Effectiveness of Structured Case-Based Learning Versus Traditional Didactics in Enhancing Clinical Decision-Making Among Orthopedic Residents

Summary

The manuscript describes structured case-based learning (CBL) producing moderate, durable gains in orthopedic residents' decision-making, improving accuracy, appropriateness, speed, knowledge, and communication. CBL effects persisted after adjustment for baseline ability and attendance, supporting adoption of flipped, structured case discussions, explicit decision nodes, and guided debriefs as part of residency didactics.

Abstract

Clinical decision-making is central to orthopedic residency training but is challenging to teach using traditional didactic lectures, which emphasize information transmission over active reasoning. Structured case-based learning (CBL) has been proposed as a learner-centered alternative that targets diagnostic reasoning, management planning, and decision-making under uncertainty. To compare the educational effectiveness of structured case-based learning versus traditional didactic lectures (TDL) in enhancing clinical decision-making among orthopedic surgery residents. A retrospective, multicenter cohort study was conducted across four postgraduate medical education programs in China. A total of 120 orthopedic residents were included (CBL and TDL, n = 60). Both groups completed an 8-week curriculum covering eight high-risk orthopedic topics with equivalent instructional time and objectives. The CBL intervention incorporated flipped pre-work, progressive case disclosure, forced decision nodes, and structured debriefing, while the TDL arm used slide-based lectures with question-and-answer periods. The primary outcome was a prespecified composite clinical decision-making score derived from standardized objective structured clinical examination (OSCE) decision stations, a Script Concordance Test, and time-to-correct-decision metrics. Secondary outcomes included knowledge performance, appropriateness of management, communication scores, retention at 8 weeks, learner satisfaction, engagement, and cognitive load. Assessors were blinded to the instructional group. Baseline characteristics and performance were comparable between groups. The CBL group achieved significantly higher composite decision-making scores than the TDL group at post-intervention and at 8-week retention, with moderate effect sizes. Secondary outcomes, including OSCE performance, reasoning under uncertainty, decision speed, knowledge scores, appropriateness of management, and communication ratings, consistently favored CBL. Learner satisfaction was higher in the CBL group, while cognitive load and attendance were similar between groups. Structured case-based learning was associated with superior educational performance compared with traditional lectures among orthopedic residents, with durable gains in decision-making. These findings support the integration of structured, decision-focused case discussions into residency didactic curricula.

Introduction

Clinical decision-making lies at the core of orthopedic residency training. On any given call night, residents must integrate incomplete histories, evolving physical findings, imaging, laboratory data, and system constraints into timely and defensible management plans. Unlike factual recall, such judgments are contextual and probabilistic, shaped by uncertainty, time pressure, and variability in patient goals and risk profiles. Traditional lecture-based didactics remain the dominant instructional format in many residency programs because they efficiently transmit standardized knowledge aligned with examination blueprints. However, accumulating evidence suggests that structured case-based learning (CBL), particularly within flipped or blended designs, more directly targets the cognitive processes underlying expert clinical reasoning and may therefore be better suited for developing diagnostic accuracy, management planning, and communication under uncertainty¹. In orthopedic education, early studies indicate that engaging residents with realistic cases, progressive disclosure of information, and forced commitment at key decision points can complement or outperform lectures on outcomes relevant to practice, including application of knowledge and examination performance². Postgraduate medical education has increasingly shifted toward learner-centered and competency-based approaches that emphasize critical thinking and decision-making. CBL situates problem-solving within authentic clinical scenarios, helping bridge the gap between theoretical instruction and real-world application. While CBL is widely adopted in Western training systems, many programs in mainland China continue to rely predominantly on didactic lectures. This context presents an opportunity to evaluate the effectiveness of CBL in a system undergoing transition toward outcome-based education. The present study compares structured CBL with traditional lecture-based teaching across multiple Chinese teaching hospitals, focusing on residents' knowledge acquisition, problem-solving ability, and learner satisfaction.

