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Medical Education

Integrated Case Learning

Contributed by Dr. John Russell
Director,

Mildura Regional Clinical School

Monash University

Learning to think like doctors can be difficult for undergraduate medical students in their early clinical years. Integrated Case Learning, which we call ICLs, were developed as a method of helping medical students in their early clinical years across the theory-practice gap. In other words, it’s a simulated clinical reasoning process which aims to address these practice transition issues.

The ICL model arose from the observation that third year undergraduate medical students were required to digest large amounts of information with limited support or direction about how to prioritise, synthesise and use this knowledge when faced with a real patient with real health problems. Learning to deal with complex and potentially contradictory information related to a particular patient’s situation is “ one of the most difficult processes in becoming a physician”.

I would argue that traditional teaching approaches based on classical presentations fails to help the less experienced physician to recognise the common, but atypical presentation. (Patients don’t read the text books.) ICLs give the students the opportunity to practice the doctor-patient encounter in a safe and supported environment. In developing the ICL model, we articulated several assumptions about learning:

Language, social interaction and mediated action are of central importance in development of understanding
Creating a safe but challenging clinical environment can encourage students to take risks with their learning
Simply being exposed to clinical care experiences in the hospital environment will not necessarily enable learners to connect different forms of knowledge, skills and practices
Encouraging students to become more self aware of their own practices of learning can deepen understanding
Participating in group role plays and simulated clinical reasoning can create a shared space for students to reflect, with others, on aspects of doctor-patient encounters

Let me explain how it works.

The tutorial group is made up of eight students in the third year, their first clinical year, of the five year Monash University undergraduate degree.

Real cases are drawn from the Emergency Department, where I also work, collating the history, examination findings, investigation results, and management plans, de-identifying them for use in the class room. The degree of complexity of each case is set at the level of the learners.

Early on in the year, we may stop at the point of diagnosis. Later in the year we go further and discuss management options.

ICL overview

Students are assigned roles in turn.

Two students take on the role of the “doctor”. This feels safer for the students rather than being the “rabbit in the spotlight”. It also allows the tutor to hear the dialogue between the two “doctors” to help him/her understand their thought processes and how they are formulating their possible diagnoses. Students are encouraged to make public some of their tentative clinical thinking processes in the flow of working through the case.
One student is the scribe, and will put down the important parts of the history and examination findings on the whiteboard.
The rest of the students in the tutorial group are known as the participant observers. They have an active role in the process, but can only speak when invited to do so.
The tutor with the clinical notes takes on the dual role of “patient” and tutor, and responds to the “doctors” questions when asked. The tutor does not solve the case for the students but mediates and “redirects” the action by asking reflective and analytical questions, like

“what were you thinking about when you mentioned……….?”

“why did you order LFTs in this case?”

Students are asked to justify any examination or test they order.

Without going into any detail here, due to time constraints, the “doctor” works through the doctor/patient interview in a structured way, from the presenting complaint to the diagnosis ( or even the management). The scribe summarizes the history and then the examination findings on the white board, and after each step in the process, the “doctor”, and later the rest of the group, consider the differential diagnosis. For instance,” in the light of your examination findings, have you been able to eliminate any of your initial differential diagnoses, and also have some further possibilities come to mind?” As part of the process, the “doctor” will be handed actual blood results and xray films that they have ordered on the “patient” ( if in fact they have been done – and if they haven’t, it makes an interesting discussion point with the students. Can you justify why you have ordered that test? I may or may not agree with them, and it certainly makes them more careful and specific in their test ordering, rather than ordering every test they can think of, because they are aware that they may be challenged). You may wonder, but the students do not appear to have any difficulty about being challenged by the “patient”/tutor about a test they have ordered! The students then consider the investigations and try and arrive at a diagnosis, once again returning to consider the list of differential diagnoses on the board.

Hopefully at the end of the process they will have arrived at a diagnosis, or at least narrowed the field of possibilities to just a few. And once they are more clinically experienced, as I mentioned earlier, we follow the cases through to consideration of the management of the problem.

Why do ICLs work?

engagement – education should be engaging, informative, and fun
low tech
easy to assemble and run
engages all the students in the process and helps them to develop their critical thinking and that has been borne out by their feedback during our research
gives them more confidence when faced with a real patient – they are practicing for the ”real thing” in a safe and supportive environment

What do the students learn?

Language, medical language – when they start on the wards for the first time, the doctors appear to be speaking in a foreign language and the students level of comprehension is low
Uncertainty – a fact of medical life that we all have to understand and learn to deal with, but which is a daunting prospect for the new learner
I think it teaches them to be aware of the traps in clinical medicine, and I think ICLs are very good at making students aware of them , namely
- Search satisfaction – the doctor stops looking further as soon as an abnormal result is detected, and fails to ask whether the problem could possibly be due to something else. ICLs make the student stop and think “What else might this be?” What an important question.
- Diagnosis momentum – the diagnosis is fixed in a doctor’s mind despite incomplete evidence and this diagnosis is then passed on from doctor to doctor ( once again, not asking the question, “What else could this be?”)
- Confirmation bias – this is a process by which the doctor confirms what he/she expects to find by selectively accepting or ignoring information
- Anchoring – a shortcut in thinking where the doctor doesn’t consider the multiple possible diagnoses, but quickly and firmly latches on to a single possibility
ICLs teach the students to think broadly about a patient’s problem, to stick to the facts before them, and logically work towards the definitive diagnosis.
The ICL environment appears to create a connective bridge between the classroom and clinical practice.

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DeirdreB	Latest page update: made by DeirdreB , Feb 3 2009, 6:31 PM EST (about this update About This Update Edited by DeirdreB 1 word added 1 word deleted view changes - complete history)
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