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Teaching, Leadership, Self-directed learning, Medical student, IntroductionThe Indian medical curriculum is governed by the structural curriculum provided by the Medical Council of India (MCI). After two decades, the curriculum has been restructured from traditional discipline based on competency driven curriculum ( 1,). However, prior to this restructuring many pre-clinical faculties of the medical institutes have been introducing various interactive techniques like that of case-based learning (CBL). The researchers in the basic science course have concluded that case-based teaching (CBT) stimulates the students to apply cognitive skill as per clinical context ( 2,), and develops and improves complex-problem solving skills ( 3,, 4,), thus emphasizing the patho-physiological basis, in clinical context. Researchers have identified that usage of actual real-world clinical cases in CBT allows the students to reach a correct diagnosis and recognize the importance of inter-relatedness, ( 2,) by linking the learned concepts ( 5,). Moreover, researchers have identified that CBL provides better opportunity to students for the usage of different resource materials and have better interaction with their peer and instructor ( 6,). Authors have reached various conclusions as per score acquired after the end of the CBT course some found enhanced performance using lectures ( 7,- 9,), whereas others concluded to have better performance with CBL ( 10,- 13,). Moreover, some showed no differences between the two methods ( 14,- 16,). Studies differ in results as compared to the implementation of the CBL pedagogy, group size, and many other factors which might lead to variations in the outcome of the process ( 3,, 17,).Developing countries, like India, have limited human and infra-structural resources facilities for teaching medical students thus, there is a need and requirement to look for free portal which would be easy to work on not only for the faculty members, but also for undergraduate students. Web-based learning activities are considered independent, active learning processes, allowing large group of learners together as &,lsquo virtual&,rsquo group ( 18,) however, they cannot replace the traditional teaching strategies in medical educational setting ( 19,). The digital approach of learning may not be superior to traditional method, but it has a great potential to motivate the students towards self-directed learning ( 18,, 20,). Presently, all the Indian medical institutes have informational websites, as per requirement by the MCI, although the usage of the technology for teaching-learning aspect is still awaited in the majority of medical institutes. Google groups have been used for various medical faculty development programs within the country, India, like Advanced Course in Medical Education (ACME) thus, they can be used as one of the methods for students&,rsquo learning.At our institute, we introduced a voluntary optional teaching learning approach using Google group, as an e-learning tool, for first year undergraduate medical students from August 2017 to July 2018 (2017-18) batch and August 2018 to July 2019 (2018-19) batch. We aimed to expose those pre-clinical students to prospective real life situation for physiology and anatomy subjects by contemporary case-based learning method. The perception and learning outcome of those students were assessed for this newer approach of teaching learning strategy.MethodsThis non-randomized interventional study was conducted on undergraduate medical students from two consecutive batches 2017-18 (Academic year August 2017 to July 2018) and 2018-19 (Academic year August 2018 to July 2019). The purpose of the study was explained to each batch of the students. 43 students from 2017-18 batch and 41 from 2018-19 batch, out of 150 students from each year batch, volunteered to participate in the study. The students who volunteered to participate were considered as the experimental group (Group-B) and those who did not participate were enrolled as the control group (Group-A).The experimental (Group-B) undergraduate medical students from each year batch (2017-18 &,amp 2018-19) were again explained about the aim, purpose and methodology of the study and written consent was taken. The voluntary participants were divided into groups (8-10 students per group). All the groups were requested to prepare an independent Google group, including the principal investigator, concerned faculty member, and student