The use of small group case-based exercises in human gross anatomy: A method for introducing active learning in a traditional course format

Clinical Anatomy 7:357-366 (1994)

MEDICAL EDUCATION

The Use of Small Group Case-Based Exercises in Human Gross Anatomy: A Method for Introducing Active Learning

in a Traditional Course Format JOHN T. HANSEN AND SHARON K. KRACKOV

Department of Neurobiology and Anatomy (J. T. H . ) and Curriculum Dmelopment Ofice (S. K . K. ) , Univenity of Rochester &/loo/ of Medicine and Dentistry, Rochester, Ntw York

As part of the curricular change at the University of Rochester School of Medicine and Dentistry, we focused on active learning and greater integration of basic and clinical sciences. With these objectives in mind, this report describes the use of small-group, case-based exercises in our gross anatomy course and provides one example of integrating such activities into a traditional course. In addition to formal lectures and laboratory dissection, students meet approximately every fourth class period in small groups to discuss a clinical case which focuses on the relevant anatomy taught at that time. Two first-year students lead each small group; one fourth-year student facilitator also attends to provide clinical correlations, answer questions, and reinforce the anatomy. Formative feedback suggests students enthusiastically endorse the self-directed active learning; they feel these exercises offer both a valuable approach to learning and an opportunity to practice presentation and leadership skills. First-year students enjoy the interaction with fourth-year facilitators and the fourth-year students appreciate the opportunity to review basic science material. Our data suggest that students learn to “think” about the anatomy, and we hope learn to use their understanding and knowledge base in a practical fashion. Moreover, these case-based exercises can fit nicely into a variety of curricular formats, especially where problem-based tutorials may not be feasible or desirable. o 1994 Wiley-Liss, Inc.

Key words: small groups, case studies, gross anatomy, active learning

INTRODUCTION Barrows has written extensively about problem-based learning (PBL) as a technique and its use at McMaster University and Southern Illinois University (Barrows, 1980, 1983, 1985, 1986, 1988; Distlehorst and Barrows, 1982). However, most medical schools still adhere to a

In recent years, calls for reform in medical education have focused especially on a reduction in passive learning, an increase in clinical relevance of the basic sciences, and a decompression Of the basic science curriculum (Physicians for 21st Century, 1984). During the fairly traditional approach to the basic science cur,.iculum,

centered largely around formal lecture past decade, several innovative and progressive approaches have evolved in the basic sciences. Some

Camp’ 1990)’ Harvard (Colvin and 1989)’ McMaster (Neufeld and Barrows. 1974: Neufeld et al..

In 1985, after several years of intensive study and planning, the University of Rochester School of Medi-

in the preclinical program. Several essential objectives

schools~ such as Bowman Gray and cine and Dentistry introduced major cirricular changes

1989), and‘the University of New Mexico (Kaufman; 1985; Kaufman e t al., 1989) have implemented case- based tutorial programs that integrate basic and clinical sciences in a problem-based, small-group experience.

Received for publication May 4, 1992; revised June 8, 1994.

Address reprint requests to Dr. Hansen, Box 603, Department of Neurobiology and Anatomy, University of Rochester Medical School, 601 E h w o o d Avenue, Rochester, NY 14642.

0 1994 Wiley-Liss, Inc.

368 Hansen and Krackov

Human Gross Anatomy: Gross Structure and Functior Histology, Biochemistry

Cell Structure and Function:

formed the basis for the basic science revisions at Rochester. These included a focus on active learning, and a greater integration of basic and clinical science. The rationale behind this emphasis was a firm belief on the part of the faculty and student planners that much of the basic science information can be learned and applied most effectively when students participate ac- tively in the process of acquiring new knowledge.

T h e faculty in our human gross anatomy course (Gross Structure and Function) decided to address these objectives by implementing small-group, case-based exercises. Unlike the McMaster University or Southern Illinois University tutorials, these are not classic problem- based learning exercises. Instead, they provide a more structured opportunity for medical students to participate in a small-group exercise that fosters greater participation, and more active discussion and learning than is usually afforded by lectures. This report describes the use of these exercises in our gross anatomy course and provides just one example of integrating small-group exercises into a traditional course. This learning format, in one form or another, now has gained wide acceptance in a number of other basic science courses at Rochester.

