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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 99-104

Case-based learning: Introducing an innovative paradigm for learning medical microbiology in a rural medical college of North India


1 Department of Microbiology, SHKM GMC, Nalhar, Nuh, Mewat, Haryana, India
2 Department of Community Medicine, ACMS, New Delhi, India
3 Department of ENT, SHKM GMC, Nalhar, Nuh, Mewat, Haryana, India
4 Department of Microbiology, DY Patil Univ of Health Sciences, Pune, Maharastra, India
5 Department of ENT, SHKM GMC, Nalhar, Nuh, Mewat, Haryana; Department of Microbiology, NMCH, Jamuhar, Sasaram, Bihar, India

Date of Submission07-Dec-2020
Date of Acceptance28-Jun-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Jyoti Sangwan
Department of Microbiology, SHKM GMC, Nalhar, Nuh, Mewat, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_201_20

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  Abstract 


Introduction: It has been observed that there is inadequate retention of microbiology and its inappropriate application to clinical science among medical graduates. To address this problem and facilitate student's learning, we need to adopt active, student centric teaching learning methods. Case-based learning (CBL) is one such method .The present study was planned to introduce Case Based Learning (CBL) in Microbiology and assess its advantages in understanding the topic in comparison to traditional didactic lecture and to observe perception regarding CBL among faculty and students.
Material and Methods: 96 MBBS second Prof Students were enrolled in the study after obtaining informed consent and Institutional Ethics Committee approval. Theory lectures and CBL sessions were taken on the selected topics. At the end of both, the lectures and CBL sessions, a post test (MCQ) was conducted. A repeat test was taken after 4 weeks from the first post-test (MCQ) for each topic to see the retention of topic. Feedback of students and faculty were taken on a pre-validated questionnaire and analysed using a 5 point Likert scale.
Results: A total of 96/100 (96%) students participated in the study. The CBL scores were significantly higher than DL session scores (P < 0.001). The difference in scores was significant even after four weeks of session (P < 0.001). Student reported satisfaction in being taught by CBL method in 5-point Likert scale feedback form (mean score >4) and recommended it for future batches.
Conclusions: The study concludes that Case Based Learning is an active method of student centric learning resulting in better understanding, critical analysis, communication and retention of subject topics among students. The faculty also approved of the method in spite of being demanding and lack of adequate resources opining that the method is of special use in discussing clinically relevant topics.

Keywords: Active learning, adult learning, case-based learning, didactic lecture, innovative teaching learning


How to cite this article:
Sangwan J, Lathwal S, Naik S M, Mane P, Khan S, Lohan K, Kumar M. Case-based learning: Introducing an innovative paradigm for learning medical microbiology in a rural medical college of North India. J NTR Univ Health Sci 2021;10:99-104

How to cite this URL:
Sangwan J, Lathwal S, Naik S M, Mane P, Khan S, Lohan K, Kumar M. Case-based learning: Introducing an innovative paradigm for learning medical microbiology in a rural medical college of North India. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Jan 24];10:99-104. Available from: https://www.jdrntruhs.org/text.asp?2021/10/2/99/332851




  Introduction Top


Conventional methods of teaching such as a lecture which more often is a didactic lecture (DL) do not provide the required impact on student learning; this being especially true for basic subjects. The first 2½ years of medical education are devoted to basic sciences program where most educators give little or no importance on how the knowledge or skills would be applicable or useful in subjects taught at a later stage. Many students from the higher classes have stated that the basic sciences curricula are theoretically overloaded. They could recall less information and that curricula were less applicable to clinical practice. In the absence of such a teaching environment, students concentrate more on gaining good marks, rather than focusing on how the basic science information can be applied in a clinical scenario. Therefore, in the last few decades, the concept of interactive learning has evolved. The adoption of active learning strategies strengthens student learning as they focus not only on imparting knowledge but also on acquiring reasoning and problem-solving skills.[1]

Case-based learning (CBL) is one such strategy. It is an andragogical approach in which a case or inquiry is used to acquire knowledge, skills, and attitude. It engages students in the discussion of a clinical case that resembles a real-life situation and provides information such as history, physical findings, and laboratory results. Students interact with each other and work together as a collaborative team to solve the case. The teacher's role is that of a facilitator.[2],[3]

