how to write a case study for anatomy and physiology

The Biology Corner

Biology Teaching Resources

Student Designed Case Studies for Anatomy

Instead of a final exam, give your students a final project for their anatomy class – Design Your Own Case Study

Students in my anatomy class complete many case studies throughout the year focused on body system units. Case studies are a way to add a personal story to (sometimes) technical information about physiology. For my high school students, I try to find cases that are about younger people or even children, cases like “ A Tiny Heart ,” which tells the story of a baby born with a heart defect. Students seem to be more engaged when the cases about about people closer to their age or very young.

As a final project, the honors anatomy students make their own case study. They get to choose their topic, though I recommend they choose something they have a personal stake in. For example, one student chose to do her case on Lupus, because her mother has that condition.

The instructions outline how to write the case based on a simple flow chart.

Start with an introduction of a person by telling a story or narrating an event. Next, describe the tests needed to make a diagnosis. Tests can include X-rays, blood tests, urine tests, or other physical exams.

Students should include specific details here and images if appropriate. Following the diagnosis section, they should focus on the specific anatomy and physiology of the disease. Because homeostasis is a major theme of the class, students should focus on how the disorder causes an imbalance in the system

The last section will include how the disorder can be treated. In some cases, there will not be a cure, but the symptoms can be managed. Each section should contain 2-3 questions, similar to how cases we’ve done in class are organized.

While it may be better to assign this as a group project, during the 2021 pandemic, this was an individual assignment, due to the difficulties with working together. I think it would work very well as a project that 2-3 individuals could work on together.

Shannan Muskopf

Using Case Studies for Anatomy and Physiology

Integrating case studies for anatomy and physiology students can be a great way to encourage solving problems while giving them a taste of the medical profession. The analysis required to make a diagnosis is a real-world application of the Claim- Evidence- Reasoning format designated in the Next Generation Science Standards*. Certainly wet labs and experiments can also require the same skills in solving problems and writing conclusions, but case studies are an easy extension of these skills. And certainly, there is no course in which case studies are easier to integrate than Anatomy and Physiology.

Human Anatomy and Physiology is usually taught by dividing body systems and teaching one system at a time, which is the way I teach my Anatomy & Physiology course . It makes for an organized approach that is easier for teachers to plan and students to study. It diminishes, however, the interconnection between the body systems and can prevent students from seeing the human body as a whole.

Case studes are a great way to use problem-solving strategies while bringing attention to multiple body systems at one time.

Case studies are a great way to use problem-solving strategies while bringing attention to multiple body systems at one time. For example, my case study about hypercalcemia discusses hormones from the endocrine system and how they relate to the circulatory and skeletal systems.

I started incorporating case studies into my A&P course this year and students were immediately receptive. Rather than using obscure medical conditions and disorders, I tried to use ones that my students may encounter throughout their lives. In fact, one of my students learned about Bell’s Palsy just a few months before his aunt was diagnosed with it.

As my A&P course is an introduction for high school students and most of them are not necessarily planning to be medical professionals, I kept the case studies relatively simple and assigned them to my Honors students as extended homework assignments. I created guided reading and research options for each case study. At the beginning of the year, students were simply asked to read the case study assignment and answer questions about the particular diagnosis. This was the first time these students had ever seen an assignment about medical conditions and I felt it was necessary to lead them with baby steps. After 2 or 3 case studies of this type, I switched to the research-based case studies. In this type, students are given the symptoms and a diagnosis, then asked to research how the condition causes those symptoms.

In future years, however, I’d love to be able to offer a more interactive approach by providing my class with a few symptoms, allowing them to decide which diagnostic tests to use, and then reporting imaginary results to lead them toward an accurate diagnosis. I did provide my students with a list of common diagnostic tests to help them understand the terminology as they came across it.

Interactive case studies may provide a more collaborative approach to learning and encourage students to evaluate the best course of action based on a set of results. This technique is recommended in nursing education programs to “ bridge the gap between theory and practice .”

If you’ve been considering using case studies in your classroom, please check out the bundle of 12 that I have created. You can also download my Common Diagnostic Tests list for FREE !

**Please note: NGSS is a registered trademark of WestEd.  Neither WestEd nor the lead states and partners that developed the Next Generation Science Standards were involved in the production of these lessons, and do not endorse it. 

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Lachman's Case Studies in Anatomy

Professor of Neuroscience and Cell Biology; Associate Dean for Student Affairs

Associate Professor, Department of General Surgery

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This resource is a thoroughly revised edition of a popular collection of 50 anatomical cases. Each chapter starts with a clinical case presentation, followed by diagnosis and therapy and then an extensive discussion of the anatomy that is relevant to the case. The patient presentations provide the history and physical examination findings in a format consistent with that which the student will utilize in clinical training. Diagnostic and therapeutic procedures that are discussed have been brought up-to-date and are consistent with current medical practice.

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1.1: Case Study- Getting to Know Your Body

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• Suzanne Wakim & Mandeep Grewal
• Butte College

Case Study: Under Pressure

Looking at the photo of a football game in Figure \(\PageIndex{1}\), you can see why it is so important that the players wear helmets because players may fall on their heads or on top of each other's heads. Football often involves forceful impact to the head as players tackle each other. This can cause damage to the brain — either temporarily as in the case of a concussion, or long-term and more severe types of damage. Helmets are critical to reducing the incidence of traumatic brain injuries (TBIs), but they do not fully prevent them.

