Jones & Bartlett Learning Health Blog

    This is Your Brain on Fiction: Why Teaching with Case Studies Works

    Posted by sharonb on Sep 4, 2012 3:00:52 AM

    A health care management case study is a short story depicting an organizational scenario which can be non-fiction or fiction. As in all short stories, it should have a beginning, middle, and an end. And it should also engage readers’ higher order thinking skills (HOTS). The case study method is an example, par excellence, of problem-based learning (PBL), an educational approach that engages the student and provides opportunities for deeper learning. The purpose of this blog post is to provide an overview of the HOTs, the attributes of a good case study, the neuroscience of why case studies are effective, and to offer some tips on selecting and writing good case studies.

    Higher Order Thinking Skills (HOTS)

    As health care management educators, our goal is to create reflective practitioners who can be flexible and responsive to the dynamic health care environment. This can only come about when we engage students’ HOTS. For all the Bloom taxonomy aficionados, this will come as no surprise: good case studies require students to use HOTS. They must:

    • Analyze the scenario in the case using critical thinking skills and examine underlying issues that might not appear on the surface.
    • Apply their knowledge of health care management to the case and reflect on the impact of health care issues on the case.
    • Create or synthesize a proposed solution to the problem or conflict in the case.
    • Assess the feasibility of the proposed solution.
    • Evaluate the impact of the proposed solution on the stake holders in the case.

    In addition, students must be able to utilize their lower order thinking skills (LOTS), however the LOTS should support the HOTS. Some examples of Bloom’s taxonomy verbs for LOTS include: identify, remember, recite, name, label, outline, discuss, explain, match, and describe. These are foundational thinking skills, required for all, but not the focus of a case study.

    Attributes of Good Case Studies

    One of the ongoing struggles we have as educators is finding good case studies to illustrate wicked problems in health care. Some of the features of good case studies include:

    • “Illustrations of major organizational issues;
    • Emotional and intellectual engagement;
    • Instructions for reading and analyzing the case; and,
    • Discussion questions to guide the students” (Davis, 2009, p. 223.)

    I would add one more item to this excellent list:

    • Make sure the case studies you select tell a story.

    Joseph Campbell, author and teacher, was a prolific writer on the power of the hero’s journey and archetypal myths in our collective psyche. Ever since man stood in caves and recounted stories about the hunt, humans have craved stories. Good stories and good story tellers engage all the senses of the audience and keep them on the edge of their seat. While health care organizational situations may not always be riveting reading, we can utilize story telling techniques to engage students so they will identify with the protagonists and put themselves into the story.  Why does this work better than a basic textbook? Because our brains respond to stories.


    Thanks to the power of functional neuroimaging, we now know that when someone reads fiction that includes food descriptions and smells, such as coffee or perfume, the olfactory cortex lights up. Non-evocative words, like chair or desk, cause no changes (Paul, 2012). Likewise, photos of people in painful positions cause regions of the cortex associated with pain response to respond. Through reading, people can experience a wide range of emotions from disgust, fear, shame, and embarrassment, to affection, humor and laughter. Our brains do not distinguish between the real exposure and the fictional exposure. By using the right materials to immerse students in a story, we can create a learning experience to stimulate the portions of the brains associated with emotional responses, even empathy (Lamm & Decety, 2006). As someone who writes both non-fiction and fiction, I have learned to infuse my non-fiction writing with fictional techniques. Here are some tips from fiction to consider when selecting or writing case studies to engage your students and their HOTS.

    Goal, Motivation and Conflict (GMC)

    In fiction, one of the first things a writer learns is to focus on GMC. No one wants to be accused of creating a character who is Too Stupid To Live (TSTL). These are the girls in the teenage slasher flicks who go into the dark house alone and unarmed when they’ve been warned there is a serial killer on the loose. The audience shrieks “Don’t go into that house!” but the TSTL character goes in anyway, because that’s what the director says she has to do. Case studies should not star protagonists who are TSTL, either. They need real goals, motivation and conflicts.

    Goals—What does the main character (MC) want? It should be important, not something like, “I want a turkey sandwich.” Does the manager want to staff his organization without a union being involved? Does a Latina want a promotion that she feels she’s been denied? Good goals, substantive goals are essential to setting the stage.

    Motivation—Why does the main character want to solve the problem(s)? Is the CEO worried the union will wreak havoc? Is he worried he’ll lose his job? Is the Latina who was passed over for a promotion thinking about suing the organization? Again, the motivation should have substance.

    External Conflict—What external issues contribute to the conflict? Is the economy so bad that the CEO thinks unions shouldn’t be an issue? Or is the organization in such a remote region that staffing is challenging? Do the people who live in the community surrounding the organization look different from the people working in the organization? Is the Latina woman passed over for the promotion from the community?

    Internal Conflict—What internal conflicts do the characters in the case have? Has the manager been given orders to stop the union “at any cost?” And does the manager think if he can’t keep the union out that he’s a failure? Is the Latina a single parent, afraid of being fired from her job? At the same time, does she feel like she has to speak up to represent her community?

