Making the Case for Case Studies

You have accessSIG 4 Fluency and Fluency DisordersIntroduction12 Oct 2023Making the Case for Case Studies John A. Tetnowski, Charles D. Hughes, and Jennifer T. Tetnowski John A. Tetnowski https: //orcid. org/0000-0002-6363-6116 Oklahoma State University, Stillwater Google Scholar More articles by this author, Charles D. Hughes Eastern Kentucky University, Richmond Google Scholar More articles by this author and Jennifer T. Tetnowski https: //orcid. org/0000-0003-4897-451X Oklahoma Health Sciences University, Oklahoma City Google Scholar More articles by this author https: //doi. org/10. 1044/2023PERSP-23-00121 SectionsAboutAbstractPDF ToolsAdd to favoritesDownload CitationTrack Citations ShareFacebookTwitterLinked In Many humans learn through inductive (rather than deductive) reasoning and are more equipped to learn from a “story” or a “case. ” The American Speech-Language-Hearing Association (ASHA, n. d. ) has identified “case-based learning scenarios, ” that is, case studies and real-life scenarios to improve the transfer of learning into practice. In this type of learning, clinicians can examine/evaluate, analyze, and discuss/apply problems related to the case. These are all higher levels of learning based on Bloom's Taxonomy of Learning (Bloom, 1956). Bloom's taxonomy is a hierarchical model that classifies learning into levels of complexity. Furthermore, the inductive process used in case studies promotes a learner's ability to answer open-ended questions (Nilson, 2016), such as those proposed in the clinical practice of speech-language pathology. For these reasons, and many more, we introduce this forum of SIG 4 Perspectives regarding “case studies” as a method of learning clinical principles. The purpose of this introduction is not to simply introduce the case studies that follow, but to prepare the reader for what they may learn and how important these cases can be in their continuing education. Case studies have been used as a valuable tool for learning in areas as diverse as medicine and business. Made famous by the Harvard Business School, case studies represent a large portion of the classroom instruction methods that are employed. Kamat (2013) estimated that as much as 80% of the curriculum at Harvard Business School is based on case studies. In medicine, Case Western Reserve Medical School began using case studies as an integral part of their learning in the 1950s, and this model has been adopted by many other top medical schools (Dubin, 2016). Dubin further states that the case study method can enhance critical thinking. Despite the wide use of case studies as a method of learning in top business schools and medical schools, there appears to be a lack of respect for, or a reluctance to use, case studies in other fields (Concato, 2013; Flyvberg, 2006). According to Hartman (2017), “EBP has become the hegemonic model for how the social work community has decided its practitioners ought to understand and utilize research for practice” (p. 228). In other words, by adopting evidence-based practice (EBP) as a guiding framework for treatment, practitioners are also implicitly valuing, or being instructed to value, experimental design research over case-study owing to the EBP's orientation toward the Oxford University Centre for Evidence-Based Practice (2009) classification. This orientation influences the education of preservice learners as they are conditioned to orient toward evidence-based practice. As we look for effective means of learning, rote learning has been shown to be ineffective for meeting the needs of an advanced society or a field as complex as speech-language pathology (Abdelshiheed et al. , 2023). Developed in the 1950s, Bloom's Taxonomy of Learning is a method that ranks levels of learning (Bloom, 1956). The highest levels in this taxonomy include creating, evaluating, and analyzing, while the lowest level is remembering. If the objective of journals, textbooks, and other tools for learning is a higher level of synthesis, then we must match the level of learning to the expected outcomes. Critical thinking and active learning are two methods that many experts agree can enhance higher levels of learning. Case studies can provide this avenue for learning. A search on ChatGPT revealed that “case studies” is the among the top three strategies to promote active learning. In terms of teaching “critical thinking, ” ChatGPT lists “case studies” as second. The AI-generated output is consistent with the findings of Bezanilla et al. (2019) as well as best practices in clinical education and supervision advanced by ASHA (n. d. ). Clearly, the use of case studies can enhance deeper thinking and better understanding of the strategies that speech-language pathologists use in their daily practice. Traditional Ranking of Case Studies It is unfortunate that case studies do not carry as much “prestige” in the field of communication disorders and sciences. In a 2004 ASHA publication, case studies are not even mentioned in a paper dedicated to levels of evidence (Robey, 2004). In the Oxford Centre for Evidence-Based Practice (2009), the highest levels of evidence are awarded to systematic reviews and randomized control studies (rated 1 and 2 on the 5-point scale), while case studies and expert opinion are awarded the lowest levels of evidence (rated 4 and 5 on the 5-point scale). This type of