhanced with this new teaching learning meth- program implementation.
odology, as students were able to answer application-based Challenges faced. First, the most difficult task in introducing
questions as well. The results of the study also indicate that the this new teaching-learning methodology was to change the
assimilation of the knowledge was also improved because mindset of the senior teachers to drift them away from the
discussing a case after the didactic lecture was helpful in existing curriculum.
reinforcing the key elements of the topic. The retention of Second, as CBL requires teamwork, we were required to
knowledge was also better because students were required to convince each and every staff member to seek their coopera-
study the same topic from all subjects simultaneously so as to tion.
integrate the knowledge to solve the given problem. Limitations of the study. This study has certain limitations,
Similar types of studies have been introduced in some such as more time and space, infrastructure, and facilitators are
medical colleges in India, and the results have been encourag- required to cover the topic and sometimes it is difficult to
ing (3, 15). An early clinical exposure program consisting of convince some faculty members. As the new methodology was
CBL in endocrine physiology in a medical college in India also introduced to all phase I MBBS students, a control group was
demonstrated that the majority of students (96.4%) gave an missing in the study.
overall rating of the program as good to excellent on a Lessons learned. A greater number of new interventions
five-point Likert Scale (9). should be adopted in the teaching-learning process, as it helps

Advances in Physiology Education • doi:10.1152/advan.00076.2012 • http://advan.physiology.org


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How We Teach
CASE-BASED LEARNING IN ENDOCRINE PHYSIOLOGY 359

all teachers and students to develop a holistic approach toward D. Agree


the patient, which will be reflected by the health of society in E. Strongly agree
the coming years. Furthermore, the results of this study should 6. CBL helps in understanding the principles of group dynamics.
be compared with the traditional teaching-learning methodol- A. Strongly disagree
B. Disagree
ogy. C. Neither agree nor disagree
Conclusions. Physiology is a science with an emphasis on D. Agree
homeostatic mechanisms, and its understanding is required to E. Strongly agree
study medicine and pathology. As CBL motivates students 7. CBL deprives students of an opportunity to acquire knowledge
toward self-directed learning and to develop analytic and from experienced and good teachers.
problem-solving skills, it will be beneficial for students’ entry A. Strongly disagree
into clinical departments and finally in managing patients B. Disagree
successfully. C. Neither agree nor disagree
D. Agree
APPENDIX A: CASE HISTORY E. Strongly agree
8. CBL gives an opportunity for even staff members with poor
First session. Hema, a 20-yr-old woman, visited the Medical teaching skills to be good facilitators.
Outpatient Department with a history of swelling in the front of the A. Strongly disagree
neck since the last 6 mo. Recently, she also developed complaints of B. Disagree
palpitation, excessive sweating, and tremors. There is a significant C. Neither agree nor disagree
history of weight loss in last 3 mo, but with no loss of appetite. She D. Agree
does not have any hoarseness of voice or difficulty in swallowing or E. Strongly agree
breathing. On examination, she was told that she is suffering from 9. CBL facilitates a better and healthy teacher-student relationship.
goiter and advised to seek further investigations. It was further found A. Strongly disagree
that there were no signs of exophthalmoses. B. Disagree
Second session. After 1 wk, Hema returned to the doctor with C. Neither agree nor disagree
her reports. Upon investigation, it was found that her thyroxine levels D. Agree
were raised and thyroid-stimulating hormone levels were less than E. Strongly agree
normal. A thyroid scan confirmed the diagnosis of multinodular Feedback questionnaire on CBL for teachers. The follow-
goiter. She was prescribed anti-thyroid drugs and ␤-blockers and ing is the feedback questionnaire on CBL for teachers:
advised to consult a surgeon. 1. CBL is a better method of teaching/learning than the conven-
tional one.
APPENDIX B A. Strongly disagree
B. Disagree
Feedback questionnaire on CBL for students. The following C. Neither agree nor disagree
is the feedback questionnaire on CBL for students: D. Agree
1. CBL is a better method of teaching/learning than the conven- E. Strongly agree
tional one. 2. CBL promotes self-study and problem-solving abilities of the
A. Strongly disagree students.
B. Disagree A. Strongly disagree
C. Neither agree nor disagree B. Disagree
D. Agree C. Neither agree nor disagree
E. Strongly agree D. Agree
2. CBL promotes self-study and problem-solving abilities of the E. Strongly agree
students. 3. CBL helps in the recall and application of basic sciences to the
A. Strongly disagree given clinical scenario.
B. Disagree A. Strongly disagree
C. Neither agree nor disagree B. Disagree
D. Agree C. Neither agree nor disagree
E. Strongly agree D. Agree
3. CBL helps in the recall and application of basic sciences to the E. Strongly agree
given clinical scenario. 4. CBL helps in better retention of knowledge.
A. Strongly disagree A. Strongly disagree
B. Disagree B. Disagree
C. Neither agree nor disagree C. Neither agree nor disagree
D. Agree D. Agree
E. Strongly agree E. Strongly agree
4. CBL helps in better retention of knowledge. 5. CBL helps in improving communication skills of the students.
A. Strongly disagree A. Strongly disagree
B. Disagree B. Disagree
C. Neither agree nor disagree C. Neither agree nor disagree
D. Agree D. Agree
E. Strongly agree E. Strongly agree
5. CBL helps in improving communication skills of the students. 6. CBL helps in understanding the principles of group dynamics.
A. Strongly disagree A. Strongly disagree
B. Disagree B. Disagree
C. Neither agree nor disagree C. Neither agree nor disagree

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How We Teach
360 CASE-BASED LEARNING IN ENDOCRINE PHYSIOLOGY

D. Agree results of experiments; S.A.G. drafted manuscript; S.A.G. edited and revised
E. Strongly agree manuscript; S.N.C. approved final version of manuscript.
7. CBL deprives students of an opportunity to acquire knowledge
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