1. ENHANCING STUDENT ADAPTION TO A CASE BASED LEARNING ENVIRONMENT
Problem: Four years ago a new engineer education: “Medicine with an industrial specialization” started, and for the Medicine part of the education (Bachelor level) it was decided to use a case based PBL model in combination with project work in groups. It appeared to be difficult for the students to adapt to two different PBL approaches at the same time, and with the project being the most popular the learning outcome of the case studies was not satisfactory after the first semester, but improved on the following semesters.
Lars Peter Jensen
Associated Professor at Automation and Control
Department of Electronic Systems

2. Solution:
To rearrange the curriculum and only use the case model in the first semester and then add a small project in the second semester, to be expanded in the following semesters.
The expectations were that the students would then adapt satisfactory (learning outcome) to the case model in only one semester.
To help the process, a small course, using lectures and reflections to raise the students awareness on how to learn in the new learning environment, were planned, and
To keep the individual students’ focus on his/her own learning process, they were forced to write a personal portfolio about their behaviour and learning in the cases every week and to reflect across these at the end of the semester.
Agenda:
Short presentation of case model and the course
Investigating both the individual learning portfolios and a case analysis document on group level, with focus on how the students learn and collect knowledge – individually and in the group (Peer Learning).

3. The Case Model
The case model is imported from Hull York Medical School in England [1]. It is a development of the PBL case model invented/developed at McMaster University in Canada1968 and reframed at Maastricht University in In Aalborg University’s version it looks like this:

4. Case start
A case starts with a two hour session, where the case group (10 – 14 persons) is presented a short (1 pages) medical history of a patient, and explores the first five steps of the case model:
Read the case and clarify new items

5. A PBL CASE FROM MEDICINE
family physician practice
Woman, 22 years old, not married, lives with her parents, she is a nursing
aide in an old peoples home, youngest of 5 children.
The G.P. sees her every now and then with complaints of hyperhidrosis*.
Complaint now: since three days sick and vomiting, everything comes back. Stools normal, no abdominal pains. She is not feeling very ill, on the other hand she is not feeling able to work.
When asked whether there has been anything special recently, the patient relates that for three weeks she has been in charge of a nursing department of the old peoples home, because the person normally in charge went on holidays. "The old people looked down at me as a youngster, they did not accept any instruction from me". The complaints started directly after this period, when the head of the department had returned from her holiday (three days ago).
You don't notice any abnormality in her physical appearance.
* Hyperhidrosis: excessive sweating

6. Case start
A case starts with a two hour session, where the case group (10 – 14 persons) is presented a short (1 pages) medical history of a patient, and explores the first five steps of the case model:
Read the case and clarify new items
Define problems
Brainstorm explanations
Arrange explanations
Define learning objectives
During the session the group has selected a chair and a scribe and there is a teacher present as facilitator, securing that the group comes up with appropriate learning objectives.

7. Middle and end of Case 6. Private study, collecting knowledge
In the period until the case ends (six days) the students can get input from some of the learning resources shown in the top and bottom of figure 1, but they are also expected to do their own private study (2-3 days expected) to collect the necessary knowledge to obtain the learning objectives.
7. Case end
A case is ended at a two hour session, where the members of the case group present the knowledge they have obtained and share and discuss it with the case group members, not only to be sure they have understood it correctly, but also to learn from each other, since everyone haven’t gained exactly the same knowledge. The perspectives from the case to the clinical visits are also made and the learning outcome from the case is reflected.

8. Course Setup
A short course (2 ECTS) was designed to help the students adapt to the case model. Elements:
Learning styles and first reflection
After app. three weeks, where the students had tried the first three cases. group based reflection on the major steps in the case’s and a test: “Index of Learning Styles” by Richard M. Felder and Barbara A. Soloman
Exchange of best practice
After the first session of cases (five) was finished: a best practice exchange workshop following a Café model
Communication and conflict handling
About three weeks later: a lecture about communication and how to handle conflicts, followed by a personal test about communicative behaviour and role play’s about conflict handling
Management of cases, and case analysis document
Two weeks before the end of the semester: a short lecture about how the case groups were organized and performed management, and a guide on how to write a case group document analyzing how the students in each case group together had used the cases to gain knowledge and obtain the learning goals.
Group consultation
After this lecture the groups started to work on the case analysis document for the rest of the day, and meanwhile the lecturer visited each group ½ hour for consultancy on the reflection and writing, or other items important to the group.
Personal reflection portfolio
The reflective part of the course and the adaption to the case model was also supported by mandatory writing of personal portfolios by the students every week and a written reflection across these at the end of the semester, showing the development of the student in terms of adapting to the learning environment.

