Introduction
Medical education is a complicated one with theory in form of didactic lectures, practicals and clinical case studies with live patients. In the first two — 2&1/2 years of medical education, the students are mainly exposed to conventional lectures and practicals in a practical lab in the college atmosphere. The clinical application of these subjects during these years is comparatively minimal and is basically done when the student ultimately enters the 3rd year with the clinical subjects. Thus, the students feel the pressure to secure good marks in these subjects and tend only to read and learn rather than to apply the knowledge in the clinical setting'.1
It is essential for the student to have an active learning method rather than passive absorption of information, which is normally seen in didactic lectures to understand the subject and retain the information for a longer period of time.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13
The microbiology teaching is quite challenging as it involves the student to learn many microorganisms with similar properties leading to confusion during memorising. An introduction of clinical correlation would be beneficial in teaching as well as learning'. Case based learning or case study learning or case method learning was first introduced by Baron Carl von Rokitansky, a Viennese pathologist over 50 years ago in his teachings on correlation between pathological anatomy and disease presentation'.14
Medical Council of India (MCI) and now National Medical Council (NMC) has recommended a clinical and case based learning for the l and 2nd year students also as a new curriculum all over India. This led to the introduction of problem based student centric curriculum, which demanded an active participation from the students and motivated them for self direct learning. This new curriculum is being implemented by all the medical colleges, all across India. This change is a new trend in contrast to the conventional teaching methods, thus it is a great challenge to train not only the students, but also the faculty in the newer ways of training.15, 16, 17
This style of teaching introduces the application of the knowledge in the clinical settings by more active and interactive learning methods so that the student is able to assess a situation critically and analytically. 1, 2, 5, 6 Hopefully, the conventional taking notes during the class and memorising before exams will be a thing of the past in the foreseeable future.
The newer trends include case based learning, which basically involves the presentation of a real life scenario, with the students using their knowledge to interact with each other and with the instructor to solve the problem. The case involves the sign and symptoms of the patient, case history and investigational data, which are presented to the student. The students critically analyse the case and interact with each other to come to a diagnosis. This instructor here merely acts as a facilitator. 2, 6, 7
This study was therefore done to determine the effectiveness of case based learning approach as a preferred teaching method in comparison to Conventional Didactic Lectures with the feedback obtained from the undergraduate MBBS students.
Materials and Methods
This prospective study was conducted by the Department of Microbiology at ESIC Medical College & Hospital, Hyderabad, India. The study group included 100 Medical students attending microbiology classes with 75% attendance and more. Students who did not attend exams and those who did not have at least 75% attendance were excluded from the study. The study content was explained to the students and informed consent was taken from all the students included in the study as well as the concerned staff members and the medical education unit members.
The students were divided into 2 groups of 50 each. Group A attended case based learning for the first time at the start of the study and later Didactic lecture. An internal examination was conducted after the CBL session to assess the performance. Group B attended Didactic lectures first followed by the internal examination and then case based study was done for them.
For Case based learning, the Group of 50 students were further divided into 5 smaller groups of 10 each (Al, A2 --- A5 & B1, B2 --- B5). Each small group had a faculty as a facilitator to guide their discussions. 1 week prior to the day of the CBL, the topic which was on applied microbiology was given to the students, with the case scenario handouts, important articles, videos, PPTs etc. A questionnaire was prepared and given to the students with related questions to guide them with the method of interpretation and clinical correlation.
A pretest, in the form of multiple choice questions was given before the start on the day of discussion, which was for 2 hours. The discussion was started by the facilitator by putting forth the scenario and allowing the discussion to carryon. All the students were given the opportunity to discuss and put up their ideas within the purview of the set questionnaire. A group leader, who was chosen before the start of the discussion would summarise the discussion answering all the questions in the questionnaire. At the end of the session the students were asked to answer the posttest questionnaire.
In the next session, which was after the 1st Internal assessment examination, the students attended a different topic vide didactic lecture for 1 hour. A pretest and a post test was taken for the same before and after the session.
For Group B, similar pattern was followed, except that didactic lecture was taken first for them for 1 hour with pretest and post test questions. This was followed in the next session after the Internal Examination by case based learning for 2 hours, where the group was divided into smaller groups of 5 with a facilitator for each group as was done for the Group A. Pretest and post test was done before and after the session and during the session, all the students were made to involve in the discussions as per the given questionnaire.
A 3 point Liklert scale was given to the students with 24 questions and with 6 questions to the faculty to know their opinion on the usefulness of CBL. Data was collected and the evaluation was done with Kirkpatrick Model.
