Comparison of case-based learning and traditional method in teaching postgraduate students of medical oncology

Abstract

Purpose: Case-based learning (CBL) is now used as a teaching strategy to promote clinical problem-solving ability. The purpose of this study was to determine whether CBL is superior to the traditional teaching method in teaching lung cancer curriculum to oncology students.

Methods: This study was a randomized controlled trial, enrolled 80 first-year oncology postgraduates from Bengbu medical college in the past 3 years. They were randomized to divide into 2 groups, had courses with the same lung cancer contents and timing. The experimental group (n = 40) utilized the CBL method while the control group (n = 40) used the traditional lecture-based teaching method. A questionnaire was used to attain the students’ learning satisfaction and self-efficacy of the course, and a post-study examination was used to assess end-of-course performance.

Results: Complete data were obtained from participating students (n = 40 in CBL; n = 40 in traditional teaching). The CBL group performed significantly better in questionnaire and examination compared to traditional teaching groups. Students showed high levels of satisfaction and problem-solving ability in the CBL group.

Conclusion: Compared with the traditional teaching method. The case teaching method is a more effective teaching method to improve the ability of problem-solving for graduate students in medical oncology.

Introduction

Medical oncology is a comprehensive subject, which is responsible for the difficult task of diagnosis, treatment, teaching, scientific research, and prevention. The rapid development of oncology and the relative lag of oncology teaching mode put forward higher requirements to the medical education system in the 21st century and raised a great challenge to medical educators. Medical oncology is also a highly practical subject, which greatly emphasizes the ability of clinical thinking and complex clinical problem-solving of oncology physicians. In response to the practical nature of oncology professions, oncology education should focus on clinical practice and integrate professional theories into clinical practice to improve students’ ability to solve complex clinical problems. (Schwartz et al. 2007).

The traditional instructional approach focuses on lecture-based instruction as the teaching center, emphasizing the delivery of syllabus and concept. The teacher explains the theoretical knowledge, the students listen and take notes, passively accept the knowledge, while medicine education has many knowledge points and the content is always boring. Little attention is given to problem-solving, collaborate learning, and lifelong learning strategies. This makes students lose motivation, lack self-study ability, and the combination of curriculum and clinical work is not close enough to train students’ clinical thinking. The traditional teaching method has been shown to be less effective than other teaching strategies in practical application and critical thinking abilities (Ilkiw et al. 2017; Dickinson et al. 2018).

Table

Practice points

This study enrolled 80 first-year oncology postgraduates, randomized for case-based learning or traditional lecture-based method to learn the lung cancer curriculum. The teaching method approach was evaluated through questionnaire and examination. The results showed that the CBL group performed significantly better in questionnaire and examination compared to traditional teaching groups (p < 0.05).

Case-based learning (CBL) is an active learning strategy, focusing on students as the center of the learning environment. Case-based approaches encourage the community-based, student-centered and patient-oriented exploration of realistic and specific situations. Students focus on the patient’s case, engage in self-guided learning, scientific inquiry and collaboration with fellows, developing critical thinking and clinical problems’ solving ability, integrating theory into practice. CBL provides a practical model for postgraduate students to relate content learning to professional practice and helps them improve the ability to collaborate studying, critical thinking, and clinical problems’ solving (Jill Elizabeth et al. 2012; Yoo and Park 2015; Hassoulas et al. 2017). Case-based learning has been delivered in various curricula, and feedback received from students suggested that CBL significantly improved students’ knowledge acquisition (Dupuis and Persky 2008; Ali et al. 2018).

In this study, we performed a randomized search comparing CBL teaching format with traditional teaching format of lung cancer curriculum. Questionnaire and examination were used to measure the two groups’ teaching outcome.

Methods

Participants

The study was conducted with all year 1 graduate students of oncology at Bengbu Medical College from Aug 2015 to Aug 2018. The study had no exclusion criteria. Before beginning data collection and analysis, ethical permission for this study was obtained from the Institutional Ethics Committee in 2015. A total of 80 first-year graduate students of oncology received a 2 day long mandatory rotation course in lung cancer. Students were randomly assigned into two groups using a 1:1 ratio. Randomization was performed using a random number generator. The experimental group participated in CBL courses while the control group participated in traditional lectures. The students could get the teaching format of their lesson, but they were not informed that there was an alternative format.

