In the present study, we have studied case-based group discussions as a form of case-based clinical teaching. Our research questions were whether in course of the seminars, clinical teachers move from posing closed, fact oriented towards open, elaboration-oriented questions. Moreover, we have investigated how frequencies of reproductive and elaborative responses given by students develop over time across the clinical seminars. These research questions were analyzed based upon video data collected in case-based clinical seminars and analyzed by multiple raters with good reliability. For determining trends regarding the teacher questions / student responses, we compared eight equally long time-segments per seminar. Thereby, we detected no statistically significant differences regarding any of the variables. However, an increase over time regarding elaborative student contributions was apparent.
Conceptual descriptions of case-based didactic approaches in medical education stress that these are useful to bridge the gap between theory and practice, to teach clinical reasoning to advanced medical students and to help those acquire clinically relevant problem-solving skills (1, 16). However, given the results of our study, it is not apparent that the clinical teachers in the seminars managed to meet these goals in their instructional practice. Our data tentatively indicates that students contributed elaborative statements to class with a positive, however non-significant trend towards the end of the case-based seminars. At the same time, clinical teachers upheld a constant rate of closed, reproduction-oriented questions until the final stage of the seminars. Hence, it is not apparent that clinical teachers modified the types of questions they posed to push their students to elaborate, for instance, upon pros and cons of different therapeutic strategies. As other authors have formulated, “reliance on lower level questions diminishes the learner’s need to synthesize and formulate higher level answers” (9, p.544). In that sense, our results suggest that the case based seminars in our study were dominated by an informal, teacher-initiated division of labor between students and clinical teachers: Seemingly, the former were primarily responsible for providing facts, giving keywords and throwing brief ideas into the discussion, while the latter were adopting responsibility of weighing and evaluating these for their relevance in clinical practice. However, as is apparent from figures 1-4, substantial variance was apparent in our data. This points towards great heterogeneity between the seminars analyzed our study – which, overall, makes it difficult to identify statistically significant effects. For future research as well as for didactic interventions, this suggests that individual differences regarding starting conditions and teaching approaches between different teachers should more strongly be taken into account (22).
In the introduction, we have drawn upon the concepts of entrustable professional activities (12) and learners’ zone of proximal development (13) to substantiate the importance of moving from basic to more advanced questions. Our results suggest that clinical teachers did not deliberately attempt to push towards students’ zone of proximal development and did not progressively entrust a leading role to students in undertaking the more complex steps in analyzing the case at hand. In most cases, clinical teachers are much better able to analyze patient cases than their students based on their clinical experience and knowledge. However, in context of case-based teaching, they need to deliberately “suppress” this ability. Our study suggests that this is challenging for clinical teachers.
We argue that our results advance research on case-based didactic approaches in medical education, specifically of CBGD. They highlight that researchers should put more emphasis on investigating how teachers and learners interact in CBGD, as well as in other, dialogue-focused formats in medical education (23). Evidence from school settings shows that productive, learning oriented instructional discourse has measurable positive effects, e.g. regarding learning outcomes (24–26). With respect to medical education, such effects are just as plausible, but have rarely been deliberately investigated. Results which underline this conjecture come from studies on pimping or prodding (27–29). Through this form of direct questioning of medical students by clinical teachers, those deliberately attempt to disclose students’ knowledge gaps and potentially humiliate them in front of their peers. The fact that there are dozens of scholarly publications on this issue underscores that dialogic instructional practices – also critical ones! – are essential aspects of medical education. Video-based studies on teacher-student interaction in medical education are hence promising, on the one hand, to more precisely describe and contextualize such phenomena; on the other hand, as a valuable basis for conceptualizing didactic interventions dedicated to improve dialogic teaching practices (30, 31).
We finally address limitations of the present study and, on this basis, draw conclusions on future research. At first, the present study provides some hints towards more student-centered and effective interaction-based medical education. However, one limitation of our research approach surely is that we did not directly analyze student-teacher interaction patterns as they dynamically unfold during teaching. Instead, we counted all clinical teacher / student utterances relating to specific question / response categories and statistically explored their distribution over time. From a research strategic point of view, this is a promising first step; however, our study does not indicate why clinical teachers did not pose more open, elaboration-oriented questions. A second point relates to the fact that we empirically investigated CBGD as one specific form of case-based clinical teaching. Other, potentially more widely practiced forms of case-based teaching include elements which give learners a more active role and higher responsibility over prolonged periods of time. Based on the present results, we argue that this surely is one way to prevent clinical teachers from playing a too dominant role during the more complex, reasoning-oriented phases of case-based seminars.