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CASED-BASED TEACHING: Models and Methods Judy Garner, Ph.D., Department of Cell and Neurobiology Keck School of Medicine Distinguished Fellow, CET.

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Presentation on theme: "CASED-BASED TEACHING: Models and Methods Judy Garner, Ph.D., Department of Cell and Neurobiology Keck School of Medicine Distinguished Fellow, CET."— Presentation transcript:

1 CASED-BASED TEACHING: Models and Methods Judy Garner, Ph.D., Department of Cell and Neurobiology Keck School of Medicine Distinguished Fellow, CET

2 CASE BASED TEACHING: Teaching by example or stories  An alternative or adjunct to didactic lecturing  Application of concepts to practical experience  Or vice versa

3 What is a case? “a case is a descriptive document, often presented in narrative form, that is based on a real-life situation or event. “a case is a descriptive document, often presented in narrative form, that is based on a real-life situation or event. “It attempts to convey a balanced multidimensional representation of the context, participants, and reality of the situation. “It attempts to convey a balanced multidimensional representation of the context, participants, and reality of the situation. –Katherine Merseth, ERIC digests, ERIC clearinghouse on Teaching and Teacher Education, Washington, D.C.

4 What is a case? “Cases are created explicitly for discussion and seek to include sufficient detail and information to elicit active analysis and interpretation by users with differing perspectives.” “Cases are created explicitly for discussion and seek to include sufficient detail and information to elicit active analysis and interpretation by users with differing perspectives.” –Katherine Merseth, ERIC digests, ERIC clearinghouse on Teaching and Teacher Education, Washington, D.C.

5 Value of cases Engaging stories Engaging stories Open-ended and challenging Open-ended and challenging Engender controversy Engender controversy Complex enough to allow students to recognize the benefits of research and collaborative teamwork in solving a problem Complex enough to allow students to recognize the benefits of research and collaborative teamwork in solving a problem

6 Value of cases Help connect concepts and practice Help connect concepts and practice Develop decision-making or problem-solving skills Develop decision-making or problem-solving skills Raise the level of critical thinking Raise the level of critical thinking Enhance listening/cooperative learning Enhance listening/cooperative learning Understand the relevance of context Understand the relevance of context A method of delivering multiple points of view A method of delivering multiple points of view As a learning technique: As a learning technique: –Active not passive! –The student is the teacher

7 Background Early use of Case-Based learning Early use of Case-Based learning –Law schools as early as late 1800s –Business schools since early 1900s –Parables and Fables— ”the moral of the story is…’ Currently Currently –Professional schools: medicine, dentistry, law, business, teachers –General education, humanities –Really confined to higher education

8 Learning Outcomes: What do you expect your students to achieve? In establishing goals, using cases may require a subtle modification of how learning goals are phrased: In establishing goals, using cases may require a subtle modification of how learning goals are phrased: –Example:  From “Know the chemical structure of a benzene ring.”  To “What is the value of knowing the structure of a benzene ring?”

9 Learning Outcomes: What do you expect? Example:  What is the value of knowing the chemical structure of a benzene ring? To get an answer the student must: 1.Know the chemical structure of a benzene ring 2.Determine how the benzene ring interacts with other organic chemical forms? And may, through the use of a case (pharmaceutical case) take it further. 1.How do you chemically alter a benzene ring? 2.Would that be useful in attempting to alter the efficacy of a particular pharmaceutical compound?

10 Learning Outcomes: What do you expect from students in your field? Collaborative learning and working in groups: Collaborative learning and working in groups: –Is this of value in your field? Cases can be used with variable degrees of student-student interaction Cases can be used with variable degrees of student-student interaction –Individual creativity vs group process –Assessment of individual student’s ability

11 Learning Outcomes: What do you expect through use of cases? Increased student engagement Increased student engagement Retention time of facts vs skills and concepts Retention time of facts vs skills and concepts –Use it or lose it!

12 Elements of Case Design Selection of appropriate cases Selection of appropriate cases –Mirroring professional experience/real world context –How complex or how simple?

13 SIMPLE CASE: Calculus 101 Chalk toss. Chalk toss. Draw a graph of the height of the chalk relative to the floor over time, with the height being the vertical axis of the graph, and the time being the horizontal axis of the graph. Draw a graph of the height of the chalk relative to the floor over time, with the height being the vertical axis of the graph, and the time being the horizontal axis of the graph.

