case study for medical education

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Virtual reality and the transformation of medical education

Jack pottle.

A Oxford Medical Simulation London, UK

Medical education is changing. Simulation is increasingly becoming a cornerstone of clinical training and, though effective, is resource intensive. With increasing pressures on budgets and standardisation, virtual reality (VR) is emerging as a new method of delivering simulation. VR offers benefits for learners and educators, delivering cost-effective, repeatable, standardised clinical training on demand. A large body of evidence supports VR simulation in all industries, including healthcare. Though VR is not a panacea, it is a powerful educational tool for defined learning objectives and implementation is growing worldwide. The future of VR lies in its ongoing integration into curricula and with technological developments that allow shared simulated clinical experiences. This will facilitate quality interprofessional education at scale, independent of geography, and transform how we deliver education to the clinicians of the future.

Introduction

The pace of change in medical practice is relentless. The complex needs of an ageing population, the range of treatment options available, the interprofessional nature of care and the complexity of healthcare systems themselves are vastly different today than they were 20 years ago.

As such, how we prepare future clinicians for practice has had to adapt. It is no longer a question of whether an individual can retain or access facts, but how they use them, evaluate them and apply them to patient care.

There is therefore a move to replace rote learning with more clinically relevant and practical teaching. Problem-based learning, communication skills training and simulation-based learning have all entered curricula. With the increasing drive to provide clinical learning experiences, and the inherent difficulties in doing so, simulation in particular has gained momentum as a method of delivering experiential learning.

Simulation is an educational technique that involves creating situations that replicate real life, letting a learner act as they would do in real life, then providing feedback and debrief on performance. Simulation is effective in many domains and has been found to be ‘superior to traditional clinical education, producing powerful educational interventions that yield immediate and lasting results.’ 1

However, while simulation is becoming central to healthcare education, it requires significantly more resources than traditional education. At a time when healthcare systems and educational institutions globally are struggling with growing demands and limited budgets, additional resources are hard to come by.

Fortunately, there has been a recent dramatic expansion in the ways in which we can deliver medical education. This has not only been through the internet and mobile devices, but through immersive technologies. These technologies – including augmented reality (AR) and virtual reality (VR) – can transform how we deliver educational experiences.

VR in particular has been adopted across medical and nursing fields. VR involves the user putting on a VR headset to become completely immersed in an interactive virtual environment. When used with appropriate educational software, this allows the user to learn from experience in the virtual world. This paper outlines what VR is; its strengths, its weaknesses, the evidence behind it, its use in practice and where the future lies.

What is virtual reality?

VR is the use of software to create an immersive simulated environment. Unlike traditional user interfaces, to experience VR, users put on head-mounted display (HMD) which places the user inside an experience, where they can engage with the environment and virtual characters in a way that feels real. VR has a unique power, more than any other technology that has ever existed, to make users believe they are in a different environment. This allows them to learn from experience as they would do in real life. 2 This ability to deliver experiences on demand is where the power of VR lies.

Screen-based learning

Confusingly, screen-based learning has previously been referred to as ‘virtual reality’ in the medical literature. However, there is now an understanding that the value of virtual reality comes from immersion and the sense of presence – the feeling of ‘being there’ – that it generates. 3,4 As such, only VR that is immersive – using headsets that completely block out the real world – is now referred to as ‘virtual reality’.

360-video is a method of filming in 360 degrees to create a complete picture of the environment. To record 360-video, a camera is used that can film in every direction at once. Such recordings can then be viewed using a VR headset, allowing the viewer to feel like they are in the middle of the film. 360-video is a suitable medium if the aim is to provide the learner with a non-interactive experience of an environment. Examples of use include using 360-video to immerse patients in new virtual worlds to distract them during painful procedures.

However, 360-video is a largely passive experience. Viewers cannot interact realistically as the video is purely a linear recording, nor can they move realistically as the video is recorded from one location. This disconnect between the user’s movement in the real world with their lack of movement in the virtual world can also lead to a sense of nausea in 360-video.

Interactive VR

By contrast, interactive VR involves a totally immersive, dynamic, adaptive, interactive world.

If you can imagine being in a highly realistic computer game, you will have some approximation of what VR feels like. In the context of medical training this can include virtual wards, interactive patients, colleagues and relatives, with interaction similar to the real world.

For example, in a scenario of a patient with chest pain presenting to the emergency department (ED), the learner can be in the virtual ED, moving and interacting with the virtual environment and patient as they would in real life. They can take a history, examine, investigate, diagnose and treat the patient. Family members and an interdisciplinary team can be added, with everything from patient observations to blood gases to realistic conversation adapting dynamically, as in real life. Patients can become confused, agitated and look physically unwell, while the bustle of a virtual hospital and emotional engagement with emergency scenarios and lifelike characters in real time builds a sense of stress.

The focus in such scenarios is on decision making, critical thinking and clinical reasoning, with scenarios being designed to replicate human interaction in the real world.

Once scenarios are completed, learners can receive virtual debriefing and view automatically-generated feedback on their performance. This feedback and debrief is central to the learning outcomes in any simulation, whether delivered in VR or through a manikin. In VR, feedback can be provided on technical and non-technical skills carried out in the simulation relative to best practice. This allows learners to examine their performance in more detail and provides the opportunity for blended learning. It also facilitates peer learning as learners can share feedback with their colleagues and mentors as a basis for discussing specific learning points.

Companies, such as Oxford Medical Simulation, are already delivering such platforms globally, with scenarios covering medicine, nursing, paediatrics, psychiatry, and community health, with content expanding across fields.

What can VR offer?

VR offers distinct benefits for learners, faculty and the health system.

For learners, VR makes accessing clinical experiences simple. VR systems usually comprise a headset and laptop combination. They are commercially available, so are simple to setup, and designed for ease and safety of use. Many VR systems work with no faculty required. Learners can go to the VR system and take part in simulation whenever they like. This is not confined to large centres or high setup budgets so allows for much broader, flexible access.

This flexibility of access allows the integration of simulation-based education into everyday practice. Simulation can become a regular occurrence around other learning activities – more like going to the gym than a one-off faculty-heavy training day.

Vitally, VR scenarios are repeatable. This allows learners to make mistakes safely and then learn through deliberate practice to improve performance. This has been noted as one of the central features to successful simulation but one that cannot be accomplished with the space, time and faculty requirements of many simulation centres. 5

In addition, the psychological safety, enjoyable nature and potential for gamification of VR encourages engagement and autonomous learning.

From an institutional standpoint, VR allows simulation to be delivered at reduced cost with fewer resources. The costs of physical simulation vary widely between institutions and defining the cost of physical simulation is complex. In medical education and simulation, costs are often difficult to assess and, when attempts are made, are frequently under-reported. 6,7

Those studies that do attempt to define the cost of fully immersive medical simulation approximate that for one learner to lead one simulation scenario costs over £200; for example, McIntosh concludes ‘Set up cost was US$876,485 [£758,300] (renovation of existing facility, equipment). Fixed costs per year totalled $361,425 [£275,000]. Variable costs totalled $311 [£237] per course hour’ and Iglesias-Vázquez states that the ‘cost of ALS [advanced life support] simulation for a 4-day course is €1,320 [£1,140] per passed participant.’ 8,9

Virtual simulation costs often comprises hardware and software. High-end VR hardware costs approximately £3,000 for a setup (laptop and headset). Software costs depend on provider and quality of product, but is frequently under one-tenth of the cost of physical simulation independent of provider. 10 As such, there are substantial setup and running cost savings to be made with virtual reality.

As well as financial savings, such technologies free up space and faculty time. Faculty do not necessarily need extra training to be able to use the VR equipment – most is commercially available hardware and intuitive software. Once running, some VR setups require a faculty member to be present, others do not, and faculty input is often dictated by specific use cases of the given VR system.

VR can deliver the clinical scenario in a small space (2 x 2 m) with under 5 minutes of setup. This simplicity of use allows other simulation activities to take place in a centre while VR simulation is occurring. This can include more faculty focus on advanced communication skills or in situ simulation, neither of which is well-suited to VR.

Any virtual scenario should also be objective and standardised, ensuring consistent quality and adherence to protocols, so institutions can embed their latest protocols and ensure clinicians have practiced using them prior to seeing patients.

Additionally, many immersive systems allow the creation of bespoke simulation curricula to meet specific needs. These systems can also generate large amounts of performance data. This data is valuable for ensuring utilisation, encouraging learner engagement and for identifying struggling students who may benefit from further training.

Finally, from a global health perspective, this reduction in cost and equity of access allows simulation to be distributed globally. This potential to democratise the availability of quality medical training makes VR an exciting prospect in healthcare training.

What are the drawbacks?

Despite the advantages, VR simulation is not a panacea. Rather, it is a tool used to accomplish a defined set of learning outcomes and should be deployed as such, integrated within an institution’s curriculum and pedagogy to ensure effective use.

For example, VR is not suitable for every possible educational opportunity. It is not the best way to teach abdominal palpation; there is no need for complex immersion in this situation, just an accurate physical representation of an abdomen. The same applies for part task training, such as cannulation or many other procedural skills.

Virtual characters are often controlled by artificial intelligence (AI) systems. Though this is developing fast, it not yet suitable for certain learning objectives, such as breaking bad news. The complexities of language processing and facial expressions are, at present, best covered by a human rather than a virtual patient.

Educational barriers aside, there are difficulties with any new technology, implementing it requires faculty support. It can be difficult for faculty to engage more senior members, as they may see VR as a game, rather than an educational tool. However, many companies provide trial periods to allow educators to become comfortable with the technology, and fear of VR becomes less of an issue as its use becomes more widespread.

Key to the conversations that institutions have about VR is the acknowledgement that VR should not replace the expert educator. In much the same way that physical simulation should not replace clinical training, VR is just a technology to deliver a learning technique, in this case simulation. There are certain learning objectives that are best taught through physical simulation, there are others that are best taught through VR. Educators need to decide which objective they are looking to improve and determine the most appropriate method of delivery. With this approach, clinicians, universities and healthcare institutions can increase simulation delivery at reduced cost, while taking the burden off faculty and ensuring training quality.

Does VR simulation work?

Numerous lines of evidence demonstrate how VR and the immersion it offers deliver effective experiential learning. 3,11 The efficacy of VR is evident in practice, already being a vital teaching tool in multiple fields, including aviation, oil, shipping and the military. 12 In fact, the aviation industry credits VR-based simulation as a major contributor to a nearly 50% reduction in human error-related airline crashes since the 1970s. 13

Studies in healthcare support the value of VR. For example, medical students demonstrate significantly higher knowledge gain when using an immersive environment rather than screen-based learning. 4 Immersive VR has subsequently been widely adopted in surgical training where it has been shown to decrease injury, increase speed of operations and improve overall outcomes. It has now been absorbed into a large number of surgical programmes with excellent results. 14

While medical and nursing fields have been slower to take up VR than surgeons, there is plenty of evidence available. For example, VR can be used to train clinicians in complex procedures such as transvenous lead extraction, is effective in cardiopulmonary resuscitation training, can improve communication skills, enhance critical thinking and improve clinical decision making. 15–19

VR has also been favourably tested against physical simulation. In one paper, 84 nursing students were randomised to either a virtual or physical nursing simulation. Learning transfer was the same in both, with no significant difference in performance between groups, but the simulation in VR group was found to be significantly cheaper. 20

VR, therefore, has a number of benefits over traditional training and a solid evidence base across medical and nursing education. So how is it being used today?

