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Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 84-89

Case-based learning in neurophysiology: An educational paradigm for preparing undergraduate medical students for better clinical acumen

1 Department of Physiology, Rajasthan University of Health Sciences College of Medical Sciences, Jaipur, Rajasthan, India
2 Department of Dentistry, Jaipur National University Institute for Medical Sciences and, Research Centre, Jaipur, Rajasthan, India

Date of Submission08-Jun-2020
Date of Acceptance15-Oct-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Dr. Raman Grover
Department of Dentistry, Jaipur National University Institute for Medical Science and Research Centre, Jagatpura, Jaipur - 302 017, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_173_20

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Background: Case-based learning (CBL) is an effective educational strategy of solidifying basic physiological concepts and integrating them to clinical application and clinical sciences. The study aimed to measure its effectiveness in achieving the defined learning outcomes and assess and evaluate the academic performance and perception of 1st year medical students in neurophysiology toward developing a better clinical acumen.
Materials and Methods: A quasi-experimental study of 100 1st year medical students was conducted. 89 students in the first and 86 in the second CBL session were final participants after dropouts. After a conventional lecture on neurophysiology, they were assessed by a pretest in the form of multiple choice questions. Then, they were divided into 9 groups to solve a clinical case problem via group discussion followed by group presentation, a posttest, and an open discussion by the facilitator. Five-point Likert scale feedback was taken; the scores were statistically assessed by paired Student's t-test and the feedback was assessed by median, interquartile range (IQR), and Chi-square goodness-of-fit test.
Results: Higher mean posttest scores (2.84 ± 0.94 for the first and 3.77 ± 0.93 for the second session) suggested a statistically significant improvement in the students' academic performance (P < 0.001 and P < 0.002, respectively). Majority of the feedback responses favored a positive impact of CBL (P = 0.05; IQR averaging around 1 and 2 in majority).
Conclusion: CBL encourages active learning in physiology, and not only helps students to gain requisite knowledge but also enhances their communication and analytical skills.

Keywords: Case-based learning, competency-based medical education, integration, neurophysiology, self-directed learning, student-centric learning

How to cite this article:
Gupta R, Grover R. Case-based learning in neurophysiology: An educational paradigm for preparing undergraduate medical students for better clinical acumen. Indian J Health Sci Biomed Res 2021;14:84-9

How to cite this URL:
Gupta R, Grover R. Case-based learning in neurophysiology: An educational paradigm for preparing undergraduate medical students for better clinical acumen. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Apr 16];14:84-9. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/84/308952

  Introduction Top

The practice of medicine encompasses a lifelong responsibility to undertake and work through challenging and often unique clinical cases. Medical teachers shall agree to the fact that it is extremely important and wise to inculcate these principle skills and capabilities in the learners to generate and strengthen a good clinical acumen. At the onset, basic science subjects lay a strong foundation of understanding of clinical concepts and act as a construct to build a sound clinical ability. Routinely, to accommodate an ever-enlarging medical syllabus and a plethora of important facts and concepts, lecture-based teaching remains the predominant form in health-care profession education.[1] Despite its merits, it is monotonous and passive in terms of information transmission that in the long run, may alienate students from the classes.[2],[3] Moreover, the information overload reduces the much needed scope of clinical reasoning and problem-solving skills.

Active teaching–learning models that inherit the capability to facilitate the integration of students into the professional world and build up critical thinking skills are certainly the need of the hour. The importance of including clinical cases early by integrating basic and clinical sciences has been already incorporated in the new curriculum-based medical education in India. One such methodology is case-based learning (CBL), which is an effective educational strategy of solidifying the understanding of basic physiological facts, concepts, and principles and integrating them to clinical application and clinical sciences.[4],[5] This strategy elicits active learning principles that have a student-centric approach primarily following the footsteps of self-directed learning. The students have to analyze the problems, decide what they need to know and having gained the knowledge, and develop appropriate solutions. The prior gained cognition helps in case analysis and dissemination of new clinical findings culminating into a higher level of cognition as illustrated in Maastricht's “Seven Jump” process [Figure 1] for sequential implementation of CBL.[6]
Figure 1: Case-based learning as adapted from Maastricht's “Seven Jump” Process

