Title: Case-Based Learning in Osteopathic Medical Education
Author Name: Brooke Shultis
1. Introduction
We will be looking at the effects of implementing case-based instruction within the osteopathic medical education curriculum. The particular university we will be using during the evaluation is a medium-sized private osteopathic institution; there are four Doctorate programs, two masters’ programs, and a handful of certificate programs. For this chapter, we will be looking into the doctorate in osteopathic medicine, undergraduate portion.
2. Overview of the Case
History of Medical Education
To understand the scenario fully, a background in medical education is essential. In 1910, the Flexner Report expressed the need to take medical training from an apprenticeship to formal education (Reiser & Dempsey, 2018.) During this change, the medical school format turned into a baccalaureate degree composing of undergraduate (medical school), graduate (residency), and continuing professional education. A student doctor spends four years in undergraduate medical school, which divides into two parts: basic science (two years) and clinical disciplines (two years.) Problem-based learning is now practiced in educational settings, ever since the publication of the Flexner Report demonstrated that learning models had not changed in 70 years. (Reiser & Dempsey, 2018.) The primary purpose of problem-based learning was to connect scientific materials with clinical content. From there, educational strategies continued to develop and encourage the classroom to become more innovative.
Current Day Osteopathic Medicine Standards
The National Board of Osteopathic Medical Examiners (NBOME), Comprehensive Osteopathic Medical Licensing Examination (COMLEX), and American Association of Colleges of Osteopathic Medicine (AACOM) drive the curriculum within all osteopathic medical schools. The Association of American Medical Colleges created Core Entrustable Professional Activities (EPAs) to develop a standard of expectations for medical students upon their first day of residency. It is the undergraduate medical college’s responsibility to implement all thirteen measures into the curriculum.
The thirteen core entrustable professional activities are as followed 1) gather history and perform a physical examination 2) prioritize a differential diagnosis following a clinical encounter 3) recommend and interpret standard diagnostic and screening tests 4) enter and discuss orders and prescriptions 5) document a clinical encounter in the patient record 6) provide an oral presentation of a clinical encounter 7) form clinical questions and retrieve 8) give or receive a patient handover to transition care responsibility 9) collaborate as a member of an interprofessional team 10) recognize a patient requiring urgent or emergent care and initiate evaluation and management 11) obtain informed consent for tests and/or procedures 12) perform general procedures of a physician and 13) identify system failures and contribute to a culture of safety and improvement (Short, 2019.)
Despite the fifty-year gap, change in curriculum, and it’s stated importance in clinical skills. Hours of research creating evidence-based principles, the institution in question continues to use didactic lectures as their primary source of educational strategies.
3. Solutions Implemented
After evaluation of AACOM standards, EPA’s, current curriculum and the student population, the office of Professional Development and Online Learning suggests implementing a version of problem- based learning called case-based learning within the basic science curriculum.
Problem-Based Learning
In the mid-’60s, a group of faculty teamed up with the commonality that they were frustrated with their experience of medical school, and they thought they could create a learning strategy that improved medical education. Their response was the development of problem-based learning, where the classroom went from sage on the stage to guide on the side. Problem- based learning is learning that is driven by a challenging, open-ended question that is solved while working in small groups (2011.) Since the creation in the mid-1960s, there have been a lot of adaptations to the instructional strategy. Our primary focus will be on case-based learning, which was derived from problem-based learning but has one significant difference.
Case-Based Learning
To be able to make connections between scientific knowledge and clinical implementation, students must approach learning differently then what is present in didactic, traditional classrooms. Case-based learning (CBL) is an instructional strategy that offers learning through the exploration of a medical case. It is similar to problem-based learning, in that they both include a case, problem, or inquiry that drives the class discussion. The main difference is that with PBL, the students require “no prior experience or understanding in the subject matter.” (Dai, Wu, Jacobs, Raghuram, & Dhar, 2020.) There are four main stages when implementing CBL into the curriculum 1) present the student with relevant reading materials 2) offered students with patient case 3) allow time for self-directed exploration where the student correlates the medical history (symptoms and signs) with clinical findings 4) discuss results with the expert facilitator and classmates. (Dai, Wu, Jacobs, Raghuram, & Dhar, 2020.) The main goal of implementing CBL into the curriculum is to prepare students for clinical practice (Carey, George, Abraham, Sebastian, & Faith, 2020) and to create holistically oriented, lifelong learners. The integration of case-based learning would make strides towards the students’ ability to be able to achieve all thirteen core entrustable professional activities successfully.
CBL Implementation Plan
Our case-based implementation plan is a twofold approach; implementation of CRIBS within the first and second-year curriculum and the implementation of iHuman Patient by Kaplan Medical.
CRIBS
CRIBS is an acronym for Clinical Reasoning in Basic Science, which is where the students view a case student within their small groups. As a team, they are responsible for creating a differential diagnostic and then a treatment plan. They have two sessions to complete the patient case with the facilitation of a faculty member who is a clinical physician. Then, if the situation presents itself well, the students will run through the scenario via high fidelity mannequins within the simulation center. This approach allows students to experience the case through a cognitive clinical science basis and a clinical skills level to gain mastery.
iHuman Patients from Kaplan
The second part of our case-based learning implementation plan is integrating iHuman, which is a technology-based software that helps medical students strengthen their lab skills and cognitive-based concepts via virtual patient encounters. The software itself is very clunky; however, with the proper instructional design, it could be very impactful. Judith Kalinyak, MD, Ph.D., recently hosted a session that showed how to take adequate software and turn it into a positive learning experience. We will mimic her implementation. With the guidance of Dr. Kalinyak, the learners are taking through the patient encounter, where she may add extra flare or question their thought process. (Kaplan Medical) We will be mimicking the method presented by Dr. Kalinyak used in her instructional video. Our faculty member will give the lesson with small groups; the students lead her through the patient encounter, and our faculty questions students’ thought processes and may add extra flare.
4. Outcomes
The research behind Case-based learning
Researchers have spent countless hours investigating the effects case-based learning has on medical students and how to implement it within the curriculum successfully. The significant benefits are an increase in an in-depth knowledge and the ability to analyze the relationship between basic science and clinical practice. (Carey, George, Abraham, Sebastian, & Faith, 2020) Students have also claimed that they enjoyed the content more; it was more stimulating, increased their confidence, increased their higher-level thinking, and that they became more patient-centric. In a research article written by Suliman, et al. they found that 64% of students picked CBL over lecture and 84% improved knowledge (Suliman et al., 2020)
Our Outcomes
While we did not conduct a formal research project, we did witness an increase in student achievement, thought process, and enjoyment of the content. In a survey administered to the students before CBL implementation, our medical students felt disconnected from the clinical aspect of their education. After we implement CRIBS and iHuman, our students can see the critical connection basic science has with clinical reasoning and skills. The only negative comment we received was that the technology could be faulty, and connections would be lost; this caused students to get frustrated and, at times, shut down. We plan on giving the faculty and students a crash course on technology troubleshooting and increase our service desk staffing. Despite the technical difficulties, the students feel like they are on their way to being able to enter residency successfully.
5. Implications
Overall, we learned that future doctors could not learn successfully with didactic lectures and multiple-choice exams. They must take hold of the concepts and see how it relates to their future real world. With the implementation of CRIBS and iHuman, we were able to give students a sense of what it is like to be a clinician without putting patients at harm. The students are now not afraid of the thirteen core entrustable professional activities that will be expected of them when they enter residency and to care for patients in a confident, safe manner.