Take the example of 43-year-old Dayo. As a former professional football player who also played in college and high school, Dayo sustained many high-impact head injuries over the course of their football playing years. Dayo uses they/ them pronouns. A few years ago, Dayo began experiencing a variety of troubling symptoms, including the loss of bladder control (i.e. the involuntary leakage of urine), memory loss, and difficulty in walking. Symptoms such as these are often signs of damage to the nervous system, which includes the brain, spinal cord, and nerves, but they can result from many different types of injuries or diseases that affect the nervous system. In order to treat Dayo properly, their doctors needed to do several tests to determine the exact cause of their symptoms. These included a spinal tap to see if they had an infection, and an MRI (magnetic resonance imaging) to see if there were any problems with their brain structure.

The MRI revealed the cause of Dayo’s symptoms. There are fluid-filled spaces within the brain called ventricles, and Dayo’s ventricles were enlarged compared to normal ventricles. Based on this observation combined with the results of other tests, Dayo’s doctor diagnosed them with hydrocephalus, a term that literally means “water head.” Hydrocephalus occurs when the fluid that fills the ventricles, called cerebrospinal fluid, builds up excessively. This causes the ventricles to become enlarged and puts pressure on the brain, which can cause a variety of neurological symptoms including the ones Dayo was experiencing. You can see the difference between normal ventricles and ventricles that are enlarged due to hydrocephalus in the illustration below. Notice how the brain becomes “squeezed” due to hydrocephalus in the image on the right.

Hydrocephalus often occurs at birth, due to genetic factors or events that occurred during fetal development. Because babies are born with skull bones that are not fully fused, the skull of a baby born with hydrocephalus can expand and relieve some of the pressure on the brain, as reflected in the enlarged head size shown above. But adults have fully fused, inflexible skulls, so when hydrocephalus occurs in an adult, the brain experiences all of the increased pressure.

Why did Dayo develop hydrocephalus? There are many possible causes of hydrocephalus in adults, including tumors, infections, hemorrhages, and TBIs. Given their repeated and long history of TBIs due to football, and the absence of any evidence of infection, tumor, or other cause, Dayo’s doctor thinks their head injuries were most likely responsible for their hydrocephalus.

Although hydrocephalus is serious, there are treatments. Read the rest of this chapter to learn about the cells, tissues, organs, cavities, and systems of the body, how they are interconnected, and the importance of keeping the body in a state of homeostasis, or balance. The amount of cerebrospinal fluid in the ventricles is normally kept at a relatively steady level, and the potentially devastating symptoms of hydrocephalus are an example of what can happen when a system in the body becomes unbalanced. At the end of the chapter, you will learn about Dayo’s treatment and prognosis.

Chapter Overview: Introduction to the Human Body

In this chapter, you will learn about the general organization and functions of the human body. Specifically, you will learn about:

• The organization of the body from atoms and molecules up through cells, tissues, organs, and organ systems.
• How organ systems work together to carry out the functions of life.
• The variety of different specialized cell types in humans, the four major types of human tissues, and some of their functions.
• What organs are and the 11 major organ systems of the human body.
• Spaces in the body called body cavities, and the organs they hold and protect.
• The tissues and fluid that protect the brain and spinal cord.
• How organ systems communicate and interact in body processes such as cellular respiration, digestion, the fight-or-flight response to stressors, and physical activities such as sports.
• How homeostasis is maintained to keep the body in a relatively steady state, and the problems that can be caused by loss of homeostasis, such as diabetes.

As you read the chapter, think about the following questions:

• What is the normal function of cerebrospinal fluid?
• What is a spinal tap and how does it test for infection?
• In Dayo’s case, what organs and organ systems are probably affected by their hydrocephalus? What are some ways in which these organ systems interact?
• The level of cerebrospinal fluid is normally kept in a state of homeostasis. What are other examples of types of homeostasis that keep your body functioning properly?

Attributions

• Army vs. Navy Football game by U.S. Navy photo by Photographer’s Mate 2nd Class Jayme Pastoric, public domain via Wikimedia Commons
• Hydrocephalus by CDC released into the public domain via Wikimedia Commons
• Text adapted from Human Biology by CK-12 licensed CC BY-NC 3.0

1.1 Overview of Anatomy and Physiology

Learning objectives.

By the end of this section, you will be able to:

• Compare and contrast anatomy and physiology, including their specializations and methods of study
• Discuss the fundamental relationship between anatomy and physiology

Human anatomy is the scientific study of the body’s structures. Some of these structures are very small and can only be observed and analyzed with the assistance of a microscope. Other larger structures can readily be seen, manipulated, measured, and weighed. The word “anatomy” comes from a Greek root that means “to cut apart.” Human anatomy was first studied by observing the exterior of the body and observing the wounds of soldiers and other injuries. Later, physicians were allowed to dissect bodies of the dead to augment their knowledge. When a body is dissected, its structures are cut apart in order to observe their physical attributes and their relationships to one another. Dissection is still used in medical schools, anatomy courses, and in pathology labs. In order to observe structures in living people, however, a number of imaging techniques have been developed. These techniques allow clinicians to visualize structures inside the living body such as a cancerous tumor or a fractured bone.

Like most scientific disciplines, anatomy has areas of specialization. Gross anatomy is the study of the larger structures of the body, those visible without the aid of magnification ( Figure 1.2 a ). Macro- means “large,” thus, gross anatomy is also referred to as macroscopic anatomy. In contrast, micro- means “small,” and microscopic anatomy is the study of structures that can be observed only with the use of a microscope or other magnification devices ( Figure 1.2 b ). Microscopic anatomy includes cytology, the study of cells and histology, the study of tissues. As the technology of microscopes has advanced, anatomists have been able to observe smaller and smaller structures of the body, from slices of large structures like the heart, to the three-dimensional structures of large molecules in the body.

