Overview of the MLC
A number of questions arise about the philosophy and implementation of these courses:
How are cases selected?
Over the course of two years, the approximately 30 cases used represent a broad spectrum of clinical problems requiring application of knowledge from the various disciplines of basic and clinical science. The type of article that seems to work best is that in which a complex differential diagnosis is the main focus of discussion. “Clinical problem-solving” exercises and “Case Records from the MGH” features in the New England Journal of Medicine (NEJM) have been a major but not exclusive source of case material. The cases are chosen so that the major emphasis corresponds to what is being studied in other courses that students are taking at the same time (e.g., heart failure due to valvular stenosis when students are concurrently studying cardiovascular physiology or pathology).
Are published cases too difficult for preclinical medical students to study?
There were initial fears that published cases, such as those from the New England Journal of Medicine, would be too complex, the diagnoses too esoteric, or the discussion too specialized for medical students in the preclinical years; such misgivings about the concept of the course are consistently undermined by direct questioning of the students. When surveyed, 90-95% of students deny that the cases are too difficult to study. It seems possible that doubts about the feasibility of reading published cases arise from the misconception that the goal is to make students become experts themselves in the issues being discussed. Such expectations are, of course, unrealistic. It is not the goal that students will acquire detailed knowledge about the various topics raised. The specified task is that students will do enough background study to follow along with and occasionally contribute, perhaps only by asking a pertinent question, to a discussion of the specific case at hand. During this experience with the case, the student is guided by the paper itself and by the faculty experts to the edge of current ideas about the topic. There is no doubt that the students leave behind much in passing through this experience that will need to be explored in greater depth at another time. The expectation should be that the students (like all of us), during their education, training and subsequent professional life, will repeatedly revisit the issues raised and will have to constantly restudy and remodel their concepts, perhaps focusing on different aspects of the problems at different times. The preclinical case study experience is a beginning, not an end.
Does the course take over content objectives from other courses?
Members of the faculty initially wondered whether the case study course would take responsibility for specific content from discipline-based courses and whether they would need to adjust their lecture series because some material was being “off-loaded” into the case format. This type of discussion probably was the result of confusion that this course is some form of PBL with its idea that curriculum can be organized around case problems rather than disciplines. The goal of this course does not include organizing curriculum content around cases and adding this constraint is severely counterproductive to our stated goal. “Off-loading” forces selection of a particular type of case that “covers” the aspect of curriculum being taken over. Thus, one is either very constrained in selection of cases, or one is forced to “manufacture” the cases to fit the curriculum objectives. Further, once a case is selected or constructed on this basis, one is “locked in” for an extended period of time because the rest of the curriculum has adapted to the arrangement. In our course, over one-half of the cases are replaced each year. We keep cases that work particularly well and make room for more recently published cases to keep current with changes in medical knowledge.
The approach taken, therefore, was to suggest that the discipline-based courses remain coherent unto themselves and comprehensive in their objectives in order to allow the case reading experience to stay consistent with its own goals.
What assures that the students will remain appropriately engaged in the case reading tasks?
Motivation to study is a complex phenomenon. Ideally, students at this level are internally motivated to at least some extent, but it seems unrealistic to rely on this amidst pressure from many competing needs and goals.
Several issues arise in relation to evaluation and grading in sustaining student engagement in the goals of this course. The first is that, without the availability of supervised small group interaction, there is a need to find an alternative to subjective assessment of student preparation. How does one insure that individual students will do the independent background study needed to participate meaningfully, at least as an engaged observer, in a high-level discussion? As noted above, the solution we have developed is to administer frequent quizzes prior to class discussion to insure achievement of specified tasks in relation to the case reading. Students readily admit that they would not study the cases as carefully without the quizzes.
Another issue in relation to evaluation of the students is that the open-endedness of the task “to understand and be able to explain what happens in the case and what is discussed by the authors” is daunting and initially leads students to attempt to short-circuit the process and artificially limit its scope. Students attempt to turn the course into something more familiar and controllable by requesting specific “learning objectives” or outlines of the “main points” to study for the quizzes. It is critical that instructors counter this by emphasizing that the important points are whatever the student needs to find out in order to understand the discussion. This structure has a built-in means of activating the students’ prior knowledge and giving a starting point consistent with their prior knowledge even as it likely differs among them. The instructors create quiz questions at various levels of sophistication along possible paths of inquiry following from the case reading and students are given to understand that it is not a realistic expectation that they will get all of the answers correct. Students also have to accept that sometimes a direction they might take in their study will not be represented in the quiz. Holding to these principles against student resistance requires commitment to the process. It has been found useful to discuss the educational objectives in class frequently and to emphasize that the study of the cases has a higher purpose. Our experience is that students’ initial resistance dissipates over time but that the students are never quite satisfied that their quiz scores reflect their effort in the course.
How do we promote elaboration of ideas by students without tutor-facilitated small group discussions?
An important component of the course is having students construct written hypotheses that specify the mechanisms of disease explaining clinical phenomena in the cases. The objective is to force exploration of relationships and identification of gaps in understanding that require further study. It is our impression that this assignment is a major factor driving student questions during the class discussions and students have commented that it is in the process of writing the hypothesis that “everything comes together.” The assignment of creating the “pathophysiologic hypothesis” leads students to elaboration of ideas both because of the nature of the assignment itself and because it encourages peer collaboration. Individual students are ultimately responsible for their own understanding of the cases. However, we do encourage informal collaboration among students outside of scheduled class time, though we do not insist on it and do not provide faculty support for it. Student surveys show that more than three-quarters of the students work with at least one other student during study of each case, and that approximately two-thirds belong to a study group of two or more other students. Nearly all of these students report working on constructing the pathophysiologic hypotheses during collaboration sessions with peers.
How does this case study experience differ from "problem-based learning" or PBL?
First, the focus of the task assigned to students in our courses is to provide an explanation or rationale for what is observed them rather than to attempt to solve clinical problems. In our case study course, students are assigned readings of published cases in their entirety. The complete workup, clinical discussion and final diagnosis are thus all part of the reading. The structure of our courses shifts the students’ focus to the task of developing explanations for what they observe as clinical phenomena resulting from disease processes and what they observe in the skilled handling of a case by experts (thus modeling excellent clinical reasoning and problem-solving for the student and promoting inquiry into the rationale for what is modeled).
Because we view the world of medicine that we wish to initiate the students into as larger than they can envision on their own, the independent study task assigned to students is highly structured in our course. We share with PBL a belief in the value of independent study for the student but do not embrace their concept of “self-directed learning.” In line with our main goal to point the students in the direction of an authentic medical discussion, we provide a structure that leads them efficiently to that type of discourse. Our design has a built-in deep structure, based first on the use of formal, peer-reviewed and constantly updated published case material and second, on the real-time commentary provided by the faculty experts. The structure points students to issues that would realistically be included in a state-of-the-art medical discussion of the case and on the scaffold thus built, we expect students to investigate and discuss a sophisticated set of ideas.
What are the costs?
By abandoning both the explicit intent to teach “clinical problem-solving” and the commitment to small-group process, there is a marked reduction in the resources required for the case study experience. Instead of creating and updating case material as is required in the PBL format, the medical literature provides a continuous and rich source of well worked-up and deeply thought-through cases ever current in perspective.
The invited faculty is an elite cadre of teachers who have been uniformly willing and often eager to participate as discussion leaders for individual sessions related to their specialties without remuneration beyond credit for contribution to the university teaching mission. Our discussion leaders have included the university president, the dean of the medical school, most of the associate deans, and several department chairmen, along with numerous others distinguished in their fields and representing nearly all of the clinical and basic science departments.