9. Results
Each of the ten groups (5-8 members) delivered a case analysis document, typically about 5 pages, showing how well the group had been able to use the potential of the learning environment.
Some groups performed excellent, most of them rather good and a few were not satisfied with their performance, but came up with well argued suggestions for improvement, often based on examples of better practice they had seen from some of the other groups.
All the groups had some very good ideas to excellent behaviour in the cases, most of them already being performed. Some of those, with focus on the collection of knowledge, will be presented as quotes in the following. The quotes have been translated from Danish to English by the author, and will be presented anonymously.

10. Best practice in collecting knowledge
In three of the groups they share knowledge (Peer learning) in every case and they have developed their own style, e.g.:
“Our work in the group has been the most satisfactory part, meeting 2-3 times a week going through the learning objectives, curriculum or other items that we don’t understand.”
“We present the knowledge for each other using the black board, drawings and figures to explain and investigate the learning objectives. This way we both obtain competencies in presenting and have the possibility to develop critical skills towards what’s being presented. We also exchange both notes and references (books and links) by during the knowledge collection, making the individual work a bit easier and help our understanding of the subjects.”
“We praise, encourage and help each others, so we have a positive atmosphere and a good learning environment.”
“We have emphasised to do some social activities as a group, where the professional part was put aside, but it was allowed to discuss how the group worked together.”
“Sharing knowledge together in the group before case end is a good opportunity for those who are afraid to present at case end, to try it and have confirmed that they actually can do it.”

11. Personal reflective portfolio
In the portfolios the interesting part concerning this paper is to look at the development of each student with respect to how he or she has adapted to the learning environment. If a rough scale with only four levels is used to evaluate the students development according to the portfolios the results are:
29% are able to discuss and assess the learning resources and how they use it, but they miss the point of reflecting their own skills. Still it is passing level.
18% can also reflect their own skills and efforts but are not very specific about how to improve. The average of each of these portfolios has the level fair, but small parts of some of them might be good.
44 % goes even further and have already reach a good level of performance, and has rather precise suggestions to improvements of their weaker sides, that could improve their student performance to very good or higher.
8 % of the portfolios, typically the longest ones, show students that already perform very good or excellent, but they still have suggestions to further improvements.

12. Quotes from student
“I like to study alone, giving me time and calm to think about what I read and try to understand it. But after that it is really rewarding to go through the subjects in the group.”
“Felder’s learning style inventory have raised my awareness about how I learn the best, e.g. that I have a strong preference for visual learning. To support that I try to use drawings, tables, etc. when I read, this helps me to gain a quick overview of the subject.”
“All in all I am more aware of my personal learning style and how I learn the best. This will be a great help for me in my future life as student.”
“During the semester we have presented our knowledge about the learning objectives for each other, which improves my understanding of the subjects a lot, and secure if I have understood things right. If you can’t explain it to others you haven’t the full understanding. I also use this idea when reading on my own, using a black board to present for my self when I finish reading. Doing this exercise I gain a big overview and better understanding of how things are connected.”

13. CONCLUSION
The subject of this paper was to investigate if the rearranged curriculum enhanced the students adaption to the case based learning environment and this seems to be the case. One could then ask if that is due to the fact that the students only had to adapt to one new learning environment or the course and the portfolios also helped?
There is no direct evidence of the influence from the course, but it created the setting, where the group based reflections, was on the agenda several times during the semester, and the case analysis documents show that this has developed the use of the group (Peer learning) as a learning resource very much.
The individual portfolios clearly show a development of most of the students learning potentials and awareness of how they learn the best, giving them a very good possibility for continues improvement of their learning method.
The conclusion is that reflection is a great helper when adapting to a new learning environment and the possibilities for this created in the new curriculum seems to be good.
The course, case analyzing documents and personal portfolios is using only limited resources (100 hours), a low cost for helping the students adapt to a new learning environment.