    Character and Language—Who are the characters? What is their level in the organization? What do they sound like? Be sure the cases reflect the words and the language the characters would use. The manager fighting the union would not use the same vocabulary as the woman who’s about to sue her organization for discrimination.

    And today’s final tip:

    Point of view – Whose head are we in? Unless it is a very long case study, or is written as a script for role play, the case should pick one point of view and stick to it.  Writers are told to pretend to have a camera mounted on their head. All the character can see is what is in that camera’s view finder. Here is a list of the potential points of view and some examples of each.


    First person—“I got a phone call from the charge nurse on Two West in the middle of the night about Joe.”

    Second person—“You are the administrator on call and you receive a call in the middle of the night about Joe.”

    Omniscient third person---Little did Fred Johnson know, dear reader, that at the exact moment his head hit the pillow, a crisis would be brewing on Two West.

    Third person—Fred Johnson woke up to the sound of his phone ringing. The call came from the charge nurse on Two West. Joe, she said, arrived at work under the influence of alcohol.

    Third person, deep point of view---The phone rang like a fire alarm next to Fred’s head. He rolled over in bed and tried to remember where he was. He blinked and glanced around. Home, not his office. So why was the phone ringing off the hook?

    “Hullo?” Fred’s tongue clung to the roof of his mouth. Who the heck was calling at three in the morning?

    “Fred, this is Heidi on Two West.”

    Heidi. No faces came up with the name. Not even a glimmer.

    He shook his head to clear the cobwebs of sleep. “Yes?”

    “It’s Joe Rogue. I think he’s drunk. He stinks like beer and is slurring his words. I called security and now he’s combative. What should we do?”

    Why did this crazy stuff happen in the middle of the night? Just once he’d like to get an uninterrupted night’s sleep.


    Which point of view did you feel most engaged with? My guess is the last one, the one with the most details that make the reader feel as if he is in Fred's head. That's exactly what you want your students to feel. You want the student to be lost in the story.

    Case studies provide an excellent opportunity to immerse our students in a safe, fictional representation of the world in which they will be working. Students can make mistakes, misinterpret motives, misread people’s motivations, all in a risk free world. Case studies give the instructors an opportunity to enter the fictional world as a guide and to provide corrective feedback before students enter the workforce. Once graduates enter the real world of employment, the risks are greater and the impact of their actions has consequences. By encouraging students to have these vicarious experiences early on, before they enter the workforce, we help them to become confident, competent, reflective practitioners.

    Now, tell me a story.

    Sharon B. Buchbinder, RN, PhD

    Sharon Buchbinder got into a lot of trouble as a child for making up stories. She is Professor and Program Coordinator for the MS in Healthcare Management at Stevenson University in the Graduate and Professional School and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of three books from Jones and Bartlett: Introduction to Health Care Management (with Nancy H. Shanks), Career Opportunities in Health Care Management (with Jon Thompson) and Cases in Health Care Management (with Nancy H. Shanks and Dale Buchbinder) to be released in spring 2013.

    Here are some additional resources if you are interested in this topic.

    Barkley, E.F. (2010). Student engagement techniques: A handbook for college faculty. San Francisco, CA: Jossey-Bass.

    Buchbinder, S.B. (2009, September 17). Can we tame the wicked problems in health care? Retrieved from

    Buchbinder, S.B., Alt, P.M, Eskow, K., Forbes, W., Hester, E., Struck, M., Taylor, D. (2005). Creating learning prisms with an interdisciplinary case study workshop. Innovative Higher Education, 29 (4): 257-274.

    Buchbinder, Sharon B. & Cox, Donna M. Healthcare management case study guidelines. In S.B. Buchbinder & N.H. Shanks, N. (Eds). Introduction to healthcare management, 2nd Ed. Boston , MA: Jones & Bartlett, 2012, pp. 367-374.

    Campbell, J. (2008). The hero with a thousand faces, 3rd Ed. Novato, CA: New World Library.

    Davis, B. G. (2009). Tools for teaching, 2nd Ed. San Francisco, CA: Jossey-Bass.

    Lamm, C. & Decety, J. (2006). Human empathy through the lens of social neuroscience. TheScientificWorldJOURNAL 6, 1146–1163. Retrieved from

    Missett, T. C., Reed, C. B., Scot, T. P., Callahan, C. M., & Slade, M. (2010). Describing learning in an advanced online case-based course in environmental science. Journal of Advanced Academics, 22(1), 10-50.

    Paul, A.M. (2011, March 17). Your brain on fiction. Retrieved from

    Sankar, C. S., & Raju, P. K. (2011). Use of presage-pedagogy-process-product model to assess the effectiveness of case study methodology in achieving learning outcomes. Journal of STEM Education: Innovations & Research, 12(7), 45-56.

    Topics: administration, Author, author, health administration, Health Administration, health care management, Sharon B. Buchbinder, Problem Based Learning, Sharon Buchbinder Blog, Case studies, Higher Order Thinking Skills

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