Results
Out of the 100 students included in the study, 91% were satisfied with the new CBL method, and 83% of the faculty showed a positive response to the same.
In the pretest scores in the Group A, during the CBL method, the minimum marks scored was 17 by 5 students (10%) and the highest was 22 by 2 students (4%), while in the post test, the least marks scored was 20 by 1 (2%) students and 25 out of 25 was the highest score by 1 (2%) students. Most of the students in the pretest scored 20 by 15 (30%) of the students followed by 18 and 21 by 10 (20%) students each. In the post test, the most common score was 23 by 18 (36%) of the students while 13 (26%) scored 22 out of 25 marks (Figure 1).
The Likert scale for feedback was given to the 7 faculty members with 6 questions on CBL method. (14.3%) staff member disagreed that didactic lecture was a better method of teaching compared to CBL, while 2 (28.6%) were neutral and 4 (57.1%) agreed that Didactic was better and a II these 4 found CBL to be cumbersome. All the faculty members agreed that this technique is the way of the future and must be implemented, however, 2 of them maintained that the didactic lectures should continue, while 4 wished CBL to replace the didactic lectures.
Table 1
Feedback of students for CBL method by faculty
A 3 point Liked scale with 25 questions was given to the students to assess the CBL method. Most of them found CBL to be far better than the regular didactic lectures. They found that in the long term, CBL was better (68%) and 85% of the students found it to be good to remember the subject. 50% of the students found that CBL helped them to analyse the case and preparation off the subject and 44% of the students felt that they participated more in the class. Most of the students felt that the faculty was more approachable for doubt clearing and discussions, both during the class and after to class, thereby imbibing more confidence in them (72%). 78% said that they are able to concentrate well in the class and 58% said that they have become active learners.
Table 2
Discussion
Learning the various microorganisms, whether bacteria, fungi, viruses or parasites and associating them with the disease in the patient is the essence of microbiology, In the conventional method, the organisms and the clinical relevance are taught in the second year, with an emphasis more on the theoretical knowledge rather than the clinical association, The students are expected to relate these learnt knowledge in the third year onwards, when the move on to the clinical subjects.
With the revised curriculum, and the introduction of the case based learning, the students are initiated to learn and apply the knowledge of the causative organisms and their clinical aspects in a give case scenario. The Introduction of CBL also encourages a small group teaching and discussion, which enable the students to study before hand and participate in discussions, with personal attention given by the faculty.
In the present study, we found the students to be motivated and interested taking part in most of the discussions in the CBL method. This was similar to the results by Michel et al and Gurleen et al, who stated that the students found CBL more interesting.8, 9
Most of the students in the present study felt that CBL was a better study tool as compared to the didactic lectures as it gives them more opportunity to participate, discuss and analyse a case, In a similar study, Gupta et al found 76% of the students CBL session to be more interesting and easier to learn than didactic lectures, while in another study by Gurleen et al, 75% of the students found it to be better. 9, 10
50% of the students in the present study felt that CBL method helped them to analyse and prepare better for their exams and 48% felt the memorising the ideas was better with CBL. A study by Tayem et al stated that 82% students were able to prepare better when exposed to CBL method rather that conventional lecture method.11 Similar was the case with 74% of the students in a study by Gurleen et al and 89% by Gupta et al.9, 10 In a study by Dube et al, 50% of the students felt CB to be better, which was similar to ours. We felt that since the study was done only for 8 weeks, we had a lower result. With more exposure to the CBL over time, more students would be interested.
72% of the students stated that they felt more confident with the CBL learning method and 88% of them felt that it helped them to be less stressful as compared to the didactic lectures especially before the examinations. A study by Adiga and Adiga state that CBL helped in achieving strategy, deep achieving approach, triggered motivation among the students.12 Chilwant et al reported that 73% of the students were motivated with the CBL method of study and 71% of them feel that they would fare better in the examinations.13
68% of the students in the present study felt that this method would be better than the regular didactic lectures and 70% of them suggest more classes to be conducted with CBL rather than the conventional method. A study by Chilwant reported a 76% of students who were willing the didactic lectured to be replaced by the case based learning method. 13
Conclusions
Our faculty was a little more laid back. Since most of them were used to the conventional teaching methods, they were a little hesitant in the CBL method and found didactic lectures to be easier to teach. They felt that the CBL method was more cumbersome, though they felt that it was a good change in the teaching method. However, it was felt that in future the teaching should shift towards the clinical case scenario so that the students would discuss more. In a study by Gurleen et al, the faculty felt that the CBL experience was very motivating not only to the students, but to the faculty as well.
