A Guide to Using Case-Based Learning in
Biochemistry Education
Verena Kulak
Genevieve Newton*
From the Department of Human Health and Nutritional Sciences,
University of Guelph, Ontario N1G 2W1, Canada
Abstract
Studies indicate that the majority of students in undergraduate biochemistry take a surface approach to learning,
associated with rote memorization of material, rather than
a deep approach, which implies higher cognitive processing. This behavior relates to poorer outcomes, including
impaired course performance and reduced knowledge
retention. The use of case-based learning (CBL) into biochemistry teaching may facilitate deep learning by increasing student engagement and interest. Abundant literature
on CBL exists but clear guidance on how to design and
implement case studies is not readily available. This guide
provides a representative review of CBL uses in science
and describes the process of developing CBL modules to
be used in biochemistry. Included is a framework to implement a directed CBL assisted with lectures in a contentdriven biochemistry course regardless of class size. Moreover, this guide can facilitate adopting CBL to other
courses. Consequently, the information presented herein
will be of value to undergraduate science educators with
C 2014 by The
an interest in active learning pedagogies. V
International Union of Biochemistry and Molecular Biology,
42(6):457–473, 2014.
Keywords: case-based learning; nutrition; biochemistry; active
learning
Introduction
An ongoing challenge for science educators is to find effective ways to facilitate the successful achievement of learning outcomes by undergraduate students. Beyond the
learning of content, there is a general need to develop
problem-solving, critical thinking, and communication
skills. Herreid [1] and Darabi et al. [2] describe that effective problem solving is related to asking for evidence, practicing cognitive flexibility, seeing alternative strategies, and
attempting creativity. Developing and exercising these
traits require a high-level of student engagement that is
commonly associated with a deep learning approach, first
€ ljo
€ [3] and further discussed by
defined by Marton and Sa
others [4–6]. To achieve these goals, scholarly research on
active learning models using cooperative techniques such
as case-based learning (CBL) has increased.
*Address for correspondence to: Human Health and Nutritional Sciences Department, University of Guelph, Guelph, Ontario N1G 2W1,
Canada. E-mail: newton@uoguelph.ca
Conflict of Interest: none.
Received 25 September 2013; Accepted 7 September 2014
DOI 10.1002/bmb.20823
Published online 23 October 2014 in Wiley Online Library
(wileyonlinelibrary.com)
Biochemistry and Molecular Biology Education
In science education, CBL aims at teaching content while
actively engaging students in real-life case study scenarios,
in order to expose students to the scientific process [7]. Evidence shows that CBL can encourage students to: (a) gather
and apply information to solve problems, (b) facilitate relevant information retention, and (c) refine communication [5].
It can also expose learners to decision-making roles and the
teamwork typical of professional environments. Lastly, CBL
can encourage students to develop the skills necessary for
life-long learning [8]. However, lecturing is still the favored
method of science teaching. Lecturing at the undergraduate
level typically includes an emphasis on memorizing facts and
a dismissal of concept application, which leads learners to be
disenchanted with science [9]. Most learners subjected to
these conditions opt to use lower order cognitive skills, which
are associated with a surface learning approach [5]. Moreover, the tendency toward a surface approach has been
remarked around the world in diverse fields such as nursing
[10], speech pathology [11], anatomy [12, 13], chemistry [14],
physics [15], and biochemistry [16–20]. These findings underline a need to encourage instructors to implement alternative
pedagogies such as CBL that may facilitate a higher level of
student engagement [21].
CBL has increased in popularity particularly among
biology instructors, but its use in other sciences is less significant [15]. Specifically, it is speculated that traditional
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Article
lecturers are unfamiliar with the evidence on CBL or do
not find it compelling. Indeed, there are several questions
that remain unanswered. For instance, there is still limited
evidence regarding the specific effect of CBL on promoting
a deep learning approach. To pursue this question, some
concerns need to be addressed. First, there is a lack of
detailed guidance and consensus on how to design cases
that can be used as research instruments. Second, effective
implementation of CBL is challenging. It requires systematic development of clearly defined learning objectives [17],
workload, and time limits [18]. It should also account for
the instructors’ teaching style and their willingness to facilitate students’ self-teaching [5]. Therefore, proper guidance
on case implementation is needed. Third, it is important to
provide an accessible introduction to CBL theory and practice to effectively engage novice instructors in the research
process. This article seeks to fill the aforementioned gap by
presenting a representative review of CBL, a cohesive stepby-step strategy to design and incorporate CBL into biochemistry education, and some insight into methods of
determining the outcomes of including such techniques into
biochemistry courses.
General Description of CBL
Definition of a Case
A case is the teaching medium in CBL. A case can often be
presented as a narrative resembling real-life situations that
provide a clear context and a central character, specimen,
or element, where a difficulty needs to be resolved [22, 23].
Therefore, the presentation of a problem is the initial step in
the learning process [24]. The narrative can be accompanied
by supporting information or scaffolding tools that facilitate
knowledge construction; tools such as research articles, laboratory results, or video screenings [8, 18, 25]. Case descriptions can be ambiguous but should contain enough detail to
elicit active analysis and interpretation [26, 27]. Cases can
be integrated with lectures or other pedagogies thereby
assisting in teaching content [28]. Cases can be provided in
advance of lectures and laboratories, although they may
also be presented after relevant lectures or in any other
sequences that suit the instructor’s style or learning outcomes. This strategic placement allows the students to structure their learning and to base the initial case analysis on
prior knowledge or through their own research [29–31].
Definitions of CBL and PBL
CBL is mainly rooted in the cooperative learning premise in
which the instructor acts as a facilitator in the construction
of knowledge. The instructor helps to direct students away
from an exclusively passive, in-class lecture-driven mode
[32]. Some authors consider CBL as a derivative model of
Problem-Based Learning (PBL), a popular pedagogic strategy that is widely used in medicine and law [33–35]. Other
workers use the terms interchangeably and simply refer to
458
a case as a problem [36–38]. Therefore, there is currently
a lack of clear distinction between PBL and CBL in the literature [39]. This adds difficulty to gathering specific evidence on CBL benefits and potential uses, which may in
turn discourage instructors from introducing CBL to suit
their own courses. The present guide agrees with a distinction between CBL and the classic PBL curriculum model as
described in Heinrichs [40]. The following paragraphs
define this distinction in more detail.
