European Journal of Cardiovascular Medicine

The evolving demands of society, advancements in scientific knowledge, and innovations in medical education demand continual updates into the medical school curricula. Engaging undergraduate medical students and fostering their successful attainment of learning objectives has become an increasingly complex task for teachers/instructors¹. Conventional teaching methods, such as didactic lectures, tutorials, tend to be monotonous and teacher centered where students act as passive recipients of vast amounts of knowledge. This contributes to increased stress, information overload, and the production of medical graduates with inadequate critical thinking and problem-solving abilities².

One effective approach to promote meaningful learning is case-based learning (CBL).It involves discussion-driven small-group sessions that strengthen comprehension and enhances the acquisition of cognitive skills. When medical topics are linked to real-life scenarios, students are more likely to engage deeply and retain what they learn, as they recognize the relevance of these concepts to their future clinical practice³.CBL revolves around a well-structured clinical problem that encourages students to identify their learning needs, engage in inquiry, and integrate theory with practice. Through active participation, it strengthens their analytical skills, enhances their ability to apply knowledge in clinical settings to manage patient care and promotes lifelong learning⁴.

A study from the United States found that both students and faculty showed a strong preference for case-based learning with guided inquiry compared to problem-based learning, which relies on open-ended inquiry⁵.The National Medical Commission (NMC), India, has also advocates the introduction of case-based learning (CBL) in basic medical sciences⁶.Case-based learning (CBL) in community medicine provides a distinctive platform to explore basic, social, and clinical sciences in connection with a case, while integrating these with clinical conditions and presentations, thus encompassing both health and disease. Despite its potential, evidence regarding CBL's effectiveness in Community Medicine in this region remains limited, prompting this study. Therefore, this study was undertaken to compare didactic lectures with case-based learning (CBL) and to assess the utility & effectiveness of CBL as perceived by the medical students

The study was conducted in the Department of Community Medicine at a private medical college, Patna, Bihar. Permission from the institutional clinical research ethics committee was obtained prior to the study.

Inclusion Criteria: All students of 3^rd year MBBS (Batch 2021)

Exclusion Criteria: 1. Those students who were found to be absent on the day of study.

2. Those students who did not attend both the lecture and the CBL session.

Sample size: Out of 100 MBBS students, 85 students participated in the study.

Data Collection process: Prior to the start of the study, informed consent was obtained from the enrolled students, and they were sensitized about the method and the topics before the class. A brainstorming session was conducted among two senior faculty members of the department to develop and define the content for the case-based learning sessions. The cases and MCQs for the questionnaire were designed and subsequently validated with inputs from other faculty members in the department. The CBL topic selected was non-communicable diseases, including hypertension, diabetes mellitus and their detailed case histories.

Initially, a one-hour didactic lecture was delivered on the scheduled day covering the selected topic of non-communicable diseases. The session included an overview of their epidemiology, clinical features, screening, diagnosis, complications, and strategies for prevention and control, such as lifestyle modifications, health education, rehabilitation, chronic disease management, and the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). Then a pre-test in form of multiple-choice questions was undertaken to assess the knowledge of the students after the didactic lecture.

Subsequently, the CBL session was conducted in which students were divided into sub-groups to facilitate small-group discussions. Each group was provided with the same structured case scenarios as part of the case-based learning module. Case studies were presented in Powerpoint format with defined learning objectives. The students engaged in group discussions, worked collaboratively to reach conclusions, and subsequently discussed their findings with the facilitators. The sessions were jointly facilitated by the same faculty members and provided guidance and encouraged active participation from all students. At the end of this session, a post-test using the same preliminary questions as in the pre-test questionnaire was administered to evaluate improvement in student performance.

A 5-point Likert scale (Graded from 1-strongly disagree to 5-strongly agree) feedback form containing 10 questions was administered to all the participating students to capture their perception on the usefulness of the Case based learning session⁷.

Statistical Analysis

Data was entered in Microsoft Excel (2010) and was analysed using the Statistical Package for the Social Sciences (SPSS) software trial version 26.0. Firstly, the test of normality (Kolmogorov–Smirnov test) was applied, and the data was found to be non-normally distributed; hence median scores were calculated both in pre-test and post-test. A Box and whisker plot was created. “Wilcoxon signed-rank test” was then used to find the association between pre and post-test scores.p < 0.05 was considered as statistically significant.

A total of 85 medical students were included in the study. Figure 1 illustrates the Box and Whisker plot showing the median test scores of students before and after the CBL session. The median score of students before CBL (pre-test) was found to be 6.0 which increased to 7.0 after conduction of CBL (post-test). This improvement in test scores was found to statistically significant by the Wilcoxon’s Signed Rank Test (p<0.001) as depicted in Table 1.

Fig 1: Box and Whisker Plot showing the Median Test Scores before and after CBL

Table 1: Distribution of Pre and Post test Scores of students

Table 2 demonstrates the perception of students towards Case based Learning using Likert scale. Overall, most of the students had positive feedback in relation to CBL. The weighted average came out to be 4.23. Maximum 83 (97.6%) students found the CBL session very useful. Majority 73 (85.88%) of the students agreed that the session on CBL was interactive. Maximum i.e. 82 (96.47%) were of the view that CBL helped them in structuring the basic knowledge for use in the clinical context and improved their critical thinking and reasoning skills. 75 (88.24%) felt that CBL had increased their interest in the field of Community Medicine. More than 90% (77; 90.59%) students agreed that CBL assisted in initiating self-directed learning skills and increased their motivation for further deep learning. 79 (92.94%) of students believed that CBL had promoted more meaningful learning than the didactic lecture and same number agreed that CBL had helped to retain the contents of the subject rather than just memorizing the facts. About one-third of students (30; 35.29%) were of the opinion that CBL took more time than required to revise the topic already taught. Majority 81 (95.29%) students recommended applying this method to all other Preventive & Social Medicine topics.