In medical microbiology, students are taught about various infectious diseases and the microorganisms associated with them. So, it is essential that students know the pathogenesis of the disease, the causative agent involved, and the scientific way of diagnosing the disease. From a student's point of view, understanding this overall correlation from a theory lecture is difficult. In Indian medical schools, Microbiology is taught in classrooms and students are given very little exposure to the practical and clinical aspects of the subject emphasizing learning by rote. This makes the subject boring and clinically irrelevant as students fail to understand its utility in practice.[4]

Recently, the concept of teaching Microbiology with the help of a clinical case scenario has been studied.[2],[3],[5] This is known as CBL which offers many advantages over traditional DLs such as

  • As it is a small group teaching, there is more opportunity for each student—so individualized learning.
  • Allows scientific inquiry, hypothesis generation, and derivation of conclusion.
  • There is a development of critical thinking and reasoning and analytical skills.
  • There is an integration of knowledge and practice.
  • There is collaborative learning.


Students interact with each other and work together as a team to solve the case with the instructor acting as a facilitator who does not let the discussion digress from the case and its aspects.[1],[5] So, in this way, CBL can help improve a student's understanding of the applied aspects of Microbiology.

Hence, given the above reported advantages of case-based learning, the present study was conducted to introduce the CBL in Microbiology at the undergraduate level in a relatively new medical college situated in the most aspirational district of India and to see its effectiveness in understanding the given concept and improved retention of the subject. Also, the perception of students and faculty involved in conducting CBL was recorded regarding this newer method of teaching and learning.


  Methodology Top


Ninety-six MBBS second Prof students were enrolled in the study after obtaining approval of the Institutional Ethics Committee wide letter no. SHKM/IEC/2018/4. Informed consent was obtained from the participants. The study was conducted in the Department of Microbiology. The sessions were taken during the 2-h practicals in the afternoon. The study duration was 6 months.

Preparation

The faculty of the Department of Microbiology was sensitized toward the need for the development of higher-order cognitive skills such as critical thinking, analysis, and reasoning among the medical students. The concept of CBL and its advantages were presented to the faculty. Three faculty members and three post-graduate students from the Department of Microbiology were sensitized and trained for group dynamics and CBL. The case scenarios of two topics from the MBBS scheduled timetable, i.e., community-acquired Urinary Tract Infection and Enteric Fever were prepared with the help of a clinician keeping in view the requirement of a first contact physician as per the Medical Council of India (now National Medical Commission) vision document 2015. After that questions for discussion during the CBL session were finalized and validated in-house. The pre-test and post-test Multiple Choice Questions (MCQs) were prepared. The Feedback questionnaires for students and faculty were designed, validated, and pretested with colleagues and students from the previous batch.

Conduction of CBL

The students were sensitized about the concept of CBL and group dynamics. The participants were divided into two groups—Groups A and B, of 48 students each. For each CBL session, these 48 students were further divided into three groups of 16 students each. In the first session on community-acquired UTI, A pre-test was conducted before starting the session. Then, Group A underwent a CBL session whereas Group B had DL on the UTI. Once the session was over, a post-test was conducted. In the second session conducted a week later on Enteric Fever, the groups were crossed over. This time, Group B had a CBL session for Enteric Fever whereas Group A had DL for the same. Similar to the previous session, pre- and post-tests were conducted. DLs were taken for each topic using PowerPoint presentation.

Batches A and B were given the clinical case scenario a week before the session and were instructed to study the case and do some further reading from suggested sources. The CBL sessions were conducted in the demonstration room of the Microbiology Department and each lasted for approximately 100 min. During the CBL session, the students were divided into three subgroups of 16 students each. Along with each group, there was one faculty member whose role was of a facilitator.

The first pre- and post-tests were conducted for each batch immediately after the CBL and DL sessions were completed, and then a repeat test was taken after a 4-week duration from the first post-test. This was to check for retention of knowledge. These tests were in a multiple-choice questions format with 20 questions of half mark each. The post-test marks were divided into two categories (CBL and DL) of 10 marks each for comparison between the two post-tests.

At the end of each CBL session, the perceptions of the students were taken using a validated questionnaire which had two sections: (a) section I had 10 close-ended questions with 5-point Likert scale response (b) section II had two YES/NO/open-ended questions. The faculty feedback was taken after 4 weeks of the CBL sessions. The questionnaire had seven close-ended questions with a 5-point Likert scale response and two YES/NO/open-ended questions.

