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Upstate Medical university Case Study

MSII Instructions

MLC II : Introduction and Guidelines for Students (2013-2014)
Course Director: Paul F. Shanley, M.D.
Assistant Director: Karen C. Kelly, M.S. (

What does this course consist of?

The essence of the course is the reading of a series of cases and articles from the medical literature. The readings for the year are available on the MLC web site. The cases are to be read with the overall objective “to understand and be able to explain what happens and what is discussed.” To this end students will find it necessary to consult reference texts and other resources to fill in gaps in their knowledge.  Other readings will be assigned to highlight or deepen understanding of aspects of basic science suggested by the case or to further highlight the differential diagnosis process. The task is potentially daunting and students will find it useful to form study groups with their peers outside of class time to discuss issues raised by the cases and to share information and insights. The level of student understanding will be assessed by quizzes given several times per week and by analysis of written assignments (e.g., " pathophysiologic hypothesis”). Class time will largely consist of student questions to faculty members about issues that they were not able to satisfactorily resolve independently.

What is new for 2013-2014?

Quizzes will be administered via audience response systems (“clickers”) previously piloted during the 2012-2013 academic year.

What are the goals of the course?

The goal of the course is to make the student conversant in the language of medicine and to provide a conceptual and experiential framework for the student’s education and future training. The emphasis is on “pathophysiology” which is understood as mechanisms of disease at the organ system level.  Pathophysiology provides the transition from basic to clinical science since organ dysfunction is still the level at which most clinical assessment and intervention occurs. Additional expected benefits of the approach include facilitation of integration of the basic science curriculum, smoother transition from basic science to clinical clerkships, and promoting independent, self-structured learning.

How will I find the cases?

The list with the dates that students will be responsible for having read and studied each case and any associated supplemental articles and/or handouts is found on the "Schedule" tab on the website under "MLC II." The full-text PDF files will come up by clicking on the title (off-campus access requires iPage log-in).

How do I study the cases? What am I expected to do?

The student’s overall objective is “to understand and be able to explain the underlying mechanisms of what happens to the patients and the rationale for what is done or discussed by the authors” in the case reports. The student will not be expected to “solve” the cases (i.e., make a diagnosis or determine appropriate management). Since the student will have the entire published report on each case, it is merely a matter of reading the report of how experts do these things and filling in the background information that allows one to follow along.  To this end, the student should pursue the following specific objectives:

  • Attain an understanding of the biology of disease and apply knowledge of the relevant background concepts in the basic sciences to case reports and readings.
  • Define all medical terminology used in the case presentation.
  • Compile notes on the facts of the case in standard format for write-up
  • Generate a problem list and attempt to group findings into pathophysiologic syndromes.
  • Formulate a differential diagnosis for each of the patient’s major problems at each stage of the clinical presentation, incorporating an evidence-based medicine framework for structuring and applying scientific knowledge into the clinical reasoning process.
  • Relate the clinical data and further workup to sorting among the diagnostic possibilities and determine the basis for interpretation of any special studies used in the work-up of the case.
  • Determine the mechanism of action and rationale for each drug or other therapeutic intervention used in the case.
  • Summarize the prototypical features of each disease in the differential diagnosis suggested by the discussant in the case report and outline the author’s clinical reasoning in discussing the diagnostic hypotheses.
  • Construct a “pathophysiologic hypothesis” to account for the clinical findings based on the patient’s underlying diseases.
  • Acquire the ability to critically assess scientific data presented in terms of the conclusions drawn by the authors, identify what is established and what the question is with respect to the clinical issue being addressed and appropriately apply the findings to specific clinical problems.
  • Develop awareness of the ethical issues raised by the case reports and/or readings (e.g., conflicts of interest, patient safety, informed consent, etc.).

What does the "Being a Physician: Differential Diagnosis & Evidence-Based Medicine" component consist of?