14 IN FEET sec

15 SIMPLE CASE: Calculus 101 After finishing, students exchange their graphs. They are asked to write a brief paragraph describing the position of the chalk based on the graph they are looking at. Each paragraph should include: After finishing, students exchange their graphs. They are asked to write a brief paragraph describing the position of the chalk based on the graph they are looking at. Each paragraph should include: –Maximum height of the chalk –Length of time the chalk was in the air.

16 SIMPLE CASE: Calculus 101 After the exercise there is a discussion about After the exercise there is a discussion about –the importance of scales and units in graphs. –do they get a sense of change in velocity of the chalk through this exercise even though not explicitly requested? –communicating information in general This exercise then can be expanded by variations (dropping the chalk, bouncing the chalk off of the wall, velocity of the chalk over time, etc.)

17 COMPLEX CASES CASES IN AN INTEGRATED MEDICAL CURRICULUM CASES IN AN INTEGRATED MEDICAL CURRICULUM

18 Neurosciences in Medicine Neuroanatomy Neurophysiology Neurochemistry Gross anatomy of the Head and Neck Neuropathology Neurology Ophthalmology Neuroradiology Neurosurgery Psychiatry CNS and Autonomic Pharmacology

19 Choice of cases Case selection must take into account Case selection must take into account –How common is the case in real life –Ability of the case to integrate multiple subdisciplines –Ability of the case to effectively teach important learning objectives in the course –The case must not be too burdensome in the acquisition of data for the answers

20 CHOICE OF CASES SEQUENCE OF CASES: SEQUENCE OF CASES: –PRIOR KNOWLEDGE –LOGICAL ORDER –EARLY CASES REVISITED AS SYSTEM PROGRESSES AND KNOWLEDGE INCREASES

21 CASE THEMES OF THE WEEK Cases: Week 2: Trauma, Substance abuse, Acute Stress Disorder Week 3: Parkinson’s Disease with Depression Week 4: Stroke with Adjustment Disorder Week 5: Panic Disorder (Brain tumor) Week 6: Herpes Encephalitis, Status Epilepticus, Delirium Week 7: Evidence based medicine (Stroke studies) Week 8: Alzheimer’s Disease with Psychosis.

22 Week 1 INTRO to NS I ICM Resting Membrane potential and Action potential Cranial Cavity and Brain Reticular formation EEG and Sleep Neural Cell Biology CNS Development Tissue response to injury Gross Anatomy Lab Sensory Physiology and receptors NeuroanatomyLab Pathology Lab Vascular Overview Mental Status Exam Congenital defects of the CNS Mentor Group INTRO to NS II ICM WORKSHOP: Students receive case plus reading Neuroanatomy Lab MENTAL STATUS EXAM assignments in case book Microanatomy of the CNS

23 PPP Case 1: Trauma, substance abuse, Acute Stress Disorder PPP Case 2: Parkinson’s Disease with Depression Disorder PPP Case 3: Stroke with Adjustment Disorder PPP Case 4: Generalized Anxiety Disorder (Brain Tumor) PPP Case 5: Herpes Encephalitis, Epileptic seizures, Delirium PPP Case 6: Alzheimers Disease with Psychosis Development Series Autonomic Nervous System Series Neuromuscular series Special Senses Series KEY: Each Lecture/Laboratory that corresponds to:

24 Week 1 INTRO to NS I ICM Resting Membrane potential and Action potential Cranial Cavity and Brain Reticular formation EEG and Sleep Neural Cell Biology CNS Development Tissue response to injury Gross Anatomy Lab Sensory Physiology and receptors NeuroanatomyLab Pathology Lab Vascular Overview Mental Status Exam Congenital defects of the CNS Mentor Group INTRO to NS II ICM WORKSHOP: Students receive case plus reading Neuroanatomy Lab MENTAL STATUS EXAM assignments in case book Microanatomy of the CNS

25 Week 2 Chemical Neurotrans- mission ICM Motor Neurons and Spinal Reflexes The Orbit Psychological Trauma Limb-Axial Somatosensory Paths Upper Motor Neurons/Lower Motor Neurons Gross Anatomy Lab Endogenous Pain Pathways NA Lab Neuroradiology PPP CASE 1 DISCUSSION Mentor Group Headache ICM Workshops Neurological Exam Sensory Cranial Nerves and Paths Otolaryngology Exam WORK ON PPP CASE #1 NA Lab Ophthalmology Exam