PBL commonly presents complex, open-ended problems
about topics previously unknown to the students. In the classic PBL model, solutions result almost exclusively from group
effort and self-teaching. Learned content depends on what
the students determine their own knowledge deficiencies are,
so solutions may vary from group to group [41, 42]. Lectures
are almost non-existent in PBL, and since group discussion is
so important, there is a general requirement for “fluid” classroom layouts with boardroom style tables and movable
chairs, which can be expensive to provide [43]. During problem processing, the instructor mediates students’ discussion
within each group instead of delivering information [44]. On
the contrary, Grauer et al. [45] indicated that in CBL, cases
are more structured, shorter, and less complex than in PBL.
Discussion does not normally dominate in-class time; therefore there is less dependency on specific classroom layouts.
Most CBL users aim to connect concepts by addressing predetermined learning issues or knowledge deficiencies [46].
Both PBL and CBL aim at teaching material on a “need
to know” basis: students become researchers and gather further information, integrate it, and then decide among themselves, which are the best solutions [36]. Medical schools use
PBL or CBL variants in preclinical courses including introductory biochemistry. However, the classical PBL method
with very little lecturing is time intensive for instructors [29].
Adapting this model to undergraduate biochemistry courses
outside of medicine presents specific challenges. Student
audiences in undergraduate biochemistry continue into varied science majors, so curricula are content-driven instead of
focusing on open-ended clinical diagnoses. In a large class
context, it may be unrealistic to expect a fair investment of
instructor’s time at the group level. To date, most publications on undergraduate case studies refer to the instructor’s
role as a facilitator at the whole class level [28, 47]. In CBL,
the instructor presents the case to the class and generally
does not interact intensively with each group during case
processing. Instead, the instructor may facilitate consensus
with the class as a whole to generate an integrated solution
after each group has worked on their own [34]. Hence, the
degree of instructors’ engagement at group level has been
interpreted as a methodology difference between PBL and
CBL [39].
Types of CBL Approaches
Cases can be processed in different ways depending on
topic, timelines, and learning outcomes. For instance,
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Biochemistry and
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timelines for case processing can vary from one to several
weeks [7]. Heinrichs [40] described four stages in solving a
case: (a) hypothesis generation to identify the cause; (b)
gathering of data and supporting information; (c) establishment of secondary learning issues and performing selfdirected study; and (d) hypothesis reassessment and merging of answers to reach an overall conclusion. Variations
on how these stages are attained give rise to several types
of case studies. Case types can be seen as part of a spectrum in regards to the degree of variation in elements such
as student involvement, group work, integration with lectures, case complexity, supporting information, and the
role of the instructor. Herein, PBL is interpreted as being at
one extreme of the spectrum of case study scenarios, with
a very high degree of self-directed learning, none or minimal didactic lecturing, a high level of case complexity, and
a collaborative learning environment guided by a trained
mediator. The variants of case studies discussed here—
lecture-based [22, 35], directed [7], interrupted [1], jigsaw
[48], and PBL [36]—differ primarily in the degree to which
students are self-guided and the degree of group interaction as shown in Fig. 1. The characteristics of each type
are described in Table 1.
History of Use
Herreid [22] postulates that the use of cases as an educational tool arises from the human appeal for story telling.
Kulak and Newton
The first recorded accounts of teaching with cases at the
university level date back from 1870 at Harvard Law
School, where Christopher Langdell introduced the Socratic
Method combined with original cases. Students were asked
to draw their own conclusions to imitate practicing lawyers
instead of memorizing law textbooks. Harvard Business
School also adapted this approach to emphasize discussions
following lectures [49]. During the early 1900’s, James Lorraine Smith, Clifford Albutt, and Richard Cabot independently used clinical cases in lectures to teach pathology in
medical schools at Edinburgh, Cambridge, and Harvard
respectively, following the precedent of the Paris school of
medicine from the late 1800’s [50]. By the end of the 20th
century most law, business, and medical schools globally
integrated cases to illustrate or apply content from lectures
in their curricula [49]. In science teaching, during the
1940’s, Conant [51] was the first to publish a variation on
the lecture-case method. He narrated case stories to transfer scientific principles to the general public. During the
1960’s, Eakin [52] would appear as a well-known scientist
in front of student audiences and by way of monologues
reasoned out loud how scientific principles were elucidated
in their historical context. In the West, during the 1970’s
and 1980’s, constructivism and developmental psychology
inspired the transformation of education at all levels. This
led to a more “student-centered” approach, including an
emphasis on group work to construct explanatory models
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CBL types classified based on the degree of group work, self-direction, use of lectures, and case complexity.
FIG 1
TABLE 1
Characteristics of the CBL types discussed in this article (Reproduced from Refs. 1, 7, 22, 35, 36, and 48)
Type of CBL
Lecture-based
Main characteristics
Instructor enacts or describes case and solution as part of regular lecture.
Students are passive (audience members) but can be asked to connect case to lecture material.
Directed
Allows for blended teaching: group work plus lectures or other pedagogies.
Supporting material is provided (figures, tables, texts, videos, etc.).
Specific questions accompany case and answers are close-ended.
Instructor facilitates discussion of the general solution with the whole class. Suitable to introductory courses, prior knowledge is provided in lectures.
Interrupted
Progressive disclosure of information to groups:
First stage: just a few clues are provided and students must generate a tentative solution.
Following stage(s): more details are provided to further develop solution.
Helps to illustrate how the scientific process works (handling incomplete data, generating tentative
hypotheses, encountering difficulties). Instructor facilitates discussion of the general solution
with the whole class. Suitable to advanced courses where prior knowledge is required.
