Project Report: September 2018

CURRICULUM INNOVATION PROJECT

MCI ACME Batch 2018 A

Title Page

Title of the Project: Introduction of case based studies among First prof. MBBS
students in the department of Biochemistry.

Author:
Dr Rachna Sabharwal
Associate Professor
Department of Biochemistry
Govt.Medical College Jammu

Address for correspondence

Dr JyotiSangwan
House No 302
Block B1, SHKM GMC, Nalhar, Nuh, Haryana- 122107

Mobile- 8199972272
E-Mail Address: jyolathwal@yahoo.co.in

Table of Content

Page No.

Summary 3-4

Curriculum Innovation Project

Background 5-6

Aims and Objectives 6

Methodology 6-8

Observations and results 9-11

Discussion 11-13

Conclusion 13

Implications 13

References 14-15

Acknowledgements 15

Annexures 16-18
SUMMARY

Background
The medical education in India is rapidly progressing and improving since last decade. Medical
graduation course is of total four and half years duration with one year clinical training in India. First
year of this course mainly deals with basic medical science subjects like Anatomy, Physiology and
Biochemistry. The subject of biochemistry is a key subject which forms the base of laboratory medicine
and includes diagnostic methodology. Clinical biochemistry topics link the basic knowledge with clinical
content. Hence, these topics are extremely important in learning process and for practice of medicine in
future. In medical colleges in India, biochemistry is mainly taught by didactic lectures, practicals and
tutorials. These are popular teaching methods which can deliver loads of information to the students.
The approach of students towards learning depends upon learning styles, environment and context.1

Case based learning (CBL) in context with clinical biochemistry can be an important
learning tool to achieve deep learning. Clinical biochemistry integrates basic science with clinical
science. Case based learning is an established pedagogical method that uses case studies as active
learning tools. CBL uses a clinical case or problem or inquiry to stimulate and underpin the acquisition of
knowledge, skills and attitudes.2CBL uses a guided enquiry method and provides structure during small
group sessions. The role of facilitator is also important who assists the students, engage in analysis and
helps in arriving at solutions or strategies.3 Case method involves learning by doing and developing
analytical and decision making skills which is closely related to learning objectives in clinical
biochemistry. So keeping in mind the above facts the present study was planned to
introduceCase Based Learning (CBL) in Microbiology teaching and assess its effectiveness
in understanding the subject along with its perception among faculty and students.

Aims and Objectives:

1. To introduce Case based Study to IInd Professional students as a method of teaching

medical Microbiology.
2. To assess the effectiveness of CBL in understanding a concept of medical microbiology.

To observe the perceptions of students and faculty after introducing Case Based Learning (CBL)
in Microbiology
Material and methods: After obtaining clearance from institutional ethical committee, educational
research will be carried out in the department of biochemistry, GMC, Jammu. Both, the faculty and
students will be sensitized to introduction of case based learning methods. Feedback forms for students
will be prepared with the help of faculty of the department. A total of 150 First prof. MBBS students will
be included in the study. Two topics will be covered (Jaundice and Diabetes Mellitus) in two CBL sessions
of one hour duration each, in one week Interval. The students will be divided into small groups of 8-10
students. Both the topics will be covered in didactic lectures before introducing CBL method. A written
test of students will be taken for the topics after didactic lectures and after introduction of CBL to assess
the students’ level of understanding. Structured feedback questionnaire (including both open ended and
close ended questions) after getting validated by the faculty on acceptability and usefulness of this
method will be filled by the students . Attendance of the students will also be noted in theory lectures
and CBL sessions. Faculty’s feedback will be taken by Focused group discussions regarding their
perception on introduction on CBL followed by statistical analysis.

Methodology: The study was conducted on 150 MBBS firstProf Students in the department of
biochemistry Govt.Medical College Jammu. Theory lectures were taken for both the selected
topics i.e.Jaundice and Diabetes Mellitus. Then case based learning sessions were conducted for
both the topics. At the end of both the lectures and CBL sessions, a post test (MCQ) was
conducted. A repeat test was taken after 4 weeks from the first post-test (MCQ) for each topic.
Also, the perceptions of students and faculty were taken on a validated feedback questionnaire
and analysed on 5 point Likert scale.

