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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 4  |  Page : 729-733
Enhancing active learning in microbiology through case based learning: Experiences from an Indian medical school

1 Department of Microbiology, Melaka Manipal Medical College (Manipal campus), Manipal University, Manipal, Karnataka-576 104, India
2 Department of Pathology, Melaka Manipal Medical College (Manipal campus), Manipal University, Manipal, Karnataka-576 104, India

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Date of Web Publication27-Oct-2010


Background: Case-based learning (CBL) is an interactive student-centered exploration of real life situations. This paper describes the use of CBL as an educational strategy for promoting active learning in microbiology. Materials and Methods: CBL was introduced in the microbiology curriculum for the second year medical students after an orientation program for faculty and students. After intervention, the average student scores in CBL topics were compared with scores obtained in lecture topics. An attempt was also made to find the effect of CBL on the academic performance. Student and faculty perception on CBL were also recorded. Results: In a cross sectional survey conducted to assess the effectiveness of CBL, students responded that, apart from helping them acquire substantive knowledge in microbiology, CBL sessions enhanced their analytic, collaborative, and communication skills. The block examination scores in CBL topics were significantly higher than those obtained for lecture topics. Faculty rated the process to be highly effective in stimulating student interest and long term retention of microbiology knowledge. The student scores were significantly higher in the group that used CBL, compared to the group that had not used CBL as a learning strategy. Conclusion: Our experience indicated that CBL sessions enhanced active learning in microbiology. More frequent use of CBL sessions would not only help the student gain requisite knowledge in microbiology but also enhance their analytic and communication skills.

Keywords: Active learning, case based learning, microbiology

How to cite this article:
Ciraj A M, Vinod P, Ramnarayan K. Enhancing active learning in microbiology through case based learning: Experiences from an Indian medical school. Indian J Pathol Microbiol 2010;53:729-33

How to cite this URL:
Ciraj A M, Vinod P, Ramnarayan K. Enhancing active learning in microbiology through case based learning: Experiences from an Indian medical school. Indian J Pathol Microbiol [serial online] 2010 [cited 2023 Nov 28];53:729-33. Available from:

   Introduction Top

Active learning happens when students are given the opportunity to develop a more interactive relationship with the subject matter of a course, encouraging them to generate rather than simply receive knowledge. In an active learning environment, teachers facilitate students' learning. [1],[2] Adoption of active learning strategies strengthens the student learning as they apply their own experiences and previous knowledge. [3] CBL is an active learning strategy closely related to the Problem based learning (PBL). CBL in fact incorporates many traits derived from PBL. [4]

Case-based learning (CBL) is an interactive student-centered exploration of real life situations. A case is used as a trigger to initiate the learning. The cases place events in a context or situation that promote active learning. Cases are generally written as problems that provide the student with the history or background of a patient and the clinical situation of the patient. Additional supporting information such as vital signs, symptoms, and laboratory results are also provided. [5]

The medical school offers the bachelor of medicine and bachelor of surgery (MBBS) program which runs in two phases, Phase I and Phase II. Students undergo phase I training in India and it comprises first year (Phase I, Stage I), second year (Phase I, Stage IIA) and an additional six months of clinical training (Phase I Stage IIB). Anatomy, physiology and biochemistry are covered in Phase I Stage 1 where as in Phase 1 Stage II, pathology, microbiology, pharmacology and forensic medicine are taught. Stage II B and Phase II components deal with the clinical subjects. Students undergo Phase II training in Malaysia.

The content delivery in majority of our medical schools is predominantly lecture based, and the assessment methods often fail to probe analytical and reasoning skills a medical student ought to have. As a result of revolutionary trends in medical education, a number of educational strategies are being experimented which include, self directed learning (SDL), problem-based learning (PBL), task-based learning (TBL), co-operative learning (CL) and peer assisted learning (PAL).[6],[7],[8],[9] There is an emphasis in many Indian medical schools to decrease the quantum of rote memorization and adopt learning strategies that enhance critical thinking among students. [10]

The microbiology curriculum is delivered in a traditional discipline-wise, system based approach. The exponential growth in microbiology knowledge has prompted educationists to look into strategies that would foster adult learning styles. In order to introduce active learning among undergraduate medical students, the curriculum development committee decided to incorporate CBL sessions in the microbiology curriculum. This paper is a description of events that followed.