Jigsaw
Students form groups and become experts at only one question and then the expert groups disband. New groups form with one expert member for each question. Solution results from integrating the contributions of each expert.
PBL
Groups are provided complex cases without many clues. No supporting information is given. Students come up with their own questions to solve. Solution is open-ended and depends on
where each group decides to focus their efforts. Instructor is trained in mediation to facilitate
discussion at group level.
of phenomena instead of memorizing facts [53, 54]. Additionally, there was recognition in academia of the
information-surge in many fields and the resulting need
for life-long learning, plus the need to develop interpersonal skills [36, 55]. Consequently, McMaster University
developed a PBL curriculum to train medical students in
solving complex situations and to offset increasing student
dissatisfaction with more traditional methods of teaching
[56]. Student groups were expected to solve clinical cases
by searching for the information themselves. This represented a shift from the traditional pedagogical paradigm
that relied on lectures to transfer most of the information
and to rely instead on other methods that facilitate developing the ability to ask relevant questions and make decisions on how to use information to generate appropriate
solutions. Early evidence on these alternative techniques
reflected a renewed enthusiasm in the classroom environment by instructors and students alike. This assisted in
the dispersion of cooperative learning tools in science
education [57]. At present, versions of PBL or CBL have
been adopted worldwide to teach medicine, dentistry,
nursing, engineering, general sciences, and the humanities [24, 58].
460
Pedagogical Impact of CBL & PBL
Like many other active learning techniques, CBL and PBL
derive from constructivist and other contemporary cognitive evidence indicating that experiences and contextualization promote knowledge transfer and the retention of information [4, 41, 59]. Evidence shows that CBL facilitates
accessing Bloom’s [60] higher-order cognitive skills such as
application, analysis, synthesis, and evaluation more than
lecturing alone [7, 18, 61–63]. CBL and PBL also provide
opportunities to practice and self-evaluate discipline-specific content [21, 28, 64]. Additionally, problem solving in a
face-to-face group setting has been shown to decrease failure rates [65]. In most variants of case studies, small
groups of students are challenged to listen and to make
trade-offs with others while confronting their own assumptions and values related to a topic, hence developing effective team work and improving communication skills [27,
66]. It should be noted, however, that some researchers
have found no effect of the implementation of PBL on
encouraging a deep learning approach [67, 68]. Therefore,
no generalizations can be made so far, as careful analyses
of the parameters measured vary greatly among studies.
Reports often lack information concerning the specific PBL
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Biochemistry and
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How to Develop a Case Study
Effects of CBL/PBL in Biochemistry
The success of a case depends on how effectively it facilitates acquiring, integrating and applying information and
how engaging it is to the students [73]. Case length, realism, and level of intrigue are important for gathering initial
attention, creating student involvement and promoting an
appropriate depth of discussion [9, 24, 74]. Cases can be
fact-driven and deductive with exact single solutions (closeended questions) [75], or they can be context-driven and
open-ended so that multiple solutions are reasonable [22].
Factors to consider when selecting, designing or implementing cases are class size, complexity of topic, allotted
time, academic level, and desired learning outcomes [76].
The level of difficulty or case complexity depends on the
amount of data and level of analysis required. In addition,
the expertise of the instructor as a group facilitator should
be considered, particularly because introducing CBL pedagogies may result in resistance from students unfamiliar
with them. To address this challenge it is helpful to provide
the case to the students along with a general framework of
CBL for them to follow, as well as a timeline and the goals
of the activity [66]. Struyven et al. [77] identified poor
instructional planning as the main cause of failure. The
success of CBL can also depend on the alignment of a case
with its assessment. For detailed guidance on this process,
refer to Biggs and Tang [5] and their suggestions on holistic
case study assessment. Short-answer questions or multiple
choice questions can be implemented in exams aligned
with CBL units. However, the emphasis should be on judging higher levels of cognitive learning such as understanding of contextual factors, problem analysis, and problem
solving [78]. Some examples on the type of questions suitable to accompany case studies are discussed in section
“Learning issues.” Other suggestions on how to assess students under a CBL environment are presented in section
“The Directed Case Method”.
Biochemistry and molecular biology are interdisciplinary
fields where a large amount of information is integrated
into an overall view of life processes. Biochemistry teaching
tends to be content-dense and lecture-driven. Assessment
is commonly done via multiple-choice tests focusing on
fact-recollection. Typically, these courses follow a lecturetextbook-laboratory format where lectures deliver 80% of
content to large student cohorts [16, 17]. This teaching context has lead to a lack of understanding of chemical interactions and their role in metabolic pathways [18, 19]. Additionally, Anderson et al. [69] indicated that in large
biochemistry classes, individual interactions between faculty and their many students is limited. This environment
does not provide opportunities to implement active learning
and does not discourage students from rote learning. Biochemistry is considered to be a difficult subject for most
students in part because it contains abstract concepts that
are difficult to understand if relationships to everyday
experiences are not demonstrated [20, 70, 71]. Normally,
undergraduate curricula are composed of one or two biochemistry courses presenting the main pathways that are
then integrated into a general view of cell metabolism.
Cornely [47] reported that in lecture-based courses, students were able to handle the individual metabolic paths
fairly easily but had trouble making connections among
them and relied on memorizing content to prepare for
tests. This has been interpreted as the result of student’s
inability to analyze, integrate, and apply previous knowledge. It has also been reported that students in introductory courses often lack critical thinking skills as well as
personal and social responsibility skills [16]. These findings
demonstrate a need to motivate students to understand
rather than memorize material as well as a need to foster
interest in active learning.
The literature is punctuated with examples of instructors using a student-centered or active learning approach
as an alternative to lecture-dominated courses. Dods [44]
described an early example of using PBL in biochemistry
and found that it promoted more effective learning of content than lectures. Rosing [72] indicated that there was a
higher level of satisfaction among students and instructors
using PBL in clinical biochemistry. Anderson et al. [69]
used a PBL curriculum in an introductory biochemistry
course and found that compared with non-PBL there was
an improvement in standardized test scores and that students had a more positive attitude toward the learning
experience. Hartfield [8] found similar results when using
CBL in an advanced biochemistry teaching unit. This evidence shows that increased student satisfaction and reduction in failure rates can result from applying CBL or PBL to
biochemistry courses.