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CBL not only helps in developing clinical knowledge but also plays an important role in facilitating leadership skills, communication skills, team-based learning, and enhancing critical thinking. This helps the learners to relate the content learned in classroom to professional competence in later years. All these attributes render CBL as one of the important factors leading to improvement in academic performance.[7],[8] Moreover, despite an obstinate approach to accept the change, regular use of directed case analysis is a valuable addition to break the monotony of the traditional methods of lecture, textbook reading, and laboratory sessions for the teaching of human physiology.

The study aimed to measure the effectiveness of CBL in achieving the above-mentioned defined learning outcomes with specific objectives to assess and evaluate academic performance and perception of 1st year medical students by introducing it in neurophysiology toward developing a better clinical acumen.

  Materials and Methods Top

Study design

The study was an experimental educational research and was undertaken as a “quasi-experimental” interventional study design.


The study was carried out in November 2019 at the Department of Physiology in collaboration with the institutional Medical Education Unit of a premium medical college at Jaipur, Rajasthan, India.

Selection of participants

The sample population size was calculated with the precision/absolute error of 5% and at type 1 error of 5%. It consisted of 100 volunteer first professional year medical undergraduate students (18 years and above) who were not previously exposed to any kind of clinical teaching. Students who were absent in both sessions of intervention were not included in the study.

Participant dropouts

Eleven students in the first CBL session and 14 students in the second CBL session were absent in both the interventions, thereby considering to be dropped out of the study. Henceforth, 89 students in the first and 86 in the second CBL session, respectively, were considered as the final selected participants.

Ethical guidelines followed by the investigators

The study was conducted after taking approval from the Institutional Ethical Committee of Rajasthan University of Health Sciences- College of Medical Sciences' Ethical Committee with Ref No. RUHS-CMS/Ethics Comm./2018/101 dated 15.09.2018 and written informed consent from the participants.

Interventions and methods of measurement

All selected participants were informed of the objectives of the study, and their anonymity was ensured by coding them for analysis. The study commenced with a didactic lecture on the related topic for 30 min. This was followed by a pretest using a validated questionnaire that comprised 5 multiple-choice questions. They were based on factual recalls and higher level of cognition to test the learners' analytical skills. The question type comprised clinical vignettes and best answer types. The students were then divided into 9 groups (8 groups of 10 students each and 9th group of 9 students for first CBL session and 8 groups of 10 students each and 9th group of 6 students for second CBL session). The groups were given a similar short clinical case and related set of questions to be solved within 30 min. The case was related to the topic already taught in the didactic lecture. Questions were prepared and validated with the help of departmental faculty experts. Suggestions were taken from the experts of clinical departments, depending on the topic chosen for the CBL. Stress was laid on open-ended questions with an intention to render extensive interaction and learning in the course of discussion. Students were provided with textbooks, reference books, and access to internet for resource material. Group dynamics was facilitated, thereby providing opportunities to communicate and participate in the discussion and involve in effective team work. A group leader and a record keeper were chosen for each group for proper moderation, coordination, and time management for the discussion.

A group of three facilitators ensured active participation of all students and guided them throughout the case solving. The answer sheets were collected after the stipulated time, and to ensure active participation, a random student from each group was asked to present and answer the assigned questions. The students were now given the posttest that again comprised a validated questionnaire with similar difficulty level as the pretest. Thereafter, the facilitator (chief investigator) conducted an open discussion summarizing the applied clinical concepts and explained the given case scenario. A similar second paper-based CBL session was administered after a period of 15 days.