Adaptive and Regulatory Mechanisms: Physiology, Neural Sciences

METHODS Teaching Methods

General course organization. Gross Structure and Function at Rochester comprises a total of 192 contact hours and is the major basic science course taken by our first-year students during the initial 10 weeks of medical school (Fig. 1). T h e other competing courses students take at this time are Patient, Physician and Society, and Introduction to Human Health and Illness, a whole class patiendcase program which runs concurrently with the basic science courses throughout the entire first and second years.

The more traditional features of the Gross Structure and Function course include formal anatomy overview lectures, systems embryology lectures, clinical correlation lectures by guest clinicians, laboratory dissection exercises, and midterm and final laboratory and written examinations. T h e course meets for 4 hours each day during the first 10 weeks and the unique feature of the course is the implementation of small-group, case- based exercises. A typical week of the 10 week course schedule is shown in Figure 2.

Format Number Contact Hours

Anatomy Lectures

Embryology Lectures

Clinical Lectures

Case-Based Exercises

Laboratory Dissection

Examinations

20

5

7

12

46

2

20

5

7

18

134

8

First Year Academic Program

Week 1 I 1 22 39

The Patient, Physician, and Society: Biousvchosocial Medicine i: Medical Humanities Seminars: Ethics and Law in Medicin Cokkunity Medicine Introduction to Human Health and Illness I

Fig. 1. Overall course organization.

Case-Based Exercises in Anatomy 369

Mon. 8/30 1:oo-2:oo Case Study I1 Small Groups Breast Cancer

2:00-2:30 Case Study Review Dr. Hansen

2:30-5:00 D-6, Mediastinum & Heart (pp. 15-25)

Textbook Chapter 5

Tue. 8/31 8~30-9~30 Clinical Correlation-Heart Dr. Clark Pediatrics

9:30-12:30 D-7, Mediastinum & Heart (pp. 15-25)

Textbook Chapters 6 and 7

Wed. 911 8:30-9:15 Lymphatic System Dr. Hansen

9~15-9~30 Computer Learning Dr. Goldstein

9:30-12:30 D-8, Abdominal Wall & Inguinal Region (pp.27-32)

Textbook: Chapter 8

Myocardial Infarct Thu. 9r2 8 90-9 :00 Case Study I11 Small Groups

9:00-9:30 Case Study Review Dr. Hansen

9:30-12:00 D-9, Inguinal Region & Examination of Abdomen (pp. 32-42)

Textbook: Chapters 8 and 9

Fri. 913 8~30-9~30 Abdomen Dr. Hansen

9:30-12:30 D-10, Bile Passages, Celiac Trunk & Portal Vein (pp. 42-44)

Textbook Chapter 10

Fig. 2. Sample weekly schedule.

Student evaluation. Midterm and final examinations with written and laboratory components provide objective measures of student learning. T h e written exam has several item formats: multiple choice (single best answer, USMLE-type questions), short answer fill-in-the-blank, and short answer essay questions. Multiple choice questions comprise no more than 20% of the written exam, while short answer essay questions (one half to one page answers) comprise about 60% of the exam. T h e laboratory component is an identifica- tion practical exam that includes tagged structures on the cadaver, bones, cross-section identifications, and MRI or CT identifications. T h e final written examination is comprehensive. T h e subjective portion of each student's evaluation involves faculty assessment of laboratory participation, preparedness, attendance, and

collegial interaction. Performance in the small group exercises is not evaluated directly.

Format of small group exercises. Eight small groups comprised of 12 or 13 students each meet approximately every fourth class day to discuss a clinical case related to that week's dissection. T h e initial case study of the year is a whole class exercise/demonstration during the first week of medical school, where students observe how these exercises should function. Emphasis is placed upon demonstrating how group facilitators and student participants should approach each case exercise. A faculty member leads the exercise and takes the entire class through the case, calling on students at random and challenging their assumptions. By example, the students begin to appreciate how the small groups should function. Following the whole class


exercise, we hold a brief discussion about expectations where we provide guidelines for small-group facilitators (Table 1) and reassure students that their skills in this learning format will improve.

