Case-Based Learning: The Adult Way to Eat

By Sarah Luttrell, PGY2 Psychiatric Pharmacy Resident, University of Maryland

          How best to teach a subject changes continuously, and is never unanimous among professionals. An article by Anello suggests that for students to be successful, they must “eat”¹. Eat doesn’t refer to food, but to an instructional design: Experience, Apply and Theory.¹ The application of “eat” boils down to experiencing a theory firsthand, applying the experience, and then learning the underlying theory. The example from Anello involves free trade. First, high-school students engaged in a game based on free trade concepts. Afterwards, they answered questions about their experiences, which framed the game in terms of the theory. After discussing, the didactic information was taught. The benefits to this altered classroom is that students have hands-on experience with the concept before having to comprehend a bulky abstract theory.¹

          The above shows how a classroom can be changed to fit the learners’ needs. The rationale behind this is not only to shake up the traditional student mindset, but also to learn how to apply general theories to clinical practice. Wrenn and Wrenn discuss how to ensure students aren’t simply regurgitating information, but retaining and learning how to critically apply it as practitioners.² They state the keys to ensuring success with this transition from student to clinician are active learning and constructivism.² Active learning facilitates engagement and information retention, while constructivism helps students internalize the subject by rebuilding current understanding using new concepts.² This was demonstrated in Anello’s article, as the students had to be actively engaged during the game and assessment, and then use constructivism during the didactic section to comprehend the theory. 

           

          While games are useful active learning tools during K-12 education, they’re less practical in professional education. Instead, there have been several publications in the last year regarding effectiveness of utilizing case-based learning (CBL) over lectures, requiring critical application of clinical concepts, and teamwork during team-based cases. Overall, the results have been positive. In an E.R. in Spain, medical residents who participated in case-based sessions demonstrated significantly better knowledge retention 50 days later when compared with traditional didactic techniques.³  In addition, Hong and Yu found that adding more advanced cases resulted in improved critical thinking based on higher scores on several critical thinking measurement tools.⁴ In this example, multiple ‘episodes’ of each case were used to show progression of a patient along a disease state, which better simulates a real-world scenario.⁴ This study showed that CBL developed critical thinking skills, which many students lack after graduation.² In both of the above studies, students came out with significantly better outcomes due to increased student expectations and involvement within the classroom. For the pharmacy curriculum, CBL could be incorporated for various large disease states, such as COPD, and require the use of guidelines to complete the case. This builds critical thinking skills and the ability to analyze relevant resources, which are both skills students need to master to become excellent practitioners. 

         

          One benefit of “problem-posing education,” like CBL, is that the “teacher is no longer one who only teaches, but also learns through dialogue with students.”² Each student learns differently and has his or her own way of processing, constructing and rebuilding information. Active learning sessions with engaged students lead to thorough discussions that may result in points the instructor never thought of. This leads back to Wrenn and Wrenn’s assertion that “students are also co-teachers,”² and that learning can be a two-way road rather than hierarchical.  The students learn individually, from one another, and from the professor.

          However, the ‘experience’ gained through CBL is not enough. The students in Anello’s article not only participated in the free trade simulation game, but also discussed the experience, the concepts and, eventually, the underlying theory behind the game.¹ In other words, students need to have “guided reflection and analysis.”² There must be an internal process to link past learning with new concepts, and help construct a new framework the student can continue to build upon. One way to assist students in their reflection is to have questions at the end of each module, or rotation, regarding the most challenging, rewarding, or surprising situation. In addition, less formal methods of reflection can be done after any encounter, such as asking how as student came to an answer, or what could have been done differently after a patient interaction.

Case-based learning has shown to improve knowledge retention, and to build critical thinking skills necessary for medical professionals. The material become more relevant, and, as Wrenn said, “students are more enthusiastic learners when they see firsthand that what they’re learning translates into benefits for those they serve.”² However, this method is time-consuming, and must be undertaken with the understanding that large amounts of prep work are required of both the students and the teacher. In my opinion, complex CBL should be incorporated into curriculum starting first year, but should be balanced with classical didactic teaching. If every class has intensive in-classroom work, the students will not have time to adequately prepare, and knowledge retention will suffer.  In addition, guided sessions to help frame the experiences with an adequate understanding of the concepts at hand is imperative.

References:

1.    TES [Internet]. San Francisco: TES Global Limited; c2017. “Swap the structure of traditional lessons to boost learning; 2017 Jan 20 [cited 2017 Mar 9]; [about 3 screens]. Available from: https://www.tes.com/us/news/breaking-views/swap-structure-traditional-lessons-boost-learning

2.    Wrenn J and Wrenn B. Enhancing learning by integrating theory and practice. Int J Teach Learn High Educ [Internet]. 2009;21(2):258-65 Available from: http://www.sciencedirect.com.proxy-hs.researchport.umd.edu/science/article/pii/S1471595305000405

3.    Muñoz DR, Salinas GA, Díez EF, et al. Training in management of arrhythmias for medical residents: A case-based learning strategy. Int J Med Ed. 2016; 7:322-3. Available from: https://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pmc/articles/PMC5056024/  

4.    Hong S and Yu P. Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: A randomized controlled trial. International Journal of Nursing Studies. 2017; 68:16-24. Available from: http://www.sciencedirect.com.proxy-hs.researchport.umd.edu/science/article/pii/S0020748916302449