classification has been used widely by ASHA, while it may not be the best-suited method for learning by a large portion of its membership. Almost 90% of ASHA's 199, 000 speech-language pathologists and 44, 000 speech-language pathology assistants (Zippia, n. d. ) work as clinicians in schools or health-care facilities. Additionally, there are 11, 400 members of the National Student Speech Language Hearing Association (NSSHLA, n. d. ). We need to meet the needs of the majority of our membership who work primarily in clinical care. Case studies can serve as an effective method from which these clinicians can learn effectively. What Is a Case Study and Why Are They Misunderstood? According to Creswell (2014), a case study is an in-depth study of a bounded system (individual, activity, event, or process). It is based on extensive data collection. Further, case study is a research approach that can accomplish the transmission of information based on goals that can generate in-depth knowledge through a multifaceted understanding of complex issues in real-life contexts (Crowe et al. , 2011). This “real-life” concept can be of the utmost importance to practicing clinicians. Beyond this real-life understanding, Duchan (2014) describes case studies as being like nouns; that is, they can describe a person a place, or a thing. Common misperceptions include that case studies describe only a person (for example, a teen who stutters) ; however, a case study can also describe a place (such as a classroom, or a speech and language clinic) or a thing (such as a treatment, an event, or a piece of technology). In addition, case studies are based on extensive data-collection methods that can provide a thorough description of complex issues. Treating persons with communication disorders indeed requires a thorough understanding of complex phenomena. The act of speech, or the transmission of language, is highly complex and therefore difficult to operationalize into a single variable or two. Case studies allow for the deeper and in-depth analysis required to better understand and treat human communication. Beyond the aforementioned misconception of case studies, another misunderstanding arises from the historically prevailing theoretical orientation and, thus, requires a more thorough explanation. As mentioned previously, case studies receive low ratings in most databases that rank the importance of case studies, such as the Oxford Centre for Evidence-Based Medicine (2001, 2009). One of the reasons for the lower rating may be within the terminology itself: evidence-based medicine. Medicine has long been studied in the tradition of the medical model that relies on a cure or a “fixing” of a disorder or difference. This misunderstanding is further amplified by the reliance on only one type of data that garners the highest level of evidence, which is experimental or laboratory-controlled data. Observations and quantitative measures are key factors in these experimental studies. Experimental data come from a positivist viewpoint that stresses data collection in controlled settings where one can test and verify theories (Creswell, 2014). These approaches are well suited to population-based inquiry; however, some researchers and clinicians do not seek data from controlled settings. They want to know how people react in naturalistic settings. Many experimental methodologies leave little room for evaluating complex phenomena in naturalistic settings or for analysis and interpretations of the subject being studied (or from the person collecting the data). Many clinicians need these types of data to evaluate and create treatment methods that work with real human beings in natural settings. We may want to consider a concept as complex and complicated as stuttering from a model that examines how society views stuttering and the barriers to navigating the world while stuttering. If this is the case, a social model may be superior for promoting our understanding. Social Models of Intervention Necessitate Case Study Research Social models of intervention were derived from the disability rights movement and offer a viable alternative to the medical model in that they can identify the role that society can have on a person with any type of difference. This requires studying communication in a real-life setting using in-depth analysis, in contrast to reducing human behaviors to one or two quantifiable variables. From this viewpoint, the “disability” associated with a communication disorder like stuttering is not from the “impairment, ” but how society around the person who stutters impacts that individual. This evolution in conceptualizing health resulted in the reformulation of health and functioning by the World Health Organization's International Classification of Functioning, Disability and Health (WHO, 2001) wherein physical functioning, as “body functions and structures, ” is recognized as interacting with “contextual factors” to impact “activities and participation. ” How a communication disorder impacts an individual within a society is what we seek to ameliorate in those with communication disorders. These phenomena are not readily studied in laboratory settings but lend themselves to more naturalistic settings. Once again, the goals of the social model are not necessarily to “cure, ” but to evaluate and analyze human communication behaviors and create interventions that