How is VR used in practice?

VR simulation is used in medical and nursing schools as well as in postgraduate education around the world (Fig ​ (Fig1 1 ).

Virtual reality in use. a) Nursing student wearing a virtual reality headset. b) Performing a cardiac examination on a virtual patient. c) Projecting a virtual reality experience on multiple screens for group learning. d) Pupil responses to light in a virtual patient.

Practical implementation and curriculum integration vary depending on the VR platform and institutional need. See Box 1 for case studies on the University of Northampton and Oxford University Hospitals.

Case studies of universities using virtual reality simulation.

• University of Northampton
• The University of Northampton have created a virtual reality (VR) simulation suite for nursing students, with four sets of VR hardware and a large screen integrated in a physical simulation ward. This screen allows projection of what the learner is experiencing in VR onto the screen for group teaching. In small groups, learners take turns leading VR scenarios with real-time peer contribution, before doing a group debrief like physical simulation. This integration of VR within the simulation space ensures innovation complements existing educational structures and allows learners to practice simulation at scale while maintaining the value of peer support.
• As noted by the nursing faculty:
• Nurses require people skills, soft skills and clinical skills, and we needed to be able to train future nurses in a balanced way that caters to each of these skill sets. Technological developments are allowing us to do this in a safe and supportive learning environment, focusing on immediate feedback and the opportunity to repeat the scenarios and improve over time. VR simulation allows us to integrate theory into practice in a really meaningful manner, allowing students to progress throughout their academic careers.
• University of Oxford
• The University of Oxford are using VR simulation for their medical students and doctors working in the John Radcliffe Hospital. Rather than integrating VR in a defined simulation space, the faculty implemented mobile VR trolleys to transport their equipment wherever it is needed. Peer learning has been facilitated by groups of ‘super-users’ who introduce VR-naive students to the system. As a result of this, no faculty are required for use other than when they choose to review student progress or if the students approach them with clinical issues encountered in VR.
• The faculty explained:
• Simulation is a vital part of medical education and students just don’t get to do it enough. Embedding VR simulation into what we do has enabled us to give a far greater number of learners access to simulation in a shorter space of time, and lets them do it as often as they like to transfer their knowledge to practice. It’s encouraging to see how quickly our students have adopted the technology and I’m excited to see how they progress clinically as they use it more and more.

As well as hospitals and universities, VR systems are also being used across healthcare systems, with Health Education England, East of England supporting delivery of VR simulation across 18 NHS trusts from August 2019.

As such, VR simulation can fit around institutional needs as required. Though the specific examples mentioned here refer only to education and training, VR simulations are also being used in other areas. The standardised and objective nature of scenarios has allowed various institutions to implement assessment and recruitment programmes using VR. In recruitment, VR scenarios are being used as a proxy for clinical competency and form a basis for ongoing interviews. This facilitates recruitment locally as well as overseas, as the technology works in any setting and does not need expert faculty to run.

A number of institutions are also investigating VR from the standpoint of objective structured clinical examinations, as a method of decreasing the cost and increasing the objectivity of their assessment processes. These avenues remain at an early stage but are set to expand over the coming years.

In both assessment and recruitment situations, the utility of VR is in saving time, space, physical resources, need for expert faculty and removing geographical boundaries. In both cases however, the stakes are higher than in education and rigorous validation per institution becomes vital.

Where does the future lie?

As pressure to increase delivery of simulation continues, VR simulation will continue to expand. Rather than simulation being an occasional, faculty-led, day-long event, VR will allow simulation to be more like going to the gym. Learners will be able to do a scenario at the end of their shift or even at home, allowing continual improvement in performance to suit learner needs.

The standardisation and scoring possible with VR will make it commonplace in assessment and recruitment. In time, VR will become used routinely for continuing medical education and revalidation and become a benchmark to ensure clinical competency and patient safety across healthcare systems.

Then there are the technological advances. Increasing use of hand control (for complex procedural tasks) and voice control (for communication skills) are becoming viable. Haptics (the sense of touch in VR) will become increasingly used and all of these technological advances will become integrated within scenarios, blurring the lines between the real and the virtual.

The integration of AI will not only make interaction with virtual patients more realistic but allow increasingly in-depth analysis of clinical performance. AI can be used to tease out particular issues across large numbers of learners and offer dynamic, tailored scenarios to meet specific learning needs.

Most excitingly, although much current use focuses on individual learners in VR scenarios, multiplayer VR is becoming available. Multiplayer VR allows many disparate learners to see each other, talk to each other and interact with each other (and the patient) in the same virtual scenario.

This allows remote, collaborative learning in a real time clinical case – a paradigm that has never been possible before. With such systems, a doctor in Oxford can be seeing a virtual patient supported by a nurse in Delhi while being mentored by a professor in Baltimore.

This co-learning across cultures, essentially offering clinical experiences on demand, has the ability to revolutionise global healthcare education. The increased virtual clinical exposure that VR can offer, allowing an early focus on human factors and non-technical skills, also has the ability to accelerate learning curves, and will contribute to the potential shortening of training timelines.

VR is already transforming medical education. It is helping to free learning from the classroom, allowing learners to apply their knowledge to practice and learn from mistakes. It focuses on improving competencies and places the emphasis on autonomous, blended learning, which is expected from the learners of today.

As VR continues to be implemented and integrated within curricula, its use will become mainstream. The ability for multiple learners to take part in truly interprofessional, completely life-like simulation which is not bound by geography, is set to change how we conduct medical and interprofessional education beyond recognition.

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• Volume 9, Issue 9
• Can clinical case discussions foster clinical reasoning skills in undergraduate medical education? A randomised controlled trial
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• Marc Weidenbusch 1 , 2 ,
• http://orcid.org/0000-0003-2239-797X Benedikt Lenzer 1 ,
• Maximilian Sailer 3 ,
• Christian Strobel 1 ,
• Raphael Kunisch 2 ,
• Jan Kiesewetter 1 ,
• Martin R Fischer 1 ,
• http://orcid.org/0000-0002-3887-1181 Jan M Zottmann 1
• 1 Institute for Medical Education, University Hospital of LMU Munich , Munich , Germany
• 2 Department of Internal Medicine IV , University Hospital of LMU Munich , Munich , Germany
• 3 Department of Education , University of Passau , Passau , Germany
• Correspondence to Dr Jan M Zottmann; jan.zottmann{at}med.uni-muenchen.de

Objective Fostering clinical reasoning is a mainstay of medical education. Based on the clinicopathological conferences, we propose a case-based peer teaching approach called clinical case discussions (CCDs) to promote the respective skills in medical students. This study compares the effectiveness of different CCD formats with varying degrees of social interaction in fostering clinical reasoning.

Design, setting, participants A single-centre randomised controlled trial with a parallel design was conducted at a German university. Study participants (N=106) were stratified and tested regarding their clinical reasoning skills right after CCD participation and 2 weeks later.

Intervention Participants worked within a live discussion group (Live-CCD), a group watching recordings of the live discussions (Video-CCD) or a group working with printed cases (Paper-Cases). The presentation of case information followed an admission-discussion-summary sequence.

Primary and secondary outcome measures Clinical reasoning skills were measured with a knowledge application test addressing the students’ conceptual, strategic and conditional knowledge. Additionally, subjective learning outcomes were assessed.

Results With respect to learning outcomes, the Live-CCD group displayed the best results, followed by Video-CCD and Paper-Cases, F(2,87)=27.07, p<0.001, partial η 2 =0.384. No difference was found between Live-CCD and Video-CCD groups in the delayed post-test; however, both outperformed the Paper-Cases group, F(2,87)=30.91, p<0.001, partial η 2 =0.415. Regarding subjective learning outcomes, the Live-CCD received significantly better ratings than the other formats, F(2,85)=13.16, p<0.001, partial η 2 =0.236.

Conclusions This study demonstrates that the CCD approach is an effective and sustainable clinical reasoning teaching resource for medical students. Subjective learning outcomes underline the importance of learner (inter)activity in the acquisition of clinical reasoning skills in the context of case-based learning. Higher efficacy of more interactive formats can be attributed to positive effects of collaborative learning. Future research should investigate how the Live-CCD format can further be improved and how video-based CCDs can be enhanced through instructional support.

• undergraduate medical education
• case-based learning
• clinical reasoning
• social interaction
• medical decision making

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

http://dx.doi.org/10.1136/bmjopen-2018-025973

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Strengths and limitations of this study

First empirical study on the implementation of clinical case discussions in undergraduate medical education.

Comparison of clinical case discussions with differing grades of social interaction to determine their effectiveness on medical students’ acquisition of clinical reasoning skills by between-group analyses.

Implementation of multidimensional and multilayered test instruments in a pre-test, post-test and delayed post-test design to measure clinical reasoning skills with a knowledge application test and self-assessment.

The knowledge application test utilised in this study did not allow for a more in-depth analysis of clinical reasoning skills (ie, a distinction of conceptual, strategic and conditional knowledge).

Introduction

Curriculum developers face the challenge of implementing competence-oriented frameworks such as CanMEDS (Canada; http://www.royalcollege.ca/canmeds ), NKLM (Germany; http://www.nklm.de ) or PROFILES (Switzerland; http://www.profilesmed.ch ), including the need to train clinical reasoning skills as a medical doctor’s key competence. 1–3 As such, clinical reasoning skills are crucial not only for appropriate medical decision making but also to avoid diagnostic errors and the associated harm for both patients and healthcare systems. 4

Case-based learning has been proposed to foster clinical reasoning skills 5 and is well accepted among students. 6 Case-based learning found an early representation in clinicopathological conferences (CPC, first introduced by Cannon in 1900 7 ) which are practised until today. The CPC conducted at the Massachusetts General Hospital are published on a regular basis known as the Case Records series of the New England Journal of Medicine . In those CPCs, the ‘medical mystery’ 8 presented by the case under discussion calls readers to think about the possible diagnosis themselves, before it is finally disclosed at the last part of the CPC. Despite the absence of definitive evidence for efficacy as a teaching method, CPCs have widely been used in medical education since the early 20th century to foster clinical reasoning. 9–11 While CPC case records reach lots of medical readers around the world, they have been criticised as being anachronistic with a diagnosing ‘star’ (ie, the discussant), performing, acutely aware of being the centre of attention. 12

Case-based learning formats are embedded in a context, which is known to promote learning better than providing facts in an abstract, non-contextual form. 13 A definition found in the review by Merseth suggests three essential elements of a case: a case is real (ie, based on a real-life situation or event); it relies on careful research and study; it is ‘created explicitly for discussion and seeks to include sufficient detail and information to elicit active analysis and interpretation by users’. 14 Cases may be represented by means of text, pictures, videos and the like. Realism and authenticity are varying features of cases, 15 but particularly elaborated and authentic cases provide increased diagnostic challenge, comprising added value for medical training. 16

However, due to their setup, CPCs are often passive learning situations for participants, as they listen to the discussant laying out his or her clinical reasoning on the case under discussion. According to the ICAP framework by Chi et al , 17 teaching formats increase their efficacy from passive < active < constructive < interactive learning environments. Learning is enhanced when students interactively engage in discussions among each other. Accordingly, case-based learning has been found to be particularly beneficial in collaborative settings. 15 However, another important aspect to consider in collaborative learning environments is that some students may participate passively, while others contribute disproportionately much. To foster optimal learning effects, students should thus be encouraged to be interactively engaged. One prerequisite to achieve self-guided learning in groups is a low threshold for students to come forward with their questions and participate in ensuing discussions. 18 To this end, peer teaching has been established as an effective tool to stimulate discussions. 19 To make sure peer tutors are not overwhelmed in moderating these discussions, the presence of an experienced clinician appears to be warranted 20 in addition to a specific training of the tutors.

