Case Based Learning

What is Case Based Learning (CBL), how to implement it, and how is it done at the University of Aberdeen?

What is Faculty Development & Medical Education?

Hear what professionals have to say about what shapes medical education.

04. Case Based Learning.mp3

Speaker 1 With afternoon. My name is Florian, and I'm joined today by Owen Dempsey. He's a senior lecturer and consultant in respiratory medicine. He's also the lead for the school online kids development project. Also, Owen has recently been appointed as the interim year five lead coordinator. Today we'll be discussing case based learning. So, Owen, what exactly is case based learning?

Speaker 2 Good question. Hi, Florence. Yeah. So I think about case based learning as a tool, really in the educational toolbox. So just in that toolbox, you've got lectures and you've got textbooks case based learning or CBL as part of that. And if you look at review articles and things, everybody seems to define it differently. So that's quite challenging. But essentially, if you think about a patient journey, we're all patients at the end of the day. So if you imagine going to your GP with a cough or breathlessness, that's the beginning of a journey. The person at the practice will check you over, do some tests, perhaps coming up with differential diagnosis. And then on the back of that, maybe your journey will continue. Maybe you'll see somebody in hospital and you'll get more tests and eventually you'll hopefully get a diagnosis and management. So that's really what case based learning is. It's following a case a patient through the journey with them. But the important thing is that it's interactive. So the student doing a case based learning study will be asked questions as they go along. And those questions can vary in terms of structure. But the whole thing is meant to be active learning. So it's not just sitting passively in a lecture theatre listening to a boring lecture, drawing on. It's more to do with challenging, you know, edge and hopefully bridging that gap between theory and the real world clinical practice. So that's a long winded answer. But as I say, everybody seems to define it differently.

Speaker 1 I must agree with that. Prior to this, I try to do my own research on the topic, and I could not find a clear definition. Consensus is that it really depends on the institution that's trying to implement case based learning. So how exactly is it implemented at the University of Aberdeen?

Speaker 2 Yeah. So in Aberdeen I got involved with this with the online delivery of cases. So Aberdeen Medical School had built up lots and lots of cases. And these are cases I call them student led cases. So let's say Florida and you're a student at home, you've got your laptop. You look at a case and you follow a hypothetical patient through their journey. And so we have lots of these online cases. Now, we have, I checked this morning. We've got 447.

Speaker 1 Receive.

Speaker 2 And by next year we'll have over 500. We've got a pipeline of cases that are being developed. And so that's one permutation of case based learning. But I think with the pandemic particularly, coming out of the pandemic, hopefully there's definitely an appetite for more, even more interactive learning. And ideally, getting our patients back either into the lecture theatres so you can do case based learning with patients sitting in the chair with a microphone, just like we're doing today. And that's great fun. And I did that before the pandemic. So, for example, my smoking lecture was a lecture, but I had a patient who was an old man who works at the university. He used to chain smoke, and the students loved listening to him. They didn't like my lecture at all. It was really boring. But they really enjoyed listening to this man talk about chasing women when he was a young lad, how he used smoking as a tool. And also the difficulties he had stopping smoking, and the lung disease that he developed after his smoking history. So that's that that's an example of a face to face, real patient, case based learning. I think that's the direction of travel. I think increasingly we're moving, aren't we, to that flipped classroom approach where the students would have my boring lecture at home, look at it beforehand, and then on the day that I were that was previously scheduled for a lecture, they would actually have an interactive session facilitated by a tutor. And, I think that's the direction of travel. Now, it would be wrong to suggest that case based learning is the panacea for all ills. So it's very much part of a blended approach. So students don't want just to have online cases. They don't just want to have patients in lecture theatres, they want to have a mix of things. And the way I think this will develop is that the curriculum will become, increasingly, I don't know if infiltrate is the word, but certainly there will be quite a lot of these case based sessions developing. In various clinical blocks throughout all the years. And I think if you're a young medical student, you probably want more fact based sessions. Whereas if you're an older medical student approaching the clinical world, you probably want more challenging cases where you have to use reasoning. So, for example, if you're a first year student, you might just want to know about lung cancer and have a case on that. Whereas if you're a fifth year student, you might want to have, quote, a breathless, patient, close quote. And then using your clinical reasoning skills, work your way to that diagnosis. Because in real world, in the real world, that's what happens, isn't it? You don't go along to your GP floor and saying, I have condition X, you go along to your GP saying I have symptoms. ABC. And I think that's how medicine works, isn't it? It's a deductive process. So I think case based learning. Just to summarise, I think it's a really useful tool in the toolbox.

