Internal Medicine Family Practice Nurse Clinicians Medical Students

Adapting the Approach: Medical Students

What makes a good teaching case? There is no single answer. Content conditions differ, and cases can be adapted to almost any type of content. As a rule, medical cases depict a doctor-patient interaction. The interaction can also include other medical professionals and family members. For example, the Bright Futures cases “The Silent Cry” and “The Craffty Pupil” portray children, parents, medical professionals, social workers and others – all involved in episodes that require interpretation, diagnosis, management, recognition of appropriate guidelines and protocols, and a good deal of empathetic understanding for all involved. In cases like these, the focus may well be patient management or the following of appropriate protocols. In other cases, the focus may be on diagnosis, history taking or one of the myriad aspects of medical practice. The case may depict a patient record, with problematic test and examination results, and call for scientific interpretation. It may also require students to set priorities for these activities. Cases of another type might depict whole communities, as in the case of an epidemic. Their focus may be medical or social, or some combination of the two.

When adapting these cases for use in populations across the continuum of medical education, special consideration should be given to the learning group’s level of prior experience. For use at the undergraduate medical student population, a number of strategies may be employed to maximize the educational experience. In educational planning, a good rule is to always start with an evaluation of the learner’s current status with respect to professional development and content background. Once that is gauged, the objectives should be tailored to insure a proper fit with the learners’ and teacher’s expectations.

Additional supporting material may also be necessary for the medical student group. For example, if lab data is presented, normal values might also be distributed to students in years I and II. Background readings or supplementary resources such as radiographs, photographs or even videos of patients and families could help to fill in gaps for those with less experience in clinical settings. With this population, class discussion will be enriched by advanced preparation of the case. The case and supplementary resources could be distributed prior to the class discussion along with study questions to guide the learner’s preparation.

Another option is to use the case multiple times; progressively disclosing additional information, as in the problem-based learning strategy currently practiced in medical schools. This method gives students the opportunity to return to the case at a higher level of understanding after additional reading and study. With more time devoted to any one case, there are opportunities for a range of activities including impromptu role plays of dialogue that could occur between patient and health care provider, building a family genogram or plotting growth curves together. These and other strategies that demand more active participation from the student will enliven discussion and support learning.

Because case discussion aims to approximate the professional environment, medical students are given the opportunity to practice behaviors of their profession in a safe environment with the supervision of a faculty.1 The following guidelines are offered to assist facilitators in developing their role as partner in the learning that will take place before, during and after any good case discussion. Begin with a student leading off the discussion, generally in response to a very open-ended question (i.e. “what’s going on in this case?”).

1. Place the students in the role of the physician/problem solver throughout the discussion.
2. Brainstorm to generate many ideas quickly and to build group unity.
3. Promote horizontal learning.
4. Stay with the specifics of the case – keep returning to data and comments within it to force students to support their decisions.
5. Ask for clarification of any incompletely developed ideas.
6. Provoke discussion by calling attention to unexplored aspects of the case study.
7. Support a variety of opinions as they arise, particularly those ideas that may have “died” when first presented, but seem to fit later discussion.
8. Validate student life experiences and subjective responses, as well as more factual contributions.
9. Silence yourself and formulate a question when inclined to break into a lecture if the content can be drawn out of the group.
10. Hypothesize alternative clinical situations in order to explore unknowns.
11. Encourage synthesis of ideas and contributions to tie loose ends together.
12. Carefully consider yourself as a role model – a doctor is a teacher.
    • Offer but do not impose your own opinions
    • Lecture only to briefly supplement
    • Encourage and support self-directed learning
    • Remain after class to offer further resources, activities and reflections on case

Medical cases are often presented with extremely detailed teaching notes or “teacher preparation guidelines.” These may advise the instructor about everything from attitudes (including explicit attention to learners’ goals in their preparation for class) to content (detailing, for example, the symptoms of irritable bowel syndrome). The guidelines help instructors prepare to open class (ideally with a single, open-ended question); manage the middle of the discussion (with clarifying comments, appeals to a number of participants to join the discussion, attention to varying the types of questions asked, and attempts to encourage student-to-student interaction); and end the class with closure, clarity and, if possible, help in getting students to transfer the learning to clinical situations or other course work.

Elizabeth Armstrong, Ph.D.

Reference:
1. Boehrer J, Linsky M. Teaching with Cases: Learning to Question. In: Young RE, editor. New Directions for Teaching and Learning. San Francisco: Jossey-Bass Inc. Pub. 42; 1990.