26 Week 3 Motor Cranial Nerves ICMAcetylcholine Innervation patterns to the head and neck Direct acting Parasympatho- mimetics Motor Cranial Nerve Lab Autonomic Nervous System Gross Anatomy Lab Brain Tumors Movement Disorders Path Lab Corticobulbar paths Movement disorders Cases PPP CASE 2 DISCUSSION Mentor Group Mood Disorders ICM Workshops Neurological Exam Basal Ganglia Otolaryngology Exam WORK ON PPP Case 2 NA Lab Ophthalmology Exam

27 Week 4 CerebellumICM Muscarinic Blockers Fascia and Lymphatics of the Head and Neck Ganglionic Blockers and Stimulants Cerebellar Pathways and Disorders Cerebrovascular Disease Gross Anatomy Lab Delirium NA Lab Pathology Laboratory Development of the Head and Neck CASE 3 DISCUSSION Mentor Group Cholinesterase Inhibitors Catecholamines Neuromuscular Blockers CNS Vasculature WORK ON PPP CASE #3 NA Lab

28 Week 5 NEUROSCIENCES WRITTEN MIDTERM EXAM Infratemporal Fossa and TMJ Pathology of CNS Infections STUDY TIME Gross Anatomy Lab Pathology of CNS Infections Lab Sympatho- mimetics CASE 4 DISCUSSION Microbiology of CNS Infections NEUROSCIENCES PRACTICAL MIDTERM EXAM Microbiology Laboratory

29 Week 6 Sympatho- mimetics ICM Adrenergic Blockers Middle Ear Indirect acting Sympatho- mimetics Adrenergic Blockers Neuromuscular Disorders Gross Anatomy Lab Sympatholytics Seizures and Seizure Disorders Visual Physiology Microanatomy of the Eye Neuromuscular Cases EBM Case Discussion Mentor Group Vestibular and Auditory Systems ICM Workshops Neurological Exam Otolaryngology Exam Work on EBM Case Vestibular and Auditory Lab Ophthalmology Exam

30 Week 7 Pharmacology of the Eye ICM Opiates and Neuropeptides Cranial Nerves IX and X Opioid analgesics and antagonists Central Visual Pathways Hypothalamus Gross Anatomy Lab NA Lab Hypothalamus Lab Antidepressants, Mood Stabilizers Case Workshop PPP Case #5 Discussion Mentor Group Demyelinating Diseases Serotonin, histamine and GABA Work on PPP Case #5 Anxiety Disorders Thalamus

31 Week 8 StimulantsICM Stupor and Coma Sleep Disorders Schizophrenia Cases Sedative- hypnotics Cerebral Cortex and Higher Cerebral Function Dementia Disorders Antipsychotic drugs Limbic System Cortex laboratory Pathology of Dementia Disorders Higher Cortical Function Limbic System Laboratory Seizure Cases and Antiepileptic Drugs PPP Case #6 Discussion Mentor Group Drugs of abuse, dependence, and addiction Work on PPP Case #6 Substance Abuse Anxiolytic Drugs

32 1) Patient History and Symptoms: Fred Hoskins, a 17-year-old boy, was admitted to the emergency room at 1:30 (AM) after a car accident. Fred Hoskins, a 17-year-old boy, was admitted to the emergency room at 1:30 (AM) after a car accident. Fred’s friends, who had also been involved in the car accident, had told EMT personnel that Fred had been trapped in the car upside down, suspended from his seatbelt, and it took the firemen over an hour to release him from the wreckage. Fred’s friends, who had also been involved in the car accident, had told EMT personnel that Fred had been trapped in the car upside down, suspended from his seatbelt, and it took the firemen over an hour to release him from the wreckage. During the accident, Fred had received a blow to the head and had been rendered briefly unconscious after the accident but had regained consciousness within a few minutes. During the accident, Fred had received a blow to the head and had been rendered briefly unconscious after the accident but had regained consciousness within a few minutes. He had been terrified throughout the entire ordeal that the car would explode. His friends had also told EMT personnel that Fred had been at a “rave” prior to driving home. He had been terrified throughout the entire ordeal that the car would explode. His friends had also told EMT personnel that Fred had been at a “rave” prior to driving home. In the emergency room, his examination was normal but he was sleepy, and he was held for observation. In the emergency room, his examination was normal but he was sleepy, and he was held for observation. EXAMPLE OF A CASE:

33 2) RELEVANT DATA Vital Signs on admission Vital Signs on admission Test Results: Drug screen, Blood Alcohol, CT Test Results: Drug screen, Blood Alcohol, CT Further sequelae: time course Further sequelae: time course Surgery Surgery Post surgical interview after hospital admission Post surgical interview after hospital admission Detailed post-release interview Detailed post-release interview

34 CASE THEMES OF THE WEEK Fridays: Written case with ~6 general discussion questions received Examples: What is your differential diagnosis? Include in your answer a discussion of how you would differentiate among the different types of intracranial hemorrhages. What is your differential diagnosis? Include in your answer a discussion of how you would differentiate among the different types of intracranial hemorrhages. What psychiatric disorder does this patient manifest after the accident that wasn’t present before it? How is it diagnosed? It appears to be a good predictor of what other major psychiatric disorder? What psychiatric disorder does this patient manifest after the accident that wasn’t present before it? How is it diagnosed? It appears to be a good predictor of what other major psychiatric disorder?

35 CASE THEMES OF THE WEEK Monday afternoon: Small groups meet after doing reading. Discussion of general diagnosis, and negotiation for answer “responsibility” of individual students. Later in the week the students share answers so each has a complete set.

36 CASE THEMES OF THE WEEK Monday through Thursday: Students share answers so each has a complete set. Friday morning: Students present answers to the questions to their peers and instructor (experts) with discussion as different answers are discovered.

37 Web posting: Detailed answers to questions. How can one distinguish among subdural, epidural, subarachnoid, or intraparenchymal hemorrhage? Which of these types of hemorrhage is evident in the CT scan? 1) Epidural bleeds (between the dura and the cranium) are usually confined to the limits of the overlying cranial bone (the dura adheres to the suture points). The smooth contour of the hematoma in the CT suggests the blood is confined in the space between the bone and dura. Patients with epidural bleeds are often characterized as experiencing a brief period of unconsciousness, followed by a conscious lucid period, then later lapsing back into unconsciousness.

38 Case 2: Data

39 Case 2: Trauma with Acute Stress Syndrome: Learning Objectives After examination of this case, each student should be able to: After examination of this case, each student should be able to: –Distinguish among subdural, epidural, subarachnoid, and intraparenchymal hemorrhage. (N, Npath, GA, NA, NRad) –Discuss the pupillary light reflex and oculomotor signs in terms of CNS herniation. (NA, GA, N ) –Describe the progression of herniation. (GA, NA, N) –Explain the significance of papilledema. (N, GA, Npath, Ophthal) –Define the difference between substance abuse and substance dependence (Pharm, Psych, NC) –Define the criteria for Acute Stress Disorder (Psych) –Describe, in general, the treatment plan for epidural hematoma (N, Nsurg, GA) –Describe, in general, the treatment plan for Acute Stress disorder (Psych, GA, Pharm)

40 SUMMARY: The use of complex cases: The use of complex cases: –Facilitates understanding of the complexity of real life situations to be faced by medical students –Allows abstract conceptual information to be applied to situations likely to be experienced by the students –Integrates information from multiple subdisciplines and multiple points of view as it is focused upon a single problem –Helps the students recognize that even in sciences there is not always a “right” and a “wrong” answer –Underscores the professional value of cooperative learning and working

41 No courses No courses Series of problems or cases solved by student small groups Series of problems or cases solved by student small groups Facilitators/ Tutors Facilitators/ Tutors Small group (6-10) Small group (6-10) Self-directed study Self-directed study PROBLEM-BASED LEARNING (PBL)

42 Problem based learning (PBL) Identification of learning issues Identification of learning issues Data acquisition Data acquisition Case solution or development of a plan of action in solving the case Case solution or development of a plan of action in solving the case

43 “PERFORMANCE” IN THE CLASSROOM Cases don’t necessarily have to be narrative or didactic Cases don’t necessarily have to be narrative or didactic –Use of AV aids –Use of performance (skits) –Use of unexpected changes in a situation.

44 Case Exercise: Form small groups Form small groups Generate learning issues Generate learning issues Data acquisition (if possible) Data acquisition (if possible) Presentation of case Presentation of case

45 Case writing exercise: Think about a learning goal you wish your students to achieve Think about a learning goal you wish your students to achieve Identify a “real-life” situation in which one would use that learning goal Identify a “real-life” situation in which one would use that learning goal Write a short vignette Write a short vignette Design a ‘stem’ that will direct the students towards achieving the goal through examination of the case Design a ‘stem’ that will direct the students towards achieving the goal through examination of the case


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