Jane M. Kidd

The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23.

Background: Case-based learning (CBL) is a long established pedagogical method, which is defined in a number of ways depending on the discipline and type of ‘case’ employed. In health professional education, learning activities are commonly based on patient cases. Basic, social and clinical sciences are studied in relation to the case, are integrated with clinical presentations and conditions (including health and ill-health) and student learning is, therefore, associated with real-life situations. Although many claims are made for CBL as an effective learning and teaching method, very little evidence is quoted or generated to support these claims. We frame this review from the perspective of CBL as a type of inquiry-based learning. Aim: To explore, analyse and synthesise the evidence relating to the effectiveness of CBL as a means of achieving defined learning outcomes in health professional prequalification training programmes. Method: Selection criteria: We focused the review on CBL for prequalification health professional programmes including medicine, dentistry, veterinary science, nursing and midwifery, social care and the allied health professions (physiotherapy, occupational therapy, etc.). Papers were required to have outcome data on effectiveness. Search strategies: The search covered the period from 1965 to week 4 September 2010 and the following databases: ASSIA, CINAHL, EMBASE, Education Research, Medline and Web of Knowledge (WoK). Two members of the topic review group (TRG) independently reviewed the 173 abstracts retrieved from Medline and compared findings. As there was good agreement on inclusion, one went onto review the WoK and ASSIA EndNote databases and the other the Embase, CINAHL and Education Research databases to decide on papers to submit for coding. Coding and data analysis: The TRG modified the standard best evidence medical education coding sheet to fit our research questions and assessed each paper for quality. After a preliminary reliability exercise, each full paper was read and graded by one reviewer with the papers scoring 3–5 (of 5) for strength of findings being read by a second reviewer. A summary of each completed coding form was entered into an Excel spread sheet. The type of data in the papers was not amenable to traditional meta-analysis because of the variability in interventions, information given, student numbers (and lack of) and timings. We, therefore, adopted a narrative synthesis method to compare, contrast, synthesise and interpret the data, working within a framework of inquiry-based learning. Results: The final number of coded papers for inclusion was 104. The TRG agreed that 23 papers would be classified as of higher quality and significance (22%). There was a wide diversity in the type, timing, number and length of exposure to cases and how cases were defined. Medicine was the most commonly included profession. Numbers of students taking part in CBL varied from below 50 to over 1000. The shortest interventions were two hours, and one case, whereas the longest was CBL through a whole year. Group sizes ranged from students working alone to over 30, with the majority between 2 and 15 students per group. The majority of studies involved single cohorts of students (61%), with 29% comparing multiple groups, 8% involving different year groups and 2% with historical controls. The outcomes evaluation was either carried out postintervention only (78 papers; 75%), preintervention and postintervention (23 papers; 22%) or during and postintervention (3 papers; <3%). Our analysis provided the basis for discussion of definitions of CBL, methods used and advocated, topics and learning outcomes and whether CBL is effective based on the evaluation data. Conclusion: Overwhelmingly, students enjoy CBL and think that it enhances their learning. The empirical data taken as a whole are inconclusive as to the effects on learning compared with other types of activity. Teachers enjoy CBL, partly because it engages, and is perceived to motivate, students. CBL seems to foster learning in small groups though whether this is the case delivery or the group learning effect is unclear.

Blurring the boundaries: scenario-based simulation in a clinical setting

Context  The ability to perform clinical procedures safely is a key skill for health care professionals. Performing such procedures on conscious patients is challenging and requires a combination of technical and communication skills. We have developed quasi‐clinical scenarios, where inanimate models attached to simulated patients provide a convincing learning environment. Procedures are rated by expert observers and by the ‘patient’ and recorded for subsequent review. This study explores the potential of locating such scenarios within a real clinical setting, allowing participants to experience the challenges of the workplace while ensuring patient safety. An innovative portable digital recording device (the ‘Virtual Chaperone’) is evaluated for use in clinical settings.

The impact of gender dyads on doctor-patient communication: a systematic review.

OBJECTIVE Systematic review of evidence about the impact of gender dyads on clinician-patient communication. METHODS Search of Medline, CINAHL and PsychINFO (1960-2007) and the British Library of grey literature, and hand searching of Patient Education and Counselling and Social Science and Medicine (2005-2007), returning 648 articles. Ten studies met all inclusion criteria. RESULTS Gender dyads influenced the patient agendas elicited, talk content, communication style, non-verbal communication, the exhibition of power, and consultation length. Consultation length was studied and affected by gender dyads more frequently than any other phenomenon. Distinctive differences between the dyads were identified, largely as expected, but with some surprises. For example, female/female dyads were the most patient-centred, and had longer consultations containing the most talk. However they also contained the most bio-medical talk. CONCLUSION The evidence base is small, and a more rigorous approach to reporting quality indicators is needed. However, observed dyad differences may provide different opportunities for effective communication and clinical outcomes for patients. Further research with a primary focus on gender dyad effects is needed to test this. PRACTICE IMPLICATIONS Findings have implications for policy, healthcare organisations, and individual doctors alike, raising awareness about workforce issues and communication skills training needs in particular.