The limitations of lecture-based instruction are well documented in surgical education. Although lectures facilitate coverage and standardization, they position learners primarily as passive recipients of information and provide limited opportunities to articulate hypotheses, commit to management decisions, and receive targeted feedback. These higher-order reasoning skills are essential for orthopedic practice in emergency departments, clinics, and operating rooms. Variability in clinical exposure further complicates training, as residents may not encounter a balanced mix of pathologies or decision points during a given rotation. Structured CBL addresses these gaps by deliberately simulating common and high-risk scenarios, prompting learners to justify diagnostic and therapeutic choices, adapt to evolving information, and reflect on outcomes within a supported environment that encourages feedback and iteration¹. Evidence that reallocating didactic time toward interactive formats can improve standardized examination outcomes further supports this pedagogical shift².

The COVID-19 pandemic accelerated reassessment of traditional educational models by forcing rapid adoption of virtual and blended learning formats. Orthopedic programs worldwide experimented with synchronous video conferences, asynchronous repositories, and national webinars, exposing both the limitations of passive online lectures and the potential of interactive approaches^3,4,5. Reports from this period describe reduced operative exposure but expanded access to diverse didactic content, guest expertise, and cross-institution collaboration-conditions favorable to well-designed CBL^4,5. Many programs have since retained blended portfolios that pair concise pre-session preparation with interactive case discussions, simulation, and asynchronous forums requiring learners to commit to decisions and engage in reflective debriefing. Concurrently, orthopedics has seen the development of curated, multi-institutional curricula that operationalize flipped and case-based principles at scale. Nationally shared programs emphasize thinking like an orthopedic surgeon through standardized pre-work and structured discussion prompts, demonstrating feasibility and adaptability to residency education^6,7. Studies across orthopedics and related disciplines reinforce that interactivity, intentional case design, and alignment between teaching and assessment -- rather than delivery platform alone -- determine educational quality^8,9,10,11. Research on online and virtual case-based formats shows measurable gains in clinical reasoning compared with traditional instruction, particularly when cases incorporate progressive information disclosure, forced commitments, and structured reflection^{12,13,14,15,16}. CBL has also been extended through simulation and immersive technologies, allowing residents to rehearse decision-making in rare or high-stakes scenarios such as severe trauma, ethical dilemmas, and quality improvement initiatives^{17,18,19,20,21,22}. These approaches emphasize choices and justification rather than psychomotor skills alone, aligning with the cognitive demands of orthopedic practice.

Meta-analyses across medical and allied health education further support the generalizability of CBL's advantages over traditional lectures, strengthening the rationale for rigorous evaluation in orthopedic residency settings²³. Shared repositories and collaborative case rounds have emerged as practical enablers of structured CBL, helping standardize access to decision practice despite variability in operative exposure and clinical volume^{24,25,26,27,28,29}. Together, these converging lines of evidence motivate a focused comparison of structured CBL and traditional didactics for orthopedic residents using outcomes aligned with real clinical work. Beyond knowledge tests, meaningful evaluation should encompass diagnostic accuracy, appropriateness, and timeliness of management decisions, operative planning, and communication performance. Structured CBL is not intended to replace lectures but to rebalance didactic time toward activities that more closely mirror clinical decision-making. Lectures can provide concise conceptual frameworks, while CBL challenges residents to apply those frameworks under uncertainty, articulate trade-offs, and receive feedback. The present study tests the hypothesis that a deliberately scaffolded, assessment-aligned CBL curriculum yields superior gains in clinical decision-making and communication compared with lecture-based instruction covering equivalent content, thereby informing future curricular design in orthopedic residency education³⁰.

Protocol

The protocol obtained approval for this retrospective educational study from the institutional review board/ethics committee at each participating postgraduate medical education (PGME) training center. Conduct all procedures in accordance with the Declaration of Helsinki and applicable institutional regulations. A waiver of informed consent was provided here in accordance with institutional review board requirements for minimal-risk educational research. Ensure that participation or non-participation does not influence academic evaluation, clinical duties, or promotion decisions.