The remaining case studies are discussed in small groups. Anatomy teaching faculty do not attend the small-group sessions. However, two first-year students are assigned to facilitate each group; a fourth-year medical student volunteer also joins each group to serve as a resource person and provide basic clinical information where relevant.

Each group discusses the assigned case for 1 hour. Following this, the first-year students and fourth-year volunteers reconvene for a 30 minute whole class

wrap-up session” led by the course director. T h e objectives of the wrap-up session are to emphasize the anatomy pertinent to the case, discuss controversies, and ask thought-provoking questions that stimulate further discussion. There is also an opportunity to clarify issues raised in the individual small-group discussions.

Clinical cases. Appropriate cases are either written by fourth-year students from real cases they have en- countered or are abstracted from weekly clinicopathological exercises that appear in the New England Jour- nal of Medicine (see Appendix A for a sample of a case study written by a fourth-year medical student). When using the clinicopathological exercises in the New Eng- land Journal of Medicine, we obtain written permission to abstract and use these cases strictly for our course. Each case narrative begins with a one or two paragraph patient history that is significantly simplified and condensed in form.

T h e brief case narrative is followed by a list of learn-

( 6

TABLE 1. Guidelines for small group facilitators

Come prepared. Review the case, references, texts; prepare visuals, handouts.

Plan in advance with other student facilitators and faculty. Take responsib&y for the learning process, not content.

Emphasize acquiring and sharing knowledge. Don’t be obsessed with absolute answers. Encourage application, integration, synthesis.

Serve as a resource-but not as the source for all information. Question and probe, but don’t provide answers. Challenge assumptions.

Guide and facilitate discussion. Be a good listener, don’t dominate discussions. Involve all students in the group. Keep discussion relatively focused. Focus on action, what to do next.

Establish a comfortable learning climate. Foster good interpersonal relationships. Encourage students to be candid. Don’t be critical of wrong answers. Be flexible and willine to exdore new areas.

ing objectives. These objectives are directed primarily at understanding the gross anatomy related to the case, but also may relate to biopsychosocial issues raised in the narrative, e.g., an ethical dilemma, an issue of cost containment, or a medical-legal imperative (see sample case in Appendix A).

A list of questions follows the objectives. T h e questions explore the anatomy of the case as it relates to the clinical presentation and serve as starting points for the small-group discussions by helping students focus on important concepts.

T h e case write-up concludes with a glossary of clinical terms that introduces the students to a working clinical vocabulary. Students are expected to consult a medical dictionary to learn the definitions. Common eponyms are included in the glossary because physicians use them as part of their clinical vocabulary, but the correct anatomical terminology also is stressed. Several pertinent journal references from the anatomical and clinical literature follow the glossary.

Data Methods Course evaluation. T h e course is evaluated by the

Medical School’s Curriculum Development Office as part of the overall evaluation of the medical curriculum. T h e focus of the evaluation is formative and involves collecting information from students and faculty. This information is fed back to the course director and forms the basis for making changes to strengthen the program. First-year students and teaching faculty complete a general course questionnaire at the end of the course to document overall perspectives. First-year students and fourth-year small group facilitators also complete a case-based exercise questionnaire that provides feedback about the overall strengths and weaknesses of these exercises, the case write-up and associated questions, references, small-group facilitators, and the large group “wrap-up” session. Fourth- year students did not rate themselves.

All questionnaires have both quantitative and qualitative components. Quantitative data is analyzed by computer and qualitativeharrative feedback under- goes personal review. Data are not subjected to statis- tical analysis. T h e Curriculum Development Office prepares a summary of all feedback which is sent to the course director for circulation among teaching faculty. Questionnaire data are supplemented by observation of case-based exercise sessions by the Director of the Curriculum Development Office, and by small-group discussions about the course among students and the course director; these sessions are moderated by the Curriculum Development Office Director.

This report presents small-group, case-based exercise questionnaire data collected from first-year stu-


dents and fourth-year student facilitators over three years 1989-1990, 1990-1991, and 1991-1992. Since 1992-1993, the school has adopted a consensus group system for course evaluation; one third of the first-year class (35 students) were asked to provide feedback about Gross Structure and Function. Because of this change in format, we have not included data after

T h e format of the quantitative scale changed somewhat over the study years. T h e 1990-1991 and 1991-1992 questionnaires contained a four-point scale to rate various aspects of the case-based exercises (Poor, Fair, Good, or Excellent). In 1989-1990, the quantitative items were rated on a three-point scale (either Poor, Good, Excellent or No, Somewhat, Yes). All quantitative information was summarized by computer.