Further insight into the clinical reasoning process will be accomplished through the utilization of case-based exercises centered on common clinical complaints and the evidence-based process to evaluate, diagnose and treat patients with these symptoms. For 2013-2014, this component is jointly taught and run with the Practice of Medicine-2 course, with pre-testing of assigned content in MLC-2 and post-testing on unit examinations in POM-2.  To that end, the student should pursue the following specific objectives:

  • Acquire an evidence-based approach to differential diagnosis for key presenting signs and symptoms
  • Recognize the pivotal findings from the patient history or diagnostic evaluation at decision-making points and identify the management of these presenting problems
  • Determine the relative value of available tests in ruling in or ruling out individual diagnoses and distinguishing among them

Relationship of course objectives to medical program objectives and assessment


What textbooks are being used in the course?

Two books will be utilized extensively in MLC II for the 2013-2014 academic year:
1) Lange Pathophysiology of Disease (e-book through library)
2) Lange Symptom to Diagnosis: An Evidence-Based Guide (e-book through library)

images of textbooks used in course

Where should I go to get information on what I don’t understand?

Click here for recommended online and print resources.

Interaction and discussion of the cases among students is strongly encouraged. Ultimately the individual student is responsible for ensuring that the information obtained from peers (or instructors) is accurate. There is no recourse to “authority” (course instructors, guest faculty) other than a consensus of published material.

What is the attendance policy?

Attendance is required because much of the class is interactive and discussion-oriented. A pattern of unexcused absences may result in failing the course and referral to the College of Medicine Professionalism Officer.

What are the expectations for professionalism?

  • An acceptance of fellow students and faculty as professional colleagues deserving courtesy and respect;
  • A focus on learning rather than meeting minimum course requirements or simply studying for the assessments;
  • An acceptance of uncertainty, ambiguity, and inevitability of change in relation to medical knowledge & practice;
  • A respect for alternative views or differing interpretations of scientific or clinical information, and a respect for different teaching styles and practices;
  • A willingness to assume personal responsibility for fulfilling course requirements;
  • A willingness to help the faculty identify errors or deficiencies in course materials, and to provide specific, thoughtful, and constructive feedback relating to sessions & other course content on the formal Course Evaluations

Cheating (e.g, infractions outlined in the student honor code, such as utilizing unauthorized material or electronic devices for quizzes, academic dishonesty, etc.) will be actively monitored. If confirmed, an incident report will be submitted and the matter referred to the College of Medicine Professionalism Officer for possible further action.

How are the quizzes going to work?

Evaluation will be primarily through the use of multiple quizzes related to each case and associated readings. In addition to the quizzes, students will have various written assignments including a “pathophysiologic hypothesis.” Note that the date on the schedule refers to the first quiz on a given case or paper. Most cases will have additional quizzes on the dates following the first quiz. The quiz will be the first thing done in class each day so please arrive on time; the case or reading will not be discussed by instructors prior to the quiz.
1.     The quizzes will be in various formats. Most will be computer scored, multiple choice format.

2.     Quizzes will generally proceed in the following sequence -

  • The first quiz on a given case
    • Assessment of general understanding of the facts of the case
    • Students are permitted to have a handwritten episodic time line & problem list and a copy of their concept map; no other material is allowed
  • Follow-up quizzes on a given case
    • Assessment of deeper, mechanistic understanding of the events of the case
    • Students are permitted to have the published case report with any personal handwritten notes in the margins or on the back, their handwritten episodic time line & problem list and a copy of their concept map; no other material is allowed
  • Quizzes on the differential diagnosis chapters
    • Assessment of general understanding of the problem-oriented approach to a given symptom
    • Students are permitted to have the published chapter; no other material is allowed
  • The usage of unauthorized electronic devices during quizzes (e.g., cell phones) is prohibited.

3.     The quizzes related to each case or reading will cover the specific objectives listed previously. All class discussion on general or case-specific objectives will come after the quiz related to them. Please do not go to instructors for case-specific individual help before the quiz. One fundamental idea of this course is to learn how to gather, structure and evaluate information independently.

Are class sessions videotaped?