Taken together, while traditional CPCs encompass some important dimensions of effective case-based learning environments, they are not systematically aiming at constructive or interactive learner activities that are known features of effective teaching formats. 17 21 Therefore, we introduced clinical case discussions (CCD) in undergraduate medical education to account for these features. We still use the case records of the Massachusetts General Hospital, 9 as these cases exemplify realistic patient encounters and fulfil the criteria for an interactive collaborative learning process as explained above. In the CCD approach, cases are typically presented with information until the admission of the patient to the hospital. This event is usually the starting point of an interactive discussion phase of the group about possible diagnoses and diagnostic strategies. After all test results have been discussed, the actual diagnosis is disclosed and the pitfalls and take-home messages of the case are summarised.

To investigate the effectiveness of the CCD approach in undergraduate medical education, we designed an intervention trial and assessed clinical reasoning skills in medical students before and after participating in live CCDs or being exposed to video recordings of live CCDs. We compared these formats and their effects on clinical reasoning with the more traditional approach of working through written cases. When carrying out this randomised trial, we hypothesised that participation in live CCD sessions would lead to a higher increase of clinical reasoning skills than simply reading the cases. To better understand possible effects of the CCD learning environment with its social components on learning outcomes, participation in live CCDs as outlined above was additionally compared with the effects of watching videos of CCDs online. This comparison also seemed relevant from an economic point of view as videostreaming of lectures and seminars is prevalent at many institutions in higher education, allowing for flexible and scalable access to learning materials. 22 To investigate the potential of different CCD formats for regular curricular use, we also measured subjective learning outcomes after the intervention and correlated student self-assessments with objective changes in their clinical reasoning skills.

Participants

Initially, we recruited 106 volunteer medical students at the Medical Faculty of LMU Munich. Randomisation was performed in a two-step procedure. First, we selected a sample of roughly 100 enrolled students. Next, we stratified participants by creating triplets on the basis of the variables age, gender, year of study, prior CCD participation and performance in a knowledge application pre-test. This was done in an effort to limit the risk of random misdistribution of the selected sample. From each triplet, we randomly assigned participants to the experimental groups. A total of 90 participants eventually completed the study, 31 of them were male and 59 female. They were aged 20–41 years (M=23; SD=2.97) and in their first to eighth clinical semester (M=3.50; SD=1.78).

The study was approved by the ethics committee of the Medical Faculty of LMU Munich (approval reference no. 222–15). Written informed consent was obtained from all study participants and they received a financial reimbursement of 50 Euros on completion of the trial.

Patient and public involvement

No patients or public were involved in this research.

Study design

We conducted a single-centre randomised controlled trial consisting of a total of five course sessions with a parallel design (see figure 1 ). One week prior to the first CCD session, participants were introduced to the principles of the CCD approach and the sequence of this trial in an introductory session where they also took a knowledge application pre-test (T_0). In the experimental phase, participants attended 3 weekly interventional course sessions of 90 min each in one of three experimental groups with the respective CCD formats. Participants took a knowledge application post-test at the end of the last experimental course session (T_1), 4 weeks after pre-testing. A delayed knowledge application post-test was conducted 2 weeks after completion of the interventional courses (T_2); we deliberately chose that time interval to investigate the sustainability of possible effects while balancing the risk of postintervention confounding. 23

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Study design. Full data sets of 90 medical students were analysed. T_0, knowledge application pre-test; T_1, knowledge application post-test; T_2, delayed knowledge application post-test.

In all experimental groups, the intervention was based on the same three, independent internal medicine cases. Chief complaints in these cases were paraesthesia (first session), fever and respiratory failure (second session) and rapidly progressive respiratory failure (third session). 24–26 Cases were worked through in an iterative approach in different formats: (1) peer-moderated live case discussions in an interactive setting (Live-CCD, n=30), (2) a single-learner format utilising an interactive multimedia platform displaying video recordings of the live case discussions (Video-CCD, n=27) and (3) a single-learner format in which the students worked with the original paper cases of the NEJM (Paper-Cases, n=33). The cases were prepared in a way that participants in each format were exposed to the same case information.

In all three groups, cases were presented in a specified structured manner similar to the original CPC (see figure 2 ). In each format, the students (‘discussants’) had to fill out a form after the admission in which the case had to be summarised and a list of clinical problems and working diagnoses had to be provided. Subsequently, between discussion and summary a second case summary had to be completed in which the final diagnostic test and the most likely diagnosis had to be proposed.

Live-CCD structure. CCD sessions are divided into three parts. In the admission part, the presenting student shows the discussants his prepared slides (based on the original NEJM case record), after which the group has to agree on an assessment of the patient under discussion. In the interactive discussion part, the students prioritise the medical problems, link them to possible aetiologies and order tests to further corroborate or discard differential diagnoses. After all these tests have been discussed, students order the putative diagnostic test. The result is disclosed along with the pathological discussion and ‘take home messages’ on important differentials in the third part of the session. CBC, complete blood count; CC, chief complaint; CCD, clinical case discussion; CMP, comprehensive metabolic panel; CXR, chest radiograph; FH, family history; HPI, history of present illness; Meds, medications; PE, physical examination; PMH, past medical history; PT, prothrombin time; PTT, partial thromboplastin time; ROS, review of systems; SH, social history; UA, urine analysis; VS, vital signs.

In the Live-CCD group, the case presentation was prepared beforehand by a voluntary discussant (‘presenter’), who presented the facts in the admission (according to the structure shown in figure 2 ). Electronic slides and flipcharts were used to transport case information. Original test results were revealed by the presenter during the discussion only when requested by the group of students. Furthermore, the presenter summarised the differential diagnosis, important pathophysiological features of the case at the end of the session and provided a short take home message. The moderating medical students (‘moderator’) were recruited among previous CCD participants. They had experience in CCD moderation and had had an introductory training (2 days) in higher education methods and group facilitation prior to the study. The moderator facilitated the discussion process and ensured a reasonable approach to the patient encounter (eg, with respect to timing and hierarchy of ordered tests) in close communication with the discussants. Moreover, the moderator helped students develop their diagnostic strategy by co-evaluating their requested findings and the reasoning employed. Supervision of the correctness of medical facts and the correct diagnostic approach were ultimately granted by a clinician who could stop the discussion at any point when faulty reasoning was evident or discussants explicitly requested the facilitation of an experienced physician. The clinicians’ level of involvement into the discussion was left at their own discretion. We varied the staff between each Live-CCD to minimise effects of personal teacher characteristics. Live sessions typically lasted 90 min and were recorded with multiple cameras.

Students in the Video-CCD format worked on a single-learner multimedia workstation on which a video recording of the Live-CCD was displayed. These recordings also contained the electronic slide presentation from the Live-CCD and enabled simultaneous observation of the discussion from multiple camera angles. Participants could pause and partially skip the videos.

In the Paper-Cases group, participants received the case information of each CCD section sequentially (ie, admission, discussion, summary) in a print format. In both single-learner formats, students could choose their personal working speed. There was neither a prespecified minimum nor a maximum time they were required to work on the cases. In each of the three formats, full access to the internet was permitted for additional information.

Instruments

Learning outcomes with respect to clinical reasoning were measured with a knowledge application test that consisted of 29 items (ie, a maximum of 29 points could be achieved) and was to be filled out within 45 min. The knowledge application test was based on instruments previously developed at the Institute for Medical Education at LMU Munich. 27–29 It comprised multiple choice items, key feature problems and problem-solving tasks, addressing the conceptual, strategic and conditional knowledge of the participants (see figure 3 ). Meta-analyses on retest effects suggest that score increase is higher for identical forms than for parallel test forms. 30 In order to limit such effects, we applied parallel forms of the knowledge application test for premeasurement and postmeasurement (ie, topics covered by the individual items were the same, but the items were reformulated and their order was permutated). Overall test difficulty was chosen to be high in order to avoid ceiling effects, as students from all clinical years were allowed to participate in the study. Overall test reliability was satisfactory (Cronbach’s α=0.71).

Knowledge application test. Exemplary items are shown for each of the knowledge types addressed (arrows point to the correct answers). The test included 11 items on conceptual knowledge, nine items on strategic knowledge and nine items on conditional knowledge. BMI, body mass index; BP, blood pressure; EMS, emergency medical service; HR, heart rate; PE, physical examination; RR, respiratory rate; SpO 2 , oxygen saturation; T, temperature;

Subjective learning outcomes were measured at T_1 with a short questionnaire consisting of nine items (eg, ‘I learnt a lot during the CCD course’, ‘The CCD course increased my learning motivation’ or ‘I recommend the implementation of the CCD teaching format into the curriculum’; the full questionnaire is available as an online supplementary file ). Participants were asked to rate these items on a Likert scale ranging from 1 (I don’t agree) to 5 (I fully agree). Reliability of the corresponding scale was good (Cronbach’s α=0.95). Additionally, study participants were asked to share their views on positive and negative aspects of the respective training format through open items at the end of the questionnaire.

Supplemental material

Statistical analysis.

The required sample size (N=128) was estimated to detect medium effect sizes with a power of 80% and a significance level of α=0.05. For between-group analyses, one-way analyses of variances were conducted with post hoc Bonferroni tests for multiple comparisons.

Effects of the CCD format on learning outcomes related to clinical reasoning

Experimental groups differed significantly with respect to the knowledge application post-test (see table 1 ), F(2,87)=27.07, p<0.001, partial η 2 =0.384. The Live-CCD group (M=14.10; SD=3.32) outperformed both the Video-CCD (M=11.69; SD=3.34) and the Paper-Cases group (M=8.50; SD=2.44). Post hoc Bonferroni tests revealed significant differences between Live-CCD and Video-CCD (p=0.011) as well as the Paper-Cases group (p<0.001). The difference in the knowledge application post-test between Video-CCD and the Paper-Cases group was also significant (p<0.001).

• View inline

Overview of the findings of the study

Two weeks after course completion, the effect of the teaching format was still found in a delayed knowledge application post-test, F(2,87)=30.91, p<0.001, partial η 2 =0.415. Both Live-CCD (M=13.36; SD=3.23) and Video-CCD (M=11.84; SD=2.92) outperformed the Paper-Cases group (M=7.89; SD=2.41). Post hoc Bonferroni tests revealed significant differences between the Live-CCD and Paper-Cases group (p<0.001) as well as between the Video-CCD and Paper-Cases group (p<0.001). However, the difference between Live-CCD and Video-CCD was not significant in the delayed knowledge application post-test (p=0.146).

Effects of the CCD format on subjective learning outcomes

Experimental groups differed significantly with respect to subjective learning outcomes (see table 1 ), F(2,85)=13.16, p<0.001, partial η 2 =0.236. Participants of the Live-CCD group (M=4.20; SD=0.63) assigned better ratings to their course format than participants in the Video-CCD group (M=3.18; SD=1.24) and the Paper-Cases group (M=3.00; SD=0.99). Post hoc Bonferroni tests showed that the Live-CCD differed from the Video-CCD (p=0.001) and the Paper-Cases group (p<0.001) in this regard. An additional Duncan post hoc test confirmed that the Video-CCD and the Paper-Cases group did not differ from each other in this regard (p=0.48).