Table 2: Perception of medical students on Case Based Learning (CBL) (N=85)

Weighted Average= 42.35/10= 4.23

Community Medicine being more closely aligned with clinical science, allows for easier integration of clinical relevance into case design and learning activities. The present study revealed that Case-Based Learning (CBL) was more effective for teaching Community Medicine to undergraduates, as reflected in  MCQ test scores and positive perceptions of CBL. There was a statistical improvement (p<0.001) in test scores after CBL session (post-test) as compared to didactic lecture alone (pre-test). Similar results were reported in the study by Ojha S and Patankar F, where MCQ evaluation revealed a statistically significant improvement in student performance following both CBL and didactic lectures (Wilcoxon Sum Rank Test = 4.367; p < 0.001)². Likewise, in the study on case-based learning for infectious diseases by Kartikeyan S and Malgaonkar AA, a highly significant difference (p < 0.0000001) was found between mean pre-test (41.45 ± 8.99) and post-test scores (71.84 ± 7.90)⁸.This highlights that students achieve better learning outcomes when they engage actively and collaborate in teams, a finding supported by studies through improved post-test scores.

CBL enables students to explore real or simulated scenarios, and through the analysis and discussion of various solutions, they gain a deeper understanding of complex issues and hence enhance their analytical skills. According to the present study, most students (more than 90%) considered CBL beneficial, as it aided their understanding of the subject within a clinical context and strengthened their critical thinking and problem-solving abilities. These findings are consistent with the study by Kadam DM, Sejao AV on vector-borne diseases where nearly all students (99.60%) perceived CBL as helpful in understanding key concepts, 95.65% highlighted its role in developing critical thinking, 95.66% felt that CBL sessions promoted more meaningful learning compared to lectures and nearly all students agreed that ‘CBL sessions can be used to teach other topics in Community Medicine’ ⁹.

Further, our study observed that Case based learning encourages the application of concepts, linkage of knowledge between the basic and clinical sciences, enhances content comprehension, improves knowledge retention, and supports the growth of self-directed learning skills along with motivation for deeper, continued learning. Similar findings were obtained by Ambike MV et. al. in which 98.23% of students believed that CBL made them realize the importance of building their basic knowledge of sciences to understand clinical application, 85.84% got motivated for self-directed learning (SDL) and 81.41% said that CBL helped them in better retention of knowledge¹⁰. However, 12.38% of students thought that this activity was extra burden along with the regular curriculum which is congruent to the present study where 14(16.5%) of students also felt that ‘CBL takes more time than required to revise the topic already taught’. This could be because CBL requires more preparation and time alongside an already demanding curriculum for the students. This perception may also stem from challenges in time management and the sudden shift from passive to active learning methods.

To address this, it is recommended that CBL sessions should be better integrated with the existing curriculum to avoid duplication and enhance relevance. Activities should be focused, time-bound, and structured to maintain student engagement without overwhelming them. Additionally, providing orientation sessions can help students understand the long-term benefits of CBL. Regular feedback should also be obtained to refine the format, duration, and frequency of such sessions

Strengths and Limitations of the study

The study has several notable strengths. The study used realistic case scenarios on non-communicable diseases (hypertension and diabetes), enhancing clinical applicability and student engagement. It combined both quantitative data (pre- and post-test scores with appropriate statistical analysis) and qualitative feedback (student perceptions), providing a comprehensive evaluation of CBL effectiveness. The study also addresses a literature gap on the utility of CBL in Community Medicine, a discipline that has conventionally relied on didactic teaching methods, especially at the undergraduate level.

Despite its strengths, the study had some limitations. Firstly, the study was limited to third-year MBBS students, although Community Medicine is taught from the first year through the third year of the MBBS curriculum and even till internship. Secondly, the allocated time for CBL Session was inadequate, and a longer duration is required to facilitate comprehensive discussion with the students. Thirdly, the study did not include the perceptions of faculty regarding the effectiveness of CBL. Also, the study assessed only the short-term outcomes of CBL.

The case-based learning (CBL) approach notably improved academic performance, interest, and motivation among undergraduate medical students when compared to other teaching methods, particularly didactic lectures. CBL can significantly enrich Community Medicine teaching by promoting deeper understanding and critical skills. Above all, framing case-based scenarios around real-life situations, where students take on the role of a physician, enables them to understand their responsibilities as primary care providers. Further studies are warranted to establish more definitive conclusions about long term utility of CBL and strategies for seamless curricular integration. Nonetheless, CBL appears to be superior to or as effective as other teaching methods and may be successfully implemented for all undergraduate medical students.

Conflict of Interest: None declared

Funding: Nil

Approval of Institutional Ethical Review Board: Clinical Research Ethics Committee, NSMCH, Patna (Approval letter number-CREC/2024/07 dated 07/02/2024)

Acknowledgement: We express sincere gratitude to the students who participated in the study as well the colleagues of the Department for their continued guidance and support.

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