group members, so that they were able to work online.On-line CBL for participatory/experimental groupOne of the students within the group was chosen a leader, either by the group members or by the instructor, blindfolded. The group leader was in touch with the instructor via e-mail only. There would be no in-person communication between the instructor and the groups. In case any student within the group had issues, he/she could contact the instructor independently via email or in person, if required. The instructor had the flexibility to provide guidance to the leader in the case of any serious issue.Based on the topics covered via conventional lecture series, for the concerned batch, for anatomy and physiology course, a clinical paper case was prepared by the instructors and relevant application-based questions were framed integrating the basic science courses horizontally and vertically. This was sent to each group by the instructor. All the groups received the same case for the discussion. A specific timeframe was laid by the instructor for the completion and submission of the task. Attending the conventional lecture for the topic was not mandatory for the participants to join the e-learning Google group. Role of the leaderThe group leader was there to share the cases within the group, as a soft and hard copy and motivate the group members to participate in the discussion by finalizing the venue and time for face to face or online discussion, so as to reach the final outcome of the case. The leader also initiated the discussion in the framed group and compiled the final response to each question as agreed and approved by the group members, after using various resources at their own level (self-directed learning approach). At the end of the activity, the leader uploaded the answers for the questions on the framed Google group. A feedback response was provided by the instructor for each clinical case after submission by all the group leaders. Group leader also intimated the instructor about those members who failed to participate.With every new clinical case, a new group was formed, with a new student as the group leader. This imparted leadership qualities and developed the team building skill for the discussion within the group members. A total of 4 sessions with such methods were conducted for 2017-18 batch, while only 2 sessions were conducted for 2018-19 batch.Participants had the openness to withdraw from the study without seeking permission from the instructor. In case they wanted to rejoin the group for subsequent cases, then as a prerequisite instructor&,rsquo s permission was required.Learning analysisAfter every case, a test was given to all the students of the class for the topic and learning outcomes of the two groups, participant- Group-B (43 from 2017-18 batch &,amp 41 from 2018-19 batch) and non-participant- Group-A (107 and 109 from respective batches), were compared.On completion of the test, the cases were openly discussed within the class for better understanding of every student enrolled in the course. This motivated some more students to participant for the research study. After the first case discussion, the participants increased from 15 to 43 in 2017-18 batch, while in 2018-19 batch it increased from 25 to 41.Quantitative and qualitative assessmentData related to perception of students for corrective implementation and importance of online CBT were collected using a survey questionnaire, having open-ended and closed ended questions, based on three-point Likert&,rsquo s scale, after getting it validated by subject experts. The readability index had the text for the average grade level of about 6 (easily understood by a 11 to 12 year old one). The content validity ratio (CVR), after inputs from the six qualified experts for each item for accuracy, items as per objective of the study and grammatical correction was +1 for 19 and 0.61 for 6 items, thus having the content validity index (CVI) 0.88 ( 21,). A pilot test was done for those survey questions on 2016-17 batch (N=10) first year undergraduate students, who had undergone a similar process on voluntary basis. The Cronbach&,rsquo s Alpha (CA) value for those 25 items for these students was 0.86.A focus group discussion (FGD) guideline with questionnaire was developed and validated (CVI-0.941) for identifying the perceptive of participants regarding the tool. Prior to initiation of FGD, participants were explained that the research investigators were interested in their truthful feelings and attitudes