T h e open-ended narrative component of the questionnaires provided valuable information about strengths and weaknesses of the case-based exercises. Student feedback is shared with the course director and the teaching faculty. This information also is kept on file in the Curriculum Development Office and forms part of the promotion and tenure data used when faculty are reviewed. Each year following the completion of the course, the faculty meet to discuss how they feel the course went and then review the student comments. Our students and faculty feel this type of information is critical to gaining a full understanding of the issues surrounding student impressions and in facilitating changes to strengthen the program. All qualitative feedback was reviewed to look for trends and notewor- thy findings. Verbatim examples of narrative feedback are included in the Results.

1992- 1993.

RESULTS Overall Impressions About the Case-Based Exercises

Feedback from first-year students. Participation was voluntary and response rates over the three years are shown in Table 2. Some students did not answer every question, so for some individual items, the overall number of responses was slightly less than the rate noted in Table 2. Across all three study years, first-year

TABLE 2. GSF case-based exercises response rate

First year Fourth year students students

Studv vear N % N %

1989-1990 97 66 9 67 1990- 199 1 75 77 7 58 1991-1992 50 50 8 30

TABLE 3. Overall impressions about case-based exercises

Study year N“ N(%)b N(%)b N(%)b N(%)b Poor Fair Good Excellent

First-year students

1990-1991 61/98 l(2) l(2) 9(15) SO(81) 1991-1992 45/100 O(0) O(0) 9(20) 36(80) Fourth-year students 1989- 1990 6/9 O(0) N/A O(0) 6(100) 1990-1991 6/12 O(0) O(0) l(17) S(83) 1991-1992 10/25 O(0) O(0) l(10) 9(90)

1989-1990 61/97 O(0) N/A 25(41) 36(59)

“ N represents the number of students who answered this particular question over the total number of students in the class that year. bNumber who responded in this category and the percentage that number represents of all students who responded to the question. Percents are rounded off to nearest whole percent.

students’ overall rating of the case-based exercises were favorable (Table 3). T h e exercises were rated “excellent” (the most positive option) by the majority of respondents each year; no more than one student rated them “poor” (the most negative option). Students wrote comments like “Bring disease and patient care closer,” “Applied knowledge of anatomy,” “My favorite part of the course. T h e things I remember most clearly and easily are the ones that were associated with the case studies.” A number of students felt the case-based exercises helped them learn the material and added comments like “Organize the facts into a framework,” “Facilitated understanding of important concepts,” and “Very helpful in putting anatomy together with real situations-made anatomy relevant.”

There were some suggestions for improvement. Be- tween 35-40% of the students wanted their fourth-year facilitator to remain with their small group throughout the entire course. Moreover, some students (about 10-15%) felt that only the small-group leaders should have access to the references.

Feedback from fourth-year students. Most fourth- year students also praised the case-based exercises (Table 3). Each year, 80-100% of students rated them

excellent” and no ratings were “poor.” Some noted “Fosters problem solving-they got to think like doc- tors instead of test takers,” “ . . . Brings some clinical relevance to first-year students. It also makes learning anatomy more fun and is a great opportunity for fourth- years to brush up on some anatomy.” “I wish we’d done this our first year! A very positive experience. Enjoyed being able to interact with first-years and review anatomy. Opportunity to teach, relearn the material.” The weaknesses they noted generally focused on first-year students “getting bogged down” in clinical details of the case and not focusing on the overall picture and how it relates to their work in anatomy. Some suggested

6 6

362 Hansen and Kraclrov

more time be allotted to complete work in the small groups.

Case Presentation, Questions, References Feedback from first-year students. Most first-

year students also rated the case presentations and associated questions and references highly. Almost all students (98%) rated them either “good” or “excellent” each year. Only one student rated them “poor” over the three study years. Some narrative comments included “Interesting relevant cases to remind us why we are here,” “Questions probed us to think about the relations of anatomical structures,” “Vocabulary lists were very helpful,” and “Cases clearly written and questions pointed out important conclusions we should glean from the studies.” In earlier years, some weaknesses centered on the case write-up (“Sometimes contained too much material, detail”). However, the case write-ups were shortened and simplified in response to this feedback and the comments did not reappear.

