Case Based Instruction Faculty Development

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Case Based InstructionFaculty Development

• January 21, 2008
• Brad Appelhans, Ph.D.
• Stuart Flynn, M.D.
• Howard Silverman, M.D.
• Paul Standley, Ph.D.
• Kerr Whitfield, Ph.D.

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Objectives

• Describe the features of case based instruction
  and its scheduling in our curriculum
• Describe the roles of the Case Management Team,
  Block Director, case author, facilitators and
  students in successful CBI experiences.
• Review an example of a CBI used successfully last
  year by discussing the learning issues, session
  objectives and exam question writing.
• Realize that CBIs can take on many different
  appearances and rely on different effective
  scheduling strategies the objectives will anchor
  the process in all cases.

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Todays Topics

• Welcome / Overview of CBI methodology and role in
  the curriculum
• CBI Case Flow (Opening/Closing)
• Facilitation / Small group process 101
• Panel
• Wrap-up

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What is Case Based Instruction (CBI)?

• It is a teaching modality using a clinical
  case-based scenario
• Students learn new material
• Students apply previously learned material
• It is student centric
• Facilitators guide
• Students team learn and team teach
• It should
• develop and hone critical thinking skills
• encourage discovery

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Scheduling CBI in our Curriculum

• Goal is to schedule a CBI for each week of
  instruction
• Non-exam weeks 2 hour open on Mondays, 2 hour
  close session on Fridays
• Exam weeks 2-3 hour openclose session on Monday
• Goal is to choose a case and objectives that
  parallel the weekly theme

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Role of the Case Management Team (CMT)

• Review entire block and all cases implemented
• Review weekly theme
• Assist in developing sound learning objectives
• Basic science
• Clinical science
• Theme
• Assist in choosing the case (e.g., diabetic
  ketoacidosis)
• Review case after completion to recommend
  improvements / modifications

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Steps in Preparing a Case

• Block director and CMT agree on case and
  objectives
• Block director recruits author(s)
• Author writes the case
• Author reviews the case with facilitators
• Facilitators meet with students during two
  sessions
• Author writes and reviews case-based exam
  questions with facilitators

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Example of CBI Objectives List(aka Learning
Issues)

• Describe and compare pulmonary ventilation vs.
  pulmonary perfusion in the normal state and in
  states of restrictive and occlusive pulmonary
  diseases.
• Describe the diffusion barriers to gases entering
  and exiting the pulmonary vasculature and relate
  how these barriers are altered in pulmonary
  disease states.
• Compare and contrast arterial blood gases (and
  their meanings) from a normal patient and a
  patient diagnosed with pulmonary thromboembolism.
• Define dyspnea, list its potential causes, and
  explain why our patient presents with dyspnea
  despite a normal chest X-ray.
• For the following diagnostic tests list the
  sensitivity, specificity, positive predictive
  value and negative predictive value for
  diagnosing PE and how the pre test probability
  affects the predictive values d-dimer,
  ventilation-perfusion lung scan, helical CT, and
  pulmonary angiography.

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What might a case look like?

• Presenting complaint
• History
• Physical findings
• Lab results
• Diagnosis (if not an objective)
• Treatment (if not an objective)
• Follow up (if not an objective)

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How are the two sessions different?

• Session 1
• The opening
• Review case (entirely, or new data mid-week)
• Determine what must be researched / learned
• Major objectives (learning issues) those
  scripted by CMT / Block Director / Case author
• Personal other student-authored objectives
• Midweek
• Students collaboratively research learning issues
  using all available resources
• Facilitators may be sought for general guidance
• Session 2
• The closing
• Students present their research and entertain
  questions
• Continually refer to the patient to ground the
  experience
• Facilitators do not teach, but guide and prompt
• Wrap-up discussion (placing things in broader
  context, final details, etc.)
• Distribute additional materials if desired /
  necessary

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An Example of a Case

• In this example, the presenting complaint is
  posted on AZMed for students the Friday before
  the case begins all of the rest of the materials
  were released during session 1 by projecting them
  on the screen over the course of the two hours
  (paperless!).
• HOWEVER, this choreography is not required, and
  materials could be released in other ways
  (e-mail, etc.) and at other times (e.g.,mid-week).