Kulak and Newton
Characteristics of a Good Case
What to Include/What not to Include
Successful case design is labor intensive, as it should
include up-to-date and evidence based content and a nonlinear descriptive vignette that reflects real-life scenarios. A
vignette may include a description of symptoms, the progression of a disorder, or a disturbance in the environment
as experienced by the main character [28]. The description
should be presented in one or two paragraphs with an
engaging context. In most CBL types, the initial information
may have very specific guidance items and questions to be
provided to students. It is counterproductive to design cases
that are too long and provide tangential or irrelevant information that may confuse students, especially if time to
solve the case is limited and students have no prior knowledge of the subject [47]. In undergraduate science courses,
it is not recommended to design vignettes about political or
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or CBL method used and the complexity and degree of difficulty of the topics presented.
Good case features and their cognitive advantage. (Reproduced from Refs. 29, 40, 41, and 59).
FIG 2
religious views that may disengage the students from the
science themes to be explored. In addition, a vignette that
is too short will not motivate students to find out what happened next. For example, when introducing a case discussing a Salmonella infection via a food source, avoid simplified statements such as “A 25 year old male was admitted
to a hospital suffering from suspected kidney failure.” This
sentence provides a lot of information in a fairly impersonal manner. A more suitable introduction would be “On a
Friday night after work, Tom and his friends headed to a
local pub to celebrate his 25th birthday. Tom decided to
have some fresh made chicken tapas to start up.” This can
be followed by specific details on eventual symptoms that
462
led to kidney failure. A narrative that provides a name and
a setting is more likely to engage undergraduate students
from the beginning. It is also advised to avoid re-using
cases or related questions that post solutions easily found
online to prevent students from simply copying answers. A
compilation of good case features to include and their cognitive advantage is shown in Fig. 2.
Learning Outcomes
The first steps in case design include a careful consideration of the learning goals and the main route of action that
directs the students towards achieving them through case
analysis. In addition, when learning goals are being
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Biochemistry and
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Learning Issues
During case processing, students need to define knowledge
deficiencies, also called learning issues, relative to a particular topic. Learning issues can be provided by the instructor via specific questions or can be developed by the students themselves depending on what the learning goals are
[46]. For instance, during the initial stages of case processing, students should determine what is going to help them
with solving the case “Which types of molecules, cells, tissues, and organs are involved? What is considered their
normal functioning, physiology? What caused the physiological, metabolic problems?” These types of questions
allow for interpretation and integration of concepts. Other
questions requiring synthesis and evaluation can follow
“Why is a particular co-enzyme important in this system?
How can this system be restored? Why these symptoms
indicate impaired metabolism in this character?” Careful
selection of questions or guiding items is important to
define the level of difficulty or degree of analysis that the
instructor expects the case to provide. This follows reports
from Anderson et al. [69] indicating that knowledge application and integration are required in scenario-type questions leading to conclusions instead of fact recollection.
More specifically, an introduction to glycolysis can be
done with a case on galactosemia in humans (an inborn
error of metabolism causing an inability to convert galactose to glucose). If the vignette provides a series of symptoms and a diagnosis, learning issues related to glycolysis
can be initiated by close-ended descriptive questions that
require knowledge and comprehension, for instance: (a)
What is causing the accumulation of galactose? (b) What
Kulak and Newton
are the biochemical effects of galactosemia? These can be
followed by questions requiring analysis, synthesis, and
evaluation: Galactolipids are necessary for myelin formation. Explain how a patient on a galactose free diet would
synthesize galactolipids.
When teaching photosynthesis, a case involving a disturbance in a phytoplankton community can be designed.
For marine autotrophs, a case on carbon fixation could be
accompanied by a series of questions such as (a) Explain
how CO2 is used in photosynthesis, (b) Discuss the effect
that iron-rich waters have on marine phytoplankton and
how this ultimately affects the marine food chain, (c) Construct a concept map of the complete carbon cycle, its relationship to atmospheric CO2 formation and release of CO2
by burning fossil fuels, (d) How would all this affect a phytoplankton community living in Artic waters? Herein, the
first question requires knowledge and comprehension while
the second, third, and fourth questions require analysis,
synthesis, and evaluation of facts.
For content-heavy courses, such as biochemistry, a
series of cases can be presented throughout the academic
term to cover various topics [80]. For instance, multiple
cases can be sequenced to illustrate the different metabolic
paths, each presenting relevant learning issues to each
path. Case contexts and protagonists can differ to allow for
multiple voices and perspectives that intrigue the students
and keep them motivated. For instance, for humans and
other heterotrophs, carbohydrate metabolism can be taught
via five cases, covering glycolysis, the electron transport
chain (ETC), the citric acid cycle, as wells as gluconeogenesis and glycogen metabolism. For autotrophs, a case on
carbon fixation could be followed by others on cellular respiration. Fermentation pathways could be emphasized in
microbiology or advanced biochemistry courses.
Step-by-Step Case Design
Careful design results from the constructive alignment or
integration between the different pedagogical elements
imbedded in case studies [31]. This relieves some of the
pressure and workload that is experienced by students and
mitigates negativity in students’ perceptions of CBL. The
instructor should write the case and envision how the students may go about processing the data and learning
issues. Moust et al. [29] discussed problem solving and its
associated cognitive processing. These workers described
the case as a trigger to learning in a relevant context, with
the initial analysis helping the student to activate prior
knowledge and to define knowledge deficiencies. The problem solving process is hypothesized to stimulate growth via
self-study and group work and to lead to synthesis and
evaluation that aids in solving the case. In most PBL where
cases are open-ended, consensus on the solution may come
from group discussion mediated by the instructor. In CBL
types where cases are close-ended, solutions are more
straightforward and providing an answer key can facilitate
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established in a CBL environment, case design should
include how those goals would be shared with students
[79]. The instructor should consider what the students are
expected to know, practice or value by the end of the case.