After the introduction of CBL into the microbiology curriculum, this study was conceived with the following objectives.

  • To investigate faculty and student perceptions on CBL
  • To compare the academic performance of students in the topics covered during CBL and didactic lectures.
  • To study the effect of CBL on the academic performance

   Materials and Methods Top

The microbiology curriculum has four blocks of approximately 10 week's duration. The content coverage in each block is provided below:

Block I - Basic concepts in microbiology and immunology

Block II - Infections of the nervous system, skin, muscles, bones and joints

Block III- Infections of gastrointestinal, hepatobiliary, cardiovascular and respiratory systems

Block IV- Infections of the uro-genital tract, infections in the compromised host and immunization

A weekly schedule in microbiology included five didactic lectures and one laboratory session of two hours duration. Based on recommendations of the curriculum development committee, two hours of didactic lectures were deleted from the weekly schedule making it a total of three lectures per week. It was further restructured by allotting CBL sessions to the vacant grids.

Cases for CBL sessions were identified before the commencement of each block. These were factually based complex problems written to simulate real life situations. Cases were debriefed, and debated among peers so as to ensure maximum clarity. Beginning from the construction of cases to validation and assessment were discussed at length in regular departmental meetings convened. A sample case used in the respiratory block is provided below.

A Sample Case Used in the Respiratory Block

A 34-year-old old school teacher developed fever, headache and gradually progressive dry cough. His cough worsened over the next two days becoming productive with small amounts of sputum. History revealed that he was previously in good health. Physical examination showed mild pharyngeal erythema and minimal cervical adenopathy. No exudate was noticed. Chest examination appeared normal. However, his chest radiograph showed bilateral patchy infiltrates. Gram stain of sputum showed a few polymorphonuclear cells but no bacteria were seen. Blood and sputum cultures were negative for routine bacterial pathogens

The study population included 166 students enrolled in the MBBS Phase I, Stage II component of the medical program in India . An orientation program on CBL was conducted two weeks prior to the commencement of CBL sessions. This program introduced students to the use of case study approaches in microbiology and educated them about the need for active learning in medical curriculum. Issues related to case processes and group dynamics were also dealt with.

The case sheets with history and relevant findings were made available to the students during commencement of each block. In a block, students had six CBL sessions each of two hours duration.

During presentation sessions, the class was divided into five groups and a faculty member from the department of microbiology was identified as a facilitator for each session. Students were asked to present the learning objectives individually. Role of the facilitator was limited to keep students focused on learning objectives and to ensure group dynamics. Topics discussed during CBL sessions were evaluated by including these contents during block examinations, which was conducted at the end of each block.

A cross sectional survey was conducted among the students using a questionnaire to assess the students' perceptions on CBL. The questionnaire [Table 1] contained 20 items that were finalized after a focus group discussion. These included items regarding CBL and how it linked to their learning, analytical and communication skills. It also probed into the validity of CBL in better understanding of microbiology subject matter, examination performance and promotion of cooperative learning. The responses were in the YES/NO pattern. The purpose of the questionnaire was explained in detail to the participating students and confidentiality of the results was assured.
Table 1 :Questionnaire on case-based learning and participants' responses

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To assess the academic performance of students in the topics covered during CBL and conventional lectures, we compared, the average scores obtained by the students for the CBL portions in two block examinations with their average scores obtained in the lecture topics.

To find the effect of CBL on the academic performance, we compared student scores of the batch that had used CBL (Group B) with their immediate senior batch (Group A) that had undergone training through didactic lectures alone. The same faculty participated in the content delivery to both the batches. The assessment pattern was also standardized. Performance of these groups in the topics covered in block II and III were compared, by analyzing the mean scores obtained in each blocks.