Findings: A total of 144/150 (96%) students participated in the study. The CBL scores were
significantly higher than Didactic Lectures session scores (P < 0.001). This difference was also
seen in scores after four weeks of session completion (P < 0.001). Student reported satisfaction
in being taught by CBL method in 5-point Likert scale feedback form and recommended it for
future batches.

Conclusions: This study showed that Case Based Learning is an active method of learning
resulting in better understanding and retention of subject of biochemistry. Students found this
method more interesting, useful in understanding the topic, problem solving and provides a
scope for interaction with faculty .
 CURRICULUM INNOVATION PROJECT

Background:

The medical education in India is rapidly progressing and improving since last decade.
Medical graduation course is of total four and half years duration with one year clinical
training in India. First year of this course mainly deals with basic medical science subjects like
Anatomy, Physiology and Biochemistry. The subject of biochemistry is a key subject which
forms the base of laboratory medicine and includes diagnostic methodology. Clinical
biochemistry topics link the basic knowledge with clinical content. Hence, these topics are
extremely important in learning process and for practice of medicine in future. In medical
colleges in India, biochemistry is mainly taught by didactic lectures, practicals and tutorials.
These are popular teaching methods which can deliver loads of information to the students.
The approach of students towards learning depends upon learning styles, environment and
context.1

Students often complain that basic sciences curricula are theoretically overloaded, they could
recall less information and that curricula were less applicable to clinical practice. In the absence
of such teaching environment, students are more concentrated on gaining good marks, rather
than focusing on how the basic science information could be applied in clinical scenario.

Therefore in last few decades; concept of interactive learning has evolved. Adoption of active
learning strategies strengthens the student learning as they apply their own experiences and the
knowledge gained to solve problems.[1] Case based learning (CBL) is one such strategy. It is an
interactive, student centred approach. It engages students in discussion of clinical case that
resembles real life situation and provides information such as history, physical findings and
laboratory results. Students interact with each other and work together as a group to solve the
case.

Case based learning (CBL) in context with clinical biochemistry can be an important
learning tool to achieve deep learning. Clinical biochemistry integrates basic science with
clinical science. Case based learning is an established pedagogical method that uses case
studies as active learning tools. CBL uses a clinical case or problem or inquiry to stimulate and
underpin the acquisition of knowledge, skills and attitudes.2CBL uses a guided enquiry
method and provides structure during small group sessions.
This Case Based learning allows students to work as a team to solve a clinical case scenario with
the knowledge they have gained. It provides opportunity for the student to interact with each
other and with faculty. They generate the knowledge, organize it in meaningful manner and try
to solve the problem. [5] So in this way it helps in improvement of student’s understanding of
applied aspects of Microbiology. ]
Case based learning (CBL) is an interactive, student centred approach. It engages students in
discussion of clinical case that resembles real life situation and provides information such as
history, physical findings and laboratory results. Students interact with each other and work
together as a group to solve the case. The teacher’s role is that of facilitator. [2,]

The role of facilitator is also important who assists the students, engage in analysis and helps
in arriving at solutions or strategies.3 Case method involves learning by doing and developing
analytical and decision making skills which is closely related to learning objectives in clinical
biochemistry.
Hence, keeping in mind the above reported advantages of case based learning, the present
study was conducted to introduce the CBL in microbiology at undergraduate level in a
relatively new medical college and to see its effectiveness in understanding the given
concept. Also, the perception of students and faculty involved was taken regarding this
newer method of teaching and learning.

Aims and Objectives:

 3. To introduce Case based Study to IInd Professional students as a method of teaching
medical Microbiology.
4. To assess the effectiveness of CBL in understanding a concept of medical microbiology.
5. To observe the perceptions of students and faculty after introducing Cse Based Learning
(CBL) in Microbiology.