can address “social implications” and “barriers to success” in real-life settings. This stance has long been adopted by disability rights activists and has worked its way into research in communicative disorders and specifically stuttering (e. g. , Constantino, 2018). The case study design fits this paradigm quite well. Case Studies in Communication Disorders and Stuttering Case studies are not new to the field of communication disorders. Important findings developed through case studies are among the most influential studies in this field. Classic case studies in child language developed through these methodologies laid the foundations for grammatical acquisition and pragmatics of language (e. g. , Berko, 1958; Dore, 1973). In our field of stuttering, early writings by Wendel Johnson and colleagues (e. g. , Tudor, 1939) such as “The Monster Study” used case study methodology to test and define/redefine theories and practice. Van Riper's (1973) four subtypes of stuttering were based on retrospective case studies of his clients. More recently, research methodology has made use of multiple case studies to produce “systematic reviews” to improve the power of single case studies, folding them into more comprehensive findings (Muzra et al. , 2019). This systematic review of case histories further verified the positive effects of speech therapy on stuttering, demonstrating that case studies play an important role in stuttering intervention and treatment. As noted earlier, clinicians may prefer case study research for increasing their knowledge and understanding of stuttering. This is not just the trend for clinicians who may prefer practice-based evidence to evidence-based practice (Green researchers are also interested in case study research, or patient-oriented research (Concato, 2013). As a matter of point, an earlier study in SIG 4 Perspectives shows 441 citations for a methodological paper on qualitative case studies (Tetnowski, 2015). Clearly, there is interest by both clinicians and researchers in case study methodology. As case studies grow in interest, Yin (2014) has proposed how to clarify the “niche” for case studies. Yin suggests using case studies for (a) comparing case study research to other case study findings, and (b) comparing case study findings to other methodologies used in social sciences. On the first point, we agree and suggest not only comparing to other case studies but to gather case studies in systematic reviews to clarify finding, such as Muzra et al. (2019). As a prototype, we can also use the systematic review of Muzra et al. to compare with experimentally based meta-analysis. In this case, the findings of Muzra et al. 's (2019) systematic review are in complete agreement with the findings of Herder et al. 's (2006) meta-analysis regarding the merit of providing intervention for people who stutter. The literature of many years supports the use of case study research. Summary, Conclusion, and Caveats For most of its history, the field of speech-language pathology has followed a medical model, but more recently the field has seen the value of using social models. Medical models accentuate a “cure” for any disorder or difference while the social model offers a counter narrative. It highlights the way society is structured as disabling, rather than the physical impairment itself (Damico et al. , 2021). Disability is experienced when a person is unable to participate fully in society through a mismatch between their body functioning and the environment around them; thus, disability becomes a dynamic process, not an inherent characteristic. The social model provides a mechanism to align the constructs within a society that can facilitate an individual's ability to navigate their lives in real-life settings. New articles by authors like Constantino (e. g. , Constantino, 2018) stress the social model and how it fits into the neurodiversity movement. Other articles by Tichenor and colleagues have shown the variability that exists in stuttering that is so difficult to study using only experimental studies (e. g. , Tichenor Handbook I: Cognitive domain. In M. D. Engelhart, E. J. Furst, W. H. Hill, Handbook I: Cognitive domain. David McKay. Google Scholar Concato, J. (2013). Study design and “evidence” in patient-oriented research. American Journal of Respiratory and Critical Care Medicine, 187 (11), 1167–1172. https: //doi. org/10. 1164/rccm. 201303-0521OE CrossrefGoogle Scholar Constantino, C. (2018). What can stutterers learn from the neurodiversity movement? . Seminars in Speech and Language, 39 (4), 382–396. https: //doi. org/10. 1055/s-0038-1667166 CrossrefGoogle Scholar Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed. ). SAGE. Google Scholar Crowe, S. , Cresswell, K. , Robertson, A. , Huby, G. , Avery, A. , & Sheikh, A. (2011). The case study approach. 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The treatment of stuttering. Google Scholar World Health International Classification of Functioning, Disability and Health Google Scholar R. (2014). Case study and SAGE. Google Scholar (n. d. ). and in the Retrieved June 9, 2023, from Google Scholar John A. Tetnowski is the for Perspectives of the ASHA Special SIG Charles D. Hughes on the of SIG 4 and was the for this Jennifer T. Tetnowski has that or at the of to John A. T. This is part of the Case Studies in Oct in Oct to & American Speech-Language-Hearing