The perception of students in regard to the usefulness of CBL was assessed and evaluated with the help of a prevalidated 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree) questionnaire at the end of the second CBL session. The questionnaire comprised the following questions:

  1. Was this technique helpful in understanding the topic more effectively than lectures?
  2. Did this technique help the learner to improve his/her ability to think and solve problems rather than just memorize information?
  3. Did this technique help the learner to improve his/her understanding of the questions in the post-CBL examination and answer them easily?
  4. Did this technique involve deeper learning approach and help in development of critical thinking?
  5. Did this technique help the learner to increase his/her interest towards learning?
  6. Did this technique help the learner to clear his/her doubts?
  7. Did this technique motivate the learner to learn physiology?
  8. Did this technique encourage the learner's intellectual curiosity?
  9. Did this technique keep the learner engaged during the session?
  10. Did this technique provide an opportunity for self-learning?
  11. Did the learner feel confident about the subject after this technique?
  12. Was it a satisfying learning experience?
  13. Was the facilitator helpful?
  14. Would the learner like to involve in more of such CBL techniques?
  15. Was there equal contribution from all the team members?

Data collection, processing, and statistical analysis

The responses to questions were converted into scores. The data were coded and entered in Microsoft Excel 2010 software (Microsoft Corporation, Washington, United States). The marks scored in the pretests and posttests during the sessions were analyzed by paired Student's t-test, and P = 0.05 was considered statistically significant. The median and interquartile range (IQR) and Chi-square goodness-of-fit test were used to measure student perceptions. [Figure 2] depicts a flowchart illustrating the performed methodology.
Figure 2: Methodology

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  Results Top

Among one hundred first professional year undergraduate medical students, 89 students in the first session of CBL and 86 students in the second session of CBL were enrolled in the study as per their presence during the sessions and completion of the questionnaire for the interpretation of results. The first session comprised 56 males and 33 females. The number of males and females reduced to 54 and 32, respectively, in the second session.

[Figure 3] illustrates the comparison of pre- and post-test CBL scores. The mean pretest and posttest scores with standard deviation were calculated to be 1.94 ± 0.97 and 2.84 ± 0.94, respectively, for the first session and 3.34 ± 1.17 and 3.77 ± 0.93, respectively, for the second session. The paired t-test applied for both sessions showed a significantly higher posttest scores (P < 0.001 and P < 0.002), suggesting a statistically significant improvement in the academic performance of the students postintervention. [Table 1] illustrates the comparison of the mean pretest and posttest scores of the two CBL sessions in regard to gender. This was found to be statistically insignificant.
Figure 3: Comparison of pretest and posttest scores of two CBL sessions

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Table 1: Comparison of mean pre- and post-test scores of two case-based learning sessions according to gender

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[Figure 4] illustrates the “mean frequency distribution of student responses” of both CBL sessions. Analysis of student perception based on feedback questionnaire is summarized in [Table 2]. Majority of the responses favored an extremely positive impact of CBL. The highest Chi-square values of 155.294 and 130 indicated an extremely large number of observed positive responses than their expected values, suggesting that the participants had the most probability of agreement to the fact that CBL encouraged their intellectual curiosity and improved their thinking and problem-solving skills, respectively. This was followed by a better understanding of the topic as compared to conventional lectures (Chi-square value of 119.176). The lowest Chi-square value of 52.235 (CBL's role in motivating to learn physiology), although indicated fewer agreements and greater neutral opinions as compared to other responses but a substantial large amount of observed value as compared to the expected data, suggests an undoubtedly positive feedback. All P values were less than 0.00001 and statistically significant (P ≤ 0.05). The majority of the IQR for the two CBL sessions averaged around 1 and 2 (strongly agree and agree), suggesting a positive consensus. Overall, the students opined that apart from fostering their learning ability, CBL sessions improved their critical and analytical thinking and enhanced their confidence in the subject. In regard to the usefulness of the experience of CBL as a method of learning, students expressed the need of more such sessions compared to traditional methods. They claimed that the facilitator rendered great help. Majority of students recommended this method of learning and recognized that they had a satisfying learning experience. The results were statistically significant (P ≤ 0.05).
Table 2: Analysis of student perception regarding case-based learning

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Figure 4: Mean frequency distribution of student responses

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  Discussion Top

The efficacy and competency of a clinician's diagnostic and clinical skills directly correlates with the learning and experiences gained from prior clinical cases and patient problems. When clinical case material forms the epicenter for medical training at a preclinical phase, the students not only identify and acknowledge the relevance of basic sciences as a scaffold to build up clinical facts and concepts but also channel a pathway for self-directed active participation at an early stage ensuring a brighter future. The Medical Council of India with an effort to revolutionize its archaic system of medical academia introduced competency-based medical curriculum incorporating learner-centric approaches and emphasizing on reinforcing conventional lectures with teaching–learning methods that involve active learning.