Anatomists take two general approaches to the study of the body’s structures: regional and systemic. Regional anatomy is the study of the interrelationships of all of the structures in a specific body region, such as the abdomen. Studying regional anatomy helps us appreciate the interrelationships of body structures, such as how muscles, nerves, blood vessels, and other structures work together to serve a particular body region. In contrast, systemic anatomy is the study of the structures that make up a discrete body system—that is, a group of structures that work together to perform a unique body function. For example, a systemic anatomical study of the muscular system would consider all of the skeletal muscles of the body.

Whereas anatomy is about structure, physiology is about function. Human physiology is the scientific study of the chemistry and physics of the structures of the body and the ways in which they work together to support the functions of life. Much of the study of physiology centers on the body’s tendency toward homeostasis. Homeostasis is the state of steady internal conditions maintained by living things. The study of physiology certainly includes observation, both with the naked eye and with microscopes, as well as manipulations and measurements. However, current advances in physiology usually depend on carefully designed laboratory experiments that reveal the functions of the many structures and chemical compounds that make up the human body.

Like anatomists, physiologists typically specialize in a particular branch of physiology. For example, neurophysiology is the study of the brain, spinal cord, and nerves and how these work together to perform functions as complex and diverse as vision, movement, and thinking. Physiologists may work from the organ level (exploring, for example, what different parts of the brain do) to the molecular level (such as exploring how an electrochemical signal travels along nerves).

Form is closely related to function in all living things. For example, the thin flap of your eyelid can snap down to clear away dust particles and almost instantaneously slide back up to allow you to see again. At the microscopic level, the arrangement and function of the nerves and muscles that serve the eyelid allow for its quick action and retreat. At a smaller level of analysis, the function of these nerves and muscles likewise relies on the interactions of specific molecules and ions. Even the three-dimensional structure of certain molecules is essential to their function.

Your study of anatomy and physiology will make more sense if you continually relate the form of the structures you are studying to their function. In fact, it can be somewhat frustrating to attempt to study anatomy without an understanding of the physiology that a body structure supports. Imagine, for example, trying to appreciate the unique arrangement of the bones of the human hand if you had no conception of the function of the hand. Fortunately, your understanding of how the human hand manipulates tools—from pens to cell phones—helps you appreciate the unique alignment of the thumb in opposition to the four fingers, making your hand a structure that allows you to pinch and grasp objects and type text messages.

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4 Reasons You Should Use Case Studies in Anatomy and Physiology Class

• August 24, 2022

Case Studies in Anatomy and Physiology

If you’re looking for a way to engage your students in anatomy and physiology class, consider using case studies. Case studies in anatomy and physiology are a great way to provide real-world examples of how the concepts you’re teaching can be applied in real life. Here are four reasons why you should use case studies in your anatomy and physiology class:

Looking for more ways to engage your anatomy students? Then check out The Ultimate Guide to Engaging Students to Learn Anatomy | 7 Secrets to Implement Today

1. Case studies can help students understand complex concepts.

Anatomy and physiology can be tough subjects to grasp, but case studies can help simplify complex concepts. By providing real-world examples, case studies can help students better understand how the concepts they’re learning in class can be applied in the real world.

2. Case studies can make the class more interesting.

Let’s face it, anatomy and physiology can be pretty dry subjects. But case studies can help bring the material to life and make the class more interesting. Students are more likely to be engaged in the material when they can see how it applies to real-world scenarios.

3. Case studies can help students retain information.

When students are able to apply the concepts they’re learning to real-world scenarios, they’re more likely to remember the information. Case studies can thus be a valuable tool in helping students retain information from your class.

4. Case studies can help students prepare for future courses.

Finally, case studies can help students prepare for future courses. By providing real-world examples of how the concepts they’re learning can be applied, case studies can help students see how the material they’re learning in your class will be relevant in future courses.

So if you’re looking for a way to engage your students and help them better understand and retain the material you’re teaching, consider using case studies in your anatomy and physiology class.

Case Study Medical Examples

If you’re looking to learn about anatomy, case studies are a great way to do it. By studying real-life examples, you can see how the human body works in action.

There are plenty of case studies available online and in textbooks. However, it’s important to be choosy about which ones you study. Make sure to pick ones that are well-written and illustrate key points clearly.

Here are a few examples of case studies on different topics in anatomy:

• The Cardiovascular System: A Case Study of Myocardial Infarction
• The Respiratory System: A Case Study of Asthma
• The Digestive System: A Case Study of Crohn’s Disease

Each of these case studies provides valuable insights into how the relevant system works. By studying them, students can gain a better understanding of how their own body works.

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Directed case study method for teaching human anatomy and physiology

Affiliation.

• 1 Department of Biology, Niagara University, New York 14109, USA.
• PMID: 8712252
• DOI: 10.1152/advances.1996.270.6.S19

A mastery of human anatomy and physiology requires a familiarity with a vast number of details about the human body. A directed method of case analysis is described that helps students deepen and solidify their understanding of anatomical and physiological facts, concepts, and principles. The successful case had four distinctive features as follows: clear learning objectives, a concise and informative scenario, straightforward and didactic questions, and an emphasis on information readily available to the student. A directed case study is presented, and its salient features are described. A procedure for integrating case analyses into an undergraduate anatomy and physiology course is outlined. Student response to this type of case study suggests that this method improves the ease of learning, the depth of learning, and an appreciation of the relevance of and a curiosity about anatomy and physiology. The addition of case analyses to a two-semester integrated course in anatomy and physiology was also associated with an improvement in exam performance. The regular use of directed case analysis is a valuable addition to the traditional methods of lecture, textbook reading, and laboratory for the teaching of human anatomy and physiology.