For instance, in a biochemistry course, a main goal regarding content is not to simply memorize the chemical structure of glucose or the end products of glycolysis, but to
determine the value of knowing the structure of glucose or
how glycolysis is achieved or regulated. In a CBL environment, where a disruption to the normal carbohydrate
metabolism is introduced, the students would have to know
the structure of glucose in order to determine how or why
glucose interacts with other biochemical molecules for glycolysis to occur. By processing a case, students can go further by explaining how the glucose molecule is affected
within a system and if it is relevant to alter the supply of
glucose or other factors to modify certain metabolic circumstances. So, students are required to relate and analyze facts to explain a cause and effect context. Beyond the
learning of content, students are expected to exercise other
attributes like communication, teamwork, and professional
ethics. It is important to emphasize to students that these
are relevant learning goals.
Flow chart of case development. (Reproduced from Refs. 29, 80, and 123).
FIG 3
consensus. The instructor should generate a possible solution for open-ended cases or a detailed answer key for
close-ended cases beforehand to confirm that the learning
issues are covered effectively. If questions are provided by
the instructor and are close-ended, their solutions should
not be overlapping. Figure 3 schematizes a process to follow in case design.
Figure 4 shows a representative case based on up-todate evidence on the ETC and integrates the features mentioned above. This case integrates the biochemical basis of
ETC and what happens when a systemic disturbance is
introduced in a human subject. The condition afflicting the
main protagonist, Avery, relates to intake of a dietary supplement and its eventual negative physiological effect: liver
failure, an obvious clinical manifestation. This case stems
out of real clinical cases where supplements containing
usnic acid were the cause of metabolic injury. Some published clinical cases, which are likely to be found by the
students while doing their own research, are on the prodC and LipoKinetixV
C . The inclusion of these
ucts SomalyzV
products in the representative case was purposely avoided
because they contained antioxidants and were blends of
several bioactives. This was done to prevent cognitive frustration. Note that the fictitious supplement BulkFX is a
blend of a pharmacological dose of usnic acid, a small dose
of caffeine and the polysaccharide inulin.
The case and the accompanying learning issues nest
concepts within concepts: each learning issue has a specific
objective and there is a progression in cognitive complexity
that the students should address. Students are not merely
exposed to what the ETC is or the cascade reactions that
occur under normal circumstances, but how the pathway is
affected by the introduction of a disruptor and why the disruption affects whole-body homeostasis. Learning issues
one and two help to build a specific biochemical perspective that relates the ETC to oxidative phosphorylation.
464
Issues three to six allow for a progression to a broader
biochemical-physiological perspective by integrating the
disturbance on ETC as a trigger for tissue, organ, and systemic failure. Moreover, issues four to six should encourage
students to determine if the metabolic path affected could
be modified by other elements, which requires synthesis
and evaluation skills. To conclude, the case solution results
from looking at the ETC from three perspectives. First, students would be concerned with only the biochemical details
and the role of the compounds cited from test results
thereby relating the biochemical pathway to the clinical
outcomes, or simply put, to describe the symptoms from a
straightforward biochemical perspective. Second, students
should be able to interconnect the character’s condition to
other biochemical pathways demonstrating a deeper
understanding of how processes are interconnected and
highly integrated even though seemingly segregated and
compartmentalized within the living cell. In other words,
students should value the role that the ETC and oxidative
phosphorylation play in cellular respiration. Third, students
are asked to consider the broader physiological impact of
changes to normal biochemical processes. Students should
be able to discuss that ingesting the given dietary supplement over time, triggered the observable symptoms, and
disrupted the normal processes in Avery’s body. Overall,
students are asked to look at the ETC from an increasingly
broader perspective: from a disruption in the pathway, to
its impact on cells starting with the mitochondria, to further consequences on organs and tissues that provide
observable outcomes and health risks (Fig. 5). This provides the opportunity to perceive a biochemistry topic
beyond a static compilation of data and more as an opportunity to acquire, integrate, analyze, and interpret biochemical data that can assist in solving real-life dilemmas.
To illustrate how the same case can be modified and
implemented onto the different types of CBL, refer to Table
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Biochemistry and
Molecular Biology Education
2 for the resulting versions. It can be noted that the
lecture-based method does not use group work and students have a passive stand, so they might not be engaged
to the same degree in the case as with other CBL types.
The instructor shares all solutions as the case unfolds, so
Kulak and Newton
there is little opportunity for students to integrate knowledge themselves. The jigsaw method works well with topics
that are not content-heavy, when students have prior
knowledge or when there is generous time for class discussion. This is because each student develops expertise at
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ETC representative case. Case was adapted from several primary references 118–122.
FIG 4
FIG 5
Concept integration for the ETC representative
case.
only one question and it needs to be enough time for concept
integration. With content-heavy introductory courses, the
learning issues need to be adapted in a way that allows for
each member to work on the basics independently to avoid
knowledge deficiencies. For instance, the learning issues in
the representative case would require that all members
develop knowledge progression from biochemical into physiological concepts on the ETC. The interrupted method
expects students to handle inconclusive evidence in stages,
so it may be more suitable to advanced courses where students have prior knowledge and may be more capable of
handling progressive knowledge construction [1]. The case
when adapted into PBL becomes open-ended so each group
may have diverse learning issues and proposed solutions,
therefore the knowledge acquired will vary from group to
group. This may not be advantageous for introductory,
content-heavy courses or complex subjects such as the ETC
when time is limited. In addition, there is a need for a
trained facilitator who can invest significant amount of time
with each group to mediate discussion [43]. Several workers
have found that the directed CBL method proved advantageous to teach introductory biochemistry and other content
heavy disciplines due to its specificity and ease of alignment
with lectures [28, 46, 74, 81–83]. The following section discusses the directed CBL in more detail.