To investigate the relations between the subjective assessment and the knowledge application tests applied at the end and 2 weeks after the course, we calculated correlations between the different outcome measures. Subjective learning outcomes correlated on a medium level with both the knowledge application post-test (r=0.343, n=88, p=0.001) and the delayed knowledge application post-test (r=0.339, n=88, p=0.001).

In the Live-CCD group, 83% of the students were in favour of implementing routine Live-CCD into the medical curriculum. Only 45% and 31% of students from the Video-CCD and Paper-Cases groups voted for an implementation of their respective course in the curriculum. With respect to the open items from the subjective learning outcomes questionnaire, participants from all groups praised the quality of the cases. Participants from the Live-CCD group particularly valued their course format for providing an opportunity to practice ‘diagnostic thinking’ and the ‘focus on practice elements’. They also mentioned that ‘you can look up theoretical knowledge, but you cannot look up applied knowledge’. Students in the Video-CCD group, on the other hand, praised features of the digital learning environment as they could ‘pause, reflect or quickly do a Google search’ when watching the case discussions. However, they also criticised it was not possible for them to ‘participate in a more active way’.

This randomised controlled study shows that even relatively short CCD interventions can lead to improved and sustainable learning outcomes with respect to clinical reasoning. This provides evidence that the CCD approach, which is based on CPCs, is an effective teaching resource to foster clinical reasoning skills in medical students. We had hypothesised that a more interactive course format would result in an improvement of clinical reasoning skills when compared with less interactive formats. Results show that the Live-CCD indeed leads to the highest learning outcomes in medical students compared with less interactive formats. Consistent with our hypothesis, clinical reasoning skills, as measured with our knowledge application test, had the highest gain in the Live-CCD group. These positive effects of the CCD teaching format on clinical reasoning skills proved sustainable as shown by the results in the delayed knowledge application post-test. Overall, these results are in line with a recently published study on diagnostic reasoning 31 where students who worked in pairs were more accurate in their diagnosis than individual students despite having comparable knowledge. Collaborative clinical reasoning has thus far been under-represented in the literature and yet, seems to solve many of the educational problems regarding diagnostic errors. 32

The significant difference between the Live-CCD and the Video-CCD group can be explained by the findings of a meta-analysis that showed technology-assisted single-person learning to be inferior to group learning because of the decreased social interaction. 33 However, it is important to note that 2 weeks after the course, participants of the Live-CCD and Video-CCD groups did not differ significantly anymore while both groups still clearly outperformed the Paper-Cases group. In other words, watching a video of the live case discussion was found to be more beneficial for learners regarding their clinical reasoning skills than just reading the printed cases. We cannot rule out that Live-CCD and Video-CCD groups did not differ in the delayed knowledge application post-test due to underpowering of the study. As our trial was not designed to detect smaller effect sizes, this finding has to be treated with caution. Subjective learning outcomes suggest that students prefer the live discussion over the other formats. The subjective assessment correlated with the students’ performance in both knowledge application post-tests. Additional qualitative data from the open item answers suggests that the Live-CCD format supported students in performing clinical reasoning and that the active discussion of cases was particularly valued by the students.

Generalisability

The conclusions of this study are applicable to a broader audience of medical students. The CCD approach and its respective formats can easily be implemented in routine medical education. Peer teaching courses hold the promise of being more easy to install and more easy to staff than courses led by faculty. Of course, Live-CCDs still come with certain personnel requirements, as faculty as well as a moderator need to be present. Extensive preparation was not necessary for the clinicians involved though as they served as facilitators and provided guidance only in situations when they were explicitly asked for their clinical judgement or when they felt that the discussion went astray. Total time requirements might still be lower compared with other teaching formats. Likewise, the implementation of a singular 2-day training for moderators should not require extensive resources. The study population consisting of students with heterogeneous levels of clinical experience implies that the CCD is an effective teaching format not only for students at the beginning of their clinical career but also for intermediate students. Generalisability is potentially limited as only students from one medical school participated in our study.

Limitations of the study

There are certain limitations of this study that have to be addressed. One important limitation is the single-centre nature of this study and the relatively small sample size. Before the CCD approach can be implemented on a larger scale, a validation of our findings is therefore required. Caution is clearly warranted with the effect sizes shown in this trial, as it has been shown that effect sizes of learning intervention trials tend to be inflated compared with the effectiveness of the intervention when used in routine education. 34 Since we did not limit the time students had to work on the cases, we cannot entirely rule out that less time was spent on task in the single-learner formats and particularly the Paper-Cases group. Against this backdrop, we suggest replication to further validate the results found in this study and strengthen the outlined implications. The knowledge application test utilised in this study did not allow for a more in-depth analysis of clinical reasoning skills (ie, a distinction of conceptual, strategic and conditional knowledge). Larger item numbers could facilitate a reliable assessment of changes on the level of corresponding subscales. Finally, we cannot relate the underlying reasoning process with the measured knowledge gains. Further studies on clinical reasoning processes of individuals and groups are methodologically challenging but urgently needed for the advancement of a model of clinical reasoning and for improving teaching clinical reasoning. 35

Future research questions

Based on our findings, the CCD approach is a useful asset for medical educators to widen the range of clinical reasoning teaching tools. Live-CCD can thus be seen as a prime candidate for routine implementation in clinical reasoning curricula. Future research should aim to identify which Live-CCD elements (roles, case contents or course structure) contribute in which way to the improvement of clinical reasoning skills in medical students. The question if and to what extent such skills are applicable across domains is currently being discussed. 36 Future studies may also address the issue of transfer (ie, to what extent can clinical reasoning skills obtained in case-based training later be applied to different cases?). 37 Regarding the Video-CCD, means of instructional support to increase the effectiveness and interactivity of the video-based format should be investigated in an attempt to exploit its full potential.

Acknowledgments

The authors thank Johanna Huber and her team for technical support with the evaluation, Thomas Brendel and Thomas Bischoff for help with the video production and Mark S Pecker for critical reading of our manuscript and valuable suggestions. The authors also thank the CCD student discussants and moderators for their contributions. We wish to sincerely address our gratitude to the CCD team for organisational support with the study: Nora Koenemann, Simone Reichert, Sandra Petrenz, Fabian Haak, Bjoern Stolte, Simon Berhe, Bastian Brandt and Thomas Lautz. Marc Weidenbusch wishes to express special thanks to Bernd Gansbacher for introduction to CCDs.

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MW and BL are joint first authors.

Contributors MW, BL, MRF and JMZ planned the study. MW, BL and CS were responsible for data acquisition. MW, BL, MS, RK, JK, MRF and JMZ analysed and interpreted the data. MW, BL and JMZ drafted and revised the manuscript. All authors contributed to the significant intellectual content and gave final approval of the version to be published.

Funding This work was supported by the German Federal Ministry of Education and Research (grant no. 01PL12016) and an intramural grant of the Medical Faculty of the University of Munich (Lehre@LMU).

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data are available upon reasonable request.

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• Published: 03 March 2022

Educational Case Reports: Purpose, Style, and Format

• Alan K. Louie   ORCID: orcid.org/0000-0002-6762-1835 1 ,
• Richard Balon   ORCID: orcid.org/0000-0001-6598-2242 2 ,
• Eugene V. Beresin   ORCID: orcid.org/0000-0001-5627-7146 3 ,
• Anthony P. S. Guerrero   ORCID: orcid.org/0000-0002-2496-4934 4 ,
• Mary K. Morreale   ORCID: orcid.org/0000-0002-7921-0822 2 ,
• Rashi Aggarwal   ORCID: orcid.org/0000-0002-9744-3638 5 ,
• John Coverdale   ORCID: orcid.org/0000-0001-9301-4687 6 &
• Adam M. Brenner   ORCID: orcid.org/0000-0001-7244-651X 7  

Academic Psychiatry volume  46 ,  pages 147–150 ( 2022 ) Cite this article

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Case reports continue to play a time-honored role in academic medicine, by communicating clinical findings and advancing medicine [ 1 ]. Though a less rigorous level of evidence, because they describe one case that later may prove to be anomalous or “one-off,” some cases nevertheless have led to significant discoveries. Other fields, including law, business, and education, utilize their versions of case reports, often termed case studies. Law students read legal cases, proceedings, judgements, and verdicts. Business journals publish detailed accounts of the success or failure of corporations. The most germane to medical education is the use of case studies in graduate schools of education. Examples include reports of the implementation of a new teaching method, interventions, or programs at a particular school and, more broadly, the effects of a change in educational policy or regulations.

In this editorial, we discuss case reports about medical education and reflect on lessons we might learn from the tradition of case studies in the field of education at large. To be clear, we are focusing on reports in medicine about educational methodologies, interventions, initiatives, policies, application of adult learning theory, and the like. These reports are not to be confused with clinical case reports that are meant to be educational. Several journals specializing in medical education accept educational case reports, commonly about innovations in teaching medical students or residents. For instance, educational case reports have a specified manuscript type in some journals (e.g., Teaching and Learning in Medicine ) , while several other medical education journals have manuscript categories that will consider manuscripts that are essentially educational case reports (e.g., Innovation Reports ). To the extent that the nature of traditional case reports in clinical medicine differs from that of case studies in the discipline of education, one might suggest that medical education case reports could borrow the most useful guidelines from each field.

Academic Psychiatry includes among its types of manuscripts Educational Case Reports, which previously were subsumed under the educational resources’ column [ 2 ]. From 2014 to 2021, the percentage of this manuscript type has averaged 12% of the total published articles of all types in the journal. The acceptance rate is similar to the rate for all peer-reviewed articles in the journal. The exact nature of the articles in this manuscript type has evolved over time, as have the associated instructions to the authors. In recent years, the editors have encouraged, through the editorial process and suggested revisions, educational case reports to follow the description in this editorial. In what follows, we attempt to clarify further their current purpose, style, and format.

The following text is found in the instructions for authors of Academic Psychiatry [ 3 ]:

Educational case reports are practical in nature and might analyze, descriptively or ethnographically, how a particular teaching practice was applied in a specific setting. Examples include unexpected and subtle discoveries made while developing an innovative teaching method, reforming a curriculum, or launching a new course. A holistic review process considers that case reports in education tend to be naturalistic and relatively lacking in empirical data, but outcome data are still expected, such as qualitative or quantitative participant feedback. Quality of data, novelty of the case, and topic significance will be considered.

Comparison with the Journal’s In Brief Report category will be valuable. Both Educational Case Reports and In Brief Reports might be used to describe a novel teaching intervention implemented at a single site or institution. The In Brief Report would be most appropriate when the authors wish to focus on statistical analysis of the outcome measures. By contrast, an Educational Case Report would be chosen when the authors believe that the primary goal of publication is to share lessons learned from the process of defining the need, creating the intervention, overcoming the challenges in implementation, or interpreting ambiguous outcomes. It is important that the authors identify which of these (or other) kinds of lessons their case report is meant to illustrate.