Publication types

• Case Reports
• Anatomy / education*
• Education, Medical, Undergraduate*
• Evaluation Studies as Topic
• Physiology / education*

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• Contributors
• Acknowledgments

Clinical Anatomy: A Case Study Approach

Mark H. Hankin, Dennis E. Morse, Carol A. Bennett-Clarke

• Chapter 1:  Nervous System
• Chapter 2:  Thorax
• Chapter 3:  Abdomen
• Chapter 4:  Pelvis
• Chapter 5:  Perineum
• Chapter 6:  Neck
• Chapter 7:  Head
• Chapter 8:  Back
• Chapter 9:  Upper Limb
• Chapter 10:  Lower Limb
• Appendix:  List of Clinical Terms (Referenced by Case)
• References & Suggested Readings

Please Wait

Anatomy of a case study

We did some research into the best (and worst) practices for writing case studies so you don’t have to. here’s what we’ve found..

Here at Convivio we’re rethinking how we do case studies. Rather than just assume we know what we’re doing and crack on with writing some, we thought we’d do well to use similar approaches to user research and desk research for our own work as we use for our client work.

We had a look at a wide variety of examples of case studies, looking at them from several angles — their focus, structure, components, content, layout, design, how they’re used and presented collectively and singly, and more. We’ve looked all over, at the good, the bad and everything in between. We’ve tried to find the consistent features that work well, the unique elements that stand out, the things to avoid, and to distinguish between the adequate, the good and the great.

Here’s what we’ve found.

The case study title is a linchpin — the reader will use it to decide whether to read the article or not. That means it has to do a lot of work — summarise the case study, capture the reader’s attention, indicate what the reader will learn, and so on.

They’re usually succinct, just five or six words, but they have some common traits.

Active voice, present tense

Most case study titles are written in the active voice, in the present tense. The active subject may be the end users, the client, the project team, but the subject is usually left implicit. In terms of grammar, this usually means verbs are ‘present participles’, i.e. an -ing word. This present participle is usually the first word in the title.

Some examples, based on real titles:

Building the new passport renewal service Improving council frontline experiences Preventing financial transaction fraud with data analytics Modernising the VAT reclaim service

• Emphasise transformation

Almost all case study titles emphasise transformation. Many titles say, succinctly, the client went from X to Y, this to that. ‘This’, their original place or starting point, is often implicit.

Some examples:

Improving outcomes for job-seekers Increasing enterprise agility with the lean canvas Journey to innovation in public healthcare

Emphasise the frontier, or be future-oriented

Case study titles often emphasise work that is trailblazing, that is done at the leading edge or even bleeding edge of something. In this respect, the work described:

• Is the epitome of best practice, or even defining best practice
• Employs frontier practices or technologies

Many use the word ‘future’ or the concept of the future in them.

Harnessing AI to provide better healthcare Unleashing the power of data in housing services

In summary:

Case study titles:

• Are succinct
• Are action-oriented
• Are forward-looking or embrace new technology

The title of a case study is frequently augmented with a lede (sometimes spelt ‘lead’). The lede appears in two forms.

Some have single lede short sentence stub that works as a subtitle , what you might write after a colon in a title like this (the bit in italics):

Preventing financial fraud with data analytics: using machine learning and networked data structures to monitor financial transactions

Some write a fuller short sentence or two :

Preventing financial fraud with data analytics We worked with [client name] to build an early warning fraud prevention system using machine learning and knowledge graph data structures.

A well-written lede improves overall readability and helps to convince readers this case study is for them.

Mostly have a single client per case study

Most case studies describe the work done for a particular client. Occasionally they are about more than one, but that is very rare.

They include the client name prominently — it may be in the title itself (occasionally), in the lede (more often), or displayed as a label or category for the case study (sometimes).

In very rare circumstances, the client name may be omitted for confidentiality reasons. In this case, the client is described with a a broad outline out the kind of organisation they are.

Categorise the case study

The most accessible case studies help the reader to understand what it’s about by using categories and other labels. For example, a reader may be interested only in your work in user research, or is looking for a continuous development partner, say, and can jump straight to case studies on those subjects.

Some common categories:

• By government agile project phases (discovery, alpha, beta, live, retirement)
• By industry or sector (public sector; healthcare; financial services; energy; etc.)
• By the type of work involved (e.g. service design; strategy; prototyping; content design; etc.)

The most readable case studies have a short outline paragraph or two at the beginning. This paragraph is a succinct summary with a simple three-part structure:

• what the situation was (the challenge)
• the work the team did (the solution)
• what the results were (outcomes)

This section is vital for setting up the original situation of the client — it helps potential readers to empathise with the scenario or context and understand how you may be able to help them.

Some put the results or outcomes as a micro-paragraph, occasionally under a separate subtitle. This can help to emphasise the transformational dimension of the work the team did.

Occasionally, this section may include a few bullet points for:

• Technologies used
• Duration of project
• Other headline facts

The main body of the case study is an essential description of the work done. The best examples focus on the first two points of the same structure as above, and the last is pulled out into its own section (see below).

It is usually written in short paragraphs of just a few sentences each.

Use subtitles

This part often has several subtitles that break the work down into distinct sections, to enhance the readability of the case study.

Summarise frequently

Bullet points are sometimes used to:

• summarise sections
• highlight actions
• identify outcomes

Illustrate visually

In the best case studies, the main body often makes good use of illustrative images that portray the work done, any outcomes or products from the work, or the project team in action.

In the worst, stock photos are dropped in without an appropriate connection to the body text.

Outcomes, results and more

In the best case studies, the outcomes and results of the work are identified separately. This is a summary paragraph or two in its own right.

This section is a chance for a specific focus on the transformation achieved through the work.

This part makes frequent use of bullet points to clearly identify:

• What happened at the end
• What things were delivered to end users and to the client
• What was learnt along the way
• Any other clear outcomes or results

Impact, key deliverables and more

In the best case studies, specific impacts of the work are identified in short headline bullet points.

These are used in two potential places:

• As distinctive design elements in the case study itself;
• On the sase study section page on a web site.