Goal
According to MCI regulations on Graduate Medical Education, the goal is to create an Indian
Medical Graduate (IMG) with requisite knowledge, skills, attitude, values and responsiveness.[6]
To achieve this goal, the Biochemistry curriculum needs to be made competency based.

The present study has been conducted keeping this in mind, so that teaching by case scenarios,
students will be more attentive in class and it will increase their interest in the subject and
improve their retention of learning. Subsequently which will help in applying their knowledge of
Biochemistry in the clinical scenario which will help them in patient care in future.

Aims & Objectives

Aim: To introduce case based learning (CBL) as a teaching learning tool among undergraduate
students to improve students understanding of clinical aspect of Biochemistry.

Objectives

1.To introduce case based Learning(CBL) as a teaching method among first Prof MBBS
students in subject of Biochemistry.

2.To assess the effectiveness of CBL in understanding a given concept of clinical Biochemistry.

3.To assess the perceptions of students and teachers towards the case based studies in the subject
of Biochemistry..
Methodology:

 Study population: The study was conducted on 150 first professional students.
 Place of study: Department of Biochemistry Govt. Medical College Jammu.
 Study duration: Four months.
 Study design: Cross sectional, observational study.
 Permission was taken from Institutionalhical Committee.
 The faculty of the department was sensitized regarding the method used in the study.
 Two topics i.e. Jaundice and Diabetes Mellitus , were selected from MBBS scheduled
time table.
 CBL scenarios were prepared and were discussed among the faculty. The questions for
discussion during CBL session were finalized and validated.
 Feedback questionnaires for students and faculty were designed and validated.
 The students were informed about the concept of Case Based Learning, group dynamics
and an informed consent was taken.
 First, Group A had CBL session on Jaundice whereas Group B had DL on the same topic.
After these sessions, the groups were crossed over. This time Group B had CBL session
for the next topic ie Diabetes Mellitus whereas Group A had DL for same. Didactic
lecture were taken for each topic using power point presentation.
 Three faculty members and three senior residents from the Department of Biochemistry
were sensitized and trained for group dynamics and CBL.
 Both the Batches, A and B and were given the clinical case scenario a week before the
session and were instructed to study about the case and do some further reading from
suggested sources.
 CBL sessions were conducted in demonstration room of Biochemistry Dept. and each
lasted for approximately 90 min. During the CBL session, the students were divided into
five subgroups of fifteen students each. Along with each group there was one faculty
member whose role was of facilitator.
 A post test was conducted for each batch immediately after the CBL and DL sessions
were completed, and then a repeat test was taken after 4 weeks duration from the first
post test. The post tests were in multiple choice questions format with twenty questions
 of half mark each. The post-test marks were divided into two categories (CBL and DL) of
ten marks each for comparison between the two post-tests.
 At the end of each CBL session, perceptions of students were taken using validated
questionnaire which had two sections: (a) the section I had eight closed-ended questions
with 5-point Likert scale response. (b) The section II had two YES/NO/open-ended
questions. (Annexure-I)
 The Faculty feedback was taken after 4weeks of CBL sessions. The questionnaire had
five closed-ended questions with 5-point Likert scale response. (Annexure-II)

 Statistical analysis: Qualitative data were expressed in percentages, and quantitative

data were expressed in the form of mean ± standard deviation and significance of
difference was assessed by t-test. A p value of < 0.05 was considered statistically
significant. All statistical calculations were done using computer program Microsoft
Excel Version 7 (Microsoft Corporation, NY, USA) and SPSS Version 20.0 (Statistical
Package for the Social Science SPSS Inc. Chicago, USA).
 Figure 1 depicts methodology in brief.
Figure 1: Flow chart depicting Methodology in brief.