The participants including 28 males and 52 females aged 23–28 years-old. They were randomly assigned into two groups: Experimental group 40, male 12, female 28, aged 25.91 ± 4.17 ($\overline{x}$±s, age), adopting case-based teaching method; Control group 40, male 16, female 24, aged 26.15 ± 3.92 ($\overline{x}$±s, age) using traditional teaching method. There was no statistical difference between the two groups (p > 0.05), and there was no statistical difference between the two groups in terms of gender, age, entrance achievement, self-study ability and subject preference (p > 0.05). Table 1 illustrates the general characteristics of the 80 participants.

Table 1. Comparison of general data between two groups of students.

Group	Sex		Age/year ($\overline{x}$ ± s)	Entrance achievement/score (x ± s)
	Male	Female
Control group (n = 40)	16	24	26.15 ± 3.92	79.23 ± 6.74
Experimental group (n = 40)	12	28	25.91 ± 4.17	78.86 ± 6.69
T (χ^2)value	0.8791		0.2652	0.2464
p value	0.3484		0.7916	0.8060

Design

The educational material was a systematic lung cancer curriculum including the epidemiology, anatomy, molecular formula, etiology, staging, molecular typing, molecular staging, clinical manifestation, diagnosis, differential diagnosis and treatment of the lung cancer. In the control group, according to the teaching outline, the traditional computerized teaching PowerPoint format is used, while no pictures or soundtrack were included in the PowerPoint. Students listened and took notes, and the teacher assigned certain homework to students after class. The teaching time spent in traditional learning was ∼40 min every course. The total teaching knowledge was delivered in 6 courses.

In the experimental group, students were divided into small group sessions. Prior to the class, the teacher selected several typical real lung cancer patients with the help of physicians from the affiliated hospital, the teacher telephoned the patients to get their permission to allow students to inquire about their medication history, daily activities, and family history information. Students are solicited to self-directed learning of lung cancer related information. During the course of teaching, the chosen patients shared their personal medical history, workup, and treatment process with oncology postgraduates at first, and then students were instructed to inquire about the patients. After the inquiry, the teacher discussed the possible diagnosis of the disease, the clinical signs and the causal mechanism of the complications according to the patient’s main complaint, the present medical history, and the past history. The students were asked to discuss what examinations should be carried out, analyze the mechanism of abnormal manifestations according to the results of patients’ auxiliary examinations, and discuss the feasible treatment plan according to the above medical history. At the end of the course, the teachers summarize and evaluate students’ discussion results, teach the main points of diagnosis and treatment, diagnostic ideas and experiences, solve the problems encountered by the students in the course of teaching, and collect the students’ opinions on the evaluation of the course. During the course, teaching PowerPoint is used to show the patients’ information and disease history, as well as to summarize the materials of the course. The teaching time spent in traditional learning was ∼40 min per course. The total teaching knowledge was delivered in 6 courses. We controlled for potential confounding variables including: the setting, time difference, audio/video assistance. There were no differences between the experimental and control group in these variables.

Effectiveness assessment

The effectiveness and satisfaction of the two teaching methods were evaluated by examination and questionnaire survey. The questionnaire was distributed to the students at the end of the teaching course. The questionnaire included five self-evaluation items. Students fill in a “yes” or “no” after each item in the questionnaire, depending on whether the teaching has strengthened their abilities. Questions were related to the participants’ feelings and perceptions about various aspects of the course in attempts to get their feedback about the overall impact of the course. A text box for students’ individual opinions of the course was also presented at the end of the questionnaire. Then, the students were asked to evaluate the teaching satisfaction of their group, including satisfaction, general and unsatisfactory, and the teaching satisfaction rate was evaluated as (satisfactory + average)/total number × 100%. Finally, all students were required to test their knowledge retention with an examination after teaching in 2 weeks. The examination is a percentage system, the main examination content is the basic knowledge and the case analysis covering the aspects of lung cancer presented in the course, the question types are the single choice and the multiple-choice questions. The examination paper is prepared by the chief physician of oncology. After the examination completed, the principal investigator calculated the test scores.

Statistical analysis

All statistical analyses were carried using SPSS version 24.0 software. The measurement data were expressed in the form of $\overline{x}$±s. Significance was assessed from independent sample t-test. The categorical data were analyzed by the chi-square test, Comparison of teaching effect between two groups. p < 0.05 set as statistically significant.