CBL certainly holds relevance in advancing the medical teaching–learning strategies, and the present interventional study followed the trajectory of implementing the technique and evaluating its effectiveness in undergraduate preclinical medical education to teach neurophysiology. The positive student perception and improved academic performance suggest a significant improvement in student learning: assimilation and retention of knowledge and development of clinical reasoning and analytical skills.

Studies conducted in India and across the globe have certainly authenticated the benefits of CBL in medical education. Ma et al. in China compared the effectiveness of CBL to lecture-based learning in teaching clinical laboratory immunology course.[9] Dulloo et al. in Oman benefited the students in teaching cardiovascular and respiratory physiology to undergraduate medical students.[10] Pearson et al. in School of Medicine, Rochester, New York, conducted an innovative pilot testing of incorporating case-based series in population-oriented prevention program in a problem-based medical curriculum at the Department of Preventive and Community Medicine with positive outcomes.[11] Hansen et al. in Iowa assimilated the CBL model in obstetrics and gynecology.[12] Engel et al.[13] and Garvey et al.[14] positively conducted CBL strategies in orthodontics and final-year Dublin Dental School students, respectively. Bhardwaj et al.[15] in India conducted a comprehensive integrated teaching program in all medical departments using CBL. Gade et al.[16] introduced this model in teaching cases in endocrine physiology. Ali et al. introduced an interactive CBL system for medical education with a great success rate in terms of student interaction: group and solo learning and clinical skills.[17] Johnston et al. evaluated early year learners' perceptions of anatomy within an integrated and CBL osteopathy curriculum.[18] Evidently, a trend of uniformity has been observed in regard to positive faculty and student perception in regard to the above-mentioned studies as they imply similitude with our study in neurophysiology.

Female students performed better as compared to males as observed in a study conducted by Robert Ward in regards to development and implementation of computer-based case scenarios,[19] although there was no statistically significant gender predilection in mean academic scores in our study.

In context of ability and skills, the results in our study indicated that majority of students agreed or strongly agreed that problem-solving, self-learning, knowledge integration, oral and written communication, critical thinking, and team work and initiative were the most developed areas during their learning experience. This was in concurrence with various studies and literary works by scholars and researchers as mentioned above.[10],[11],[17]

Although the deep rooted concept of minimum human resource availability in Indian medical institutes will pose substantial challenges toward implementing such contemporary and productive teaching–learning methods, determination and dedication of medical faculty can surely help materialize and incorporate these strategies on a regular basis.

  Conclusion Top

CBL has proven to be a valuable asset in medical education as at its core, it inherits the potential to develop skills and competence that are useful in a medical student's professional life as patients become the stimulus for learning. It encourages active learning in physiology, and not only helps students to gain requisite knowledge but also enhance their communication and analytical skills. Undertaking further research in this area is important and significant for effective implementation of such strategies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Bhardwaj P, Bhardwaj N, Mahdi F, Srivastava JP, Gupta U. Integrated teaching program using case-based learning. Int J Appl Basic Med Res 2015;5:S24-8.  Back to cited text no. 15
Gade S, Chari S. Case-based learning in endocrine physiology: an approach toward self-directed learning and the development of soft skills in medical students. Adv Physiol Educ 2013;37:356-60.  Back to cited text no. 16
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Johnston S, Vaughan B. 'We need one more hour solely based on anatomy… Give us anatomy!' Early- year learner perceptions of anatomy within an integrated & case-based learning osteopathy curriculum. Int J Osteopath Med 2020;36:49-54. [Doi: 10.1016/j.ijosm. 2020.02.001].  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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