Statistical analysis

The qualitative data were expressed in percentages and median and the quantitative data were expressed in the form of mean ± standard deviation and the significance of difference was assessed by t-test. A P value of <0.05 was considered statistically significant. All statistical calculations were done using Microsoft Excel Version 7 (Microsoft Corporation, NY, USA) and SPSS Version 20.0 (Statistical Package for the Social Science SPSS Inc. Chicago, IL, USA).


  Results Top


Total 100 MBBS second Prof (IV semester) students gave consent for this study. Out of 100 students, 96 (96%) students actually reported for the study.

On comparison of the post-test scores, the class scores were higher for the CBL sessions than the DL sessions in both the tests: One taken immediately after the sessions and another taken at an interval of 4 weeks after the completion of the sessions. The difference in the score of the two methods was found to be statistically significant. The difference in scores was more in the test taken after 4 weeks (P < 0.001) [Table 1]. Also, it was observed that there was a decrease in the mean score of both the groups over time, which is expected, but the decrease was significantly higher in the DL group than the CBL group meaning the latter were able to retain the self-acquired knowledge for a longer duration [Table 1].
Table 1: Comparison Between Test Marks of Didactic Lectures and Case-Based Learning Sessions

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When we analyzed the perception of the students about CBL, a majority of the students were satisfied with the use of this newer teaching-learning method. The mean score ranged between 4.3 and 4.6 for all 10 closed-ended 5-point Likert scale-based feedback questions. The students agreed to the development of critical thinking, reasoning, a better understanding of the topic, improved communication skills, motivation for self-study, teamwork, increased attentiveness during class as the advantages of CBL. Eighty-six out of 96 (89%) students agreed that CBL should be continued for future batches [Figure 1] and [Table 2]. In response to the question about whether CBL should be used alone or in combination with theory lectures, 68/96 (70.8%) were in favor of the CBL and theory combination. It was opined that a brief PowerPoint presentation of 10–15 min should precede CBL. Also, a few students suggested that all small groups should have good teachers, which can be addressed by a thorough preparation by all the participating faculty. Similarly, some other suggestions given by the students are represented in [Figure 2].
Figure 1: Perception of students regarding CBL

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Table 2: Feedback of Students About Case-Based Learning

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Figure 2: Suggestions given by students regarding CBL

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The faculty feedback analysis showed that all the faculty observed an increase in critical thinking, interaction among students and with teachers and better retention of topics in students. However, a majority (5/6) opined that the method is labor-intensive and time-consuming. On enquiring what was more labor-intensive, four out of six conveyed that the preparation of cases and MCQs took a lot of time. The faculty perception is shown in [Table 3]. The faculty view on the possible solutions was to recruit more faculty and to keep the CBL sessions for only selective, more common clinically relevant diseases.
Table 3: Perception of Faculty About Case-Based Learning

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  Discussion Top


The recently introduced Competency-Based Medical Education (CBME) curriculum emphasizes the possession of basic concepts of medicine, clinical knowledge, and communication skills along with ethical values by a medical graduate.[1] Understanding the basic concepts without clinical exposure during the early years of medical education has been a challenge. Many students opine on retrospection that they could recall very little information from the early years and could hardly apply that to clinical practice. The introduction of a student's centered teaching-learning methods such as CBL for teaching basic subjects like Microbiology may address this issue and can improve a student's understanding of applied aspect of the subject.[2]

In our study, we could demonstrate that the students' understanding of the topic was significantly better with CBL compared to the traditional approach (P < 0.001). Since CBL is a learner-centered approach where the students collectively address the clinical problems from a perspective that requires analysis, it helps in a longer retention of the concept learned.[2] In the present study, we found better retention of topics learned using CBL even after 4 weeks compared to DL (P < 0.001). Other authors also observed similar trends.[2],[4],[6]

After analyzing the perception of students regarding CBL, we observed that around 90% of the students either strongly agreed or agreed to a better understanding of the topic, almost the same number (93%) agreed that they were motivated for self-study. Further, more than 90% of the students agreed to improved problem-solving ability and 89% agreed to be more attentive during the learning session. Similar trends have been reported by Suvarna S Tathe.[5]

In our study, we found that the agreement among the students toward improved interaction with teachers, teamwork, and better communication skills was 92, 89, and 88%, respectively. Similar results were interpreted by Yasin Tayem et al.[7] and Nazish Fatima et al.[8] in their studies.[9]