Speaker 1 So thinking back about the example that you just gave with the patients coming in, it's difficult when you have uncontrollable variables in your, in your teaching because, for example, I'm thinking about a patient, some seniors might just be drawn into the charisma of the patient but lose sight of the learning objective.

Speaker 2 Yeah. So you you have to in an ideal case, you want to make it authentic. So you want to have real cases. Ideally, you want to make it a common condition. So there's no great point in having a case that's very esoteric and, you know, rare as hen's teeth. That might be my interest, but it's not relevant to the students doing the case. You need to tell a story. Humans are storytelling people. That's why we have podcasts. And you've got to coming to your question, you've got to align the case with, a learning outcome. So, for example, the student needs to know about the common presentations of lung cancer. So it's got to somehow align with those aims and objectives. I think you've got to make it interesting as well, because let's face it, nobody's going to do an online case or participate in a face to face case if it's boring. Well, generally with patients, they're anything but boring. They're much, much more interesting. And in an ideal world, that's how we should really do it. But the pressures on the teaching system, of course, with increasing numbers of students, several hundred students, it does make it very challenging to do that. And Organisationally, it's quite difficult sometimes to set these sorts of sessions up. And I think, as I mentioned earlier, there are various permutations. Just to give you an example. We had a real patient who had Covid who, was is, at home, with oxygen cylinders that he would never be able to come in. But we managed to he was very techie. So he, joined does online. I was in my office. The multidisciplinary team were in their offices and 200 medical students in their first year where their homes. And that session worked really well and was remarkably interactive. So I think technology, Covid has really unmasked, or accelerated the use of technology in medical education. And although nobody wants to sit in front of a computer, as I've said, we can harness the tools that we have and still make it interactive and still involve patients. So I think that's the direction of travel.

Speaker 1 It sounds as if implementing KBL, either online or face to face requires a lot of, assistance and support from, a wide range of, of, speciality and, and of staff. Was that difficult to to achieve?

Speaker 2 Yeah. So the example I've just given, I did with a colleague and, she sat beside me fielding questions. We were using online software, slido.com. Slido.com, which is really cool. And as you know, you can get real, real time answers, you can do quizzes, etc., etc. there's lots of these software products out there. So you do need a hand with this. And I think if there are people out there who are anxious about using newer technologies, that is a hurdle. It's also quite hard sometimes when you're an NHS clinician and you're maybe not familiar with the layout of the university and who all the people are, and this is our first time meeting. So it's difficult to know what people do and what help is out there. And, you know, for example, you don't want to come let's say I was a gastroenterologist, I was doing a lecture on inflammatory bowel disease, and I had a patient that would come along. It is a little bit anxiety provoking when you're not familiar with the technology, maybe the microphones, the connection online. If you were doing an online patient, you would need to be able to connect online. Unfortunately, the NHS in the university software sometimes doesn't. Isn't that compatible? There are usernames and login, so there's lots of friction there in terms of the system design to allow us to do our job. But if you can get help, it really works well.

Speaker 1 So support is available. It just takes a bit to realise that you can ask for help.

Speaker 2 Yes, I is knowing who to ask. Absolutely. Yeah.

Speaker 1 And when you discuss CPU, do you require, speciality tutors to help lead the sessions or is it something that, for example, a more generalised tutor could, could do.

Speaker 2 Yeah. So it depends on the type of CBL that we're doing. So if we're doing the historic online case based learning, no tutors needed, that's a whole lot of people are needed. But not not at the time of delivering the session. The student does it themselves for a tutor based session. And we're now developing these cases. Ideally, the content should be presented in such a way that the tutor just has to turn up, with a quick look at the answers under the slides before they go in. So you could have generic tutors giving these sessions, although I think ideally you would want to have the speciality folk involved because that will give it a certain rigour won't it? And they'll be able to branch off into various anecdotes and make it real for the students. If you're reading off a script and then perhaps you're not a gastroenterologist, it's a bit more challenging if you get asked questions.

