Developing Case Presentations For Clinical Training Peter J. Katsufrakis, MD, MBA Keck School of Medicine Pacific AETC

Objectives At the conclusion of this workshop, participants will be better able to: Describe benefits of using cases in teaching. Identify steps used in developing a case. Employ cases effectively in training health care providers.

Rationale for Case-based Training Effective educational technology Efficient use of trainee “down time” Means to capture “great cases” Supplement random clinical experience Different focus than “grand rounds” cases

Uses for Cases Independent study Stimulus for informal discussion & teaching Evaluation Program Learner Formal didactic presentation

Steps in Case Development Step 1: Identify goals & objectives. Step 2: Describe the patient. Step 3: Focus the learner on discrete clinical decision points. Step 4: Present balanced, parallel, viable options. Step 5: Analyze options; choose course of action. Step 6: Introduce new information and proceed to next clinical decision point. From: Developing Clinical Case Studies: A Guide for Teaching. Eds: Ann Downer, MS, EdD and Sue Swindells, MBBS

Step 1 Identify Goals & Objectives Characterize the audience Characterize the audience’s learning needs Describe specific objectives for the activity

Step 2 Describe the patient Provides opportunity (challenge!) to employ your creativity Often helpful to draw on real patients Beware HIPAA restrictions

Steps 3 and 4 Step 3: Focus the learner on discrete clinical decision points. Present sufficient information to justify decision Step 4: Present balanced, parallel, viable options. Avoid identifying the answer by how you structure potential responses

Step 5: Analyze options and select course of action

Step 6: Build on Case, Moving to Next Decision Introduce new information and proceed to next clinical decision point. Process allows return to step 3 Multiple iterations cycle through steps 3 to 6. Select Course Of Action Provide New Information Focus on Clinical Decision Present Options

Varying the Model to Add Excitement to the Facilitator’s Life

Variant of Steps 3+4: Open-ended question Example: “What would you do next?” Appropriate for: Smaller group Scenario with several viable options Promoting discussion and dissent Group where individuals will interact

Step 3+4 Variant: Open-ended question (cont.) Requires that the facilitator: Be knowledgeable enough to respond to the various possible responses. Be skilled enough to draw out participation from the group. Be able to balance, focus, and redirect individual members. Be comfortable with less “control.”

Modification of Step 5 for the Open-ended Question All options offered by participants should be addressed at least briefly Rewards participants for voicing ideas Provides feedback re: correctness of the response (for the clinical question being considered) Provides feedback re: suitability of the response (for the purposes of the learning activity)

Revisiting the Model

Revisit Step 1: Learner Assessment By what means can we assess learners? Formal assessment of knowledge, attitudes, and/or behaviors prior to training session, e.g., written survey. Ask organizer/inviter to characterize the audience.

Learner Assessment: What Else Can We Do? 2-3 brief, key questions asked of sample of participants (or representatives of participants) Telephone On-the-spot assessment or verification of assumptions

Learner Assessment: What Do We Need to Know? Content to include in assessment: Educational training Specialty, if applicable Experience with HIV (years, no. patients) Characteristics of care system (resources, colleagues) Baseline understanding of proposed session content

Revisit Step 2: Describe the Patient What information is necessary, sufficient, or excessive? May include: Age Sex HIV status Current symptoms Pertinent medical history Social history PE and lab findings

Describe the Patient (cont.) Need to provide sufficient information for an informed respondent to answer the question(s) posed Limit information not needed to answer the question(s) posed Inefficient if unnecessarily wordy Distracts from intended educational message Ultimately, a question of judgment

Advice to Avoid Pitfalls Clarify definition of a “case” Ensure cases link to objectives Develop consistent process & format guidelines Beware ambiguous questions & cases Allow for changing treatment standards Case approach may not be ideal for all training objectives

Special Challenges When Teaching With Cases Converting didactic presentation into case format Dealing with audience of very diverse backgrounds and educational needs

Converting From Didactic to Case-oriented Teaching Revisit your educational objectives Are they truly suitable to the audience and goals? Are there areas less well addressed that could be strengthened with a case presentation?

Converting From Didactic to Case-oriented Teaching (cont.) Look at existing content Can it be organized readily around a single case, or series of brief vignettes? Could cases provide effective brief introductions to existing didactic material?

Converting From Didactic to Case-oriented Teaching (cont.) Look at your past successes & challenges Have you (or audience members) previously inserted personal experiences and enhanced a presentation? Might using cases engage your audience in “dry” material?

Challenges of a Diverse Audience Different training background Different experiences Different assumptions Different expectations of training

Benefiting From a Diverse Audience Brief self-introductions by all Clarify expectations at outset Design activities so all participate Call on specific audience members Pose “How would this be different if we were a... ?” questions, drawing on quiet audience members’ characteristics

Audiovisual Tools Written cases complete, lengthy narrative brief, progressive disclosure PowerPoint linking to other content “Jeopardy” presentation

Audiovisual Tools (cont.) Audience response Computer-based system Colored index cards Show of hands Case authoring software, e.g., DxR Development Group, Inc.

Summary Using cases for clinical teaching can enhance training effectiveness Following the steps described makes this complex task manageable Incorporating cases into didactic presentations can revitalize existing material

Acknowledgements Ann Downer, MS, EdD and Sue Swindells, MBBS Ann Khalsa, MD, MSEd