A number of educational case report manuscripts are rejected by Academic Psychiatry , unfortunately, due to a frequent misunderstanding that the main objective of publishing an educational case report is to disseminate and share a course curriculum, created by the authors, absent outcomes other than student satisfaction. Sharing of curricula is a worthy objective, sparing others the task of creating the same curriculum on their own, but it is not the purpose of this manuscript type. Dissemination of one’s curriculum might be better accomplished by submission to websites that have a review process for curricula and regularly post them (e.g., MedEdPortal [ 4 ] and the website of the American Association of Directors of Psychiatric Residency Training [ 5 ]). The authors may list these peer-reviewed postings on their curriculum vitae.

Academic Psychiatry has been publishing fewer and fewer case reports that present new curricula, for several reasons. First, page and space limitations prevent the inclusion of particulars necessary for the dissemination of a curriculum in detail. Second, the journal’s reviewers evaluate submissions on the basis of their expertise in medical education and not in the content area of the curriculum being described in the manuscript. For example, if an author wants to share a model curriculum for teaching emergency psychiatry, a curriculum reviewer would be needed to assess whether the content about emergency psychiatry was accurate, appropriate, and acceptable for wide dissemination. Academic Psychiatry , however, does not provide reviews in subspecialty content areas, like emergency psychiatry; reviewers instead are asked to assess manuscripts on the basis of what they impart to the reader about medical education. Educational case reports about an emergency psychiatry curriculum should describe lessons learned about education, like difficulties in implementing the curriculum, how students reacted to the teaching methodology, the use of simulation, and educational outcomes. The fact that the curriculum, in this example, is about emergency psychiatry is somewhat incidental to these tasks. Of course, the content of the curriculum is of importance, but it only needs to be described to the extent necessary to explicate the educational lessons and observed outcomes.

By definition, an educational case report is usually about one “subject” (or at most a few in a multiple case report) whose case is described and studied with rich details. Educational case reports often use methods that are more qualitative and descriptive, in contrast to surveys or trials, which collect more superficial quantitative data from large samples that are amenable to statistical analysis and generalizable to populations. Thus, an educational case report may be idiographic, or even ethnographic, in style in order to tell the story of its singular subject. Akin to most qualitative research, educational case reports are more naturalistic in design, highly influenced by the specific context or single setting. They are generally narrative in style, since they tell the story of why the authors made the educational intervention and how the process played out.

Here, we may find some divergence in style between case reports in education from those in clinical medicine, in which clinician authors might frame the report as quasi-experimental and hypothesis-driven. For instance, the clinician may use the subject as his or her own control, involving periods on a medication, then off the medication, and finally back on the medication, and correlating symptom changes with these periods. Symptom severity might be given numerical ratings represented with descriptive statistics. Despite the disadvantage of having only one subject, many clinical case reports have been written in this manner and have been valuable, leading to larger quantitative studies.

Authors of educational case reports may want to continue in this clinical case report style but should also feel free to infuse elements of style from qualitative research traditions. This approach is appropriate for educational case reports due to their greater complexity. In particular, the subject is generally not a person, as in clinical cases, but rather, the unit of study is more often an educational intervention (e.g., course, curriculum, initiative). In telling the “story” of an intervention, the authors need to define clearly its boundaries [ 6 ]. Unlike a person who has easily understood physical boundaries, educational interventions need borders drawn between the subject of the report and the context in which it is embedded. For instance, in studying educational outcomes, is one looking at the effects of a single exercise embedded in a session, of a session embedded in a course, or of a course embedded in a curriculum, and how does one separate the effects of each? Which is the subject—the exercise, the course, or the curriculum? These important questions might use qualitative methods by including the learners in a focus group and understanding how the teaching intervention was understood and potentially assimilated into practice.

Additionally, the context surrounding the educational intervention is usually complex in the academic world, with multiple learners and many uncontrollable and unpredictable influences, perhaps more so than in clinical settings with one patient and pure pharmacological treatments. This context may include details that are not content-specific: whether attendance is required and consequences exist for not attending; whether advance readings for a flipped classroom model are reviewed by learners; if faculty are given protected time or paid for teaching and the course is given protected hours of instruction by the administration; how grades are determined; and other details often omitted in descriptions of model curricula. These factors influence the quality and effectiveness of education, such that the same curriculum delivered in two different contexts may have quite different degrees of success or failure, and may help readers to decide whether to adapt a described educational intervention in their institution (e.g., depending on resources).

The qualitative part of an educational case report should interrogate the “how” and “why” of the case [ 7 ]. Many authors overemphasize the “what,” the content of the curriculum, and focus on whether the “what” was effective, usually with learner satisfaction surveys. While this formula has resulted in some perfectly useful case reports, we do not think it leverages the strengths and potential of an educational case report. More valuable are the “how” (e.g., learning process) and “why” (e.g., mechanisms of learning) questions with regard to learning processes and speculation about mechanisms and causation. Readers may find transferability of some of these processes and mechanisms to their context. Of note, the “how” may include unanticipated and/or unpreventable changes or challenges relating to the educational intervention, occurring during the period of study, which may lead to modification of the intervention midstream. In clinical trials, this occurrence is undesirable, because conditions of the trials will then change, but in an educational case report, describing such changes gives a sense of the forces impinging on the intervention and its ability to adapt to them, which offers lessons learned along the away and the attempts to redirect efforts.

Many educational case reports describe a new course or curriculum designed in response to an educational need or gap in knowledge, skills, or attitudes. The report should start with evidence of this need and gap based on review of the literature (or lack of evidence in the literature), current existing solutions and how they have failed to date, and the authors’ innovative answer. Next, the educational intervention may be outlined; the content of the intervention (e.g., topics, assignments) need not be fully specified but can be shared in an abbreviated form. Particular attention should be drawn to defining the boundaries of the intervention, as alluded to earlier, and its context, along with how it is innovative. Assessment and qualitative measures, and possibly quantitative methods, used should be described that establish the educational outcomes. If quantitative methods are used, their validity needs to be addressed. Study data are then presented along with a narrative of what happened during the study, from start to finish. This text should include how the intervention ran, observation of learning processes, barriers, modifications, and changes that were required and the reaction to them, educational outcomes, and final impact and scalability. Additionally, inclusion of student perspectives, perhaps more than simple comments from evaluations, should be considered. Lessons learned along the way, propositions about how and why the outcomes came to be, and questions raised with novel perspectives should be proposed and critically argued in the conclusion. Mentioning limitations and the potential existence of multiple explanations, unsettled ambiguities, and researcher bias is also important.

The issue of informed consent and ethics review should be addressed. The manuscript should indicate the conclusions of an Institutional Review Board (IRB) review of the case report study and data to be published (e.g., exempt from further review status, approved). The IRB can advise about whether informed consent for being in the study is necessary, and the release of the case report should be considered from both the faculty members and learners.

As mentioned earlier, educational case reports may benefit from a hybrid of the styles from clinical case reports and qualitative reports. Various standardized formats for clinical case reports have been published. An international group developed the CARE ( CA se RE ports) guidelines for clinical case reports [ 8 ], and it is useful for authors to be aware of these. Several tools are provided with the CARE guidelines for authors, including a checklist for writing clinical case reports. Listed are traditional elements like clinical findings, diagnostic tools, treatments, and follow-up and outcomes. Of note, the guidelines include prompts to incorporate instruments measuring treatment adherence and side effects, explaining alteration of the treatment plan, and presenting a rationale for the clinical conclusions. Also requested is the treatment perspective of the patient and obtaining the patient’s informed consent for release of the case report. The CARE guidelines are best suited for clinical case reports, but authors may wish to adapt some elements to educational case reports, such as using tools to measure compliance with and acceptance of the educational intervention, explaining changes in the curriculum during the study, and describing a rationale for educational conclusions and lessons learned.

Authors may want to also consider formats designed for presentation of qualitative research. The Standards for Reporting Qualitative Research (SRQR) enumerates 21 points that should be covered [ 9 ]. Educational case reports may illustrate outcomes with qualitative methods like focus groups, interviews with learners and faculty, observations of the learning process, and textual analysis [ 10 ], which would provide a higher level of evidence and iterative data analysis than afforded by the use of Likert-scale student satisfaction questionnaires. SRQR endorses increasing trustworthiness and credibility with conclusions based on triangulation from more than one data source and providing transparency about any author’s attributes that might have biased the data gathering, analysis, and transferability. The application of advanced design and methods in case study research, used in education at large, may be found elsewhere [ 7 ].

Educational case reports are an important manuscript type and have been wonderful contributions to Academic Psychiatry . Educational case reports have followed the tradition of clinical case reports in medicine, which have a long history and have sometimes become early progenitors of novel perspectives and discoveries about disease and treatment. We suggest that educational case reports may also benefit from borrowing from the tradition of case studies in the field of education at large, which are considered as a form of qualitative research. In other words, educational case reports in medicine can take advantage of a hybrid style, combining elements from both clinical case reports and qualitative research studies, in proportions determined by the author fitting for the case.

Qualitative approaches and methods are useful in dealing with the great complexity of educational interventions and the contexts in which they are implemented. Qualitative writing encourages telling the story of the intervention in rich and deep detail over the course of the study, developing propositions of how and why the intervention’s processes and outcomes unfolded as they did. Therefore, one consideration for education researchers and perhaps for psychiatry in general is greater attention to teaching qualitative methods, as these have a rich foundation and are particularly applicable to psychiatry as a field. As a foundation, the format might adapt the relevant elements of a clinical case report, as described in the CARE guidelines. Then, authors who want to elaborate on the qualitative research features of their report may add in more rigorous qualitative methodologies, paradigms, and reporting standards. We are delighted to continue the fine tradition of Academic Psychiatry publishing educational case reports, and we look forward to your submissions.

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Alan K. Louie

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Louie, A.K., Balon, R., Beresin, E.V. et al. Educational Case Reports: Purpose, Style, and Format. Acad Psychiatry 46 , 147–150 (2022). https://doi.org/10.1007/s40596-022-01610-7

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The curious case of case study research

Affiliations.

• 1 Lee Kong Chian School of Medicine, Nanyang Technological University Ringgold Standard Institution, Singapore City, Singapore.
• 2 Division of Medical Education, Clinical Research Centre, Dalhousie University, Halifax, NS, Canada.
• 3 Community Health Sciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
• PMID: 33905143
• DOI: 10.1111/medu.14544

The conceptualisation of 'good' medical education research as hypothesis testing to identify universal truths that are generalisable across contexts has been challenged. Joining this conversation, the field of health professions education research is complex and contextual and there are ways of examining and reporting locally based activities and innovations, which can be of general value. This position leads to a focus on case study research (CSR), inquiry bound in time and place that generates thick descriptions and close interpretations to reach explanations. CSR has grown in sophistication in recent years and can inform practice and advance the science of medical and health professions education. The authors evaluated the current state of the science of CSR in the medical education literature by identifying and reviewing 160 papers. Most articles presented as 'case studies' were not in fact CSR. Moreover, most articles failed to go beyond a 'we did this' account. The authors explore definitions of CSR, and they examine dominant CSR methodologists, Yin, Stake and Merriam, and their respective approaches to CSR. They then set out some of the basic tenets of CSR (case definition, methods of data collection and analysis) and consider the logics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are considered next (such as emic and etic perspectives; ethical complexities; generalisability; quality; and reporting and reflexivity). The authors conclude that context is a mechanism, which needs to be understood, and rigorous CSR provides the structures and criticality to do so, opening up new areas of understanding and inquiry.

© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

• Biomedical Research*
• Education, Medical*
• Research Design

Case Studies in medical education: a platform for training medical students, scientific writing and critical thinking

Fundamental steps in artificial neural networks-based medical diagnosis

An overview of GDPR complying EU laws in writing a research proposal for human protection

• From providing a strong foundation for manuscripts to supporting many educational students research, scientific research writing case report helps to elaborate the narration about a therapeutic problem for one or more patients in the medical field.
• These case reports serve as the outline of the evidence for new interferences for an issue existing with previous therapy and also plays a vital role in producing evidence-based treatments.
• Pubrica gives you tips for the medical practitioners and professionals about the concepts and importance of case report in a research paper writing service.

Introduction

Case reports aim to give descriptive data about a clinical patient situation and to share an educational experience with medical and scientific groups. Case reports provide anacademic medium in circulating new diseases, thus increasing the knowledge of evaluation, diagnosis, and treatment of diseases. This blog outlines the need forregular case reports that are not only valuable to the general medical students but are also an essential part of medical education students. This blog also inspires medical trainers and students, residents, of all disciplines for writing case reports with the help of scientific Medical Writing Companies.

Importance of case presentation from grand rounds to journals

Medical Writing in Clinical Research for Case presentation is always an essential key for medical education and patient’s care that has to present more challengesto medical cases to an audience of medical studentsand attending physicians. Grand rounds are ancient in medicine that often, patients with severe disorders that are rare, difficult to give treatment, or difficult to diagnose are there in grand rounds. They act as a teaching tool for increasing medical knowledge and also to improve medical care. While participating in these rounds, medical students enhance critical thinking skills and grasp new information to avoid potential errors.

Case reports are an efficient tool for medical students to recognize clinical doubts get in their daily clinical practice in hospitals. Students are then allowed to draftanswers to many questions with the available adequate literature studies. During the search, students can critically appraise the medical literature and choose the specific literature for supporting the case.

While writing a case report or case series, students will perform,

• Students will gain experience in literature search and medical writing.
• Students perform the steps of evidence-based medicine,
• Providing the best evidence scientific research paper writing
• Critical appraisal for the evidence,
• Application of the evidence.

From analyzing a patient’s medical data to performing a physical test to considering various diagnoses, selecting a therapeutic plan, and determining multiple side effects and outcomes of therapeutics, case report write-ups serve an educational significance to medical students and fellows.

Case presentations are available in textbooks, conferences, daily team rounds, or grand rounds in the departments. Case presentations are an excellent source for sharing educational events. Some of the essentialacademictargets that case reports introduce is

• Creating awareness of rare disorders to provide diagnosis,
• Clarifying new doubts of a condition,
• Clarifying doubtful treatment response
• Describing to avoid future mistakes
• To improve medical writing for clinical trials.

Academic career preparation

Additionally, writing a case report will be an excellent preparation or exercise in a medical student’s profession, often preparing one for scientific research. Students can easily add the publications to their resume for fellowship applications and research proposals . They help to present some of the cases at national, international and regional medical conferences, supporting them to meet peers and staffs in the area of their study, to enhance their networking skills.

Evidence-based, innovative treatment

Case reports writing of the medical students can help to the first line of evidence for developing new therapeutics. A case, a woman with a long-standing past of psoriasis,gets treatment with infliximab, a tumour necrosis alpha-antibodies. Just after two weeks, the infusion of infliximab for her psoriasis shows significant improvement. This case report creates a new era of treatment for psoriasis. Many studies are still going about this event in medical Writing for Clinical research

Source of detecting adverse effects of treatment

These case reports may act as a source for detecting adverse effects, many times leading to the removal of certain drugs from thepharmamarket and supports research paper writing help . In the example of psoriasis, the process of psoriasis exacerbation with the application of interferon-alpha says a case report. There are several examples of severe adverse effects of drugs that get detection after the drugs should getapproval by the USFDA (Food and Drug Administration). Further, the case reports help to analyze the side effects due to interaction in drugs, as well as adverseof the medications given to renal failure patients.

The first report about a condition

When experiencing a rare pathology in the skincare clinic, the frequent procedures is to search for identical cases in any of the search engineson the internet. A vigorous literature search itself can be a useful task for a medical student .

Case report guidelines

A group of researchers publishes a set of systematic reporting guidelines to guide authors and students in writing case reports for research purposes. They come up with achecklist that gives a framework to satisfy the need for precision, completeness, and transparency for publishing case reports. By implementing their guidelines, students can write case reports with high reporting standards, and focus on individual patient care.

The challenging and diverse studies of medicine, many medical students will come across a puzzling patient case. A case report offers, medical students will know to perform a literature study, communicate with physicians in charge with the care of the patient’s health, structure a journal or manuscript, gain right name from the patient, collect data from different sources in the hospitals, clinical medicine research. Pubrica gives you vast information about the case report writing .

• Florek, A. G., & Dellavalle, R. P. (2016). Case reports in medical education: a platform for training medical students, residents, and fellows in scientific writing and critical thinking.
• Mian, A., & Khan, S. (2020). Medical education during pandemics: a UK perspective.  BMC medicine ,  18 (1), 1-2.
• Pottle, J. (2019). Virtual reality and the transformation of medical education.  Future healthcare journal ,  6 (3), 181.

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• Open access
• Published: 09 November 2023

Relationship between academic success, distance education learning environments, and its related factors among medical sciences students: a cross-sectional study

• Saeed Ghasempour 1 ,
• Maede Esmaeeli 1 ,
• Ali Abbasi 2 ,
• Ali Hosseinzadeh 3 , 4 &
• Hossein Ebrahimi   ORCID: orcid.org/0000-0001-5731-7103 4  

BMC Medical Education volume  23 , Article number:  847 ( 2023 ) Cite this article

211 Accesses

Metrics details

Academic success is among the most important criteria for determining students’ competence. Hence, one of the concerns of education system researchers has always been investigating its associated factors. Therefore, this study aimed to determine the relationship between academic success, distance education learning environments, and its related factors among Shahroud University of Medical Sciences students.

This cross-sectional study was conducted on 208 medical sciences students who completed at least two online and two in-person academic semesters. Participants were selected through the convenience sampling method and filled out three questionnaires, including the demographic information form, the Academic Success Inventory for College Students, and the Distance Education Learning Environments Survey. Finally, the data were analyzed using descriptive statistics and inferential tests (t-test, ANOVA, Pearson’s correlation coefficient, and multiple linear regression).

In this study, students reported moderate levels of academic success (107.81 ± 10.72). Moreover, they assessed their distance education learning environment as the positive points were more than the negative points (74.10 ± 14.89). Distance education learning environment ( β =  0.233 and P <  0.001) and field satisfaction ( β =  9.797 and P =  0.001) were also mentioned as factors related to students’ academic success.

According to the present results, it is suggested to improve the learning environment of distance education and increase students’ satisfaction to enhance their academic outcomes such as academic success.

Peer Review reports

Introduction

Students’ academic success in the university is one of the essential factors in their long-term career and social growth in life [ 1 ]. Additionally, it is one of the most critical concerns in any educational system [ 2 , 3 ]. Defining academic success is challenging [ 4 ]. Some papers define it as gaining knowledge and skills in a specific field and completing an academic course [ 5 ]. Some consider students’ grade point average (GPA) a measure of their success [ 6 ], and others believe that the university has duties beyond educating theoretical knowledge and should be able to create special abilities in students, especially in terms of spiritual-psychological, social, and scientific abilities [ 7 , 8 ]. However, York et al. (2015) defined academic success as acquiring the necessary knowledge and skills with the specified achievements to complete the courses, which includes six components: “Academic achievement, satisfaction, acquisition of skills and competencies, persistence, attainment of learning objectives, and career success” [ 5 ]. This complex concept includes objective and subjective dimensions. The objective dimension is the GPA and the student’s opinion about academic status. The subjective dimension includes academic satisfaction, persistence, and the perception of success in education [ 9 ].

Based on previous studies, one of the factors affecting students’ academic success is the learning environment [ 10 , 11 , 12 , 13 ]. The learning environment is defined as: “…social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape participants’ experiences, perceptions, and learning.” [ 14 ] In this regard, one of these learning environments is the learning environment of students’ distance education. During the COVID-19 pandemic, medical sciences universities directed students out of the hospital and the university toward distance education to comply with health protocols. They suspended most of their face-to-face activities and resorted to remote activities using online communication [ 15 , 16 , 17 ]. This sudden transition has been associated with challenges for universities and students [ 16 , 18 , 19 ]. Among these challenges are the deprivation of face-to-face training and meaningful clinical experiences in medical sciences [ 18 ], disruption of students’ daily schedules, nutritional disorders [ 20 ], depression, anxiety, and stress [ 21 , 22 , 23 ]. In Nepal, Kalauni et al. (2023) showed that 50.5%, 52.5%, and 44.6% of undergraduate health sciences students experienced symptoms of depression, anxiety, and stress during the COVID-19 pandemic, respectively [ 24 ]. Additionally, Yuan et al. (2021) reported the prevalence of anxiety and depressive symptoms in Chinese international medical students during this pandemic as 28.5% and 31.6%, respectively [ 25 ].

Examining the influential factors and determining the contribution of each one to academic progress helps determine strategies to identify the effective factors in academic success [ 26 ]. Various factors, such as intellect [ 27 ], progress motivation [ 28 ], mental health [ 29 ], academic self-efficacy, academic skill, academic enthusiasm [ 30 ], social support [ 31 ], academic procrastination [ 32 ], and career path adaptability [ 33 ], affect students’ academic success. According to Bayat et al. (2019), there was no significant relationship between the age and level of education of students and their academic success score, while the effect of marital status and place of residence on students’ academic success was significant [ 34 ]. Ghadirzadeh et al. (2017) demonstrated that among all demographic characteristics, only ethnicity and housing status (dormitory and nondormitory) are effective factors in the academic success of students, while age, gender, field, and academic semester did not show a significant relationship with students’ academic success [ 35 ]. However, contradictory results raise questions about the individual or social factors related to student academic success [ 36 ].

Assessing the factors associated with academic success has always been one of the concerns of researchers in the education system [ 37 , 38 , 39 ]. In addition, the COVID-19 pandemic caused significant disruptions and challenges to the students’ learning environment, and many were driven entirely to distance education. Hence, barriers to academic success that already exist in face-to-face and traditional classrooms may be compounded by this environment and exacerbated by pandemic-related stressors [ 40 ], which many believe harmed their academic success [ 41 ]. Until now, studies have yet to determine the relationship between academic success and the learning environment of students’ distance education during this pandemic. Therefore, this study aimed to determine the relationship between academic success, distance education learning environments, and its related factors among Shahroud University of Medical Sciences students.

Materials and methods

Research questions and hypotheses.

This study primarily aimed to determine the level of academic success and its relationship with the distance education learning environment. As a secondary aim, this study also tries to identify the possible relationship between academic success and demographic variables such as age, gender, marital status, academic semester, field of study, level of satisfaction with the field, income adequacy, residence status, and student’s GPA. Therefore, in addition to determining the student’s academic success rate, the following hypotheses will also be tested:

Q 1 : What is the academic success rate of Shahroud University of Medical Sciences students?

H 1 : There is an association between academic success and distance education learning environment.

H 2 : There is an association between academic success and age.

H 3 : There is an association between academic success and gender.