Speaker 1 Although we probably run into the risk of having students, again, lose sight of the case and just explore the, yeah, expertise of the tutor. Yeah. For whatever, bits of knowledge they want.

Speaker 2 Yes. That's right. There's always a risk, isn't there, with that.

Speaker 1 Yeah. But in general, have students a welcomed, case based learning.

Speaker 2 Yeah. So we don't have feedback or much feedback from the tutor based, design, but we do have tons of feedback from the online, version. I was having a wee look at the feedback that we get. So each case that they do online, there is a feedback forum. And all of this data has been gradually, accumulating over the last few years. Nobody's really been looking at it, which is dreadful, isn't it? But I was looking at the questions that, that, that, the data that we've collated and on the y axis of the graph, it's amazing. Would you like to see more case based learning? Over 12,000 responses. And the overwhelming, answer was yes. Do you think case based learning in general is useful? 14,000? Yes. 466. Don't. No, no, not every student always puts food back in. And of course, I think the response rate was something like 40% for 0%. So it might be that the remaining 60% that do it really hate it. But the feedback we get at that level is very positive. And if you look at the granular data. So these are the comments that come back on these scarefest forums that you're probably familiar with. So you get pages of A4 dense text with lots of comments, either happy or unhappy about various courses. And it does seem to me that the feedback is almost universally positive for case based learning. I would say that anyway, wouldn't I? But I think it is true. I think students really value, as I say, that clinical reasoning, making them think not just reading a textbook or listening to a lecture.

Speaker 1 Active learning in general, when you are discussing case, cases, when you're constructing, this index of cases to discuss with students, do you think into account the mission of the university? And more importantly, do you take into account some of the the issues that students have?

Speaker 2 Yeah. So there's lots of facets to that. That question really. The curriculum is a really hard thing to define. And if you ask people and I've asked lots of people do have an overview of the curriculum, very few people have, if any. And it seems to be this it's a bit like grappling with blancmange, really, isn't it? You know, what is the curriculum? Is it just a collection of things that are stuck on depending on a lecturers pet interests, you know? And of course there's the hidden curriculum as well. And you know, so it's all very complicated. What we've done in the online environment is we've followed the General Medical Council curriculum. It's, as you know, the medical licensing assessment, exam is looming for as an exit exam for students. And the GMC have, have created a list of conditions, symptoms, signs, things that they expect students to have. Done and we've tried to map our cases to that. So as a consequence, we think we're pretty good in terms of, covering the curriculum. We've not got 100% coverage at the moment. Contents of our cases. We're very aware of equality, diversity and inclusivity. So we're trying to make sure all our cases are no 50 year old white man from the northeast of Scotland. Lots of things like that are happening at the moment.

Speaker 1 Well, it's very good to know that biases are addressed when choosing cases. Is, is there any guidance in terms from from the General Medical Council or from the university, to help medical educators, in, in choosing cases.

Speaker 2 In terms of.

Speaker 1 For example, if, a medical educator has an interesting case to put forward, is there any guidance, as to what's appropriate?