Feedback from fourth-year students. The fourth- year students also felt the cases were appropriate and interesting. Across three years, most (97%) rated them “good” or “excellent.” Some comments included

Short, to the point, questions were pertinent,” “Well directed to first-year level,” and “Very relevant discussion-provoking questions.” Their suggestions for improvement generally were directed to the access to references and the original New England Journal of Medicine article.

L L

Small-Group Facilitators Feedback from first-year students. T h e majority

of first-year students enjoyed working with fourth-year facilitators. T h e advanced student leaders were rated “good” (27%) or “excellent” (68%) over three years by the majority of students and were mentioned often as a strength of the course. Comments included “They knew the significance (clinical) of the case material,” “Were still close enough to first-years to focus learning. ‘Filled in the blanks’ and made it more clinically relevant.” “The fourth-years seemed very knowledgeable and really helped to clarify details of the case studies. They all seemed very well prepared, and it was nice to have them listening in on our discussions, rather than [course facultyhthat would have been more intim- idating.’’ “They were helpful as both sources of information and role models.”

Some early feedback that fourth-years “took over the small groups” was alleviated with an orientation session for fourth-year facilitators. At these sessions, we reviewed and discussed their role and presented guidelines for facilitating small groups (Appendix B).

Over three years, most students also rated the contemporaneous first-year small-group leaders as “good”

(57%) or “excellent” (36%). However, their ratings of their peers were not as consistently high as their ratings of the fourth-year facilitators. Some comments included “Good experience to lead group,” LLEffective- they share the same perspective as the rest of the students,” “Strengthens our organizational and problem- solving skills . . . ” and “Students took the assign- ment seriously and were well prepared.” Some less positive comments included “Sometimes got bogged down in detail,” “Variable-some better than others,” and “Lacked expertise to understand/explain material.”

Feedback from fourth-year facilitators. T h e fourth-year students also praised first-year group leaders. Most fourth-years rated them “good” (31%) to “excellent” (67%) with only one student rating them as “fair.” Some said “I was impressed with the small- group leaders. They took their roles very seriously and had done much work preparing for the cases.” “Did a good job working through the cases.” T h e weaknesses they noted reflected first-year students’ variable abili- ties at group leadership, e.g., “Had difficulty discern- ing what was important.” We initiated the first case- whole class demonstration to help with this problem.

Large Group Wrap-up Feedback from first-year students. T h e large

group “wrap-up” session also was considered “good” (32%) or “excellent” (62%) by almost all first-year student raters over the three years. Some said “Very necessary. They always cleared up any confusion,” and “Gave great summary and emphasis on most important objectives.” Some students noted that these sessions sometimes felt a bit rushed. “Took a long time to get everyone organized . . . usually only 10-1.5 minutes left.” Facilitators were informed about this situation and encouraged to finish their case discussions within the hour allotted.

Feedback from fourth-year students. The fourth- year students also saw the large-group wrap-up as a positive experience. All students rated them “good” (49%) or “excellent” (51%). Some said “Focuses on main topic, i.e., anatomy, and how it relates to the particular case,” “Effective summary,” and “Brings together the key points that should be learned as well as some clinical aspects some might have missed.” They too suggested more time for these sessions (in 1990- 199 1 ).

DISCUSSION Although small-group, case-based exercises, as used

in our human anatomy course, are not problem-based learning per se, these exercises encourage a greater


emphasis on discussion and active learning, and we believe offer an excellent adjunct to the more passive lecture-centered teaching. T h e students’ comments reflect their enthusiasm, noting that they remember the material better when discussed in a case format.

We feel that the variety of learning formats used in the course provides latitude for the teaching faculty to select the method of presentation most appropriate for their learning objectives. We agree with the conclusions of Pate1 et al. (1991) that ‘‘ . . . both conventional and PBL curricula have strengths and weakness.” We feel that some topics, especially those incorporating difficult conceptual principles, may best be introduced by a formal lecture, and later reinforced in a small- group session. For example, the students first exposure to the concept and organization of the autonomic nervous system occurs in a formal lecture that is supplemented with a lecture handout. T h e following week, the concept and organization is reinforced by a case exercise of angina pectoris where the emphasis focuses on a discussion of the heart, its innervation by the autonomic nervous system, and the concept of referred pain.