Observations and results:

Total 150 MBBS First Prof students gave consent for this study. Out of 150 students, 144 (96%)
students actually reported for study.
Table 1: Comparison between test marks of didactic lecture and case-based learning
sessions

Scores on MCQ Mean score (SD)

test (n=144)
Immediately 4 weeks after p Value
after session session
After DL 5.67(0.87) 4.01(0.86) <0.001
After CBL 7.16(0.97) 6.07(1.04) <0.001
p Value <0.001 <0.001

On comparison of post test scores, the student’s scores were higher for the CBL sessions than
DLs sessions in both the tests: one taken immediately after the sessions and second taken at an
interval of 4 weeks after the completion of sessions. The difference in the score of the two
methods was found to be statistically significant. The difference in scores was more in test taken
after 4 weeks (P < 0.001) [Table 1]. Also, it was observed that among both the groups over a
period of time, there was a decrease in the mean score , which was significantly higher in the DL
group than the CBL group [Table 1].

Table 2: Perception of students regarding CBL

Sr Items Strongly Agree Neutral Disagree Strongl

No agree y
disagre
N (%) N (%) N (%) N (%) ed
N (%)
1. CBL has made the subject 100 32 10 2 0(0)
interesting
2 CBL has made the subject easy 102 30 10 2 0(0)
3. CBL has helped me in 98 34 11 1 0(0)
understanding the topic better
4. CBL process was a motivation 96() 30() 15() 3() 0(0)
for self-study
5. CBL has improved my 90() 40() 11() 3() 0(0)
communication skills
6 CBL has brought more 100() 40() 3() 1() 0(0)
interaction with teacher
7. CBL has improved my problem 100() 38() 14() 2() 0(0)
solving ability
8 CBL made me more attentive in 98() 34() 10() 2() 0(0)
 the class
9. During CBL sessions, i learned 94() 36() 12() 2() 0(0)
to work in team
10. Topics covered by CBL would 130 10 4() 0() 0
be helpful for future application
of knowledge
11. CBL should be made a regular 130() 10() 4() 0() 0(0)
part of the curriculum

Regarding perception of students about CBL, majority of students were satisfied with use of this
newer teaching learning method.. Majority of students agreed that they find the subject boring
with conventional lectures .CBL gave them better understanding of topic, improved
communication skill, more self-study, team work and increased attentiveness during class . 97%
students agreed that CBL should be continued for future batches and should be made a regular
part of the curriculum. [Table 2].

Response of students to open ended question in the feedback questionaire :

Following were some of the common suggestions by the students:

1. CBL should be a regular part of syllabus and should be taught more frequently.

2. More topics should be covered by CBL Learning.

3. More Faculty should be involved.

4. Smaller groups should be made for better interaction .

5. Should be used in other subjects as well.

 Case based learning method- Perception of Teachers regarding CBL

Degree of Agreement(perceptions)
S.NO Questions

Strongly Agree Neutral Disagree Strongly

agree disagree

1. CBL resulted in increase in interest of 5 4 0 0 0

students ie they were inquisitive and were
asking questions
2. Students were more Attentive during CBL 5 4 0 0 0
sessions

3. CBL improved students problem solving 3 2 1 0 0

ability

4. CBL brought in more interaction among 4 2 0 0 0

students and teacher

5. CBL requires more efforts on teacher’s 5 1 0 0 0

part

6 CBL is more time consuming 5 1 0 0 0

7 CBL should be a regular part of the 4 1 1 0 0

curriculum
Discussion: Increasing globalization of medicine needs a call for physicians to set the standards for
minimum essential requirements for use in medical education.

In defining the essential competencies that all physicians must have, an increasing
emphasis needs to be placed on professionalism, social sciences, health economics and the
management of information and the health care system. This must be done in the context
of social and cultural characteristics of the different regions of the world.

Furthermore, the global essential requirements are not a threat to the fundamental principle
that medical education has to identify and address the specific needs in social and cultural
context where the physician is educated and will practice. Finally in pursuing the 'global
minimum essential requirements', medical schools will adopt their own particular curriculum
design, but in doing so, they must ensure that their graduates possess the core
competencies envisioned in the minimum essentials. They must in short 'think globally and
act locally.6

Without clinical exposure during early years of medical education, the understanding of basic
sciences subjects is difficult. Many students are of the view that they could recall very less
information from early years and could not apply that knowledge to clinical practice.