towards the teaching approach. Two such FGDs were facilitated, each having 8 to 10 students with 4 elements to make sure that students were comfortable and relaxed. During the first welcoming element, the participants were familiarized with the FGD, highlighting the ground rules followed by warm-up element by introducing to the moderator, and each member, so each individual participant had time to express his/her thoughts and was encouraged to share different points of view by the use of two essential techniques, &,ldquo the pause and the probe&,rdquo ( 22,). Questions were specific, yet open-ended, and additional questions were allowed to emerge within the context of the conversation. For example, one of the general questions was, &,ldquo How online case-based learning session worked for you?&,rdquo Probing questions then allowed the participants to expand on their responses, like &,ldquo Can you please elaborate it with an example?&,rdquo Informal member checking and summarizing the content was used throughout the two focus groups to ensure that students&,rsquo responses were correctly interpreted ( 23,). Focus groups ranged in length from 40 to 45 minutes. Focus groups were recorded using an audio recording device and transcribed by the author, word by word, which was validated by an external and internal expert manually.Pre- and post-test were done based on multiple choice questions (MCQ) to assess the learning outcome of the students. Statistical analysis of the data for frequency distribution, paired t-test and Mann Whitney ranking test, was done to identify the mean and standard deviation of the response and ranking for each question as per test in both batches of students. Data for FGD was deductively analyzed manually using Braun and Clarke&apos,s (2006) 6-step thematic analysis, ( 24,) starting from becoming familiar with the data, generating initial codes, followed by searching for themes, reviewing the themes, defining the themes, and lastly writing them. Ethical ApprovalThe study was commenced after approval from Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC/ON/Medi/RP/18002 5th February 2018).ResultsThe quantitative data are analysis and represented in the form of tables, while the qualitative analysis is represented as paragraph under two main themes. Table 1, shows the comparative analysis by pre-and post-test (2017-18 batch) for participant/experimental (Group-B) and non-participant/control (Group-A) group of students. The statistical significance (p&,lt 0.001) was observed from the pre- and post-test for Group-A as well as Group-B students. The comparative post-test score for the learning outcome between Group-A and B showed statistical significance (p&,lt 0.416). The Cronbach&apos,s Alpha Reliability coefficient for 25 perceptional survey questionnaires items (Annexure-1) for the first year undergraduate medical student batch 2017-18 was 0.928 and for those of 2018-19 it was 0.912. Comparative groupsMean&,plusmn SD Difference &,amp t-statisticsPair 1 Pre test 27.56&,plusmn 10.989.640 &,amp 3.955 (p&,lt 0.0001)Non-participant group (Group-A) (N=83)Post test 37.20&,plusmn 11.87Pair 2Pre test 31.63&,plusmn 10.2910.15 &,amp 5.836 (p&,lt 0.0001)Participant Group (Group-B) (N=40)Post test 41.78&,plusmn 12.05Pair 3Post test %-Group-A (N=83)37.20&,plusmn 11.874.58 &,amp 2.058 (p&,lt 0.0416)Post-test between A group &,amp B groupPost test %-Group-B (N=40)41.78&,plusmn 12.05Table 1. Comparative statistics by student&,rsquo s t-test for the pre- and post-test in non-participatory/control group and the participatory/experimental group of students (2017-18 batch)Table 1, shows the comparative analysis of pre- and post-test for participant (B) and non-participant (A) groups of students. The two groups showed statistical significance (p&,lt 0.001) by analyzing pre- and post-test as in pair 1 and 2, while the post-test analysis of participant (B) and non-participant (A) groups showed statistically significant results (p&,lt 0.0416) for the learning outcome score, as in pair 3. Participants who appeared for both pre- and post-test were only included.Table 2, shows frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from two batches. Some rank variability was identified as per the batches although both ranked the highest for question 2.Survey Question No.Batch 2017-18Batch 2018-19Mean&,plusmn SDRankingMean&,plusmn SDRanking13.95&,plusmn 0.71054.29&,plusmn 0.780624.27&,plusmn 0.74014.59&,plusmn 0.550133.32&,plusmn 0.93253.56&,plusmn 0.91643.41&,plusmn 0.9243.1&,plusmn 