Re: Case-Informed Learning in Medical Education: A Call for Ontological Fidelity (Perspect Med Educ. 2023;12(1):120–128)

To the Editor,

MacLeod et al. [1] make a valuable case that PBL cases smuggle in unexamined ontological assumptions, and that narrative thinness is a real cost. We raise three concerns about the proposed remedy.

First, ontological fidelity, as operationalised in Table 1, asks case writers to add patient voice, practitioner reflection, messy timelines, and unresolved endings. Each addition is text. In time-boxed tutorials already strained by "PBL fatigue" [2], richer narrative content competes directly with time available for the hypothetico-deductive reasoning PBL exists to train. The authors offer no mechanism by which narrative elaboration converts into transferable clinical reasoning; the gain is experiential and affective, not demonstrably epistemic. Without evidence that narrative richness improves diagnostic accuracy or knowledge encapsulation, lengthening sessions to accommodate it risks trading a scarce resource (tutorial time) for a benefit that remains, at present, asserted rather than shown.

Second, the proposal is logistically demanding in a way the article underplays. Facilitating narrative-rich, deliberately unresolved cases well requires tutors comfortable eliciting affect, tolerating ambiguity, and resisting premature closure — a skill set closer to narrative medicine facilitation than to standard PBL tutoring. Programmes already struggle to recruit and calibrate sufficient tutors for conventional PBL [3]. Superimposing a narrative-competence requirement onto an already-constrained tutor pool compounds a known bottleneck; the article's recommendations would benefit from addressing faculty development and staffing feasibility explicitly, rather than treating tutor capacity as incidental.

Third, and most substantively, we suggest the field needs ontological commitment more than ontological fidelity. Fidelity, as the authors define it, concerns how closely a simulation resembles lived reality — an experiential and largely narrative property. Commitment, by contrast, concerns whether a case's underlying entities and relations (disease process, patient context, illness experience, clinician reasoning) are explicitly and consistently typed, so that students can build correct categorical and relational structures rather than isolated narrative impressions. A case can be narratively spare yet ontologically committed — for example, if it explicitly and consistently distinguishes the patient-as-continuant from the disease-process-as-occurrent, and marks the relations between them — without the added length that fidelity invites. Explicit categorical commitment, not narrative realism, is what should improve the coherence and transfer of case-based learning.

We share the authors' conviction that cases encode philosophical assumptions that deserve scrutiny. We would urge that the next step be a structural one: specifying what a case must ontologically commit to, rather than how real it must feel.

References

1. MacLeod A, Luong V, Cameron P, Burm S, Field S, Kits O, Miller S, Stewart WA. Case-informed learning in medical education: a call for ontological fidelity. Perspect Med Educ. 2023;12(1):120–128.

2. MacPherson R, Jones A, Whitehouse CR, O'Neill PA. Small group learning in the final year of a medical degree. Med Teach. 2001;23(5):494–502.

3. Servant-Miklos VFC, Norman GR, Schmidt HG. A short intellectual history of problem-based learning. In: Moallem M, Hung W, Dabbagh N, editors. The Wiley Handbook of Problem-Based Learning. 2019:3–24.