CBL may be introduced along with traditional lectures in a way that it creates interest, promotes
active learning and provides better understanding so that learning becomes a pleasure and
motivates the student to become life long learner. 7 (vijyetha p patil)

In our study we could demonstrate that students had better understanding of topic with CBL
compared to traditional approach (P < 0.001). Since CBL is a learner-centred approach as
compared to conventional curriculum which is teacher centric .In CBL,The students will be able
to retain knowledge by active participation and develop reasoning strategies and assume
responsibility for learning. The students collectively address the clinical problems from a
perspective that requires analysis it helps in longer retention of concept learned.[2] In present
study we also found that the topics which were taught using CBL were better retained even after
four weeks (P < 0.001). Similar findings were observed by other authors in their studies.[2,4,7]
After analysing the perception of students regarding CBL we observed that around 92% students
either strongly agreed or agreed that topic was more interesting and easy when taught by CBL as
compared to didactic lectures. Cases helped them to develop problem solving skills and
collaborative skills which they need in their future professional life. Almost same number (92%)
agreed to better understanding of topic and also that their attention span was more during CBL
sessions. 87% students felt that it motivated them for self study. Further 90% students agreed to
have learnt teamwork during CBLsessions. Similar trends have been reported by Suvarna S
Tathe[5] who concluded that 91% students agreed that learning better understanding was achieved
at the end of CBL session, 89% students agreed that CBL was an effective learning tool and
improved their problem solving skills.

In our study we found that agreement among students towards improved interaction with
teachers was very significant ie 97%. Team work and better communication skills were found to
be 90% each. A study done by YasinTayem[8] showed that84% students reported that team work
helped them to achieve lecture objectives and 68% admitted to improved communication skills.
Whereas Nazish Fatima [9] in her study showed that students found CBL as a more effective way
towards team work (99%) and improved communication skills (99%).

97% students agreed that CBL would be helpful for them in future application of their clinical
knowledge.

In answer to question whether they recommend CBL for future batches, we found that 97%
students agreed that it should be made a regular part of the curriculum. A study conducted in
Bihar [10] reported that 95% students recommended CBL for next batches.

Our faculty admitted that the whole experience was very motivating and it has improved their
student knowledge about subject. However they admitted that CBL is somewhat more labour
intensive and time consuming. Similar findings were concluded by other studies.[7,12]

Outcome:

What this study adds: Traditional didactic lectures alone fail to achieve the required impact
hence making the learning monotonous and boring with poor retention of subject. Use of Case
Based Learning in teaching Biochemistry results in better retention and active learning of
subject.

Limitations: This study has certain limitations: We have studied only the short-term outcome of
CBL. There is need to look at the long term outcome, which is possible during later years of
clinical exposure and internship .Also, only two topics were covered by CBL session because of
shortage of time. The lack of more faculty members to interact with students was another
limitation.

My Reflections

What was good: The positive and receptive response from students was overwhelming. Almost
all students asked to continue this method for rest of the topics in Biochemistry. Also planning of
the study, sensitizing my fellow colleagues, preparing case scenarios and feedback questionnaire
and then validating them, has been a great learning experience.

What could have been differently: More faculty members could have been included which
would have brought in more interaction with students. Also more number of topics could have
been taught if time permitted to further see the effectiveness of CBL. A follow up during later
years of education may also be planned in future.

The Road Ahead: Since the response of students for CBL was very encouraging, I would try
teaching my allotted topics using this method. Also, I will encourage my colleagues to use CBL
as a teaching-learning method. Also, I would follow up on my findings during later years of
these medical students. I will try to coordinate with MEU of our institution to introduce this
method of interactive teaching in MBBS curriculum at our institute.