H 4 : There is an association between academic success and marital status.

H 5 : There is an association between academic success and the academic semester.

H 6 : There is an association between academic success and field of study.

H 7 : There is an association between academic success and field satisfaction.

H 8 : There is an association between academic success and income adequacy.

H 9 : There is an association between academic success and residence status.

H 10 : There is an association between academic success and GPA.

The study’s conceptual framework to better understand the research questions and hypotheses is given in Fig.  1 .

Conceptual framework of the study

Study design and participants

This cross-sectional study was performed in the first half of the academic year 2022–2023 on 208 students of Shahroud University of Medical Sciences. Students who completed at least two academic semesters online and two in-person were included using the convenience sampling method. The sample size was 208, calculated based on the study of Bayat et al. (2019) and considering the standard deviation of 10.63, the accuracy of 1.5 at the 95% confidence level [ 34 ], and the 8% dropout of samples.

Measurements

The data collection tools in this study were three questionnaires:

Demographic information form

In this form, information about age, gender, marital status, academic semester, field of study, level of satisfaction with the field, income adequacy, and student’s residence were asked. Notably, the total GPA (the minimum and maximum scores were 0 and 20, respectively) of all participating students was also obtained from the Informatics Unit of the University.

Academic success inventory for college students (ASICS)

Students’ academic success was measured using the ASICS instrument. This questionnaire consists of 39 items and ten components, including general academic skills (items 1–7), instructor’s effectiveness (items 8–11), career decision (items 12–14), external motivation for the future (items 15–18), trust (items 19–23), personal adjustment (item 24), self-regulation (items 25–27), socializing (items 28–31), internal motivation or interest (items 32–36) and lack of anxiety (items 37–39), designed by Welles, which is graded on a four-point scale (Completely agree = 4, Agree = 3, Disagree = 2 and Completely disagree = 1). Reverse items of this questionnaire were 9, 10, 11, 19, 24, 26, 27, 28, 29, 30, 31, 36, 37, 38, and 39 (“Completely agree” with a score of 1 and “Completely disagree” with a score of 4). To calculate the score of each component or subscale, the score of each item related to that subscale must be added together. Additionally, to calculate the overall score of the questionnaire, the scores of all questionnaire items must be added together. The score range of this questionnaire will be between 39 and 156. The higher the score obtained from this questionnaire, the higher the academic success. Welles et al. (2010) confirmed this questionnaire’s face, content, and construct validity and reported its reliability using Cronbach’s alpha method, 0.93 [ 7 ]. In the study by Adib-Hajbaghery et al. (2015), first, this questionnaire was translated into Persian using the process of translation and retranslation. Then, its face validity was confirmed by students, and several experts confirmed its content validity. In addition, its total reliability coefficient was calculated using Cronbach’s alpha method as 0.76 [ 42 ]. In the present study, the reliability of the Persian version of this questionnaire was 0.84 by Cronbach’s alpha method.

Distance education learning environments survey (DELES)

The DELES questionnaire was used to evaluate students’ distance education learning environment. This tool has 30 questions, with seven principal components, including instructor support (questions 1 to 7), student interaction (questions 8 to 11), personal relevance (questions 12 to 14), authentic learning (questions 15 to 17), active learning (questions 18 to 21), student autonomy (questions 22 to 24) and student perception (questions 25 to 30). The scoring scale of the DELES questionnaire is based on a five-point Likert scale (Never = 0, Rarely = 1, Sometimes = 2, Often = 3, Always = 4), and the range of scores obtained from this questionnaire will be between 0 and 120 points. Comprehension is feeble if the score is between 0 and 30. If the obtained score is between 31 and 60, the concept of maximum score among the set of problems is received. If the score is between 61 and 90, the positive points are more than the negative points, and if the score is between 91 and 120, it indicates an excellent condition [ 43 ]. The reliability of this questionnaire was obtained by Walker et al. (2005) using Cronbach’s alpha between 0.75 and 0.94. Its construct validity was also investigated using the factor analysis method (principal component analysis with varimax rotation and Kaiser normalization) [ 44 ]. This questionnaire was first translated into Persian and retranslated by Kuhpayehzadeh et al. (2017). Then, its face validity was confirmed by students, and several experts confirmed its content validity. Cronbach’s alpha of the Persian version of this questionnaire was reported as 0.93 [ 43 ]. The reliability of the Persian version of this questionnaire in the present study was also 0.89 by Cronbach’s alpha method.

Ethical considerations

First, the necessary permissions were obtained from the Vice President of Research and Technology and the Research Ethics Council of Shahroud University of Medical Sciences (Ethics code: IR.SHMU.REC.1401.051). Additionally, the necessary cooperation was made with the officials of all four nursing and midwifery, medicine, allied medical sciences, and public health faculties and the directors of each academic field. Then, the study objectives and the link to the relevant questionnaires were placed in the students’ groups and study channels, and they were asked to complete the questionnaires in their free time.

Statistical analysis

The data were analyzed using descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential tests (t-test, analysis of variance, Pearson correlation coefficient, and multiple linear regression) in SPSS software version 16. The significance level of the tests was considered 0.05.

Two hundred eight students from Shahroud University of Medical Sciences participated in the present study, of which most students (61.5%) were women. The mean and standard deviation of the participating students’ age, GPA, and academic semester were 21.88 ± 2.43, 16.31 ± 1.26, and 5.80 ± 1.94, respectively. Additionally, the mean score of students’ academic success was 107.81 ± 10.72. Demographic characteristics and mean scores of students’ academic success are shown separately in Table  1 . Students evaluated the mean score of their distance education learning environment as 74.10 ± 14.89. The mean scores of academic success and distance education learning environment of students by their components are given in Additional file 1 . The different levels of students’ distance education learning environment are also shown in Fig.  2 .

The level of students’ distance education learning environment

Based on the results, the mean score of students’ academic success according to gender, marital status, GPA, academic year, place of residence, and income adequacy did not have a statistically significant difference. The results of the one-way analysis of variance showed that the mean score of students’ academic success in different faculties was significantly different ( P =  0.011). Tukey’s post hoc test was used to track the difference between groups. Based on this, medical students had lower academic success mean scores than public health ( P =  0.025) and allied medical sciences ( P =  0.037) students. In addition, the mean score of academic success of students according to their satisfaction with their field of study also had a statistically significant difference ( P <  0.001), so that students with high satisfaction compared to students with moderate ( P <  0.001) and low satisfaction ( P =  0.005) reached a higher level of mean scores in academic success.

Pearson’s correlation coefficient results found a positive and significant correlation between academic success, distance education learning environment, and all its principal components except student perception ( P <  0.05). A negative and significant correlation was also between academic success and student perception ( P >  0.01 and r= -0.189). Pearson correlation coefficient results are shown in Table  2 .

According to the results of the multiple linear regression model using the Enter method, 18.17% of the variance of academic success was explained by the variables inside the model. This model showed that for each unit of increase in distance education learning environment, students’ mean academic success score increases by 0.233 units ( P <  0.001). In addition, students who were more satisfied with their field of study had 9.797 units of higher academic success than students with less satisfaction ( P =  0.001). The role of other independent variables on students’ academic success is given in Table  3 .

The present study was performed to determine the relationship between academic success, distance education learning environments, and its related factors among medical sciences students. Students in this study obtained a mean academic success score of 107.81 ± 10.72. In the study of Bayat et al. (2019) on Tehran University of Medical Sciences students, it was 108.87 ± 10.63, consistent with the present study’s results [ 34 ]. Meanwhile, in the study of Ghadirzadeh et al. (2017), nursing and midwifery students of Kashan University of Medical Sciences obtained a mean academic success score of 131.14 ± 41.10 [ 35 ]. It is worth noting that this study was performed before the COVID-19 pandemic and in face-to-face training. Hence, distance education in the wake of this pandemic and its adverse effect on students’ academic success may be among the possible reasons for this difference.

In this study, the majority of students listed the strengths of their distance education learning environment more than their weaknesses. In this regard, Lin et al.‘s (2021) study showed that contrary to expectations, after the onset of the COVID-19 pandemic, students had a more positive perception of their learning environment than before the beginning of this pandemic [ 45 ]. In Khalil et al.‘s (2020) study, most students positively perceived online learning during this sudden transition following the COVID-19 pandemic [ 46 ]. These findings indicate this educational method’s significant and promising potential to deal with critical and unpredictable conditions such as COVID-19.

A positive and significant correlation was also found between academic success and students’ distance education learning environment. In this regard, Omoniyi-Esan et al. (2022) found the learning environment to be one of the factors affecting students’ academic success. Hence, students’ experiences of their learning environment had a positive and significant relationship with their academic success, achievement, and satisfaction [ 10 ]. Additionally, Al-Qahtani (2015) mentioned the students’ approaches to studying and their educational environment as important factors that affect their learning and academic achievement [ 47 ]. Various studies also showed that the perceived educational environment affects academic outcomes such as academic achievement, well-being, social-emotional adjustment, and self-esteem of students [ 48 , 49 , 50 ]. Hence, an efficient learning platform helps students cope with distance education’s obstacles and challenges more easily and take advantage of this environment to improve their academic status. Therefore, educational managers and relevant officials can play a crucial role in promoting students’ academic success by creating this platform.

Contrary to what was expected, student perception, one of the components of the distance education learning environment, negatively correlated with academic success. However, in Ahmed et al.‘s (2018) study, which evaluated students’ perception of the learning environment based on the DREEM model and its relationship with their study year and academic performance, students with higher academic achievement had a more positive attitude towards their education, while students with lower academic achievement showed a more negative perception of education [ 51 ]. On the other hand, in the study of Al-Ansari et al. (2015), which was conducted to evaluate dental students’ perception of the educational environment based on the mentioned model and its relationship with their academic performance, there was no significant relationship between students’ perception of this environment and their academic performance, which was measured using GPA [ 52 ]. The possible reasons for this discrepancy are the difference in the face-to-face or distance nature of education and the tools for measuring students’ perception of the learning environment.

Other reasons for this contradiction can be found in other studies. In this regard, Jafari Asl et al. (2015) found that students’ expectations of the quality of educational services exceeded their perceptions, so the quality of these services was considered inappropriate from the students’ point of view [ 53 ]. In addition, in the study of Tofighi et al. (2011), which was performed to determine the gap in the quality of educational services based on the ServQual model at the Tehran University of Medical Sciences, students’ expectations of the quality of educational services were not met. There was a negative gap between the perceptions and expectations of students in all dimensions [ 54 ]. There may be a gap between students’ perceptions and expectations in this study, especially in students who experience higher levels of academic success. Therefore, the learning environment of distance education did not meet the expectations of these students regarding the quality of educational services provided, and they showed a more negative perception of this environment.

In the present study, there was no significant relationship between place of residence and students’ academic success. In this regard, SadeghiMovahed et al. (2013) considered the place of residence as one of the factors related to students’ academic success, so native students reported higher levels of academic success [ 55 ]. However, Adib-Hajbaghery et al. (2015) indicated that nonnative students living in the dormitory had higher academic success [ 42 ]. In justifying these contradictory results, distance education and online teaching on platforms such as Skyroom and Adobe Connect and the lack of location restrictions on these platforms should be mentioned. Hence, it is expected that during the COVID-19 pandemic and distance education, students with and without residence in a dormitory will experience similar levels of academic success.

