Developing case studies for holistic clinical education

This is quite a long post. Basically I’ve been trying to situate my current research into a larger curriculum development project and this post is just a reflection of my progress so far. It’s probably going to have big gaps and be unclear in sections. I’m OK with that.

Earlier this week our department had a short workshop on developing the cases that we’re going to use next year in one of our modules. We’re going to try and use cases to develop a set of skills and attitudes that are lacking in our students. These include challenges with (text in brackets are stereotypical student perspectives):

• Problem solving and clinical reasoning (Tell me what the answer is so that I can memorise it)
• Critical analysis (Everything I read has the same value)
• Empathy (The patient is an object I use to develop technical skills)
• Communication (The use of appropriate professional terminology isn’t important)
• Groupwork (Assessment is a zero sum game…if you score more than me it bumps me down the ranking in the class, therefore I don’t help you)
• Knowing vs Understanding (It’s more important for me to know the answer than to understand the problem)
• Integration of knowledge into practice (What I learn in class is separate to what I do with patients)
• Integration of knowledge from different domains (I can’t examine a patient with a respiratory problem because I’m on an orthopaedic rotation)
• Poor understanding of the use of technology to facilitate learning (social networks are for socialising, not learning)

I know it might seem like a bit much to think that merely moving to case-based learning is going to address all of the above, but we think it’ll help to develop these areas in which the students are struggling. The results of my ongoing PhD research project will be helping in the development of this module in the following ways:

• The survey I began with in 2009 has given us an idea of digital literacy skills of this population, as well as some of the ways in which they learn.
• The systematic review has helped us to understand some of the benefits and challenges of a blended approach to clinical education.
• The Delphi study (currently in the second round) has already identified many of the difficulties that our clinicians and clinical supervisors experience in terms of developing the professional and personal attributes of capable and competent students. This study will attempt to highlight teaching strategies that could help to develop the above mentioned problems.
• I’ve also just finished developing and testing the data capture sheet that I’ll be using for a document analysis of the curriculum in order to determine alignment.
• Later next year I’ll be conducting an evaluation of the new module, using a variety of methods.

All of the above information is being fed into the curriculum development process that we’re using to shift our teaching strategy from a top-down, didactic approach to a blended approach to teaching and learning. Development of the cases is one of the first major steps we’re taking as part of this curriculum development process. I’ll try to summarise how the cases are being developed and how they’ll be used in the module. This module is called “Applied Physiotherapy” and it’s basically where students learn about the physiotherapy management of common conditions.

In the past, these conditions were divided into systems and taught within those categories e.g. all orthopaedic conditions were covered together. The problem is that this effectively silo’s the information and students see little crossover. In fact, reality is very rarely so conveniently categorised. Patients with orthopaedic conditions may develop respiratory complications as a result of prolonged bed rest. Patients with TB often also present with peripheral neuropathy, as a result of the association of TB with HIV. So, the purpose of the cases is also to integrate different conditions to help students understand the complexity of real-world cases.

In the first term we’ll use 2 very simple cases that each run for 3 weeks. The reason that the cases are simple is that we’re also going to be introducing many new ideas that the students may have little experience with and which are important for participation in the cases e.g. computer workshops for the online environment, concept mapping, group dynamics, presentation skills, etc. The cases will increase in complexity over time as the students feel more comfortable with the process.

Each case will have an overview that highlights the main concepts, learning outcomes, teaching activities, assessment tasks and evaluation components that the case encompasses. The case will be broken up into parts, the number of which will depend on the duration and complexity of the case. After the presentation of each part, the students (in their small groups) will go through this process:

• What do I know that will help me to solve this problem?
• What do I think I know that I’m uncertain of?
• What don’t I know that I need to learn more about?

These questions should help the students develop a coherent understanding of the knowledge they already have that they can build on, as well as the gaps in understanding that they need to fill before they can move on with the case. Each part will involve students allocating tasks that need to be completed before the next session and role allocation is done by each group prior to the introduction of the case. During this process, facilitators will be present within the groups in order to make sure that students have not left out important concepts e.g. precautions and contraindications of conditions.

At the next session, each member of the small groups present to each other within the small groups. The purpose of this is to consolidate what has been learned, clarify important concepts and identify how they’re going to move forward. At the end of each week each small group presents to the larger group. This gives them the opportunity to evaluate their own work in relation to the work of others, make sure that all of the major concepts are included in their case notes, as well as opportunities to learn and practice presentation skills. Students will also be expected to evaluate other groups’ work.

There will be a significant online component to the cases in the form of a social network built on WordPress and Buddypress. We will begin by providing students with appropriate sources that they can consult at each stage of the process. Over time we’ll help them develop skills in the critical analysis of sources so that they begin to identify credibility and authority and choose their own sources. They will also use the social network for collaborative groupwork, communication, and the sharing of resources.

Finally, here are some of the tasks we’re going to include as part of the cases, as well as the outcomes they’re going to measure (I’ve left out citations because this has been a long post and I’m tired, but all of these are backed by research):

• Concept mapping – determine students’ understanding of the relationships between complex concepts
• Poetry analysis – development of personal and professional values e.g. compassion, empathy
• Reflective blogging – development of self-awareness, critical evaluation of their own understanding, behaviours and professional practices
• Peer evaluation – critical analysis of own and others’ work
• Case notes – development of documentation skills
• Presentations – ability to choose important ideas and convey them concisely using appropriate language

This is about where we are at the moment. During the next few months we’ll refine these ideas, as well as the cases, and begin with implementation next year. During my evaluation of the module, I’ll be using the results of the student tasks listed above, as well as interviews and focus groups with students and staff. We’ll review the process in June and make changes based on the results of my, and 2 other, research projects that will be running. We want the curriculum to be responsive to student needs and so we need to build in the flexibility that this requires.

After reading through this post, I think that what I’m saying is that this forms a basic outline of how we’re defining “blended learning” for this particular module. If you’ve managed to make it this far and can see any gaping holes, I’d love to hear your suggestions on how we can improve our approach.