Case Based Instruction Faculty Development

1. 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.

2. 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.

3. Today’s Topics Welcome / Overview of CBI methodology and role in the curriculum CBI Case Flow (Opening/Closing) Facilitation / Small group process 101 Panel Wrap-up

4. 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

5. 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 open+close session on Monday Goal is to choose a case and objectives that parallel the weekly theme

6. 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

7. 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

8. 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.

9. Presenting complaint History Physical findings Lab results Diagnosis (if not an objective) Treatment (if not an objective) Follow up (if not an objective) What might a case look like?

10. 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

11. 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).

12. 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.

13. 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.

14. 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

15. Lab Results

16. Lab Results

17. Lab Results

18. Treatment / Follow-Up

19. 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.

20. Today’s Topics Welcome / Overview of CBI methodology and role in the curriculum CBI Case Flow (Opening/Closing) Facilitation / Small group process 101 Panel Wrap-up

21. Facilitation / Small group process 101 Tuckman’s (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

22. Today’s Topics Welcome / Overview of CBI methodology and role in the curriculum CBI Case Flow (Opening/Closing) Facilitation / Small group process 101 Panel Wrap-up

23. Panel Stuart Flynn, M.D. Paul Standley, Ph.D. Kerr Whitfield, Ph.D.

24. Today’s Topics Welcome / Overview of CBI methodology and role in the curriculum CBI Case Flow (Opening/Closing) Facilitation / Small group process 101 Panel Wrap-up