Peer assisted learning in patient-centred interviewing: the impact on student tutors

Effective methods for teaching patient-centred interviewing skills are resource intensive. Providing students the opportunity to work in small groups with simulated patients is highly valued and has demonstrable long-term benefits. Expanding cohorts of medical students and diminishing faculty resources led to the implementation of a peer assisted learning (PAL) project in patient-centred interviewing skills. The paper reports the evaluation of a PAL project on student tutors. The methodology included direct and indirect measures of student tutors’ skills in facilitation and patient-centred interviewing. The self-report evaluations strongly suggest that participating in a PAL project has substantial benefits for student tutors that included both interviewing and facilitation skills. Objective measures revealed no change in patient-centred interviewing skills after participating in the project. The study concludes that formalizing PAL may tap a valuable resource within the medical school and provide benefits for student tutors. Careful consideration needs to be given to ways in which student tutors are supported before, during and after the project.

Virtual patients design and its effect on clinical reasoning and student experience: a protocol for a randomised factorial multi-centre study

BackgroundVirtual Patients (VPs) are web-based representations of realistic clinical cases. They are proposed as being an optimal method for teaching clinical reasoning skills. International standards exist which define precisely what constitutes a VP. There are multiple design possibilities for VPs, however there is little formal evidence to support individual design features. The purpose of this trial is to explore the effect of two different potentially important design features on clinical reasoning skills and the student experience. These are the branching case pathways (present or absent) and structured clinical reasoning feedback (present or absent).Methods/DesignThis is a multi-centre randomised 2x2 factorial design study evaluating two independent variables of VP design, branching (present or absent), and structured clinical reasoning feedback (present or absent).The study will be carried out in medical student volunteers in one year group from three university medical schools in the United Kingdom, Warwick, Keele and Birmingham. There are four core musculoskeletal topics. Each case can be designed in four different ways, equating to 16 VPs required for the research. Students will be randomised to four groups, completing the four VP topics in the same order, but with each group exposed to a different VP design sequentially. All students will be exposed to the four designs. Primary outcomes are performance for each case design in a standardized fifteen item clinical reasoning assessment, integrated into each VP, which is identical for each topic. Additionally a 15-item self-reported evaluation is completed for each VP, based on a widely used EViP tool. Student patterns of use of the VPs will be recorded.In one centre, formative clinical and examination performance will be recorded, along with a self reported pre and post-intervention reasoning score, the DTI. Our power calculations indicate a sample size of 112 is required for both primary outcomes.DiscussionThis trial will provide robust evidence to support the effectiveness of different designs of virtual patients, based on student performance and evaluation. The cases and all learning materials will be open access and available on a Creative Commons Attribution-Share-Alike license.

Virtual patient design: exploring what works and why. A grounded theory study

Virtual patients (VPs) are online representations of clinical cases used in medical education. Widely adopted, they are well placed to teach clinical reasoning skills. International technology standards mean VPs can be created, shared and repurposed between institutions. A systematic review has highlighted the lack of evidence to support which of the numerous VP designs may be effective, and why. We set out to research the influence of VP design on medical undergraduates.

The use of handheld computers in scenario-based procedural assessments

This paper describes the authors’ experiences of using handheld computers within scenario-based formative assessments aimed at developing clinical procedural skills. Previous experiences of using paper forms in these assessments were problematic. Multiple paper forms were generated and data sets were sometimes incomplete. Forms adapted for use on handheld computers offer significant potential advantages over paper-based versions. These include streamlining the process of data collection, entry and retrieval, thereby reducing data loss and providing learners with immediate and cumulative feedback on their performance. All participants in this study found the Personal Digital Assistant (PDA) forms easy to use. Further adaptation, together with increased familiarity with PDA technology, will address users’ feedback by providing more space for free text and a larger visual field. Technical expertise is required for the development and delivery of PDA-based forms, but their potential for use in formative and summative assessments is considerable.

How Do Early Emotional Experiences in the Operating Theatre Influence Medical Student Learning in This Environment

Background: The emotions experienced by medical students on first exposure to the operating theatre are unknown. It is also unclear what influence these emotions have on the learning process. Purposes: To understand the emotions experienced by students when in the operating theatre for the first time and the impact of these emotions on learning. Methods: Nine 3rd-year medical students participated in semistructured interviews to explore these themes. A qualitative approach was used; interviews were transcribed and coded thematically. Results: All participants reported initial negative emotions (apprehension, anxiety, fear, shame, overwhelmed), with excitement being reported by 3. Six participants considered that their anxiety was so overwhelming that it was detrimental to their learning. Participants described a period of familiarization to the environment, after which learning was facilitated. Early learning experiences centered around adjustment to the physical environment of the operating theatre. Factors driving initial negative feelings were loss of familiarity, organizational issues, concerns about violating protocol, and a fear of syncope. Participants considered that it took a median of 1 week (range = 1 day–3 weeks) or 5 visits to the operating theatre (range = 1–10) before feeling comfortable in the new setting. Emotions experienced on subsequent visits to the operating theatre were predominantly positive (enjoyment, happiness, confident, involved, pride). Two participants reported negative feelings related to social exclusion. Being included in the team was a powerful determinant of enjoyment. Conclusions: These findings indicate that for learning in the operating theatre to be effective, addressing the negative emotions of the students might be beneficial. This could be achieved by a formal orientation program for both learners and tutors in advance of attendance in the operating theatre. For learning to be optimized, students must feel a sense of inclusion in the theatre community of practice.

What are the key elements of the co-production of health in clinician-patient consultations aiming to self-management support in long term health conditions?

Stress management prolongs life for CHD patients : a randomized clinical trial assessing the effects of group intervention on all cause mortality, recurrent cardiovascular disease, and quality of life