The Directed Case Method
Directed CBL along with lectures is well suited to introductory courses such as biochemistry, where students have
limited prior knowledge and timelines are short. Learning
issues are provided to students via questions constructed to
have single predetermined answers, so this method allows
for content-dense topics to be covered directly and specifically [28], resulting in homogeneity of taught content. The
representative case from Fig. 4 fits well into a directed CBL
aligned with a lecture on ETC. It can be used as a module
or unit on carbohydrate metabolism and its implementation
may follow the proposed framework shown in Fig. 6.
The directed CBL framework described in Fig. 6 allows
for the ETC unit to span over two sessions in one week.
The first session includes group randomization, case presentation and initial discussions plus a 60 min lecture. Students are expected to meet outside class and solve the
questions with the aid of textbooks and online resources. In
466
directed CBL, it is advantageous to provide students with
some specific references to maintain focus during case
development. During the final in-class session, students
present the group answers to the class or hand in a written
report. The instructor facilitates consensus so the whole
class will have access to the same unifying answers. The
representative ETC case provides six questions, suitable to
be processed by groups of six students. However, it is at
the discretion of the instructor to provide less or more
questions to suit the learning goals of a specific course.
Another modality would be to provide all groups of six students with three questions and then ask each group to
develop three more questions specific to their learning
needs. This encourages more initiative, reflection, and
higher student involvement with the process. To assess the
unit, the presentation or written report yields the same
grade for the group. To account for variable contributions
by group members, students may be asked to confidentially
evaluate other group members by submitting their estimated percentage contributions so these can be averaged
by the instructor and applied to the grade on the unit.
Challenges of Implementing CBL
Case implementation faces several challenges. Mozert and
Sudzina [66] described that the initial step of forming subgroups no larger than six students is advantageous for CBL
to allow for equal opportunity participation in peer instruction. In the example case, a group of six allows for each
student to focus on one question or learning issue and
negotiate integrated answers via group work. If students or
instructors are unfamiliar with CBL, time to adjust may be
necessary with a slow flow and depth of discussion at the
beginning. This is particularly important if students do not
find group work attractive. Ineffective group activation and
peer instruction may be a key impediment in the success of
case studies [29, 84]. Providing a set of basic rules may
help in this respect. For instance, it is helpful to explain
why working in groups is a valuable skill to develop.
Instructors should make an effort to memorize students’
names and to present the case with enthusiasm to facilitate
group activation [85].
To encourage understanding, students should be given
clear tips on how to approach the case and how to construct their answers, stressing not to copy from books or
articles but paraphrasing instead. Written communication
deficiencies become apparent when students find difficulty
in articulating and summarizing conclusions, which should
be clear and brief [28]. The instructor should obtain beforehand expertise in the case and should facilitate focused discussion to avoid diverting from the main topic and to alleviate time constraints, particularly if directed CBL with a
lecture is the chosen method.
Using CBL in Large Classes
Large-class environments are prevalent in undergraduate
settings across disciplines. Although there is no consensus
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Biochemistry and
Molecular Biology Education
ETC case adaptation into the five CBL types discussed in this article
Type
Case implementation
Lecture-based
Session one: Instructor becomes a protagonist and enacts the case as the ER physician treating
Avery. Case, test results, learning issues, and reasoning are all integrated into the story and
described out loud by the physician in a monologue. Case is given as an example to complement
a lecture on ETC. Instructor may ask students to connect case to lecture.
Directed
Session one: Case scenario is fully described: all data and references are provided. All learning
issues are provided as directed questions. A lecture on ETC is given. Everyone gets the same information. Each group solves all questions outside class.
Session two: Group answers are presented and the instructor facilitates a general discussion with
the whole class to find answers and consensus.
Interrupted
Session one: Avery’s case is not entirely described and learning issues 1 and 2 are given as questions 1 and 2. Small in-class discussion or homework is done within groups to develop tentative
solutions.
Session two: More details on Avery’s condition are given; Derek’s case and learning issues 4, 5, and
6 are given to groups to further develop the topic. Information from both sessions is integrated
and case concluded.
Jigsaw
Session one: Avery’s case is provided to six groups. Each group receives only one of the six learning
issues. Each group solves their question so they become “experts” at it. All groups should have a
clear view of the ETC basics. Requires previous knowledge because groups solving issues 4–6 handle integration of the ETC into physiology.
Session two: New groups are formed with one “expert” from previous groups, so each member
shares their answer to one question and the group integrates all answers into a general solution to
the case.
PBL
Session one: A full or briefer version of Avery’s case is given out, depending on learning goals. No
questions are provided to any group and there is no lecture on ETC.
Subsequent sessions: Case development depends on students’ initiative and contributions. Each
group develops their own questions. It might be used entirely without lectures. Requires clear definition of what is known, what is unknown and what needs to be known. Learning issues may go
beyond ETC, that is, body building diets, supplements use in body builders, and self-medication.
of what constitutes a large class, the term has been applied
to classes over 50, 60, or 100 students [86, 87]. There are
numerous reports on the use of case studies in large
classes. The lecture-method resembles traditional lectures
and can be used with large audiences but it promotes a
passive-learning approach [53]. PBL can be implemented to
large classes if appropriate physical and human resources
are available to support case processing allowing close
interaction between students and small-group facilitators.
However, limitation of resources may prevent the adoption
of the classic PBL as a new pedagogy [55].
Several workers have reported successful implementation of different small group models of CBL as well as modified versions of PBL in large science classes [88, 89]. Reddy
[90] found an improved performance in standardised
exams when implementing case studies with modified lectures that used Quick-Thinks (brief question periods
Kulak and Newton
imbedded in lectures). Nicholl and Lou [91] developed a
modified PBL with lectures and found that there was positive acceptance from faculty and students and there were
improved learning outcomes compared with classes using
the classic PBL at a reduction of the cost. Klegeris and Hurren [92] chose a tutor-less PBL model to assist students in
learning biochemical and physiological processes in a large
class. They found that the model had a significant positive
effect on student motivation to attend and participate in the
course work and that it was superior to a traditional lecture format with regard to the understanding of course
content and retention of information. They also demonstrated that student problem-solving skills were significantly improved, but commented that additional controlled
studies were needed to determine how much the PBL exercises contributed to this improvement. This research question led the authors to a second study showing that there
467
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TABLE 2
Proposed framework of a Directed CBL plus lecture with one case per week.