The results of the present study demonstrated that the increase in satisfaction with the students’ field of study leads to higher academic success. Saravand et al. (2013) showed that successful students were more satisfied with their field of study than unsuccessful students [ 56 ]. Moreover, Kim et al. (2015) stated that satisfaction with the field of study is one of the factors affecting students’ academic success [ 57 ]. Younas et al.’s (2022) study conducted during the COVID-19 pandemic showed a positive and significant relationship between satisfaction with e-learning and students’ academic achievement [ 58 ]. Kim et al. (2022) also found satisfaction with online classes during this pandemic to be one of the factors influencing undergraduate nursing students’ academic achievement [ 59 ]. This satisfaction seems to increase students’ motivation, effort, and perseverance, which are essential in improving their academic performance. Therefore, it is expected that students who are more satisfied with their field and course of study will experience higher academic success.

In the present study, medical students obtained the lowest mean academic success score compared to other students. Intensive and complex educational curricula, challenging internship courses, frequent exams, and fear of failure have made the field of medicine one of the most stressful fields of study [ 60 , 61 ]. Todres et al. (2012) listed the compactness of course units and the lack of sufficient time to study courses as obstacles to the academic success of medical students [ 62 ]. In addition, during the COVID-19 pandemic, these students were deprived of many important clinical experiences, and a large part of their educational curriculum was presented virtually [ 18 ], which many believe has hurt their academic performance [ 41 ]. Therefore, students in this popular field are expected to have lower academic success than others.

Research limitations and recommendations

It should be noted that the present study was only performed on students of Shahroud University of Medical Sciences, making it difficult to generalize the results to nonmedical sciences universities in the country. Therefore, similar studies should be performed with a longitudinal design and a larger sample size in the future. It is also recommended that future studies investigate the impact of different learning methods on students’ academic success.

Students in this study experienced moderate levels of academic success. Additionally, they listed the strengths of their distance education learning environment more than its weaknesses. There was a positive and significant correlation between academic success and this environment. Satisfaction with the field of study was also mentioned as another factor related to students’ academic success.

These findings suggest that improving students’ distance education learning environment plays an important role in enhancing their academic success and dealing with possible critical and unpredictable conditions such as COVID-19. Therefore, educational managers and relevant officials can play a crucial role in improving the learning environment and academic outcomes, such as academic success, by holding group discussion meetings to understand educational problems, increase student satisfaction, and create constructive interaction to create an ideal and satisfactory learning environment.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Analysis of variance

Academic Success Inventory for College Students

Distance Education Learning Environments Survey

Dundee Ready Education Environment Measure

Grade point average

Service Quality

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Acknowledgements

The present study is a research project approved under the number 1401005 at Shahroud University of Medical Sciences. Researchers appreciate the support of the Vice President of Research and Technology of Shahroud University of Medical Sciences. Additionally, the authors sincerely thank the officials of nursing and midwifery, medicine, allied medical sciences, public health faculties, all participating students, and others who cooperated in this research.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Department of Epidemiology, School of Public Health, Shahroud University of Medical Sciences, Shahroud, Iran

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Study design: SGH, ME, HE; Data collection: SGH, ME; Data analysis: AH, AA; Manuscript writing: All authors (SGH, ME, AA, HE, and AH). All authors have read and approved the final manuscript.

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This study was approved under the Code of Ethics IR.SHMU.REC.1401.051 at the Ethics Council for Biomedical Research at Shahroud University of Medical Sciences. Each participant was completely informed about the study protocol and provided a written and informed consent form before taking part in the study.

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Ghasempour, S., Esmaeeli, M., Abbasi, A. et al. Relationship between academic success, distance education learning environments, and its related factors among medical sciences students: a cross-sectional study. BMC Med Educ 23 , 847 (2023). https://doi.org/10.1186/s12909-023-04856-3

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Top 10 free resources for medical students

Studying at medical school can be difficult if you don’t have the right support. Find the top free resources for medical students in our handy guide.

Starting medical school can be an exciting and overwhelming time. On your path to becoming an MD , there are so many lectures, tutorials, and clinical rotations to keep up with that it can be hard to know how best to consolidate your learning and keep on top of your studies.

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Tipped by many students as one of the most effective ways to learn, Anki is one of the best study tools for medical students out there. It can take a little practice to get the most out of it, but the clever use of active recall and spaced repetition is known to be one of the most efficient and effective ways to study. Use pre-made flashcard decks covering different medical specialties or make your own deck to help you ace that exam.

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As a medical student, you’ll need to access information from lots of different medical journals. Healthline saves you time and hassle by collating articles from all of the top medical journals into one convenient place. Covering a huge range of topics from Alzheimer’s to breast cancer, and depression to sexually transmitted diseases, it’s a must for any medical student looking to maximize their study time and avoid trawling through lots of different websites.

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Discover free resources split by clinical medicine, basic sciences, and even preparing for your medical residency. Created by medical professionals who hated the style of resources they saw at medical school, this resource is a forward-thinking hub of knowledge. 

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Need some help or extra practice interpreting medical imaging? Radiopaedia is an open-edit resource for all things radiology. With around 50,000 patient medical cases and expert reports, it’s an extensive online medical resource that can really help improve your radiology knowledge. There are also some fun quizzes you can do to test how much you’ve learned and compare your diagnoses and understanding against case findings.

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From up-to-date medical articles and research to podcasts, fellowship opportunities, and leadership training, the American Medical Association (AMA) is an incredible free resource for medical students and professionals who want to continue their learning journey. The AMA Ed Hub is a particularly useful tool for helping you find and track online courses and accredited programs in one place. It offers courses in various formats so you can read, watch, listen, or interact with course content the way you need to help you learn best.

10. UpToDate

UpToDate is jam-packed with medical knowledge that can help answer a student’s essential clinical questions. As its name implies, all the information in the app is updated regularly, evidence-based, and accurate, enabling students to use it as both a quick reference and an efficient information portal covering a wide range of topics. The free app features well-cited articles that provide a great starting point for any student’s inquiry, while the paid subscription version offers even more features.

Other resources and help for medical students

Our top 10 free resources for medical students are great for helping you maximize your study time and keeping your medical knowledge up to date with fun, educational, and interactive tools. But studying and working full-time can be a lot, so as well as online resources, make sure you look after your well-being and seek out further help and support, too, when you need it.

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An case study examples on medical school is a prosaic composition of a small volume and free composition, expressing individual impressions and thoughts on a specific occasion or issue and obviously not claiming a definitive or exhaustive interpretation of the subject.

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Assessing early learning (West and Central Africa)

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Improving child and adolescent health and nutrition through policy advocacy (Argentina)

Online diagnostic testing and interactive tutoring (Bulgaria)

Supporting the socio-emotional learning and psychological wellbeing of children through a whole-school approach (China)

Engaging parents to overcome reading poverty (India)

Integrated school health and wellness ensure better learning for students (India)

Instruction tailored to students’ learning levels improves literacy (Indonesia)

A whole-school approach to improve learning, safety and wellbeing (Jamaica)

Multi-sectoral programme to improve the nutrition of school-aged adolescents (Malawi)

Parents on the frontlines of early grade reading and math (Nigeria)

Training, inspiring and motivating early grade teachers to strengthen children’s skills in literacy and numeracy (Sierra Leone) Life skills and citizenship education through Experiential Learning Objects Bank (State of Palestine)

Curriculum reform to meet the individual needs of students (Uzbekistan)

Improving early grade reading and numeracy through ‘Catch-Up,’ a remedial learning programme (Zambia)

Reimagine Education / Digital learning

Education 2.0: skills-based education and digital learning (Egypt)

Empowering adolescents through co-creation of innovative digital solutions (Indonesia)

Virtual instructional leadership course (Jamaica)

Learning Bridges accelerates learning for over 600,000 students (Jordan)

Unleashing the potential of youth through the Youth Learning Passport (Jordan)

Lessons learned from the launch of the Learning Passport Shkollat.org (Kosovo)

Opening up the frontiers of digital learning with the Learning Passport (Lao PDR)

Building teachers’ confidence and capacity to provide online learning (Maldives)

Mauritania’s first digital learning program: Akelius Digital French Course (Mauritania)

Mitigating learning loss and strengthening foundational skills through the Learning Passport (Mexico)

Expanding digital learning opportunities and connectivity for all learners (Tajikistan)

For COVID-19 education case studies, please click here and filter by area of work (Education) and type (Case Study / Field Notes).

Resources for partners

Learning at the heart of education

Key Asks 2021 - National Reviews - SDG 4 Quality Education

More from UNICEF

Transforming education in africa.

An evidence-based overview and recommendations for long-term improvements

Early Childhood Education for All

It is time for a world where all children enter school equipped with the skills they need to succeed.

A world ready to learn

Prioritizing quality early childhood education

Mission: Recovery education in humanitarian countries

Updates on UNICEF’s work to deliver education to children in crisis-affected countries, with support from the US Government

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Medical Case Study Example

Medical case studies are generally considered some of the most challenging types of academic writing assignments for several reasons: they require deep knowledge of various practices, theories and approaches; they are extremely time-consuming, since they require examining, studying and researching many materials; and they require use of specific medical terms, models, concepts and lexis.

Writing a medical case study is a serious task for any student. Therefore, when assigned to write a medical case study, a thorough preparation is in order, which includes getting thoroughly acquainted with basic standards, rules and recommendations for writing a good case study on a medical subject. Another good tip, for those struggling with their medical case study, is to review some medical case study examples written by professional writers, skilled and experienced in writing such papers.

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The following extract has been taken from a medical case study example on Communication Disorder. The main purpose of this medical case study example is to show the problem of learning disability and language delay in children. Moreover, this medical case study example highlights various therapy goals most commonly described by professionals working with children with learning disabilities.

SPEECH & HEARING CENTER

Communication Disorder. Learning Disability Therapy Goals

Case One Psychologists observe that unless a child develops appropriate play skills through interaction with peers and objects, their social development is significantly impaired. Based on this argument, the goal of the therapy is to enhance specific skills necessary for interacting with peers and objects in a playground environment.

Case Two The second case therapy is aimed to enhance a child’s ability to develop his or her speech. The therapist recognized the need to help the child develop his or her speech through the auditory model.

Case Three In case three, the therapist attempted to improve a child’s language modality. This being a non-fluent aphasia case, the clinician employed the melodic intonation therapy to help the child achieve the goal.

Case Four In the fourth case, the therapy is aimed at improving a child’s playing ability in a social setting. Since most mentally ill children exhibit different problems with interacting with peers, the imitation strategy was used in this case.

Case Five The therapy in this case is aimed at establishing what is required for intervention. In achieving this goal, the therapist sought to establish whether there were other contextual variables that facilitated the observed behaviors.

Materials: Books? Games? Toys? Homemade or Commercial Instruments? Games, books, toys, homemade or commercial instruments are vital tools that can be used to …

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This extract from a medical case study example is intended to show you how to approach your case study analysis. Even though the extract is quite short, it clearly demonstrates that to complete a good case study, you will be required to review numerous cases, distinguish specific methods, approaches, models used in each case, and finally provide your critical analysis of how effective they were. In this type of academic writing, you must be as precise, laconic and direct as possible. At the same time, you need to clearly demonstrate your ability to operate specific medical concepts and terms, distinguish even the slightest nuances and be creative in your analysis. And all of this must be completed within specific time constraints!

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