0.972253.44&,plusmn 1.1233.12&,plusmn 1.272163.73&,plusmn 0.87133.83&,plusmn 1.21073.66&,plusmn 1.44153.51&,plusmn 1.361783.54&,plusmn 1.0183.51&,plusmn 1.191893.66&,plusmn 0.94162.83&,plusmn 1.2225103.71&,plusmn 1.12143.83&,plusmn 1.3009114.1&,plusmn 0.74024.32&,plusmn 0.7904123.8&,plusmn 1.08083.98&,plusmn 1.2807133.44&,plusmn 1.12223.41&,plusmn 1.2219144.07&,plusmn 0.79034.51&,plusmn 0.5502153.93&,plusmn 0.76064.32&,plusmn 0.7905164.0&,plusmn 0.89044.41&,plusmn 0.5903173.54&,plusmn 1.0193.66&,plusmn 1.0612183.88&,plusmn 0.75073.59&,plusmn 1.1413193.78&,plusmn 1.01103.07&,plusmn 1.1923203.8&,plusmn 0.72093.56&,plusmn 1.0514213.49&,plusmn 0.87213.56&,plusmn 0.9515223.76&,plusmn 0.89113.71&,plusmn 0.9611233.63&,plusmn 0.92173.07&,plusmn 1.0624243.73&,plusmn 1.11123.9&,plusmn 1.0808253.49&,plusmn 1.27203.27&,plusmn 1.4820Table 2. Frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from the first year medical students (2017-18 (N=43) and 2018-19 (N=41))The Cronbach&apos,s Alpha Reliability coefficient for 25 perceptional questionnaire items for the first year medical students batch 2017-18 was 0.928, and for those of 2018-19 it was 0.912. Table 2 shows frequency distribution statistics and Mann Whitney ranking test for the survey questionnaires from two batches. Some rank variability was identified as per batche although both ranked highest for question 2.In order to identify perceptional difference for the study methodology between the undergraduate medical students from two different batches, an independent sample-test was done, as shown in Table 3,. Statistical significance for Levene&apos,s Test for Equality of Variances was observed for question number 1,18, and 20 between the two batches of undergraduate medical students. A comparative statistical significance (p&,lt 0.01) value was observed for question number 6 only in students of batch 2018-19, while no significant difference was observed in 2017-18 batch as per gender.Comparison of the mean for Survey feedback question for Batch 2017-18 &,amp 2018-19t-test for Equality of MeansLevene&apos,s Test for Equality of VariancesTSig.Mean DifferenceFSig.Q1Equal variances assumed-2.1120.038-0.3398.7890.004*Equal variances not assumed-2.1050.038-0.339Q2Equal variances assumed-2.3400.022-0.3300.0260.872Equal variances not assumed-2.3560.021-0.330Q3Equal variances assumed-1.0680.289-0.2120.1560.694Equal variances not assumed-1.0690.288-0.212Q4Equal variances assumed1.7050.0920.3440.0340.855Equal variances not assumed1.7010.0930.344Q5Equal variances assumed0.9540.3430.2501.4780.228Equal variances not assumed0.9510.3440.250Q6Equal variances assumed-0.5790.564-0.1321.3920.242Equal variances not assumed-0.5750.567-0.132Q7Equal variances assumed0.4590.6480.1390.0020.965Equal variances not assumed0.4590.6470.139Q8Equal variances assumed-0.0020.998-0.0011.4060.239Equal variances not assumed-0.0020.998-0.001Q9Equal variances assumed3.5930.0010.8453.3440.071Equal variances not assumed3.5690.0010.845Q10Equal variances assumed-0.7450.459-0.2010.7030.404Equal variances not assumed-0.7430.460-0.201Q11Equal variances assumed-1.4860.141-0.2471.1360.290Equal variances not assumed-1.4840.142-0.247Q12Equal variances assumed-0.7250.471-0.1850.6470.423Equal variances not assumed-0.7210.473-0.185Q13Equal variances assumed0.1070.9150.0270.3750.542Equal variances not assumed0.1070.9150.027Q14Equal variances assumed-2.8260.006-0.4190.0330.857Equal variances not assumed-2.8480.006-0.419Q15Equal variances assumed-2.3240.023-0.3872.9890.088Equal variances not assumed-2.3210.023-0.387Q16Equal variances assumed-2.5380.013-0.4150.0730.788Equal variances not assumed-2.5600.012-0.415Q17Equal variances assumed-0.5530.581-0.1240.2900.592Equal variances not assumed-0.5520.582-0.124Q18Equal variances assumed1.4350.1550.29811.3030.001*Equal variances not assumed1.4210.1600.298Q19Equal variances assumed2.9030.0050.6940.0410.841Equal variances not assumed2.8900.0050.694Q20Equal variances assumed1.3060.1950.2538.3390.005*Equal variances not assumed1.2940.2000.253Q21Equal variances assumed-0.3680.714-0.0730.4390.509Equal variances not assumed-0.3670.714-0.073Q22Equal variances assumed0.0680.9460.0140.0910.763Equal variances not assumed0.0680.9460.014Q23Equal variances assumed2.4800.0150.5310.0110.917Equal variances not assumed2.4700.0160.531Q24Equal variances assumed-0.7760.440-0.1820.4850.488Equal variances not assumed-0.7760.440-0.182Q25Equal variances assumed0.8170.4160.2432.1910.143Equal variances not assumed0.8130.4190.243*P value=extremely statistically significant |