Speaker 2 Yeah. So, absolutely. So we want to make this as easy as possible for case writers. We are in the position and it's a team effort. I'm not the only person involved with case based learning for sure. We've got, you know, tremendous colleagues. Douglas Bean and Peter Bartlett are the software developers. They do all the hard work. Hannah Robertson, who's a diabetes allergist, and Lee Allen, who's a critical care intensivist. It's just some of the team, but they're the core members. We commission cases. So if I come along to you, Florin, and say, I'd like you to write a case, rhubarb syndrome. We know you're an expert on rhubarb syndrome. Would you like to write it? You probably say, get lost because you're too busy. So what we need to do is we're basically asking people to do something for nothing and use up their valuable time. So we need to. When we started doing it, we made the mistake of asking consultants, but we are terrible. We we're absolutely terrible. We say we'll do stuff and then we never do. Or we do it really late. So we discovered after some errors along the way, that what you do is you ask, often senior medical students, younger doctors, people that need on their CV something that ticks the medical education box. It will look good on their, CVS. And often it helps if there's a curator, a co-author of Who's Old and Grey, because that old grey co-author will know if it's relevant. And, you know, if there are any factual inaccuracies. So we find the combination of young and old is really helpful, and we give them, a link to various resources online. So templates and PowerPoint formats, so dead simple. And all they have to really do is adapt the title, the aims objectives, follow the case through, and then we meet up with them when the first draft is produced, say a month later. And we talk through with the software developers just to see if the style of questions need changed. If it's interactive enough, we don't want to have a textbook on slides. That's pointless. We like lots of pictures, we like a simple story, and we want as many opportunities for this active learning to occur. So we want the students to have multiple choice questions. Maybe on an anatomical slide, a drag and drop. We incorporate YouTube video links, resources online that they can use. It should take them about 15, 20 minutes to do. And that's for the online cases for the tutor tutor based cases, we really just want about 5 or 6 slides, because most of the value and those more interactive case based learning sessions is in the chat. So all you really want for your tutor, let's say you're a gastroenterologist talking about inflammatory bowel disease. You really just want a story on one slide and then a series of questions, really headers, maybe 4 or 5 slides to make the students think. And then most of the value is in the two. And through, synchronous communication, I think that that's what works best. And then a wrap up slide or two. So yeah, we absolutely try and help our case writers who we commission and we will provide PowerPoint templates, things for the tutors. And we have a squad, a squad of medical students who are keen to write cases. So I have a medical student, Daniel Phonak, for example. Daniel is in his early years of being a medical student, I think his second or third year. And if I ask Daniel Daniel, I need somebody to write a case on rhubarb syndrome, he will go off and he will come back with a few names, and then I will find somebody senior to co-author with them.

Speaker 1 Well, that's good to hear that. Everybody involved in it, both students in the medical educators, are so keen to, you know, provide assistance and, and get involved with this.

Speaker 2 In general, they're very, very keen to get involved with this because it's something different. And certainly for the patient that we did the session here at. Had Covid. It was obviously highly relevant. We're in the middle of a pandemic and it was something a bit cool, wasn't it? And different for them. Now we don't want to lose sight of the educational objectives, but at the same time it is what they will be doing in a few years time when they're released out into the wider world. So generally we find students interact, you know, particularly well with this type of learning, they still have to, of course, have the knowledge. You still have to go to the lectures or listen to lectures, still need to read their textbooks. So it's very much, as we said at the very beginning of this discussion, it's very much part of the educational toolkit. It's not it's not the only thing our students should be doing.

Speaker 1 Well, Owen, thank you very much for that. It's eye opening to actually, hear from, from the person involved with leading, CVO what it's actually involved in, in all of this, if any of our listeners would want to get in contact and, for example, submit cases or ask for their own for guidance to to implement something similar in their own institution, would that be possible?

Speaker 2 Yeah. So if they just want to email me, I'm not sure if you'll put, you know, address.

Speaker 1 That would be available.

Speaker 2 Yes. So yeah, just email me and there is a squad of us. So we're more than happy to, ping back resources templates, have a team use discussion with them regarding their idea. And it's, you know, it's a win win for us. And also we hope for them. And if they do write a case, then obviously we write a proper thank you letter which they can upload onto their eportfolios. If they write enough cases for us and you can argue for what's enough. But if they're doing a lot of medical education work, then in that letter that we send back to them, we're signpost ways that they can apply for honorary tutor status with the university. And that's really a big carrot for people to go after. So if you write one case, I'm not sure if that qualifies, but if you write written half a dozen, for example, we we certainly would be very supportive of their application, although it's not in our power to grant that sort of status. And, we've certainly had quite a few folk that have done that, and I suspect that helps them in their job applications, and interview situations in later life as well.

Speaker 1 Well, it sounds like Sybil is the sort of thing that everybody wins from, the students, the educators, the university as a whole. Yeah.

Speaker 2 So, yeah, I hope so. Thanks very much for.

Speaker 1 Okay, thank you all for taking part in this.