1. Study design

1. Conduct a retrospective, multicenter cohort study across four PGME orthopedic training centers. Identify eligible participants who completed either structured case-based learning (CBL) sessions or traditional didactic lectures (TDL) between January and December 2023 as part of the standard curriculum. Extract data from archived academic, assessment, and training records. Assign participants to the CBL or TDL group based on the instructional format received during the study period.
2. Designate an independent investigator who was not involved in teaching, assessment, or record generation to perform group classification and data extraction. Ensure that both instructional groups received equivalent total teaching time and identical learning objectives. Define knowledge acquisition as the primary outcome and critical thinking, problem-solving ability, and learner satisfaction as secondary outcomes.
3. Research standards
   1. Inclusion criteria: Include orthopedic surgery residents in postgraduate years (PGY) 1 through 5 who were actively enrolled in participating programs during the study period. Require residents to have completed at least 6 months of prior clinical duty, attended at least 75% of scheduled instructional sessions, and provided consent for video recording during assessments.
   2. Exclusion criteria: Exclude residents who were continuously assigned to off-service rotations throughout the intervention window. Exclude residents with planned leave exceeding 2 consecutive weeks, prior participation in a formal program-wide CBL curriculum covering identical topics within the preceding 12 months, or refusal to provide consent.

2. Recruitment and sample size

1. Identify eligible residents retrospectively from institutional training records. Stratify participants by training site and postgraduate year level. Include residents for whom complete academic, assessment, and attendance data are available. Confirm that both CBL and TDL were established instructional formats at all participating sites during the study period.
2. Include 120 residents in the final analysis, with 60 residents assigned to the CBL group and 60 residents assigned to the TDL group. Perform a post hoc precision assessment based on observed variance to verify that the available sample size is sufficient to detect a moderate standardized effect size between instructional formats.

3. Interventions

1. Deliver both instructional arms over an 8 week period using the same eight core orthopedic topics selected for clinical frequency, risk, and decision complexity. Cover geriatric intertrochanteric fracture, femoral shaft fracture in polytrauma, open tibial fracture with damage-control principles, suspected compartment syndrome, periprosthetic joint infection, anterior cruciate ligament rupture with meniscal injury, metastatic bone disease with impending fracture, and cauda equina syndrome.
2. Structured case-based learning arm
   1. Conduct weekly 90 min CBL sessions for 8 consecutive weeks. Assign residents to small groups of 8-10 participants. Provide pre-session materials consisting of 20-30 min of micro-lectures, guideline summaries, and a 5-item readiness check hosted on the learning management system.
   2. Present two standardized clinical cases per session using progressive information disclosure, beginning with history and advancing through examination findings, imaging, laboratory data, and clinical evolution. Require residents to commit to diagnostic and management decisions at predefined decision nodes using polling or written justification. Incorporate decision-support scaffolds, including structured checklists, brief evidence pauses, and prompts addressing common cognitive biases.
   3. Assign two trained faculty facilitators to each session and require facilitators to follow a standardized guide outlining objectives, prompts, and timing. Conduct a structured debrief lasting 10-15 min after each case to align resident reasoning with expert pathways, identify decision inflection points, and summarize transferable heuristics.
   4. Monitor intervention fidelity by designating an educational observer at each site to complete a standardized 10-item checklist assessing adherence to required CBL elements.
3. Traditional didactic lecture arm
   1. Conduct weekly 75 min live lectures followed by a 15 min question-and-answer period for 8 consecutive weeks. Deliver lectures using slide-based presentations prepared by fellowship-trained orthopedic faculty. Ensure that lectures cover the same learning objectives and content domains as the CBL arm.
   2. Allow optional presentation of a single illustrative case vignette at the conclusion of each lecture without progressive disclosure, forced decision-making, or structured debriefing. Monitor fidelity using a standardized checklist evaluating objective statement, content coverage, pacing, and provision of a question period.
4. Contamination safeguards
   1. Schedule CBL and TDL sessions on different days or times and assign distinct faculty teams to each instructional arm. Restrict access to instructional materials using password-protected platforms. Instruct participants not to share materials across groups and track attendance and learning management system access logs.