Conclusions: The present study concluded that CBL is significantly more effective than Didactic
lectures in understanding a particular topic of of Biochemistry and also helps in retention of
learned concept better when compared with traditional lectures. Simultaneously, it motivates the
students for self- directed learning and improves their communication skills as well as analytical
skills.Although CBL requires more efforts both from faculty and students, but the end results are
worth the extra effort put into it.
Implications:Introduction of CBL as a teaching learning method along with didactic lectures
will lead to better understanding of biochemistry at undergraduate level because by this method,
students will acquire understanding of practical utility of this subject in clinical exposure in the
later years of their study. They would be able to apply this knowledge in future to provide
effective health care services to the community.

References:

1. 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.

2. Ciraj AM, 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.

3. Neal RC, Melissa KS, Vineet KS and Neil JS. Utilization of case presentations in medical
microbiology to enhance relevance of basic science for medical students. Med Educ.
2012; 17:1-7.

4. Newble DI, Entwistle NJ. Learning styles and approaches: implications for
medical education. Med Educ. 1986 May;20(3):162-75.

5. Tathe SS, Singh AL. Case based lectures versus conventional lectures for teaching
medical microbiology to undergraduate students. Int J Curr Rev. 2014; 06(04):35-41.

6. Schwarz AW. Minimum essential requirements and standards in medical education.

Med Teach. 2000;22(6):555-9.
 7. Anita Singhal. Case-based Learning in Microbiology: Observations from a North West
Indian Medical College. Int J Appl Basic Med Res. 2017 Dec; 7(Suppl 1): S47–S51.

8. Yasin I. Tayem. The Impact of Small Group Case-based Learning on Traditional

Pharmacology Teaching. Sultan QaboosUniv Med J. 2013; 13(1): 115–20.

9. Fatima N, Shameem M, Nabeela, KM Haris. Evaluation of Case-Based Lectures for

Teaching Medical Microbiology. International Research Journal of Engineering and
Technology.2015; 2 (2):272-75.

10. Kumar A, Vandana, Aslami AN. Introduction of “case-based learning” for teaching
pharmacology in a rural medical college in Bihar. National Journal of Physiology,
Pharmacy and Pharmacology 2016; 6: 427-30.

11. Ghosh S. Combination of didactic lectures and case-oriented problem-solving tutorials

toward better learning: perceptions of students from a conventional medical curriculum.
AdvPhysiol Educ. 2007 Jun;31(2):193-7.

12. Gupta K, Arora S, Kaushal S.Modified case based learning: Our experience with a new
module for pharmacology undergraduate teaching.Int J Appl Basic Med Res. 2014; 4(2):
90–94.

Acknowledgement:

First of all I would like to acknowledge the ACME faculty for guiding me while making the
project protocol, the very first step towards completing this project. Then I acknowledge the
guidance and support provided by Dr Pratibha Mane, Prof and head, Department of
 Microbiology, Dr SulabhaNaik.Prof and head, Department of ENT and Dept of Medicine
SHKM, GMC, Nalhar. I also would like to acknowledge the help provided by all the faculty
members and postgraduate students of my department. Last but not least I thank all my students
for their enthusiasm and active participation.

Annexure-I

Case based learning method- Perception of students regarding CBL

Sr No Items 5 4 3 2 1
Strongly Agree Neutral Disagree Strongly
agree disagree

1. CBL has made the topic interesting

2. CBL has made the topic easy

3 CBL has helped me in understanding the

topic better

4 CBL process motivated me for self-study

5 CBL has improved my communication

skills

6 CBL brought in more interaction with

teacher
7 CBL improved my problem solving ability

8 CBL made me more attentive in the class

 9 I learned to work in team
10 CBL will be helpful in future application
of knowledge
11 CBL should be used for future batches

12.What do feel could have done differently ? Suggestions for improvement.

…………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………………..

Case based learning method- Perception of Teachers regarding CBL

Sr No Items
Strongly Agree Neutral Disagree Strongly
agree disagree

2. CBL resulted in increase in interest of

students ie they were inquisitive and were
asking questions
2. Students were more Attentive during CBL
sessions

3. CBL improved students problem solving

ability

4. CBL brought in more interaction among

students and teacher

5. CBL requires more efforts on teacher’s

part
6 CBL is more time consuming

7 CBL should be a regular part of the

curriculum