Class sessions will largely consist of interactive discussion with instructors and will not be videotaped.

What if I want to dispute an answer to a quiz question?

Rather than debate quiz answers during class time or with instructors afterwards, students are encouraged to send a formal written challenge, citing a published reference if possible, supporting a different answer to Karen Kelly via e-mail in a timely manner following posting of the quiz answers. Quiz answers will be posted on the MLC web page under the "Answer Keys" tab for the course following review by instructors, typically later that same day following the quiz. Faculty review of quiz questions will occur and will sometimes result in dropped questions or alternative acceptable answers. Any modifications will be posted to the online answer key; due to time constraints, students will not receive an individual response to quiz question challenges.

What is the “Pathophysiologic Hypothesis” that we have to hand in?

Submission of a pathophysiologic hypothesis outlining reasonable causes for the patient's problems in terms of known underlying disease processes is required on most cases as a criterion for passing the course. The format for this exercise will be discussed and demonstrated. Instructions and examples are found on the course website by clicking on the following links for "Hypothesis Format" and "Sample Hypothesis." Students should include not only their own ID number on the assignment, but the ID number(s) of any students they collaborate with on the task as well.

Students must electronically submit their "pathophysiologic hypothesis" via Blackboard by 8 a.m. on the date of the last session scheduled for each case unless otherwise specified.

Grading of hypotheses will be Pass/Fail. After submission, hypotheses will be randomly distributed to classmates, course faculty, guest faculty and upperclassmen for review of the hypothesis (determination of passing/failing status & offering of constructive feedback). This will occur immediately following the conclusion of the class session and will be due by 8 a.m. on the following Monday morning. Following the conclusion of the peer grading, comments will be viewable to the student.

What will happen in the class sessions?

Most classes will begin with a quiz. The remaining time in class will be utilized by instructors to respond to questions posed by the students about the case. These will not be lecture sessions. Students should ask questions during class rather than waiting until after class. In the interest of fairness to all students, instructors will not answer case-specific questions individually outside of class time.

What is the grading policy?

There are two course components to Medical Literature Curriculum-2: Medical Literature and “Being a Physician.” Students will receive one grade for the Medical Literature Curriculum-2 course that combines the Medical Literature and “Being a Physician” components at the end of the spring semester. Students who fail to achieve basic competency (70%) in any single component of Medical Literature Curriculum-2 (Medical Literature or “Being a Physician”) or whose aggregate grade is below basic competency (70%) will receive a deficient grade in Medical Literature Curriculum-2. It is possible to fail or receive a conditional grade for the course because of unacceptable completion of one component (Medical Literature or “Being a Physician”). Further, students who demonstrate academic misconduct or unprofessional behavior are also at risk for receiving a deficient grade. Students are encouraged to review the Student Code of Conduct and Related Policies in the Student Handbook and posted online in Blackboard.

Component Contribution to Final Grade in Medical Literature Curriculum-2

  mlc2 overall rubric

Medical Literature Component

mlc 2 cases
Students must maintain a cumulative average of at least 70% to pass. Grades will be carried to two decimal places and will not be rounded; grades of 69.99% and below will be reported as a “Fail” for the component and for the course overall. Grades will be based on quizzes administered by clicker assessing participation in the course objectives for approaching the readings. Each scored question will count for one point and grades will be calculated by dividing the number of questions answered correctly by the total number of questions for the entire year. At the conclusion of each session, the answers will be posted; at that time, students may challenge a question in writing. Individual student scores will post to Blackboard after class completion for feedback.

Students will have a written assignment in the form of a concept map (“pathophysiologic hypothesis”) for case readings. They will be evaluated within 72 hours of class completion using the randomized peer grading option through Students will receive a Pass/Fail designation along with constructive feedback. Students must pass all written assignments. Any student that submits a hypothesis that is deemed unsatisfactory will be required to complete make-up work and will have their entire portfolio reviewed. No more than 10% of the total written assignments deemed “failing” may be made up during the course by creating hypotheses on additional cases.