4. Outcome measures (Figure 1)

1. Primary outcome
   1. Assess clinical decision-making performance at post-intervention and at 8 week retention using a prespecified composite score. Combine performance across four objective structured clinical examination (OSCE) decision stations, a 30-item Script Concordance Test, and time-to-correct-decision metrics from timed vignettes. Standardize all component scores and calculate a composite z-score as the primary endpoint.
2. Secondary outcomes
   1. Assess knowledge using a 40 item multiple-choice examination aligned to the instructional syllabus. Evaluate appropriateness of management decisions using blinded expert panel ratings. Measure communication performance during OSCE encounters using a 9 item global rating rubric. Assess retention of all outcomes at 8 weeks. Collect learner-reported preparedness, cognitive load, and satisfaction using validated scales. Quantify engagement using attendance rates, pre-work completion, and decision-commitment frequency.

5. Measurement procedures and quality assurance

1. Train standardized patients, simulation technologists, and examiners using detailed scripts and calibration sessions prior to data collection. Blind OSCE examiners, Script Concordance Test keyers, and multiple-choice graders to instructional group assignments.
2. Monitor inter-rater reliability using intraclass correlation coefficients and internal consistency using Cronbach's alpha. Use parallel assessment forms across time points and balance difficulty using pilot data.

6. Data collection and management

1. Extract baseline demographic, academic, and training data retrospectively from institutional records. Compile all data within a secure REDCap database using role-based access controls. De-identify all records and assign study-specific identification codes prior to analysis. Review video recordings solely for scoring and fidelity purposes in accordance with ethics approval.

7. Adherence and fidelity monitoring

1. Sample at least 25% of sessions at each site for fidelity assessment. Classify CBL sessions as adherent if at least 8 of 10 checklist items are met. Classify TDL sessions as adherent if at least 4 of 5 checklist criteria are satisfied. Define participant adherence as attendance at a minimum of 6 of 8 sessions and completion of at least 75% of required pre-work, where applicable.

8. Statistical analysis

1. Analyze outcomes using an intention-to-treat framework. Compare groups using linear mixed-effects models incorporating group, time, and interaction terms, with random intercepts for participants and fixed effects for site and PGY level. Adjust post-intervention and retention analyses for baseline scores. Model secondary outcomes using appropriate mixed-effects or time-to-event methods. Handle missing data using complete-case analysis when minimal or multiple imputation when exceeding prespecified thresholds.

9. Implementation timeline

1. Complete faculty training, case piloting, examiner calibration, and baseline assessments prior to intervention delivery. Deliver instructional interventions over 8 weeks. Conduct immediate post-intervention assessments in week 9 and retention assessments at week 17. Perform data cleaning, reliability estimation, and blinded statistical analysis thereafter.

Results

Baseline characteristics (Table 1)
A total of 120 subjects were assigned at n=60 to either the CBL or the TDL group. Groups were well balanced across demographic and training variables. Mean age was similar (CBL 29.0 ± 2.1 years vs TDL 29.2 ± 2.0 years; p=0.56), sex distribution did not differ (male: 70.00% vs 71.67%, p=0.84; female: 30.00% vs 28.33%, p=0.84), PGY levels were nearly identical, with each arm comprising 20.00% at PGY-1 through PGY-5 (TDL PGY-2 23.33% vs CBL 20.00%; omnibus p=0.93). Rec...

Discussion

This study evaluated a structured case-based learning (CBL) approach designed to strengthen clinical decision-making among orthopedic residents and compared it with traditional didactic lectures delivered over equivalent instructional time. Beyond comparative performance outcomes, the findings clarify the instructional mechanisms through which structured CBL operate and delineate how this method can be implemented, adapted, and extended within postgraduate medical education.

Critical s...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Decision-node polling system	Poll Everywhere / LMS tool	N/A	Captured committed choices during CBL sessions
High-fidelity simulators	Laerdal / CAE Healthcare	N/A	Used in OSCE decision stations and timed vignettes
REDCap data management system	Vanderbilt	N/A	Secure data collection, role-based access control
Statistical software	SPSS	N/A	Linear mixed effects, generalized mixed models, Cox models