.png)
The Clinical Case Discussion Model: Peer-Led Group Based Learning
Bryan E. Hernandez and Martin A.C. Manoukian
Introduction
The Clinical Case Discussion Student Interest Group (CCD-SIG) was conceived in the summer of 2015 with the idea that interactive, peer-led discussions of documented clinical encounters would help students synthesize and cement what they learned in class by presenting the information as real-life scenarios. The concept is simple: a presenter finds a clinical case study from a medical journal, consolidates the pertinent information therein, and presents the information to the peer-group in a piece-meal fashion, thereby allowing the group to mentally work through a case and build a differential as a team. It is a simulation of the thought process that would occur on a daily basis in a real-life clinical setting, such as in the emergency room, in the wards, or in an outpatient setting. However, this simplified explanation is insufficient and does not dive into the important psychological and pedagogical implications of the group meetings and their dynamics.
From its conception, and through its evolution and maturation into the entity that it currently has become, the CCD-SIG is built and run on the principles of psychological safety, kaizen/reflection, the importance of active retrieval, and the contextualization of information within a narrative in the learning process. In this article, we aim to explore the outcomes of such an environment, the level of involvement by students, and the subjectively perceived benefit that students gain from participation in the CCD sessions.
Introduction
Psychological Safety
One of the greatest strengths of the CCD-SIG is its peer-led environment that promotes psychological safety to ensure global participation and risk-taking. Psychological safety is the concept that all members within a group feel that they are heard, understood, and most importantly respected, thereby allowing the individual member to take risks more freely. Groups that incorporate psychological safety have higher participation and productivity, as shown by previous studies in other settings [1]. Within the context of the CCD-SIG, psychological safety has been facilitated by utilizing the step-up-step-down rule under which a given participant is allowed to speak, but must wait until others speak before taking another turn to contribute. This allows other members to participate without having to worry about a singular dominant participant during any case discussion.
Kaizen: Continuous Improvement
Kaizen is the philosophy of continuous self-improvement employed by the CCD to improve the efficacy and dynamics of the group discussions and to facilitate self-improvement amongst the case presenters. Group dynamics are improved by anonymous paper submission describing what went well, what could be improved, or what interesting thing was learned during the session. Such a structure was used to promote submissions without the worry of giving “negative” feedback. Facilitator self improvement was mediated by approaching the presenter(s) of the day and asking them what they thought they did well and what they could improve upon. After hearing their responses a CCD leader would offer their thoughts on what they thought went well and what could be improved upon. Overall we aim to promote a culture of reflection that strives for continuous improvement of self and the environment.
Active Retrieval
Active retrieval is another imperative cornerstone to the CCD-SIG, just as it is in general clinical practice. In the first two years of medical school, large quanta of information are amassed over a short period of time. These pieces of information are then immediately applied and evaluated via testing, but are not necessarily re-used until the clinical setting, which is usually during the 3rd and 4th years. The methodology of the first year is efficient in the immediate testing setting. However, studies have shown that, this does not necessarily hold true for delayed testing [2]. The CCD-SIG offers an opportunity for active retrieval of several pieces of information that are applicable to the many complex cases that are presented. The recollection and application of old information by a student has been shown to increase retention of that information, regardless of the difficulty level in reproducing the information [3]. Under this understanding of learning and education, we aim to increase the amount of retention of medical/scientific knowledge amongst our participants so that it may be applied in future practice.
Secondly, we aim to move to a higher cognitive application of the knowledge we acquire in the first 2 years of medical school. The modified blooms Taxonomy describes thinking skills in different stages of ascertaining, consolidating, and mastering knowledge. From the lowest to the highest, the taxonomical orders are: repetition of knowledge, comprehension/understanding, application, analysis, evaluation of information, and synthesis with use of information (Figure 1). In the clinical education setting, the goal of the CCD-SIG is to take the students’ current knowledge base and apply it to a real life clinical setting.
Process > Answer
Ultimately, the job of the CCD-SIG and the individual case presenter is not to disseminate brand new information. Rather, it is to create an environment in which the groups can refine the process of working through a patient encounter, synthesizing the relevant information, and developing appropriate differential diagnoses. To foster a more collaborative environment, upperclassmen and younger classmen are encouraged to disperse evenly among the small groups.
Due to the lunch-time talk model of the CCD-SIG, all presentations take place in a 50-minute timeframe. This necessitates preparation and thorough comprehension of the subject material on the part of the presenter in order to facilitate an adequate group discussion. During the early seasons of the CCD when there are incoming first years, it is important to acclimate them to this process by having them pair up with an upperclassman in order to achieve a better grasp of how to filter and organize information in such a way that that there is adequate information, knowledge base, and opportunities for the group to reason and discuss the case.
The Nuts and Bolts: 50 Minutes in the CCD-SIG
CCD-SIG sessions typically begin with warm up questions in the form of radiological imaging or the presentation of pathognomonic symptoms of a specific disease process to get the audience engaged. The audience size ranges from 15-30 participants per session, with most sessions garnering approximately 25 students.