In answer to the question of whether they recommend CBL for future batches, we found that 90% of the students agreed that it should be used for future batches. Kumar et al.[10] from Bihar reported that 95% of the students recommended CBL for the next batches. In response to the question of whether CBL alone should be adopted, 70% of the students opined that it should be used along with theory which could be in the form of brief PPTs before sessions or DLs whereas 30% said that it could be used alone. In a study by Ghosh from Gujrat, 84% of the students favored the combination.[11]

Our faculty admitted that the whole experience was very motivating and it improved the student's knowledge about the subject. However, they admitted that CBL is somewhat more labor-intensive and time-consuming. Similar findings were concluded by other studies.[7],[11],[12],[13]


  Conclusion Top


From this study, we can conclude that traditional DLs alone fail to achieve the required impact hence making the learning monotonous and boring with poor retention of the subject. Use of CBL in teaching Microbiology results in better retention and active learning of the subject. This study has certain limitations: We have studied only the short-term outcomes of CBL. There is a need to look at the long-term outcomes, which is possible during the later years of clinical exposure and internship. Also, only a few topics were covered by the CBL session. Along with this, more faculty members were required to interact with the students, which was another limitation.

DLs are good for giving information to the students but they lack student participation. Active learning happens when students are given an opportunity to think and interact which can be made possible with the CBL method. CBL will definitely impart relevance to medical education by blending theory with practice and induce deeper learning to create a competent Indian Medical Graduate.

Acknowledgments

This study was undertaken as a project to complete Advanced Course of Medical Education (ACME) under the guidance of faculty from MCI nodal center, Christian Medical College, Ludhiana. The author is extremely thankful to the continuous guidance and support of all the ACME, CMC, Ludhiana faculty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Ciraj AM, Vinod P, Ramnarayan K. Enhancing active learning in microbiology through case-based learning: Experiences from an Indian medical school. Indian J Pathol Microbiol 2010;53:729-33.  Back to cited text no. 2
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Chamberlain NR, Stuart MK, Singh VK, Sargentini NJ. Utilization of case presentations in medical microbiology to enhance relevance of basic science for medical students. Med Educ Online 2012;17. doi: 10.3402/meo.v17i0.15943.  Back to cited text no. 3
    
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Newble DI, Entwistle NJ. Learning styles and approaches: Implications for medical education. Med Educ 1986;20:162-75.  Back to cited text no. 4
    
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Tathe SS, Singh AL. Case-based lectures versus conventional lectures for teaching medical microbiology to undergraduate students. Int J Curr Rev 2014;6:35-41.  Back to cited text no. 5
    
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Schwarz AW. Minimum essential requirements and standards in medical education. Med Teach 2000;22:555-9.  Back to cited text no. 6
    
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Singhal A. Case-based learning in microbiology: Observations from a North West Indian medical college. Int J Appl Basic Med Res 2017;7(Suppl 1):S47-51.  Back to cited text no. 7
    
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Tayem YI. The impact of small group case-based learning on traditional pharmacology teaching. Sultan Qaboos Univ Med J 2013;13:115-20.  Back to cited text no. 8
    
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Fatima N, Shameem M, Nabeela, Khan HM. Evaluation of case-based lectures for teaching medical microbiology. Int J Eng Technol 2015;2:272-5.  Back to cited text no. 9
    
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Kumar A, Vandana, Aslami AN. Introduction of “case-based learning” for teaching pharmacology in a rural medical college in Bihar. Natl J Physiol Pharm Pharmacol 2016;6:427-30.  Back to cited text no. 10
    
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Ghosh S. Combination of didactic lectures and case-oriented problem-solving tutorials toward better learning: Perceptions of students from a conventional medical curriculum. Adv Physiol Educ 2007;31:193-7.  Back to cited text no. 11
    
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Gupta K, Arora S, Kaushal S. Modified case-based learning: Our experience with a new module for pharmacology undergraduate teaching. Int J Appl Basic Med Res 2014;4:90-4.  Back to cited text no. 12
    
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Dubey S, Dubey AK. Promotion of higher order of cognition in undergraduate medical students using case-based approach. J Edu Health Promot 2017;6:75.  Back to cited text no. 13
[PUBMED]  [Full text]  


    Figures

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