Where there’s more than one phase of work …

Sometimes a case study covers a project that went through several agile phases of development.

In the best case studies, the phases are treated separately and use the same structure as before: the situation; the work done; the results.

Case studies often use quotes, and these are usually from two sources:

• From the clients themselves, which helps to give an understanding of what it’s like to work on a project with the team;
• From users or beneficiaries, which helps the reader to see how the team’s understanding of the context and needs resulted in tangible transformation.

Both have an impact for the reader.

I love quotations because it is a joy to find thoughts one might have, beautifully expressed with much authority by someone recognised wiser than oneself. — Marlene Dietrich

Imagery and media

Images and other media are important to illustrate the case study. It’s an important thing to get right, and an easy thing to get wrong.

At its best, case studies include photos of actual work being done during the project — interactions with clients, users, in workshops, and so on.

Stock photography can work but be very careful: stock photography badly done makes the case study look false or fake and can work against you.

Good case studies often include screenshots or photos of things that have been delivered, especially where the work has resulted in developing a service, product, or some other tangible thing.

Some use video, but that’s not too common and generally only done by larger agencies with bigger budgets.

Call to action

Pretty much all case studies have a clear action for readers to make.

• How can we help you do X, Y or Z? Get in touch
• Read this next
• ‘Keep in touch’, e.g. to subscribe to a newsletter
• Find us on social media

Often these are generic, and the same for each case study.

However, the best case studies have a call to action that is tailored to the specific subject. For example, a case study focusing on accessibility might link to a downloadable guide on the subject for product owners, promote a forthcoming webinar, or include a contact form tailored to the issue.

What we’ve done

We’re still in the process of turning this research into action for our own reworked case studies.

At this stage we’ve turned our learning into a help card for writing case studies in our online handbook . We’ve also developed a template based on that help card to make it easy.

Convivio helps organisations to work better for people.

We do this mainly by helping them transform their services using digital tools, but also by spreading new ways of working.

Read our blog: blog.weareconvivio.com Follow us on twitter: @convivio Get in touch: [email protected] Visit our website at convivio.com

Written by Joe Baker

Writer, PhD in religion and narrative from Bristol University. Chief Research Officer at Convivio, the collaboration company.

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• v.9(1); 2021 Jan

Students’ perception and learning on case based teaching in anatomy and physiology: An e-learning approach

Neeraj vedi, md.

1 Department of Anatomy, PSMC, Karamsad, India

PUJA DULLOO, MD

2 Department of Physiology, PSMC, Karamsad, India

Introduction:

Case based teaching (CBT) has been accepted as an effective interactive learning strategy. Digital portals allow the students to learn the content at their own pace, explore various resources and finally enable them to discuss within group and build team work approach, which is a prime focus in the health care professional field. The aim of this study was to assess the perception and learning outcome of first year medical students towards CBT using e-learning approach.

This is a non-randomized, interventional study on first year undergraduate medical students from 2017-18 batch (43) and 2018-19 batch (41) of Sumandeep Vidyapeeth University. They were divided into a group of 8-10 members, who attended six sessions of case-based teaching via Google group. Learning outcome was analyzed by comparing the students who participated in the sessions and those who did not. Feedback survey questionnaire was analyzed by Mann Whitney ranking test and focus group discussion by thematic analysis for qualitative analysis manually.

A p value <0.01 was considered statistically significant for post-test by e-learning tool for CBT. Participants agreed that CBT is a good way to conceptualize applied aspect of basic science, enhance critical thinking, and explore varied resources. Thus, they confirmed that team building approach and leadership qualities for managing the group contributed to better understanding of the course and would be useful to them in near future.

Conclusion:

Usage of Google group technology for CBT allowed medical students to explore clinical application of basic sciences course from the first year of the program, going beyond the classroom, thus developing self-directed learning and team building approach.

Introduction

The Indian medical curriculum is governed by the structural curriculum provided by the Medical Council of India (MCI). After two decades, the curriculum has been restructured from traditional discipline based on competency driven curriculum ( 1 ). However, prior to this restructuring many pre-clinical faculties of the medical institutes have been introducing various interactive techniques like that of case-based learning (CBL). The researchers in the basic science course have concluded that case-based teaching (CBT) stimulates the students to apply cognitive skill as per clinical context ( 2 ), and develops and improves complex-problem solving skills ( 3 , 4 ), thus emphasizing the patho-physiological basis, in clinical context. Researchers have identified that usage of actual real-world clinical cases in CBT allows the students to reach a correct diagnosis and recognize the importance of inter-relatedness, ( 2 ) by linking the learned concepts ( 5 ). Moreover, researchers have identified that CBL provides better opportunity to students for the usage of different resource materials and have better interaction with their peer and instructor ( 6 ). Authors have reached various conclusions as per score acquired after the end of the CBT course; some found enhanced performance using lectures ( 7 - 9 ), whereas others concluded to have better performance with CBL ( 10 - 13 ). Moreover, some showed no differences between the two methods ( 14 - 16 ). Studies differ in results as compared to the implementation of the CBL pedagogy, group size, and many other factors which might lead to variations in the outcome of the process ( 3 , 17 ).

Developing countries, like India, have limited human and infra-structural resources facilities for teaching medical students; thus, there is a need and requirement to look for free portal which would be easy to work on not only for the faculty members, but also for undergraduate students.

Web-based learning activities are considered independent, active learning processes, allowing large group of learners together as ‘virtual’ group ( 18 ); however, they cannot replace the traditional teaching strategies in medical educational setting ( 19 ). The digital approach of learning may not be superior to traditional method, but it has a great potential to motivate the students towards self-directed learning ( 18 , 20 ). Presently, all the Indian medical institutes have informational websites, as per requirement by the MCI, although the usage of the technology for teaching-learning aspect is still awaited in the majority of medical institutes. Google groups have been used for various medical faculty development programs within the country, India, like Advanced Course in Medical Education (ACME); thus, they can be used as one of the methods for students’ learning.