Following the warm up, the clinical case presentation of the day begins. The presenter will notify the audience of the patient’s chief complaint upon arrival to the clinic (usually an emergency room or outpatient facility), as well as give the history of the patient. When giving the patient’s history, the presenter may leave out certain details, providing the audience with the opportunity to “ask the patient” themselves, thus helping in the development of targeted questioning skills. After the patient’s history is fully disseminated, the audience is given the opportunity to divide into small groups and begin forming their initial differential diagnosis. Though most presenters use the VINDICATED-P model to facilitate the development of a differential (Figure 2), it is up to the individual presenter to determine which method would be most effective. Alternative methods have been employed by presenters when deemed appropriate in conceptualizing specific clinical presentations.
After the initial possible differential diagnoses are recorded, the next step is to elicit the physical exam. Dissemination of the physical exam findings may also include the use of media, such as pictures, audio, and/or video for various interesting findings. The use of media is preferred when available because it allows students in the audience to practice interpreting physical exam findings, and to recognize how certain pathologies would present in a clinical setting as opposed to how they are described in a text book. Then, the audience is again asked to split up into groups in order to discuss, add, remove, and prioritize the list of differential diagnoses. The presenter will also ask the audience which labs or imaging they would like to “order.” The findings from the labs and imaging will then be provided to the audience, and finally the audience will divide into their groups to come up with their final diagnosis.
To conclude the session, the presenter will then ask each group to identify their top diagnosis, why that diagnosis was chosen, and which other differential diagnoses were considered plausible. After each group proposes their diagnosis, the presenter will then reveal the final etiology of the disease, as well as provide the audience with a review of the common symptoms, progression, treatment, and sequelae of the disease as take home points.
Methods
In an effort to assess the efficacy of the CCD-SIG in meeting the above standards, an online anonymous survey was sent out to 162 CCD-SIG members via social media and email. Nine questions on Survey Monkey were sent to past and present group participants to evaluate the ability of the CCD-SIG to provide an environment that is conducive to learning while also maintaining an environment that is open and nurturing to discussion and interaction. Questions included in the survey and their responses can be found in Table 1.
Results
A total of thirty-two students responded to the online poll, including thirteen first-year medical students (MS1s) (40.63%), fourteen MS2s (43.75%), and five MS3s (15.63%) (Table 1). Of the thirty-two participants, six (18.75%) had only attended one CCD-SIG presentation, seventeen (53.13%) had attended between two and five presentations, one (3.13%) had attended between six and ten presentations, and eight (25%) had attended eleven or more sessions.
To assess the CCD-SIG’s ability to help students develop and refine classroom and clinical knowledge, four questions were posed in the survey. When asked if CCD-SIG presentations helped students synthesize and apply classroom material, eighteen participants (56.25%) strongly agreed, eleven students (34.38%) agreed, three students (9.38%) were neutral, and no students disagreed or strongly disagreed. When asked if CCD-SIG presentations helped students develop critical thinking skills when identifying disease processes, nineteen participants (59.38%) strongly agreed, ten participants (31.25%) agreed, two participants (6.25%) were neutral, one participant (3.13%) disagreed, and no participants strongly disagreed. When asked if CCD-SIG presentations helped participants develop directed questions that would help in gathering a history from a patient, thirteen participants (40.63%) strongly agreed, eleven participants (34.38%) agreed, eight participants (25%) were neutral, and no participants disagreed or strongly disagreed. When asked if CCD-SIG presentations helped students develop their skills in establishing pertinent differential diagnoses, nineteen participants (59.38%) strongly agreed, eleven participants (34.38%) agreed, two participants (6.25%) were neutral, and no participants disagreed or strongly disagreed.
To assess how the participants in CCD-SIG presentations experienced the learning environment, how often participants thought about CCD-SIG case presentations, and how often participants wanted to engage in discussions, three questions were asked. When asked how often participants reflected on CCD-SIG presentations and their thought processes regarding the case discussed, seven participants (21.88%) indicated that they always do so, twelve participants (37.5%) indicated that they do so often, eleven participants (34.38%) indicated that they do so sometimes, two participants (6.25%) indicated that they do so rarely, and zero students indicated that they never reflect on cases or their thought processes after CCD-SIG presentations. When asked how participants would rank the CCD-SIG discussion environment, three (9.38%) indicated it was too competitive, twenty-seven (84.38%) indicated that it was a balanced discussion, and two participants (6.25%) indicated that there was not enough engagement. When asked how often participants prefer to hold CCD-SIG discussions, four (12.50%) indicated they would like to meet once per week, twenty-two (68.75%) indicated they want to meet every other week, six (18.75%) indicated that they would like to meet once per month, and no participants indicated they wanted to meet every other month.
