Learning through clinical cases
Most health professional programmes now use a range of clinical cases, problems or situations in order to contextualise the biomedical, social and behavioural sciences and help the learner make sense of and apply their knowledge in a clinical context.
Enquiry-based learning (EBL) is used in a wide range of subject disciplines including health professions. Learning is stimulated and driven by a process of enquiry and discovery and encompasses other learning such as problem-based learning (PBL), case-based learning (see below), projects and fieldwork. It typically starts with a ‘scenario’ and then guided by a facilitator, the students identify issues, questions, resources needed and then go on to research the topic. It is suggested that such learning is more readily retained because it has been acquired through experience and is related to a ‘real life’ problem. The other benefit is that this encourages students to take a research-oriented approach to their learning through seeking, critiquing and evaluating evidence.
See the website of the UK Centre for Excellence in Enquiry-Based Learning for many resources and case studies on EBL, case-based learning and PBL.
http://www.ceebl.manchester.ac.uk/ (accessed 29 January 2014).
Different professions have developed and adapted their own ways of teaching and, at any one time or context, particular trends and preferences dominate. Below are three common models.
Clinical case-based learning
Developing a ‘bank’ of interesting clinical cases that illustrate various aspects of clinical learning. These might include:
- case notes/extracts from a case history (e.g. Mrs X’s four previous pregnancies)
- investigations carried out and the results, X-rays, scans, etc.
- reports written by other health professionals (community and hospital-based midwives, health visitors, GP, obstetricians, social workers)
- examples of letters (referral, discharge, follow-up)
- video or audio tapes of patient encounters
- extracts from relevant articles about the clinical condition, treatment options, etc.
These cases can be used as stimulus material to encourage learners to learn about a specific clinical condition. This can be helpful, for example if the condition is a common one, but the patients the learners have had the opportunity to see have not been typical or did not stay in hospital long enough. Because the material is based on real patients and real resources, it is seen as interesting and relevant by learners and allows the teacher to pre-select material which illustrates specific learning points.
Remember to seek appropriate permissions when copying and using such material. Websites such as Patient Voices are useful sources of case-based multimedia resources.
You may find it useful to write or think about some typical clinical scenarios to use as a stimulus for discussion or to encourage learners to seek out more information about a topic. These may cover wider issues than just clinical conditions. The advantage of writing these yourself is that you can tailor them to include the issues you want learners to discuss or find out more about. These might include legal or ethical issues, public health issues, resource allocation issues, etc. Such clinical scenarios might include:
- newspaper cuttings or weblinks about clinical cases, particularly landmark cases
- articles from, for example, the British Medical Journal, Nursing Times, Health Service Journal
- reports or recommendations from local, national or international public bodies or agencies
- statistical reports showing trends or disease patterns
- a stimulus piece you have written which points learners in the right direction or which asks some key questions.
Other types of clinical scenario could be written more like anecdotes about situations in which you or colleagues have been involved. These may be used to stimulate discussion about professional–patient relationships, dealing with carers or relatives, communicating with colleagues, dealing with complaints, etc.
PBL is found in undergraduate medical and other health professions’ curricula throughout the world although the way it is used varies widely and there is a more recent trend to use case-based learning as described above. The idea is that the patient’s ‘problem’ (e.g. headache, cough, limp) provides the trigger for learning around a range of issues and topics.
Students are encouraged to take an active role in their learning by discussing a problem (or scenario) centred on a clinical situation, community problem or current scientific debate. In the clinical context, this might be a description of events when a patient attends a clinic or Emergency department. The history, presenting complaint, signs and symptoms, ethical issues, investigations needed (and their outcomes) can all be woven into the case, as required. The problem has to be written so that the students can identify the areas that they need to explore in order to be able to resolve satisfactorily gaps in their knowledge and understanding that become apparent during group discussion.
PBL is different from problem solving. In problem-solving exercises the basic assumption is that the students have the knowledge and skills required to arrive at a solution (albeit that the application to a specific problem may further stretch them). In PBL the problem is the starting point that enables students to identify for themselves new areas for their learning.
Participants work together in a structured way on a problem designed by teachers. Ideally, there should be no more than 10 members in the group, and they should select for themselves a student chair and scribe for the session. The scribe records the ideas generated by the group on a whiteboard or flip chart and the staff facilitator ensures that the group works through the problem in a methodical way. A series of steps can be identified – that below is based on the Maastricht ‘seven jump’ model.
- The group reviews the problem scenario and identifies any terms with which they are unfamiliar. Some members of the group may have some prior knowledge that will help the group.
- The students openly discuss the scenario and define the problem.
- The group brainstorms possible explanations or hypotheses which fit with the events/problems they identified.
- Some provisional explanations/conclusions are reached that would reasonably explain the essence of the case.
- The students formulate their learning objectives – those aspects which the group have determined need further study.
- Working independently (or in pairs) the students use the resources available to them to achieve the learning objectives.
- The group meets again a few days later to pool the information they have gained from private study and discuss the case in the light of this new knowledge.
Ideally, the students and facilitator should then evaluate the case and its suitability for PBL.