FIG 6
was indeed a statistically significant improvement in
generic problem solving skills [93]. Ochsendorf et al. [94]
reported that small-group case studies implemented with
weekly large class lectures generated greater student satisfaction than a lecture driven class. Their model used two
tutors that interacted with students at the large class level.
One tutor was a content expert and the other was a case
processing facilitator. Qin et al. [95] used a similar model
and found that the experience was positive for students
and facilitators.
Active learning has also been used in blended teaching
models where students and instructors interact online and
in-class. Potter and Overton [14] designed a chemistry
course in the context of sport and used concept mapping
tools, case studies, and web-based independent learning.
The student’s response to the learning resources and presentation of material was positive. Davidson [96] incorporated web-based cases, images, videos, and formative
assessment into a large class of first year undergraduates
and reported that blended teaching was successful at
increasing student’s acceptance of diverse instructional
468
methods noting that the benefits of active learning supported by online resources were dependent on the comfort
that instructors had with online software. Prunuske et al.
[97] followed an alternative strategy by designing online
lectures that could be watched ahead of class time. This
allowed for class time to be used for active learning activities. For successful implementation, instructors should
address issues such as motivation to interact [98], socialization processes [99] and paths to moderate online presence
and discussions [100]. Bridges et al. [101] found that
Course Management Systems and Learning Management
Systems assisted in the successful implementation of case
studies and lectures. Students were presented with various
online resources like lecture capture, discussions via SkyC
peV
and discussion boards. Howe and Schnabel [102]
explained that case processing using face-to-face contact
C , Desire2LearnV
C , BlackboardV
C , and webas well as WebCTV
blogs can be beneficial if the blend suits the teaching/learning style of both teachers and students. Supporting resources that provide scaffolding for case processing can be
transferrable to online platforms. The ETC directed case
CBL in Biochemistry Education
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Biochemistry and
Molecular Biology Education
Creating Engaging Topics for Biochemistry
Education
Despite its intricate links to nutrition, the biochemistry
found in most textbooks and teaching sessions describes
pathways as a set of molecules and not in direct context to
diet. Introducing nutritional elements in a CBL-based biochemistry course may allow increased student engagement
with the material, enhancing its relevance to students’ lives
and thereby promoting higher-order cognitive skills. Some
evidence shows that this novel approach yields positive
pedagogical outcomes, particularly in teaching macronutrient metabolism [7, 63, 103, 104]. Previous studies have
described the benefits of linking human nutrition to metabolic biochemistry understanding in active learning settings
that make material relatable to students’ lives. An early
report using CBL with nutrition elements is found in
Cornely [47], where most students had a positive reaction
to use of this technique. Hermes-Lima et al. [105] found
that student seminars on clinical applications like obesity,
diabetes, and iron metabolism increased concept integration and application among medical and nutrition students.
Similarly, Johnson et al. [106] noted that students using a
combined PBL-lecture format were better at integrating
biochemical concepts in an applied nutrition class. The
topics included anorexia, energy requirements for a triathlete, vitamin D deficiency, and dietary implications of cystic
fibrosis. Students also showed greater satisfaction with the
course, a greater appreciation of the need to study and a
better appreciation of nutrition as an integrated field.
Davies [7] incorporated CBL as a supplement to lectures to
integrate metabolic pathways and nutritional disorders and
reported that this format yielded better scores than a
lecture-based course. Feinman and Makowske [107] and
Pogozelski et al. [103] designed cases on the effect of lowcarbohydrate diets and found an increased level of discussion and interest among students. Heidemann and Urquhart [104] designed a case based on the dietary components of energy drinks to review biochemical principles.
The case was adapted to high school and undergraduate
classrooms with positive reception by instructors. Shaw
et al. [108] designed a case in sports nutrition where students analysed an athlete’s daily meal intake and reflected
upon protein requirements and suitability of nutritional
supplements. Macaulay et al. [109] introduced dietetic
cases into biochemical laboratory practice and reported
Kulak and Newton
that a majority of students found the experience intellectually stimulating. Other examples include Passos et al. [64]
who taught integrative metabolism to medical students by
using the students themselves as subjects in a real-life
experiment. In this study, student-subjects were fed one of
two diets, one hyperglicidic based on pasta, and one hyperlipidic based on pizza. Blood test results were then used to
generate a PBL to elucidate metabolic events. The authors
also aligned the final exam with a PBL format so students
were presented with a problem to be solved in an open–
book setting. Results showed an increased tendency by students to discuss data in terms of metabolic interpretations
rather than simply stating memorized pathways.
Since biochemistry usually includes a wide variety of
undergraduate majors, nutritional elements may not be the
only strategy to engage students’ attention. Other authors
teaching human biochemistry have designed cases based
on physical activity or non-nutritional clinical correlations.
For instance, cases dealing with alcoholism in young adults
to teach body fluid homeostasis [82], the effects of thalidomide to introduce the concept of chiral molecules [81], the
effect of environmental toxins like rotenone poisoning to
teach ETC [83], or the use of the fat substitute Olestra to
discuss lipid structure [74]. Millard [73] designed a series
of cases based on popular television medical dramas where
characters were patients at the ER suffering from drug
overuse; here, the cases were aimed at teaching enzyme
inhibition and lipid metabolism. Fardilha et al. [18] introduced a case with the screening of a feature film on Lorenzo’s oil. This was used to trigger case engagement on
inborn errors of metabolism. The authors concluded that
using a combined PBL-seminar-laboratory approach surpassed the traditional lecture-based method in facilitating
students’ ability to understand fatty acid metabolism. CBL
has also been adapted in pre-clinical veterinary education.