Peer grading is regarded as a professionalism activity within the course and spot-checking of written assignments by faculty is conducted and may result in adjustment of scores. Unprofessional behavior (e.g., not completing the exercise, arbitrary grading of work) will result in submission of an incident report to the College of Medicine Professionalism Officer.

"Being a Physician": Differential Diagnosis & Evidence-Based Medicine Component

mlc2 ddx rubric

This is an integrative component taught in conjunction with the Practice of Medicine-2 course centered on problem-oriented differential diagnosis and on principles of evidence-based medicine. Students must maintain a cumulative average of at least 70% to pass. Grades will be carried to two decimal places and will not be rounded; grades of 69.99% and below will be reported as a “Fail” for the component. Grading for MLC-2 will be based on quizzes administered by clicker assessing participation in the course objectives for approaching the readings. Each scored question will count for one point and grades will be calculated by dividing the number of questions answered correctly by the total number of questions for the entire year. At the conclusion of each session, the response data will be posted; at that time, students may challenge a question in writing. Individual student scores will post to Blackboard after class completion for feedback.

Awarding of Deficient Grades Based on Academics
Students who do not pass the course will be evaluated by the Academic Review Board for a review of their entire academic record. The Course Director will submit a recommendation for remediation to the Academic Review Board who then approves or modifies the recommendation.

Awarding of Failing Grades
Students who fail the Medical Literature component either singularly or in combination with other component will receive an overall grade of “Fail” for the course with the expectation that the student re-take the course.

Awarding of Conditional Grades
Students who fail only the Being a Physician”: Differential Diagnosis & Evidence-Based Medicine component of the course will receive an overall grade of “Conditional” for the course with the expectation that the student complete summer remedial work.

Grades of “Incomplete”
Students who receive an Incomplete in the course for missed work due to excused absences should contact the Course Director to devise a mutually agreeable timetable to complete missed tasks.

Awarding of Deficient Grades Due to Non-Academic Behavior

  1. All students must complete the mandatory evaluations that are assigned to them or they will receive a Conditional grade for the course per school policy.
  2. Professionalism incidents may warrant a deficient grade in the course irrespective of the numerical average.  School and course policies are posted on Blackboard and on the course web site.

What happens if I have to be absent and miss a quiz/hypothesis?

Students who are absent for an excused reason will be allowed to make-up up to 10% of the total missed quiz questions with make-up work at two time points during the year: end of fall semester (prior to Winter Break) and at course completion. Same policy applies for written assignments.

Absences constituting more than 10% of any component will result in a grade of Incomplete and additional coursework beyond the make-up will be required. Absences constituting more than 20% of any component will result in a student being administratively withdrawn from the course and having to repeat it the following academic year.

Note: An e-mail to Karen Kelly stating the reason is required; examples of excused absences designated by the Curriculum Committee include illness of oneself or a close family member, death of a close friend or family member, conference attendance, etc) The make-up quiz will be based on the reading of one or more additional cases depending on the number of points missed. The case(s) will be assigned at that time. More extensive details regarding the make-up process can be found on Blackboard.

What happens if need to withdraw from the course?

Students needing to withdraw from the course by the end of Unit 3 (November 18, 2013) will receive a grade of "W" for the course. After 50% of the course has been completed (start of Unit 4 on November 19, 2013 and beyond), a grade of "WP" or "WF" will be given depending on academic performance up to that point.

Who should I contact for help?

Multiple resources are available for students, including the services of Academic Support Services, AOA and course faculty.

All students will be provided with formal updates of their academic performance at the end of each unit by course faculty. Students struggling in the course, along with their advisory dean, will receive an e-mail outlining their academic situation (unit performance, cumulative average, standing in comparison to classmates, etc.) along with tips & strategies for improvement and a recommendation that they attend open faculty office hours and review sessions. Private appointments with course faculty can also be scheduled.

Who should I contact with questions or problems?

Please direct all correspondence, including absence notes and formal challenges to quiz questions to Karen Kelly (