T h e feedback from students and fourth-year facilitators suggests that small-group, case-based exercises are a rewarding experience. However, like many active pedagogical approaches, they require a significant in- vestment of time and effort, e.g., to write cases appropriate for presenting basic science information, make small group assignments, train fourth-year student volunteers, and create appropriate student and course evaluation materials. T h e course director assumes responsibility for many of these activities. Because our course appears at the beginning of the first year of medical school, fourth-year student volunteers usually possess satisfactory clinical and anatomical knowledge to challenge our students and yet keep the level of learning appropriate for students at this point in their medical education. By the end of the first year or during the second year, students are sophisticated enough in their knowledge base that most course directors using small-group, case-based exercises prefer to use resi- dents or clinical faculty to facilitate discussion.

Initially, faculty attended the small-group exercises. A reduction in the number of available teaching faculty, however, led to the idea of using fourth-year student volunteers. Student feedback and our own experience have shown that group discussion can become stilted and artificial when faculty attend. Perhaps, the perception that student comments are being “graded” subjec- tively inhibits the discussion. Regardless, the students are comfortable with fourth-year student volunteers, and their presence as facilitators has several added benefits. Fourth-year students serve as role models and

their participation in the exercises offers an excellent reintroduction to the basic sciences. T h e lack of faculty participation in the small groups does not appear to significantly detract from the learning experience and actually augments other positive aspects of the interaction between first- and fourth-year students. Often, fourth-year students are better prepared than basic science faculty to comment on clinical aspects of the case and can demonstrate various clinical tests which reinforce anatomical principles. Ninety-five percent of the anatomy students rated the interaction as good or excellent. Follow-up evaluations with our first-year students continually buttress our perception that fourth- year students are positive role models who remind first- year students of the importance of anatomy in the practice of medicine and assure them that the seem- ingly arduous journey leading to their degree is both enjoyable and shorter than they imagine.

First-year small-group leaders were evaluated less favorably, although most (93%) still were rated good to excellent. Leading small groups is a challenging experience; it becomes even more challenging when presenting material that is both new to you as well as your peers. Nevertheless, we feel the experience of small- group leadership and the associated uncertainties provide valuable learning experiences. Even if not opti- mally performed, we feel it is important for first-year students to grapple with improving their small-group leadership skills. Not surprisingly, their peers sympa- thize with them, especially if they know they are doing their best, and still value the small-group sessions overall. Students, sooner or later, will present patients and clinical cases to attending clinical faculty, and their organizational and clinical diagnostic skills will be evaluated critically during these exercises. Therefore, practice leading and facilitating case-based exercises should build student confidence and assist in honing presentation and communication skills. Moreover, the active nature of the learning process allows students to recall information associated with a particular small-group discussion. Anecdotal comments by fourth-year students support this view as they remark how small-group leadership and learning during their first year of medical school enhanced their ability to effectively present patients and cases during their clinical years.

Occasionally, small-group leaders may convey misinformation. We feel this is an expected part of self- directed learning. Fortunately, misinformation usually is corrected by the other members of the small group who have done their “homework,” by the fourth-year facilitator, or by being addressed in the whole class wrap-up session following each small-group exercise. Recognizing and dealing with misinformation is part of the active learning process, and can be a valuable learning experience in its own right.

364 Hansen and Kraclrov

The use of small-group, case-based exercises in an otherwise fairly traditional human gross anatomy course provides another learning method that students enthusiastically endorse as a more active learning experience than formal lecture. Students welcome the re- spite from passive learning and begin to develop important small-group leadership skills. Our hope is that students will learn to think about the anatomy, and learn to use their understanding and knowledge base in a practical fashion (Balla et al., 1990). Finally, the use of case-based exercises can fit nicely into a variety of curricular formats, especially in those where full-scale problem-based tutorials may not be feasible or desirable.

ACKNOWLEDGMENTS T h e authors thank Judith C. Floberg and Lisa M.

LaPoint for typing the manuscript. Supported in part by a grant to the University of Rochester Medical Cen- ter entitled “Preparing Physicians for the Future: A Program in Medical Education” funded by the Robert Wood Johnson Foundation.