Schoeman et al. [110] reported that student’s ability to connect basic science to enhance clinical literacy increased
when cases on horses and dogs were used. In addition,
Ertmer et al. [111] found that CBL facilitated student’s ability to apply biochemical principles to pre-clinical veterinary
practice. Primary source articles can also be used as references to write cases. For instance, Kim et al. [112] provides
a study using lactic bacteria found in Kimchi that suppress
the growth of pathogens by affecting pH values. This paper
can be a starting point to develop a case on food science
and biochemistry.
Several case databases with miscellaneous topics are
available from educational institutions such as the University of Buffalo and the University of Delaware [74]. These
databases include a wide variety of science topics. However, the narratives can serve as departing points to design
new cases to suit biochemistry’s learning goals. For
instance, there is a case loosely based on the 1982 Chicago
Tylenol deaths caused by Tylenol capsules contaminated
with cyanide and its effects on the ETC [83]. Using the
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framework used in this article can be implemented in large
classes and the access to web-based resources as described
above can assist students during case processing. For
instance, the learning issues or questions can be provided
to students in-class for initial discussion and their group
responses can be posted online. A general discussion board
can be made available to small groups to prevent scheduling issues outside class time and lessen the dependency on
meeting room requirements.
published cases available from these databases is a valid
option; however, careful consideration of learning outcomes and type of CBL used should be observed because
these cases vary in the educational level being targeted.
Both databases also provide answer keys that can be
accessed by registered instructors.
It is strongly encouraged that instructors interested in
active learning seek interaction with the CBL community
via online gateways and journals. The National Science
Teachers Association in their Journal of College Science
Teaching publishes cases in every issue on diverse science
topics. The case design models in these cases differ from
the one suggested in sections above. Each author explains
the teaching rationale behind their case along with objectives and an implementation format. For instance, Diener
[113] wrote a case to introduce digestion and metabolism.
The information was presented in the form of a social network’s online dialogue between two friends in lieu of a formal narrative. The protagonists were young adults discussing weight loss, which is an engaging topic for this age
group. Other resources include Barnes et al. [114, 115],
which describes the pedagogical background of case writing and implementation as developed at Harvard Business
School. The University of Wisconsin has taken case processing further by organizing case competitions among
undergraduate students. Another of their projects is called
Case It! This is a collaborative CBL support project to teach
molecular biology [116]. Their case repertoire may be a
starting point for biochemistry cases as it includes inborn
errors of metabolism.
Conclusion
This article presents a review of CBL and the potential benefits of its use in biochemistry education. It also provides
concise and clear steps to help alleviate some of the challenges in case design. In turn, its contribution may facilitate
implementing cases as pedagogical aids and as research
instruments. Furthermore, the authors hope to spark a dialogue on case preparation standards to be used in science
teaching. This is important because most authors reporting
on CBL use do not disclose how their own cases were
developed. Thistlethwaite et al. [39] raise the point that
there is no research examining the process by which cases
are prepared and presented. Additionally, it is possible that
a lack of detailed guidance and consensus on case preparation is preventing instructors from considering CBL as a
teaching aid.
Current evidence on CBL comes from diverse research
questions, as well as varied sample sizes, student demographics and course level. For the most part, published
results do not disclose the level of difficulty of the implemented cases. These variations make comparisons and
generation of new evidence difficult. So far, evidence from
systematic reviews and meta-analyses on CBL indicate that
470
student motivation and satisfaction with these pedagogies
is positive. There are strong indicators that: (a) students
enjoy CBL, (b) students perceive CBL as an enhancement to
their learning, and (c) teachers enjoy teaching with CBL
because it engages students. This means that most reports
focus on outcomes largely dependent on overall experience
indicators (i.e. students found the experience enjoyable).
However, reported experiences are often based on anecdotes or student’s interviews. Although such feedback is
very informative, there is a need to corroborate such findings with statistically sound research instruments such as
validated student and teacher questionnaires [117]. The
potential benefits of CBL seem to be many; however, its
successful implementation in undergraduate science education and its effects on learning approaches remains largely
unquantified.
The interest in moving away from lecture-dominated
curricula into active learning or hybrid paradigms has generated numerous strategies and conceptual frameworks
available across disciplines. At present, there is no consensus that a single teaching method is superior to others. Different methods bring in advantages and disadvantages that
have not yet been measured in a manner that allows for
unbiased comparison. Lundeberg and Yadav [117] pointed
out that measurement is not as precise in pedagogical
research as it is in the sciences. Quantitative measurement
may limit methodology and research questions, so evidence
comparison is generated slowly. Overall, this context creates several difficulties.
First, CBL may facilitate a direct and active cognitive
experience in the learner but its long-term effects are yet
to be measured. Second, there is also a lack of comprehensive research on the effectiveness of CBL over other active
learning techniques or traditional lectures. Third, there is
an absence of evidence regarding the degree of success of
CBL at teaching content. These difficulties may hinder the
willingness of instructors to embrace change and to introduce CBL in their courses. This change implies a new cognitive pattern versus the one promoted by traditional lectures: a shift from relying on memorization alone to
embracing the effort to analyze, synthesize, and evaluate
scientific content.
There is a lack of consensus in the literature on the
definitions of CBL and PBL. The present review discusses
CBL and PBL as part of a spectrum following ideas from
Heinrichs [40] and Eberlein et al. [41] based on the level of
student engagement. A clear effort was made to integrate
the cognitive advantages and the good case features compiled from currently published evidence. More specifically,
the case design discussed and the proposed directed CBL
framework, aim at providing a cognitive platform for integration and evaluation of biochemical concepts encountered in lectures and textbooks. By having a real-life context where students are challenged to consider
perturbations of biochemical pathways as a possible cause
CBL in Biochemistry Education
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Biochemistry and
Molecular Biology Education
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