How my students do case studies in clinical practice

Our students do small case studies as part of their clinical practice rotations. The basic idea is that they need to identify a problem with their own practice; something that they want to improve. They describe the problem in the context of a case study which gives them a framework to approach the problem like a research project. In this post I’ll talk about the process we use for designing, implementing, drafting and grading these case studies.

There are a few things that I consider to be novel in the following approach:

  1. The case studies are about improving future clinical practice, and as such are linked to students’ practices i.e. what they do and how they think
  2. Students are the case study participants i.e. they are conducting research on themselves
  3. We shift the emphasis away from a narrow definition of “The Evidence” (i.e. journal articles) and encourage students to get creative ideas from other areas of practice
  4. The grading process has features that develop students’ knowledge and skills beyond “Conducting case study research in a clinical practice module”

Design

Early on in their clinical practice rotations, the students identify an aspect of that block that they want to learn more about. We discuss the kinds of questions they want to answer, both in class and by email. Once the topic and question are agreed, they do mini “literature” reviews (3-5 sources that may include academic journals, blogs, YouTube videos, Pinterest boards…whatever) to explore the problem as described by others. They also use the literature to identify possible solutions to their problems, which then get incorporated into the Method. They must also identify what “data” they will use to determine an improvement in their performance. They can use anything from personal reflections to grades to perceived level of comfort…anything that allows them to somehow say that their practice is getting better.

Implementation and drafting of early case studies

Then they try an intervention – on themselves, because this is about improving their own practice – and gather data to analyse as part of describing a change in practice or thinking.  They must also try to develop a general principle from the case study that they can apply to other clinical contexts. I give feedback on the initial questions and comment on early drafts to guide the projects and also give them the rubric that will be used to grade their work.

Examples of case studies from last semester include:

  • Exploring the impact of meditation and breathing techniques to lower stress before and during clinical exams, using heart rate as a proxy for stress – and learning that taking a moment to breathe can help with feeling more relaxed during an exam.
  • The challenges of communicating with a patient who has expressive aphasia – and learning that the commonly suggested alternatives are often 1) very slow, 2) frustrating, and 3) not very effective.
  • Testing their own visual estimation of ROM against a smartphone app – and learning that visual estimation is (surprise) pretty poor.
  • Exploring the impact of speaking to a patient in their own language on developing rapport – and learning that spending 30 minutes every day learning a few new Xhosa words made a huge difference to how likely the patient was to agree to physio.

Submission and peer grading

Students submit hard copies to me so that I can make sure all submissions are in. Then I take the hard copies to class and randomly assign 1 case study to each student. They pair up (Reviewer 1 and 2) and we go through the case studies together, using the rubric as a guide. I think out loud about each section of the rubric, explaining what I’m looking for in each section and why it’s important for clinical practice. For example, if we’re looking at the “Language” section I explain why clarity of expression is important for describing clinical presentations, and why conciseness allows them to practice conveying complex ideas quickly (useful for ward rounds and meetings). Spelling and grammar are important, as is legibility, to ensure that your work is clearly understandable to others in the team. I go through these rationales while the students are marking and giving feedback on the case studies in front of them.

Then they swap case studies and fill out another rubric for the case study that their team member has just completed. We go through the process again, and I encourage them to look for additional places to comment on the case study. Once that’s done they compare their rubrics for the two case studies in their team, explaining why certain marks and comments were given for certain sections. They don’t have to agree on the exact mark but they do have to come to consensus over whether each section of the work is “Poor”, “Satisfactory” or “Good”. Then they average their marks and submit it to me again.

I take all the case studies with their 2 sets of comments (on the rubric) and feedback (on the case study itself) and I go through them all myself. This means I can focus on more abstract feedback (e.g. appropriateness of the question, analysis, ethics, etc.) because the students have already commented on much of the structural, grammatical and content-related issues.

Outcomes of the process

For me, the following outcomes of the process are important to note:

  1. Students learn how to identify an area of their own clinical practice that they want to improve. It’s not us telling them what they’re doing wrong. If we want lifelong learning to happen, our students must know how to identify areas for improvement.
  2. They take definite steps towards achieving those improvements because the case study requires them to implement an intervention. “Learning” becomes synonymous with “doing” i.e. they must take concrete steps towards addressing the problem they identified.
  3. Students develop the skills they need to find answers to questions they have about their own practice. Students learn how to regulate their own learning.
  4. Each student gets 3 sets of feedback on their case study. It’s not just me – the external “expert” – telling them how to improve, it’s their peers as well.
  5. Students get exposed to a variety of other case studies across a spectrum of quality. The peer reviewers need to know what a “good” case study looks like in order to grade one. They learn what their next case study should look like.
  6. The marking time for 54 case studies goes down from about 10 hours (I give a lot of feedback) to about 3 hours. I don’t have to give feedback on everything because almost all of the common errors are already identified and highlighted.
  7. Students learn how I think when I’m marking their work, which helps them to make different choices for the next case study. This process allows them access to how I think about case study research in clinical practice, which means they are more likely to improve their next submission, knowing what I’m looking for.

In terms of the reliability of the peer marking and feedback, I noted the following when I reviewed the peer feedback and grades from earlier in the year:

  • 15 (28%) students’ marks went up when I compared my mark with the peer average, 7 (13%) students’ marks went up by 5% or more, and 4 (7%) students went from “Fail” to “Pass”.
  • 7 (13%) students’ marks went down, 3 (6%) by 5% or more, and 0 students went from “Pass” to “Fail”.
  • 28 (52%) students’ marks stayed the same.

The points I take from the above is that it’s really important for me to review the marks and that I have a tendency to be more lenient with marking; more students had mark increases and only 3 students’ marks went down by what I would consider a significant amount. And finally, more than half the students didn’t get a mark change at all, which is pretty good when you think about it.