Faculty perceptions on CBL were recorded using a separate questionnaire in which responses were graded on Likert scale from strongly agrees to strongly disagree [Table 2]. Responses were given scores of zero to four for strongly disagreeing to strongly agree. The negative item was scored in the reverse manner . Besides looking into their level of satisfaction with overall planning and conduct of CBL, it also rated the impact of CBL on student learning of microbiology subject matter.
Table 2 :Faculty perceptions on case-based learning

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The marks obtained by students in the topics covered during the CBL sessions and didactic lectures were compared using paired t test. The average scores obtained by the students before and after the introduction of CBL sessions were compared by independent samples t test. Statistical analyses of the results were performed using SPSS 11.5 software for windows. The study was approved by the institutional research and ethics committee of the medical college.

   Results Top

Among the 166 students who participated in the survey [Table 1], 125 (75.30%) opined that CBL improved their learning skills. The responses also indicated that CBL sessions transformed them to be better equipped to face the examinations (62.6%) and helped them retain the relevant information (77.1%). Participants of the survey also felt that CBL contributed to better understanding of the microbiology learning objectives (77.7%) and promoted independent learning traits (81.9%). While 57.2% of them found that CBL had substantially improved their communication skills, 69.2% experienced enhanced analytical skills which they attributed to CBL.

While comparing the average marks obtained in the topics covered during CBL sessions and didactic lectures the mean scores obtained by students in the topics that were covered during CBL was found significantly higher than the scores obtained in lecture topics (P value = <0.001).[Figure 1]
Figure 1 :Comparison of students' scores on CBL and lecture topics for the Block II and III examinations. (The error bars represent SD)

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In an attempt to evaluate the effect of CBL on academic performance we found that the mean scores were significantly higher in the group (Batch B) that used CBL as a learning strategy (P value <0.05), when compared to the group that had no CBL (Batch A) sessions in their curriculum. [Figure 2]

While analyzing the faculty perceptions on CBL [Table 2], the findings indicate that the innovation received its highest ratings in the areas of retention of microbiology knowledge and clinical reasoning. The lowest ratings were recorded in the domain related to the teaching of factual knowledge.
Figure 2 :Comparison of scores in theory and practical before (Group A) and after (Group B) introduction of CBL (The error bars represent SD)

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   Discussion Top

The global minimum essential requirement developed by the Institute for International Medical Education (IIME) puts forward a set of minimum learning outcomes that medical students should demonstrate at the time of graduation. [11] Among the essentials that have been grouped under seven broad educational domains, the need for development of critical approach, research oriented attitude and communication skills among medical students deserve special mention. While it is widely agreed upon that problem solving skills are essential in the practice of medicine, there is a wide spread skepticism to transform educational strategies in this direction. This is particularly true in the Indian context. There are very few medical schools in this region who have whole-heartedly embraced these approaches. Most of the activities which foster student centered learning have been tried, purely on an experimental basis. It is a fact that our students prefer structured learning activities and assessment schemes. By introducing CBL, we were challenging a conservative mindset and a traditional curricular framework.

The approach towards learning that students adopt appears to be an important factor in determining both the quantity and quality of learning. This in turn is influenced by factors such as curriculum, teaching characteristics, departmental characteristics, and assessment methods. [12] It is generally accepted that the chances of retaining the learned material will be better if the learning is expected to occur around a realistic problem. Cases used during CBL necessarily shift the focus of student learning beyond the facts and stimulate the students to utilize scientific knowledge to frame questions and to answer them. In the process they also learn to locate and manage information, develop reasonable answers to the questions and provide support for their conclusions. This approach would help medical students improve their learning skills, analytical skills, and hone their decision making abilities. Evidently all these traits mentioned would foster active learning. The student responses that we received in this regard were encouraging.

