Case-based or non-case-based questions for teaching postgraduate physicians: a randomized crossover trial

Acad Med. 2009 Oct;84(10):1419-25. doi: 10.1097/ACM.0b013e3181b6b36e.


Purpose: The comparative efficacy of case-based (CB) and non-CB self-assessment questions in Web-based instruction is unknown. The authors sought to compare CB and non-CB questions.

Method: The authors conducted a randomized crossover trial in the continuity clinics of two academic residency programs. Four Web-based modules on ambulatory medicine were developed in both CB (periodic questions based on patient scenarios) and non-CB (questions matched for content but lacking patient scenarios) formats. Participants completed two modules in each format (sequence randomly assigned). Participants also completed a pretest of applied knowledge for two modules (randomly assigned).

Results: For the 130 participating internal medicine and family medicine residents, knowledge scores improved significantly (P < .0001) from pretest (mean: 53.5; SE: 1.1) to posttest (75.1; SE: 0.7). Posttest knowledge scores were similar in CB (75.0; SE: 0.1) and non-CB formats (74.7; SE: 1.1); the 95% CI was -1.6, 2.2 (P = .76). A nearly significant (P = .062) interaction between format and the presence or absence of pretest suggested a differential effect of question format, depending on pretest. Overall, those taking pretests had higher posttest knowledge scores (76.7; SE: 1.1) than did those not taking pretests (73.0; SE: 1.1; 95% CI: 1.7, 5.6; P = .0003). Learners preferred the CB format. Time required was similar (CB: 42.5; SE: 1.8 minutes, non-CB: 40.9; SE: 1.8 minutes; P = .22).

Conclusions: Our findings suggest that, among postgraduate physicians, CB and non-CB questions have similar effects on knowledge scores, but learners prefer CB questions. Pretests influence posttest scores.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Cross-Over Studies
  • Education, Medical, Continuing / methods*
  • Family Practice / education*
  • Humans
  • Internal Medicine / education*
  • Internet
  • Teaching / methods*