At our institute, we introduced a voluntary optional teaching learning approach using Google group, as an e-learning tool, for first year undergraduate medical students from August 2017 to July 2018 (2017-18) batch and August 2018 to July 2019 (2018-19) batch. We aimed to expose those pre-clinical students to prospective real life situation for physiology and anatomy subjects by contemporary case-based learning method. The perception and learning outcome of those students were assessed for this newer approach of teaching learning strategy.

This non-randomized interventional study was conducted on undergraduate medical students from two consecutive batches 2017-18 (Academic year August 2017 to July 2018) and 2018-19 (Academic year August 2018 to July 2019). The purpose of the study was explained to each batch of the students. 43 students from 2017-18 batch and 41 from 2018-19 batch, out of 150 students from each year batch, volunteered to participate in the study. The students who volunteered to participate were considered as the experimental group (Group-B) and those who did not participate were enrolled as the control group (Group-A).

The experimental (Group-B) undergraduate medical students from each year batch (2017-18 & 2018-19) were again explained about the aim, purpose and methodology of the study and written consent was taken. The voluntary participants were divided into groups (8-10 students per group). All the groups were requested to prepare an independent Google group, including the principal investigator, concerned faculty member, and student group members, so that they were able to work online.

On-line CBL for participatory/experimental group

One of the students within the group was chosen a leader, either by the group members or by the instructor, blindfolded. The group leader was in touch with the instructor via e-mail only. There would be no in-person communication between the instructor and the groups. In case any student within the group had issues, he/she could contact the instructor independently via email or in person, if required. The instructor had the flexibility to provide guidance to the leader in the case of any serious issue.

Based on the topics covered via conventional lecture series, for the concerned batch, for anatomy and physiology course, a clinical paper case was prepared by the instructors and relevant application-based questions were framed integrating the basic science courses horizontally and vertically. This was sent to each group by the instructor. All the groups received the same case for the discussion. A specific timeframe was laid by the instructor for the completion and submission of the task.

Attending the conventional lecture for the topic was not mandatory for the participants to join the e-learning Google group.

Role of the leader

The group leader was there to share the cases within the group, as a soft and hard copy and motivate the group members to participate in the discussion by finalizing the venue and time for face to face or online discussion, so as to reach the final outcome of the case. The leader also initiated the discussion in the framed group and compiled the final response to each question as agreed and approved by the group members, after using various resources at their own level (self-directed learning approach). At the end of the activity, the leader uploaded the answers for the questions on the framed Google group. A feedback response was provided by the instructor for each clinical case after submission by all the group leaders. Group leader also intimated the instructor about those members who failed to participate.

With every new clinical case, a new group was formed, with a new student as the group leader. This imparted leadership qualities and developed the team building skill for the discussion within the group members. A total of 4 sessions with such methods were conducted for 2017-18 batch, while only 2 sessions were conducted for 2018-19 batch.

Participants had the openness to withdraw from the study without seeking permission from the instructor. In case they wanted to rejoin the group for subsequent cases, then as a prerequisite instructor’s permission was required.

Learning analysis

After every case, a test was given to all the students of the class for the topic and learning outcomes of the two groups, participant- Group-B (43 from 2017-18 batch & 41 from 2018-19 batch) and non-participant- Group-A (107 and 109 from respective batches), were compared.

On completion of the test, the cases were openly discussed within the class for better understanding of every student enrolled in the course. This motivated some more students to participant for the research study. After the first case discussion, the participants increased from 15 to 43 in 2017-18 batch, while in 2018-19 batch it increased from 25 to 41.

Quantitative and qualitative assessment

Data related to perception of students for corrective implementation and importance of online CBT were collected using a survey questionnaire, having open-ended and closed ended questions, based on three-point Likert’s scale, after getting it validated by subject experts. The readability index had the text for the average grade level of about 6 (easily understood by a 11 to 12 year old one). The content validity ratio (CVR), after inputs from the six qualified experts for each item for accuracy, items as per objective of the study and grammatical correction was +1 for 19 and 0.61 for 6 items, thus having the content validity index (CVI) 0.88 ( 21 ). A pilot test was done for those survey questions on 2016-17 batch (N=10) first year undergraduate students, who had undergone a similar process on voluntary basis. The Cronbach’s Alpha (CA) value for those 25 items for these students was 0.86.

A focus group discussion (FGD) guideline with questionnaire was developed and validated (CVI-0.941) for identifying the perceptive of participants regarding the tool. Prior to initiation of FGD, participants were explained that the research investigators were interested in their truthful feelings and attitudes towards the teaching approach. Two such FGDs were facilitated, each having 8 to 10 students with 4 elements to make sure that students were comfortable and relaxed. During the first welcoming element, the participants were familiarized with the FGD, highlighting the ground rules followed by warm-up element by introducing to the moderator, and each member, so each individual participant had time to express his/her thoughts and was encouraged to share different points of view by the use of two essential techniques, “the pause and the probe” ( 22 ). Questions were specific, yet open-ended, and additional questions were allowed to emerge within the context of the conversation. For example, one of the general questions was, “How online case-based learning session worked for you?” Probing questions then allowed the participants to expand on their responses, like “Can you please elaborate it with an example?”

Informal member checking and summarizing the content was used throughout the two focus groups to ensure that students’ responses were correctly interpreted ( 23 ). Focus groups ranged in length from 40 to 45 minutes. Focus groups were recorded using an audio recording device and transcribed by the author, word by word, which was validated by an external and internal expert manually.