Instructors who use case-based learning say that their students are more engaged, interested, and involved in the class. [13] Apart from helping the learner acquire substantive microbiology knowledge, CBL sessions help them develop collaborative, and communication skills. Collaborative learning takes place when the participants are mutually dependent, they share responsibilities, and strive together to achieve a common goal. In a CBL learners are forced to interact with each other as these interactions positively influence learning. It is heartening to note that attributes of cooperative learning incorporated in the questionnaire were highly appreciated by the participants.

The instructor's role in CBL is that of a facilitator. Orientation programs should be conducted for faculty, stressing the need for implementing teaching approaches that would stimulate higher order thinking among the learners. Faculty apprehensions are common when one deviates from the routine. However in our study, faculty had a positive approach and judged the curricular reform to be superior in most respects. It is worth mentioning that the past experiences of some of our faculty with conduct of PBL did help substantially in the introduction of CBL as an educational strategy.

   Conclusions Top

CBL is learner-centered, where the students collaboratively address problems from a perspective that requires analysis. This may be the reason for students identifying CBL as a strategy that helped them in long term retention of microbiology subject matter in our study, which in turn helped them in performing better in their examination. The strong uncertainty avoidance in an educational context which students' exhibit is a hindering factor in implementing student centered learning strategies. Targeted interventions should aim in dismantling pre-conceived and deep rooted notions.

Our study showed that CBL used as an adjunct to lectures in a traditional curriculum, can promote active learning among medical students. The lessons learnt will help us plan and implement strategies that provide learner more self direction, corresponding with an inquiry driven, student centered approach to instruction.

   References Top

1.Armbruster P, Patel M, Johnson E, Weiss M. Active learning and student-centered pedagogy Improve student attitudes and performance in introductory biology. CBE Life Sci Educ 2009;8:203-13.  Back to cited text no. 1
2.Chan WP, Hsu CY, Hong CY. Innovative "Case-Based Integrated Teaching" in an undergraduate medical curriculum: Development and teachers' and students' responses. Ann Acad Med Singapore 2008;37:952-6.  Back to cited text no. 2
3.Mehmet Ali Gulpinar, Berrak C. Yegen. Interactive lecturing for meaningful learning in large groups. Med Teach 2005;27:590-4.  Back to cited text no. 3
4.Schmidt H. Assumptions underlying self-directed learning may be false. Med Educ 2000;34:243-5.  Back to cited text no. 4
5.Williams B. Case based learning: A review of the literature: Is there scope for this educational paradigm in prehospital education? Emerg Med J 2005;22:577-81.  Back to cited text no. 5
6.Greveson GC, Spencer JA. Self-directed learning - the importance of concepts and contexts. Med Educ 2005;39:348-9.  Back to cited text no. 6
7.Iputo JE, Kwizera E. Problem-based learning improves the academic performance of medical students in South Africa. Med Educ 2005;39:388-93.  Back to cited text no. 7
8.Harden R, Crosby J, Davis MH, Howie PW, Struthers AD. Task-based learning: the answer to integration and problem-based learning in the clinical years. Med Educ 2000;34:391-7.  Back to cited text no. 8
9.Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: a novel approach to clinical skills learning for medical students. Med Educ 2007;41:411-41.  Back to cited text no. 9
10.Ghosh S. Combination of didactic lectures and case-oriented problem-solving tutorials toward better learning: perceptions of students from a conventional medical curriculum. Adv Physiol Educ 2007;31:193-7.   Back to cited text no. 10
11.Wojtczak A, Roy SM. minimum essential requirements and standards in medical education. Med Teach 2000;22:555-9.  Back to cited text no. 11
12.Newble DI, Entwistle NJ. Learning styles and approaches: implications for medical education. Med Educ 1986;20:162-75.  Back to cited text no. 12
13.Kassebaum D, Averbach R, Fryer G. Student preference for case-based vs. lecture instructional format. J Dent Educ 1991;55:781-4.  Back to cited text no. 13

Correspondence Address:
A M Ciraj
Department of Microbiology, Melaka Manipal Medical College (Manipal campus), Manipal University, Manipal, Karnataka-576 104
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.72058

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