Discussion
The CCD-SIG was formed to provide students the opportunity to refine their medical knowledge in a low-stress, peer-led group environment where participation is actively encouraged. To meet these goals, the concepts of psychological safety, kaizen, active retrieval of information, and a focus on the mental thought process rather than the answer itself have been emphasized. So far, the feedback provided by the members of the CCD-SIG has been overwhelmingly positive. Over 90% of respondents indicated that the CCD-SIG helped them to synthesize and apply classroom material, develop critical thinking skills regarding various disease processes, and develop the ability to establish a basic differential diagnosis for patients presenting to a clinic or emergency room with various maladies. This illustrates the effectiveness of the CCD-SIG in fostering the educational growth of medical students.
However, only 75% of participants indicated that the CCD-SIG helped them in developing directed questions to patients when obtaining their history. This may be due to the fact that the CCD-SIG operates under a structure in which information is already gathered and distilled by both the journals from which the cases are obtained as well as by the presenters themselves. The necessary information will likely be given in a predetermined order due to the structure of PowerPoint presentations. This current environment allows for direct application of knowledge and reasoning within a largely complete picture of a problem. In terms of the information gathering phases in CCD-SIG meetings, we do not have a formal scaffold for gathering information. One possible strategy to test would be the incorporation of PQRST (place, quality, radiation, severity, timing) to gather data, such that all of the acquired information is not presented until this scaffold is completed.
In the first half of medical school there is some patient interaction and simulations that help foster growth in clinical reasoning. We aim to supplement that growth in critical thinking by discussing complex cases in the group setting in order to build and refine mental models that will help us approach patients in the future with similar presentations. A part of the growth process, we believe, involves reflecting on the salient and pivotal points of each case. Many CCD-SIG members do, in fact, reflect on cases at a later time after a case presentation, with over 57% of survey participants indicating that they reflect on the cases presented in the CCD-SIG always or often following the presentation.
Most importantly, over 84% of participants are satisfied with the learning environment, where they feel they have the opportunity to engage with their peers without being overwhelmed, or bored to death by uninteresting cases. As a testament to their enjoyment of the CCD-SIG process and philosophy, over 81% of survey participants indicated that they would like to have CCD-SIG presentations on a weekly to biweekly basis.
However, the data are not without flaws. The first matter to address is that only a fraction of total CCD-SIG participants are represented. Of the 162 historical participants, there were only 32 participants who completed our most recent survey. Thus, the data only represents approximately 20% of all participants’ experiences. It also follows that our survey and the group itself may have selected for only participants who found the CCD to be useful, which only tells us that the CCD works for people who like it. The results of this survey also highlight the importance of more anonymous critiques for improvement of the group, namely by asking participants to write down “Things you learned, things that went well, and things that can be improved.”
The survey also lacks statistical rigor and a lack of categorizing the experiences based on level of standing in medical school. This information could be useful to assess the efficacy of the group based on level of understanding. This can be a future goal in optimizing the information gathering and interpretation for the CCD’s performance.
Conclusion
The CCD-SIG was founded on the principles of encouraging a peer-led, group based, interactive discussion of clinical cases to foster knowledge and refine the thinking process of developing physicians. Important skills that are learned in the course of medical education include the acquisition of medical knowledge, learning how to gather information, the ability to distill information, reasoning skills, technical skills that include physical examination, and treatment approaches that are contextualized for a patient. Of the above mentioned aspects of medical education, the CCD-SIG targets four; knowledge, distilling information, reasoning, and treatment approaches. There are many limitations to the structure of the CCD, but it appears that the area that could use the most improvement and incorporation is the ability to gather information from our patients.
By maintaining an open environment that encourages interaction between members of different classes, the CCD-SIG has worked to promote student-student mentorship as well as the sharing of knowledge and techniques. Lastly, the CCD-SIG has worked to provide students with real clinical cases, so as to build students’ “mental database” of cases that they may reference in their clinical years. In doing so, the CCD-SIG hopes to help better prepare students for their time on the wards, and by doing so, also help the patients receive better medical care.
Acknowledgements
The authors thank Dan Leifer, Ian Kim, Kate Hanel, Jack Sharp, Lucy Sung, Praveen Ramesh, Amode Tembhekar, Christopher Little, and Maggie Wang for their help in developing and running the CCD-SIG. The authors also thank Dr. Mark Servis for his support.
References
1. West MA, Tjosvold D, Smith KG: The essentials of teamworking : international perspectives. Chichester, England ; Hoboken, NJ: John Wiley & Sons, Inc.; 2005.
2. Thompson W, Bartling: How recall facilitates subsequent recall: a reappraisal. Journal of Experimental Psychology: Human Learning and Memory 1978, 4(3):210-221.
3. Jacoby LL: On interpreting the effects of repetition: Solving a problem versus remembering a solution. Journal of Verbal Learning and Verbal Behavior 1978, 17:649-667.
4. Bloom BS: Taxonomy of educational objectives; the classification of educational goals, 1st edn. New York,: Longmans, Green; 1956.
5. Adams NE: Bloom's taxonomy of cognitive learning objectives. J Med Libr Assoc 2015, 103(3):152-153.