Pre- and post-test were done based on multiple choice questions (MCQ) to assess the learning outcome of the students. Statistical analysis of the data for frequency distribution, paired t-test and Mann Whitney ranking test, was done to identify the mean and standard deviation of the response and ranking for each question as per test in both batches of students. Data for FGD was deductively analyzed manually using Braun and Clarke's (2006) 6-step thematic analysis, ( 24 ) starting from becoming familiar with the data, generating initial codes, followed by searching for themes, reviewing the themes, defining the themes, and lastly writing them.

Ethical Approval

The study was commenced after approval from Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC/ON/Medi/RP/18002; 5 th February 2018).

The quantitative data are analysis and represented in the form of tables, while the qualitative analysis is represented as paragraph under two main themes. Table 1 shows the comparative analysis by pre-and post-test (2017-18 batch) for participant/experimental (Group-B) and non-participant/control (Group-A) group of students. The statistical significance (p<0.001) was observed from the pre- and post-test for Group-A as well as Group-B students. The comparative post-test score for the learning outcome between Group-A and B showed statistical significance (p< 0.416). The Cronbach's Alpha Reliability coefficient for 25 perceptional survey questionnaires items (Annexure-1) for the first year undergraduate medical student batch 2017-18 was 0.928 and for those of 2018-19 it was 0.912.

Comparative statistics by student’s t-test for the pre- and post-test in non-participatory/control group and the participatory/experimental group of students (2017-18 batch)

Table 1 shows the comparative analysis of pre- and post-test for participant (B) and non-participant (A) groups of students. The two groups showed statistical significance (p<0.001) by analyzing pre- and post-test as in pair 1 and 2, while the post-test analysis of participant (B) and non-participant (A) groups showed statistically significant results (p<0.0416) for the learning outcome score, as in pair 3. Participants who appeared for both pre- and post-test were only included.

Table 2 shows frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from two batches. Some rank variability was identified as per the batches although both ranked the highest for question 2.

Frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from the first year medical students (2017-18 (N=43) and 2018-19 (N=41))

The Cronbach's Alpha Reliability coefficient for 25 perceptional questionnaire items for the first year medical students batch 2017-18 was 0.928, and for those of 2018-19 it was 0.912. Table 2 shows frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from two batches. Some rank variability was identified as per batche although both ranked highest for question 2.

In order to identify perceptional difference for the study methodology between the undergraduate medical students from two different batches, an independent sample-test was done, as shown in Table 3 . Statistical significance for Levene's Test for Equality of Variances was observed for question number 1,18, and 20 between the two batches of undergraduate medical students. A comparative statistical significance (p<0.01) value was observed for question number 6 only in students of batch 2018-19, while no significant difference was observed in 2017-18 batch as per gender.

Independent unpaired t- test for the survey questionnaires from the first year medical student’s batch 2017-18 and 2018-19

*P value=extremely statistically significant

Table 3 shows independent sample-test for the survey questionnaires from the 2017-18 and 2018-19 batch. Statistical significance for Levene's Test for Equality of Variances was observed for questions number 1,18, and 20 (p<0.05) between the two batches of undergraduate medical students.

A comparative statistical significance (p<0.01) value was observed for questions number 6 only in the 2018-19 batch, while no significant difference was observed in the 2017-18 batch as per gender.

Data analysis for focus group discussion

The majority of participants in this study agreed with the importance of case based teaching and valued the use of digital technology for better understanding of the cases and topics related to the case. Two focus group discussions were conducted; Group-1 (N=9) had 5 Male (M) and 4 Female (F) participants, out of whom 2 participated with a role of leader (L); while Group-2 (N=8) had 3 Male (M) and 5 Female (F) participants, 4 of them participated as leaders (L) undergraduate first year medical student batch of 2017-18. Other members who were not leaders were in the group as members (NL).

Table 4 shows six themes emerged from the transcript of the two focus group discussion sessions.

Themes emerged from the two focus group discussion sessions

The present study shows a statistically significant learning outcome from the CBT compared to that of traditional lecture approach. Our study results are in the same line with Bansal and Goyal ( 25 ), Bennal et al, ( 26 ) and Dulloo and Pathare’s ( 6 ) studies, showing significant learning outcome from the CBT approach and increased academic scores on the topics taught by CBT in the physiology course. The study by Majeed ( 9 ) concluded that test performance of participants was better after didactic lectures (mean, 17.53) rather than after case-based teaching. Researchers have highlighted the popularity for the use of digital platforms for online case based learning ( 27 , 28 ), ensuring students satisfaction ( 29 ); however, some researchers concluded reduction in satisfaction level either due to defect in the learning platform ( 30 ) or poor navigation portals ( 31 ).

The present study showed varied ranking and correlation for each question as per the two batches of first year medical students. The perceptional questionnaire showed that the participants appreciated the time allocated to complete the task, and the opportunity they had for the usage of different resources to accomplish the clinical case task. Bennal et al.’s ( 26 ) study highlights that CBT promotes active involvement, motivates and increases attention span during the lecture session. Moreover, the present study also showed that both batches agreed that CBT posed challenging questions to help them develop analytical and critical thinking which would be helpful for them in near future. Majeed’s ( 9 ) study showed that 65 to 72% of students found that CBT improved their knowledge about the topic better than lectures. Dulloo and Pathare’s ( 6 ) study showed that 75.9% of students accepted CBT method as an encouraging, informative and motivational approach for learning the concepts. Participants of the present study even felt that this type of teaching learning approach was a good way for peer discussion strategy. Dickinson et al.’s ( 32 ) study concluded that CBL increased the students’ engagement in class, depth of discussion within their teams, and depth of discussion between the teams, helping the students to apply basic science concepts to the clinical material and have better understanding of the disease processes as per case, and have authentic learning experience. Moreover, some researchers indicated that CBT method was related to the course content with a clinical situation, thus having an active learning approach ( 32 - 36 ).