Results

Comparison of self-evaluation between the two groups

After the course, the self-evaluation of the experimental group was significantly higher than the control group. The participants perceived the CBL was useful to help them improve their clinical thinking, problems’ analyzing, and solving, as well as, self-study ability. And in the experimental group, students reported an increase in basic knowledge mastery and the case learning significantly increased students’ learning. In the open-ended survey evaluation, most students in CBL condition indicated that they enjoyed the new teaching format, and found it was useful in summarizing and consolidating medical knowledge skill learning, improved their capabilities to analyze the information in depth through teamwork. Some negative learning experiences also occurred. Some students were skeptical or negative toward a CBL course that requires a significant amount of time in exchange for questionable gains of knowledge. And some students, who were introduced to CBL for the first time, found it challenging to complete the course, as they lacked capable organizing skills. Also, some students complained that they prefer to learn alone and felt uncomfortable in group learning. See Table 2.

Table 2. Comparison of self-evaluation between two groups of students.

Self-evaluation	control group (n = 40)		Experimental group (n = 40)		χ^2	p
	Yes	No	Yes	No
Clinical thinking ability	27	13	36	4	6.0504	0.0139
Learning initiative	25	15	37	3	10.3226	0.0013
Self-study ability	28	12	38	2	8.6580	0.0033
Basic knowledge mastery	26	14	36	4	7.1685	0.0074
Ability to analyze and solve problems	27	13	35	5	4.5878	0.0322

Comparison between the two groups of students’ satisfaction with the curriculum

The satisfaction degree of the experimental group was 92.5％, which was higher than the control group (70%). The difference was statistically significant (p < 0.05). See Table 3.

Table 3. Comparison of the two groups’ satisfaction with the course.

Group	Satisfaction	General	Unsatisfactory	Degree of satisfaction	χ^2	p value
control group (n = 40)	20 (50)	8 (20)	12 (30)	28 (70)	6.6462	0.0099
Experimental group (n = 40)	27 (67.5)	10 (25)	3 (7.5)	37 (92.5)

Comparison of knowledge assessment results between two groups

The test scores of the experimental group were significantly higher than the control group, and the difference was statistically significant (p < 0.05), as shown in Table 4.

Table 4. Comparison of examination results between the two groups (score, x ± s).

Group	Control group(n = 40)	Experimental group (n = 40)	T value	p value
Elementary knowledge	37.39 ± 4.54	40.12 ± 4.39	2.7340	0.0077
Case analysis	37.28 ± 4.15	43.87 ± 4.37	6.9159	<0.001
Total score	74.58 ± 6.87	86.39 ± 7.15	7.5329	<0.001

Discussion

Case-based learning (CBL) originated from Harvard University in the 20th century. Unlike the traditional method, CBL needs some advanced preparation by the learners and provides a more structural strategy for learning. It is based on concrete cases and characterized by effective and interactive teaching (Gade and Chari 2013). Based on the teacher’s teaching purpose, it combines theory and practice completely, takes the related cases as the basic teaching material, simulates a real environment, and leads the students to return to some special scenes in the real life. Through the multi-direction communication between students and teachers, combined with their own theoretical basis, the enlightenment of classroom theoretical teaching, through observation, analysis, judgment, decision-making to achieve integration, flexible use of knowledge teaching methods. Case-based learning methods have been widely used in a variety of applied disciplines, such as medicine, law, management, and so on (Lee et al. 2013; Preeti et al. 2013; Bonney 2015; Berman et al. 2016).

Compared with the traditional didactic method, CBL has several benefits. Firstly, in CBL curricula, students are more actively engaged in their learning compared to traditional teaching where learners may be passive and lose their attention in class. Secondly, CBL is effective to promote application and integration of knowledge, collaboration with partners, and problem-solving ability rather than solely content delivery through the traditional teacher-driven method. Thirdly, CBL format allows for feedback on the case studies and opportunities to discuss issues with experts in the field, whereas, during a lecture, there is little feedback on the learner’s comprehension (Dupuis and Persky 2008). Furthermore, Case-based learning is also considered to promote deep understanding and high-level learning, rather than superficial studying by traditional lectures, whereby learners could conceptualize the knowledge and apply better to novel subjects, rather than rote memorization of lectures (Hofsten et al. 2010).

