CASE DISCUSSION REMEDIOS D. CHAN, M.D, MHPEd Professor, UST Faculty of Medicine & Surgery Chair, Department of Medical Education
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CASE DISCUSSION
REMEDIOS D. CHAN, M.D, MHPEd
Professor, UST Faculty of Medicine & Surgery
Chair, Department of Medical Education
CONTENTS• Role of case discussion in case-based
teaching and learning
• Goals of case discussion
• Difference between PBL and case-based teaching
• Preparation of case discussion
• Conduct of case discussion
PK
- is an interactive, student-centered exploration of realistic and
specific narratives that provide useful basis for inductive
learning (Wilkerson and Boehrer, 1992).
- requires more intense effort from both students and
instructors, than many more traditional methods of
instruction (Foran, 2002).
CASE DISCUSSION
CASE-BASED TEACHING
Methods of instructions that focuses on the use of cases as part of or central focus of the curriculum
CASE-BASED TEACHING
CASE METHOD
CASE STUDY
CASE PRESENTATION CASE REPORT
CASE
DISCUSSION
CASE DISCUSSION WITHIN CASE-BASED TEACHINGGrageda, 2010
WHAT STUDENTS RETAIN
Golich VL, 2000
Develop critical thinking - students determine relevant facts, analyze them
and draw conclusions about the cause of the problem and the appropriate
actions to take
Encourages student responsibility for learning
Enliven the classroom dynamic
Teach questioning and self-directed learning
Acquire ability to work collaboratively (collaborative learning) thus enhancing
skills in listening, articulating and participating effectively in a group
Apply theoretical concepts to actual and contemporary real-life scenarios(Foran, 2002) UCSB
GOALS OF CASE DISCUSSION
PREPARING A CASE
DISCUSSION
Identify goals or learning
outcomes
Determine type of problem or
cases
Determine format of
presentation
Decide the level of detail to be
included
Write the storyWrite the guide
questions
Identify the resources
Review the case with colleagues
and revise
Use the case and get feedback
from students
(Haffler, 1991)
Determine institutional
outcomes based on VMG and describe the
ideal graduate attributes of Institution,
University, or College
Choose or create MD program
outcomes and level of
emphasis (I,P,D) - using the CHED PSG
as guide*
Formulate course
intended learning
outcomes taking note of level of
emphasis (I, P, D)
Create specific
instructional design with
intended learning
outcomes
IN CREATING AN OBE MEDICAL CURRICULUM
10
1-Demonstrate clinical competence
2- Communicate effectively
3- Lead and manage health care teams
4- Engage in research activities
5- Collaborate within
interprofessional teams
6- Utilize systems-based approach to
healthcare
7- Engage in continuing personal
and professional development
8- Adhere to ethical, professional, and legal standards
9-Demonstrate nationalism,
internationalism and dedication to service
10- Practice the principles of social
accountability
*CHED PROGRAM OUTCOMES FOR MD PROGRAM
Sample OBE Instructional Design
Type of Problems or Cases
• Descriptive case• Unfolds over 2 -3 tutorials
• Short story used in one session
• Vignette or mini- case• A brief paragraph with one main focus
• Bullet • One or 2 sentences with focus
FORMAT OF PRESENTATION
Paper problems – mini-case or vignettes
Real patients – presented in clinical settings
Simulated or standardized patients
Videotape
Interactive electronic cases
First year levelSubject: Preventive MedicineLearning Outcomes:- Correlate the different risk factors for myocardial infarction- Describe a rehabilitation program for patients who
have had a myocardial infarction.
Mr. JB, a 58 year old car mechanic with a history of chronic obstructive pulmonary disease, was at work when he complained of pain in his chest. The pain steadily got worse and he described an aching pain in his jaw and left arm. One hour after the pain started he collapsed and his colleagues called an ambulance. When he arrived at the ER, Mr. JB was pale, sweaty, and in severe pain.PE: Blood pressure 80/60HR 64 beats/min12-lead ECG showed anterolateral myocardial infarction.He was treated with morphine, metoclopramide and aspirin and was immediately admitted at the Intensive Care Unit.
