This study aimed to demonstrate how a case-based e-learning approach influences medical students' grades. We hypothesized that the average exam results would improve with additional training with our case-based elective course compared to the students without any extra training. However, the superiority of case-based teaching can only be proven by a hard endpoint, such as the final grade.

The study findings should facilitate a discussion on the role of a case-based e-learning approach as an essential part of undergraduate and postgraduate education. Certainly, case-based teaching can be implemented without e-learning; however, this aspect was not examined in the current study and will be addressed in subsequent research.

Furthermore, the results of this study should contribute to the enhancement of e-learning methodologies, as the teaching methods incorporate a feedback system and authentic clinical scenarios (22).

In 2016, the course “Fallorientierte Lehre (Case-based teaching)—Übungen (Practice): Clinical Reasoning and Clinical Decision Making” was introduced at the Medical University of Vienna provided on a Moodle e-Learning platform (26) (Figure 1).

The course is the result of extensive research in the field of case-based learning. Patient histories from individuals treated at the General Hospital of Vienna were anonymized and processed to learning material, starting in 2014 (27). Guidelines and quizzes have been incorporated into this learning material to create patient cases (25). The test sections were analyzed to ensure good quality and efficacy (28).

The course structure (Figure 2) (12, 13), case designs (Figure 3) (13), blueprints of patient cases (13), scientific background (22), preliminary evaluation results (14), consumer demand and satisfaction, course efficacy, and didactic background had already been described (12, 26, 28). The content was carried out in German. The main idea behind the course structure was to create a stimulating environment where students can apply their knowledge and learn from mistakes without fear of failure (29).

The concept for this course was based on Bloom's taxonomy criteria (30) and followed the CanMEDS framework (31) and aimed to foster interdisciplinary and crosslinked thinking (22). Case structure is interdisciplinary as they are real world cases. Observing and supporting students are vital strategies for fostering self-assessed learning, and interdisciplinary question-based blended cases promote individual learning plans for optimal knowledge acquisition. However, evaluating these newly implemented teaching concepts should enable further improvements in the medical curriculum. In total, 25,000 exam results were tracked; participants of the elective course were matched to students of the academic year for an individual matching (11, 26).

Beginning in 2013 with small groups, large student cohorts (N = 740 per academic year) have been involved since 2016, as the course can be utilized for preparation and training for the annual final examinations.

Various studies have already analyzed aspects such as student satisfaction, skills transfer, and the transition from declarative to procedural knowledge (7). Different forms of e-learning have been implemented in the medical curriculum, such as clinical rounds (elective non-structured discussion groups) in the fifth academic year (32). As clinical reasoning is the main task and important skill to be acquired before going to real-world care working with real patients in hospital in the sixth and last academic year, the “clinical practical year”, it is necessary to test, if at the end of the fifth academic year students perform well-enough all in all in the summative integrative exam (SIP 5). In this last exam, many questions refer to clinical reasoning. The structured e-learning approach of this course was used to reach students affectively and with more sustainability.

The “Summative Integrative Prüfung” (SIP), a summative integral exam, takes place every year/semester. The last exam (SIP 5) is particularly noteworthy, as it is conducted before the clinical internships. Additionally, the “Objective Structured Clinical Examination” (OSCE) takes place in the fourth academic year (33, 34). The OSCE is used after 4 years of intensive training to evaluate cardiopulmonary resuscitation, basic ultrasound, physical examination, diagnosis and history taking, communication with severe cases and difficult situations, and hospital emergency skills (35).

Medical students from all academic years (n = 5,800) were allowed to participate in the course from the winter term of 2016/17 to the winter term of 2020/21. There were no advertisements for the course, it has been added into the teaching catalog of elective offerings at the administrative platform of the university.

Students provided informed consent to participate and completed the elective course successfully. Subsequently, they then voluntarily submitted detailed questionnaires and exam results through a native built-in Moodle plugin that anonymized all data automatically.

A total of 296 medical students participated in the case-based teaching course and completed all the tasks (26); 32 co-registered students from different universities attended the course but were not analyzed. The study population comprised of 53% female and 47% male students with an average age of 24.1 ± 2.921 (median: 24.00). The nationality of the students was not recorded. From the entrance test a proportion of at least 75% Austrian, 20% foreign mainly German-speaking EU-countries, 5% non-EU countries is known, the language is German.

The questionnaire assessed the educational environment and served as a secondary outcome measure. The instrument employed closed-ended questions, Likert scales, and multiple-choice items to evaluate various soft skills, as depicted in Table 2 (questions in the first column). To capture the attitude toward the course the semantic differential, a standardized and validated assessment was used (results also in 13). To grasp affective involvement and attitudes toward a topic, a semantic differential technique is optimal as it also shows unconscious connotations. The questions presented in Table 2 were self-selected with pending validation (26).

Apart from the main question (primary research question; exam grades), all information was descriptively analyzed and published in various studies (11–14, 22, 26).

The data were collected from the Moodle website and transferred to an SPSS database. Students' answers were used to calculate general questions and explorative analyses. The exam results of the participants were analyzed and compared with those of all medical students. T-tests (for independent samples) for each cohort and exam were performed, and descriptive statistics were used for the questionnaire.

Due to multiple testing, a Bonferroni correction was performed (36). Numeric data are presented as mean ± standard deviation. Statistical analysis, graphics, and diagram generation were performed using SPSS^® 26.0 statistics software [SPSS Inc., Chicago, IL, USA (37)]. Bonferroni correction was applied for multiple comparisons, and statistical significance was assumed at a p-value < 0.01.

In Table 1 an overview of all exam results and group comparison between students with or without participation in the e-learning course are given. Participants in the e-learning course performed significantly better on the fourth (SIP4a), fifth (SIP5) (p-value < 0.01), and third years' exams (SIP 3) (p < 0.05) (Table 1).

No statistically significant effect on examination outcomes was observed for OSCE and the annual examinations in the first and second years (SIP1a, SIP1b, and SIP2).

Students in the e-learning course obtained significantly better grades, depending on their experience level (11).

Secondary outcome parameters are presented in Table 2, including students' self-assessment (self-awareness) of soft skills and their attitude toward the offered course, which were evaluated using the open-response sections of the questionnaire employed in the study and have already been published (13, 22), but some notable parameters should be mentioned:

90.5% of the students [1.51 ± 0.774 (M ± SD)] recommended the elective course, and 74.7% suggested using a case-based teaching approach even for postgraduate board certification exams. Among the students, 65.2% preferred a bilingual teaching approach. The elective course was available only in Germany. Skill and exam tracking systems are implemented at many universities, and 56.1% of the students also favored such systems in our study.

A slightly positive increase in subjectively observed patient-centered thinking was reported [0.62 ± 0.928 (M ± SD)]. Furthermore, 60.6% of the students reported that they believed interdisciplinary thinking was cultivated [0.94 ± 0.888 (M ± SD)].

We expected the students to use the courses by themselves. Surprisingly, the students worked in groups to solve the cases, and the average group size was 1.65 students [1.65 ±2.099 (M ± SD)].