The case teaching method is a kind of teaching method in which the students can actively think and discuss the relevant knowledge acquired in advance under the careful design and guidance of the teacher, and the typical cases can be used in the teaching, which can be experienced and analyzed in the teaching. Make decisions to develop their ability to solve problems and think independently. This method has been widely used in more and more colleges and universities. Its essence is the combination of theory and practice. It focuses on developing students’ ability to analyze and solve problems and aims at improving students’ flexible use of relevant knowledge and skills to solve problems. Compared with traditional one-way teaching, case teaching is more practical. At the same time, due to the active participation of students, CBL can achieve better teaching results (Gade and Chari 2013; Crowther and Baillie 2016).

The case-based teaching method is beginning to be explored domestically after the 1990s and is being gradually applied to multiple subject fields of education. Over the past decade, the use of CBL in medical education has increased exponentially (Lee et al. 2014; Dickinson et al. 2018). The application of case teaching method to the teaching and research of oncology is less, and it is mostly a pure theoretical review. The contrast study is less without big data’s support, and lack of multi-center and large sample researches.

In this study, we performed a randomized comparison study to evaluate the efficacy of CBL as compared with traditional teaching methods among graduate students of oncology. Results showed that the students trained by the case teaching method have higher assessment scores and higher satisfaction with the course than the students with the traditional teaching method, and the students’ clinical thinking capacity is higher than that of the students using traditional teaching method. The ability of self-studying, analyzing and problem-solving have been greatly improved. These findings are in line with several types of relative earlier researches, demonstrating that the use of real patients reinforcing the clinical application of basic science knowledge, and performing an active motivational context. CBL is a powerful learning strategy for medical students at undergraduate level education as well as for professional development (Mehmet et al. 2014; Raurell-Torreda et al. 2015; Yoo and Park 2015; Brooks et al. 2017).

However, there are several limitations to this research. First, the small sample size, short teaching time and long research cycle may potentially have some influence on the research results. Second, the test to evaluate the class was only performed immediately after the class, lacking delayed testing of students. Thirdly, although the course content was the same between the two groups, differences between teachers in communication and interpersonal skills may have an influence on outcomes. Furthermore, this curriculum is only a preliminary course for first-year postgraduates, while lung cancer is a main specialty in oncology education which goes throughout the whole course. We were unable to get the final year examination results for participants to evaluate whether there were any differences in long-term improvements by either group.

Conclusion

In this study, we compared the efficacy of CBL and traditional teaching method in postgraduates of medical oncology and found students in the traditional course exhibited a worse overall score than those with CBL course. The enthusiastic and positive feedback we received suggested that case based study provides postgraduates multiple advantages: Firstly, CBL helps students to examine fact-based data, employ analytical tools, and articulate their concerns to promote their clinical problem-solving ability. Secondly, it provides students more opportunities to learn an oncology course in an interactive and case-based format to enhance their skills of self-directed and collaborative learning. Thirdly, CBL improves their ability to solve clinical problems, focusing on the integration of basic knowledge to clinical practice in the context of a case learning.

Further multi-center and large-sample researches with rigor methodology are warranted to inform instructional design and curricular integration and address the issue of whether CBL produces superior educational outcomes when compared with different teaching methods.

Glossary

Case-based learning (CBL): A form of patient-oriented, student-centered, and inquiry-based teaching and learning method that aims to prepare students for clinical practice, through the use of authentic clinical cases. These cases link theory to practice, through the application of knowledge to the cases, and encourage the use of inquiry-based learning methods.

Acknowledgments

We would like to thank the colleagues of the department for oncology medicine teaching and research for their administrative and academic support. We would also like to thank all of the postgraduates that participated in this study.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Minghong Bi

Dr MingHong Bi, MD, is a Associated Professor in the department of Clinical Medicine Teaching, the first affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China.

Zhibiao Zhao

Zhibiao Zhao, BS, is a research assistant in the department of oncology medicine teaching and research at the first affiliated Hospital of Bengbu Medical College.

Jingru Yang

Jingru Yang, MD, is a lecturer in the department of oncology medicine teaching and research at the first affiliated Hospital of Bengbu Medical College.

Yaping Wang

Yaping Wang, MD, is a lecturer in the department of oncology medicine teaching and research at the first affiliated Hospital of Bengbu Medical College.