GLOMERULAR DISEASES
INTENDED LEARNING OUTCOME
Differentiate glomerular from non-glomerular cause of hematuria
Discuss common causes of glomerular hematuria as to: epidemiology
and clinical manifestations
Interpret basic laboratory & ancillary procedures
Plan holistic management
Third year levelPediatric nephrology module
BLOODY RUDY
Rudy, 8 year old, male, consulted due to passage of tea-colored urine, facial edema and headache.3 weeks PTA patient had multiple honey-crusted rash on his face, dorsal aspect of his hands and legs. Hewas diagnosed to have impetigo and given topical antibiotic cream. The lesions dried up. One week priorto admission, he noted passage of tea colored urine with oliguria and presence of facial edema. There washeadache, nape pains and blurring of vision.Pertinent PE Findings:
Vital SignsBP: 170/100 (>P99) PR: 80 bpm RR: 20cpm T: 36.5˚CWt: 30 kg (>p95) Ht: 127cm (p50)
(+) periorbital and facial edemaPink palpebral conjunctivae, anicteric sclerae. Ophthalmoscopic exam: (-) a-v nickingNo tragal tenderness, nonhyperemic postpharyngeal wall, tonsils not enlargedSymmetrical chest expansion, no retractions, clear breath sounds breath soundsAdynamic precordium, apex beat at 5th LICS MCL, no murmurGlobular abdomen with normoactive bowel sounds, no hepatosplenomegaly, no
shifting dullness, no fluid wave, AC: 56cmNo scrotal swellingGrade 1 bipedal edemaSkin: previous scars dorsum of both hands and legs
CBC CHEMISTRIES URINALYSIS
Hgb 8.2 g/Dl BUN 26.2 mg/dL ph 5.0
SG 1.015
Hct 0.24% Creatinine 1.3mg/dL EGFR53.7 Albumin ++
WBC 13.5 x 109/L ASO 800 IU Sugar -
Seg 70 RBC >100/hpf, 25% dysmorphic
Lympho 27 Serum Na 141 meqs/L PC 45-50/hpf
Mono 1 Serum K 4.2 meqs/L Squamous fewEos 2 C3 0.12 Bacteria FewPlatelet 278 x 109/L A. Urates Few
Patient was given IV furosemide and Amlodipine. He was placed on fluid
and salt restriction. Urine output increased from 0.5 mL/kg/hr to 1
mL/kg/hr. On the 3rd hospital day his weight decreased to 26 kg and BP
110/70. IV furosemide and amlodipine were discontinued. He was
discharged on the 4th hospital.
GUIDE QUESTIONS:
1. What pertinent medical and family history should be asked?
2. What is the approach to diagnosis in a patient presenting with red-colored urine?
3. Summarize the salient features of the case and the most likely diagnosis. Briefly discuss the differential diagnoses.
4. Correlate patient’s edema and tea-colored urine with the diagnosis. Give the laboratory and clinical data that will confirm your diagnosis.
5. Differentiate glomerular hematuria from non-glomerular hematuria.
6. Explain the clinical significance of the urinary and serologic findings.
7. Classify this patient’s hypertension as to the primary or secondary and the stage. Is hypertension considered as a hypertensive urgency or emergency?
8. Looking back would the giving of early systemic oral antibiotic prevent the occurrence of AGN? Explain your answer.
9. What will be the outcome of this patient with PSAGN?
a. Reference lists (text, journals or any appropriate sources)
b. Resources – faculty members who are expert in their fields; x-rays
or laboratory results, etc.
c. Guide questions or learning outcomes
d. Tutor guide – to provide facilitator with additional teaching
guidance about the case
COMPONENTS OF CASES
Is the case developed form a real situation?Real case should not seemed to be contrived (unnatural) norfollow a “classic “ textbook description.
Does the case serve its goal?Identify the purpose of the case and assess the case in that light.