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Presenting Complaintoften posted on Friday
before the CBI

• A 47-year-old man is brought into the emergency
  room by his wife for evaluation because of severe
  shortness of breath.
• Please bring three hypothetical diagnoses to the
  case opening.

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History

• Mr. Q. is a 47-year-old man who is the vice
  president of a prestigious law firm. As a
  result of the stressful nature of his job, Mr. Q.
  has a habit of smoking two packs of cigarettes a
  day and has done so for the past 25 years.
  During the last few years, Mr. Q. has experienced
  slight shortness of breath and a mild cough with
  activity and on arising in the morning. It has
  become increasingly difficult for Mr. Q. to
  climb the stairs to his office at work, and he
  states that he must stop frequently to catch his
  breath when doing so. He generally sleeps
  propped up by several pillows as he often feels
  short of breath when supine. Recently Mr. Q.
  started to experience dyspnea at rest.
• He has had an approximate weight loss of 10
  pounds within the last six months. He denies
  alcohol or drug use. His grandfather had lung
  problems, but there is no other history of
  pulmonary disease involving the family. He does
  state that several brothers and sisters have hay
  fever. There is no history of exposure to
  extraordinary environmental pollutants.

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Physical findings

• VS BP 140/80 P 120 RR 30 Wt 150 Ht 69
  in T 98.5
• Gen App 47 yo male, pale, profound dyspnea,
  occasional pursed lipped breathing
• HEENT Normocephalic. Neck supple without masses.
  Conjunctivae pink, sclera non-icteric pupils
  equal, round and reactive to light nasal mucosa
  and turbinates erythematous and boggy normal
  dentition
• Neck No bruits, thyromegaly, nodes, JVD
• Heart Tachycardia SR, no murmur, S3 or S4
• Lungs Decreased breath sounds bilaterally,
  pronounced expiratory wheezing
• Abd No organomegaly, masses, or bruits
• Ext Pulses 2/2, minor edema, no clubbing
• Rectal Deferred

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Lab Results
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Lab Results
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Lab Results
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Treatment / Follow-Up
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Facilitator Training

• Receive facilitator version 1-2 weeks before
  session
• Provides much more detail (vs. student version)
• Designed to help facilitator understand material
• Provides prompts to use during sessions
• Author-led briefing meeting 1 week before session
• Answer content questions
• Set session choreography
• E.g., will entire case be reviewed in session 1?
  Some released mid-week? Will we expect students
  to order labs they deem appropriate?
• During session, facilitator version often has
  prompts, etc.

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Todays Topics

• Welcome / Overview of CBI methodology and role in
  the curriculum
• CBI Case Flow (Opening/Closing)
• Facilitation / Small group process 101
• Panel
• Wrap-up

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Facilitation / Small group process 101

• Tuckmans (1965) model - how groups evolve over
  time
• General strategies for small group learning
• Common challenges
• Unfocused or chatty group, disinterest in the
  case, lack of discussion of learning issues
• Quiet students
• Bad apple - hostile/pessimistic/bored/too cool
  to participate/dominating group member
• Tangential discussions and group focused on
  covering objectives
• Things to monitor

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Todays Topics

• Welcome / Overview of CBI methodology and role in
  the curriculum
• CBI Case Flow (Opening/Closing)
• Facilitation / Small group process 101
• Panel
• Wrap-up

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Panel

• Stuart Flynn, M.D.
• Paul Standley, Ph.D.
• Kerr Whitfield, Ph.D.

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Todays Topics

• Welcome / Overview of CBI methodology and role in
  the curriculum
• CBI Case Flow (Opening/Closing)
• Facilitation / Small group process 101
• Panel
• Wrap-up