Optimizing Case-Based Learning: an evaluation of tutor and first year medical student perceptions of group size and format variations

Purpose: In 2016, Case-Based Learning (CBL) entered the preclerkship years of the University of Toronto's Doctor of Medicine (MD) Program. Iterative delivery revisions led to variations in CBL group size, small-group (eight to ten students) and intermediate -group (46-60 students), and format, patient-narratives (detailed written dialogues between patients and medical students eliciting histories and physical exams) and case-reports (patient history and physical examination summaries). First-year medical student and tutor experiences with these variations were explored to understand their strengths and limitations in fostering safe and effective learning and teaching environments. Methods: In 2019 a mixed-method evaluation using surveys, focus groups, and interviews was employed. Survey responses were reported as means and standard deviations and analyzed with two-sample t-tests in Microsoft Excel Version 16.45. Descriptive thematic analysis was conducted with narrative data. Two researchers independently conducted line-by-line coding, and the codes were assembled into categories and themes. Disagreements were resolved and results finalized with the full four-person research team. Tutor and student focus group, survey, and interview data were triangulated. Results: Thirty eight medical students and 12 tutors completed surveys (14% and 15% response rates, respectively). Four student focus groups (n=28) and three tutor interviews were conducted. Students and tutors felt small-group CBL surpassed intermediate -group CBL in fostering safety and engagement. Both groups benefited from combined CBL formats, recommended patient -narratives during early training, and endorsed tutor continuity in fostering safe, tailored learning environments. Conclusions: The reported findings are useful for health profession programs utilizing CBL, especially for early learner training. The conclusions and recommendations outlined herein have contributed to optimizing future iterations of CBL at the University of Toronto. Consideration of a combination of these findings when developing CBL curricula may help other institutions achieve program goals, while ensuring a safe and effective learning and teaching experience for the next generation of healthcare providers.