Does the case contain accurate data?Check the facts with experts or the literature.
Who is the specific audience for this case?Identify that audience and assess the case in that light.
Is the case grammatically well-written?
CHECKLISTS OF A GOOD CASE
Haffler, 1991
1. Set clear expectations
- Indicate students’ responsibilities in preparing the case discussion in
class.
- Specify the rules for participating in the discussion.
2. Manage time
- Facilitator should manage time effectively.
- Synthesize and summarize important ideas raised during case
discussion in the last 15 minutes.
HOW TO CONDUCT A GOOD CASE DISCUSSION
(Wilkerson and Boehrer, 1992)
3. Asking and encouraging questions
- Use open-ended questions to encourage discussion;
- e.g. “What do you thing is going on here?”; “What would you do?”
- Use closed questions to clarify the facts of the case
e.g. “What do we know about the case so far?”
4. Listen
- Extending the period of silence following a question from one second to
three seconds can improve the quality, quantity and length of students’
responses (Tobin, 1987)
5. Organize and structure
- facilitator can provide or ask for brief summary statements to highlight
divergent points of view or underline points of agreements using the
whiteboard or flip chart.
HOW TO CONDUCT A GOOD CASE DISCUSSION
6. Avoid common problems
Insufficient “wait time”: wait at least 3 seconds
Rapid reward: responding “right, good” to the first answer may cut off further
analysis of the issue
Programmed answers: asking leading questions which are questions that
encourage a particular desired answer, often because of the way that
the questions are phrased. This discourage students from expressing their own
views
A classroom climate that discourages risk-taking: behaviors of facilitators that
make students feel that it is not safe to make an error: talking constantly; adding
comments to each idea posed; rephrases each student’s comment; serving as the
final arbiter in all decision-making; interrupting; intimidating; ridiculing
Closed questions: should be used judiciously
HOW TO CONDUCT A GOOD CASE DISCUSSION
• What are your reactions to this situation?
• What is going on here?Open-ended
• What factors influenced the evolution of events?
• Why did X decide to do Y?Diagnostic
• Who are the actors? What are their interests/positions?
• How do we know?Information
• Why do you think it was appropriate (or inappropriate) for X to do Y?
• What challenge arguments run counter to that view?Challenge
• What does X need to do to achieve his stated goals?
• How else might he have handled the situation?Action
• What immediate action should he take?
• Should he do A or B first?Priority/Sequence
• What do you think is going to happen now?Prediction
Boehrer, 1992; Christensen, 1991
QUESTION TYPOLOGY
• What might have been the result if X had done Z instead?Hypothetical • What assumptions underlie X’s behavior/actions?
• What are the downside risks of that approach as opposed to another?
Extension • Would other experienced policymakers be likely to do the same?
• What skills do participants need in order to achieve their stated goal?
Generalization
• What led to failure here?Comprehension• How do you deal with conflict at work?
• Did they do the same things here?Application
• Where else have we seen this kind of situation?
• How is that similar/different from what we see here?
Analysis/ comprehension
• How did prior actions affect – expand or limit – the options available here?Synthesis
• What is the best course of action here?Evaluation
QUESTION TYPOLOGY
COMPETENCIES QUESTIONS
Data gathering and
interpretation
1. What were the crucial pieces of information you obtained during
this consultation?
2. What was your reasoning/thinking behind your choice of
investigations? What did they show? What were the implications?
Making a diagnosis/making
decisions
1. With the information collected, what diagnoses did you consider?
What are your differential diagnoses?
Clinical management 1. Are you aware of guidelines/evidence that support your
management?
2. How did you tailor this management plan to the patient?
3. How do you justify your plans for follow-up?
Managing medical
complexity
1. Were there aspects of this case that made you feel uncertain?
2. Were there any ongoing problems that added to the complexity of
this case?
3. How will you involve the patient/members of the primary
healthcare team in the management plan?
Modified from Smith C, Treasure W, Vernon G. Education for Primary Care (2008) 19: 416-32.
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