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 s....

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 retros....

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