Nicklen et al.’s study concluded that the students accepted web-based conferencing as a suitable mediocre to participate in case-based learning (CBL). Even the participants were satisfied with the learning activity and accepted the flexibility in the program; thus, they were able to meet their learning objectives ( 37 ). The study on computer assisted teaching, by Dulloo ( 38 ), identified the flexibility and repeatability of the topic for better learning and discussion, and even motivated participants for self-directed learning. The participants in present study also felt that their self-directed learning was improved by the online CBT learning process. They mentioned “There is so much knowledge other than books which must be shared. I have learned to explore.” “Searching things in google helped me to increase the knowledge” to show why and how their self-directed learning was increased by participating in this teaching method. Researchers ( 25 , 38 - 42 ) concluded from their studies that the CBT learning increased the team spirit within the small group, developed a sense of healthy competition in between the groups, and increased the collaborative and communication skills within students. However, Abraham et al. ( 43 ) found that students expressed frustration with CBL, including confusion of faculty student expectations, insufficient faculties, student tutorials, self-directed learning strategies, lack of integration into the curriculum, and insufficient time ( 44 ). Wittich et al. ( 45 ) specified quality improvement, by CBT, to prevent patient adverse events.

Researchers also have commented for the faculty perception; they regarded CBT as time intensive ( 46 ), specifically in terms of preparation ( 47 ). Blewett and Kisamore ( 48 ) highlighted the less faculty facilitator requirement in case of online CBL which could be applied to a large group of students and having fewer intra-group problems. Smith and Christie ( 49 ) considered interactive case-based assignments as effective learning tool for inter-professional learning.

The present study also indicated that this type of online approach had a great potential to develop leadership qualities, specifically from 2017-18 batch by mentioning “managing and coordinating within group members, time-management especially being a group leader” and “interaction with others and knowing new things helped me to work as a team”. Participants from the batch 2018-19 did not show a promising outcome for the development of these qualities although they also mentioned about improving the leadership qualities “confidence of asking confusing questions while dealing with peer” and “cooperation with the team members, self-confidence”. Statistical significance for the responses observed between batch 2017-18 and 2018-19 was only for questions number 1,18, and 20, specifying that all the participants from both the batches agreed that they required this type of online clinical session and it allowed them to have better peer discussion and ability to enjoy working in a group. Our findings are similar to that of Doran et al.’s study which initially identified that students struggled to manage the process of working in groups, but once they started having collaborative work, they regarded the method as a positive feature of their learning experience ( 44 ). However, few researchers found that the learning style of the students did not influence their perceived learning experience with case-based e-learning ( 50 , 51 ).

The present study showed no gender variation as per the perceptional questionnaire in both batches, except for question 6 in 2018-19 batches. Gender variability was not focused by other researchers in terms of perception or learning for CBT.

The focus group discussions with the participants identified various benefits for the online case- based teaching strategy and identified certain components to work upon; some participants considered it as an extra burden, while few mentioned that students copy-pasted the answer from other students without understanding the basic concept. Some of the participants were not satisfied with the online feedback and suggested to have an in-person or face to face discussion for the cases with the instructor. Some wanted marking system to be introduced for the assigned task. Some asked to have questions related to previous case before starting the next session, while few wanted to have a brief outline of the topic before the case presentation. Thus, there is a scope of improvement by modifying this way of teaching clinical aspect to health professional students during pre-clinical program.

Ali et al. ( 52 ) developed an interactive CBL System (iCBLS) which was a CBL system which created real world clinical cases with a semi-automatic approach, formulated the summaries of CBL cases and provided feedback for formulated cases. Thus, allowing the students to practice real-world clinical cases before and outside the class can promote learning capabilities; save class time for effective discussion and enhance the academic experience of medical students. Waliany et al. ( 53 ) in their study have concluded that the CBT continues to grow as an instrumental pedagogical model in preclinical education with an objective of imparting real-world clinical cognitive skills.

The present study used a simple digital technology for CBL for students of pre-clinical program which requires minimum human resource and low cost technology to enhance not only clinical approach of students, but also makes them lifelong learners by directing them towards self-directed learning.

Limitations

This study had several limitations. First, the study was done in one institute, although for two batches, but with few clinical cases and few voluntary participants. The impact of this short-term strategy may be limited. The learning outcome for the batch 2018-19 was not identified and the participant group size was less than that of non-participant group. The impact on long-term change in behavior and learning outcome would take a longer time span to be identified. Extensive data would be better for statistical results. Faculty perception was not taken into account, which might have added value to the research study. There is a strong need to motivate non-participant students, so that non-bias environment will be acquired.

The old would forever be gold, whilst the new shines brightly like diamond but deprives the forge or shade. They are just rocks and stones. Change is necessary to rejuvenate the traditional Gurukul method by having practical approach to the topics taught while associating digital portals for various learning strategies, like case-based approach. It is concluded that online CBT adds to the students’ interest and inclination for enhancement of critical analysis approach and covers all the dimensions of medicine field, at their pace, without disturbing the routine formal classes. Moreover, google group is an easy, cost effective tool, which can be used by a large number of students with a single facilitator. Thus, the results can be well used by institutes having limited human and infrastructural resources, like that of India and other under-resourceful countries.

Acknowledgement

We would like to acknowledge and thank students of 2017-18 and 2018-19 batch for participating and providing transparent perception for the study; without their help, this work would not have seen the light of the day. Sincere thanks to faculty members (Dr. G. Purohit and Dr. A. Gandotra) for supporting and facilitating the focus group discussion for the study.

Conflict of Interest: There is no conflict of interest that might have bias for the outcomes of the paper.