REFERENCES Balla, J. I . , J. B. Biggs, M. Gibson, and A.M. Change 1990 The

application of basic science concepts to clinical problem- solving. Med. Ed., 24: 137-147.

Barrows, H.S. and R. M. Tamblyn 1980 Problem-Based Learn- ing: An Approach to Medical Education. New York: Springer Publishing Company.

Barrows, H. S. 1983 Problem-based, self-directed learning. J. Am. Med. Assoc., 250:3077-3080.

Barrows, H. S. 1985 How to Design a Problem-Based Curricu- lum for the Preclinical Years. New York: Springer Publishing Company.

Barrows, H. S. 1986 A taxonomy of problem-based learning methods. Med. Educ., 20:481-486.

Barrows, H. S. 1988 The Tutorial Process. Springfield: Southern Illinois School of Medicine.

Colvin, R. B. and M. S. Wetzel 1989 Pathology in the new pathway of medical education at Harvard Medical School. Am. J. Clin. Pathol., 92:S23-S30.

Distlehorst, L. and H. S. Barrows. 1982 A new tool for problem- based self-directed learning. J. Med. Educ., 57:486-488.

Kaufman, A. (ed) 1985 Implementing Problem-Based Medical Education. New York: Springer Publishing Company.

Kaufman, A., S. Mennin, R. Waterman, S. Duban, C. Hans- barger, H. Silverblatt, S. S. Obenshain, M. Kantrowitz, T. Becker, J. Samet, and W. Wiese 1989 T h e New Mexico experiment: Educational innovation and institutional change. Acad. Med., 64: 285-294.

Neufeld, V. R. and H. S. Barrows 1974 The McMaster philoso- phy: An approach to medical education. J. Med. Educ., 49: 1040- 1050.

Neufeld, V. R., C. A. Woodward, and S. M. MacLeod 1989The McMaster M.D. program: A case study of renewal in medical education. Acad. Med., 64:423-432.

Patel, V. L., G. J. Groen, and G. R. Norman 1991 Effects of conventional and problem-based medical curricula on problem solving. Acad. Med., 66:380-389.

Peplow, P. V. 1990 Self-directed learning in anatomy: incorpora- tion of case-based studies into a conventional medical curriculum. Med. Ed., 24:426-432.

Philip, J. R. and M. G . Camp 1990The problem-based curriculum at Bowman Gray School of Medicine. Acad. Med., 65:

Physicians of the Twenty-First Century 1984 The GPEP Re- port, Report of the Panel on the General Professional Educa- tion of the Physician and College Preparation for Medicine. Association of American Medical Colleges.

363-364.

APPENDIX A: THE CASE OF A WOMAN WITH ABDOMINAL P m Case Presentation

A 57-year-old homemaker presented to the Strong Memorial Hospital Emergency Department with the complaint of 5 days of midepigastric abdominal pain. T h e pain had been acute in onset and had increased in intensity up until the time of admission.

T h e woman described the pain as a constant dull ache localized to the midepigastrium without radiation, and fluctuating in intensity. Nausea and vomiting followed any attempted ingestion of solid food and she could keep down liquids only with great difficulty. There was no hematemesis and the vomitus was char- acterized as bilious and non-feculent. T h e patient had no fever, chills, diarrhea, shortness of breath, dysuria, or vaginal discharge. Her last bowel movement was 5 days ago and was formed. She is passing flatus and has been anorexic throughout the duration of her symptoms.

T h e patient’s past medical history is significant for a total abdominal hysterectomy, bilateral salpingo- oophorectomy, appendectomy, and previous admission for abdominal pain, described as localized to the right lower quadrant, which resolved spontaneously over a 2 day period. She takes no medications, and abstains from tobacco and alcohol.

Physical exam was remarkable only for a moderately distended abdomen, especially in the midepigastrium with tympany, high-pitched tinkles, and otherwise hy- peractive bowel sounds. There was tenderness to pal- pation over the area of greatest distention, but no firm mass, rebound, guarding, or Murphy’s sign. A rectal exam showed no blood in her stool.

Objectives for This Case Study 1 . Review the anatomy of the midepigastrium, large and small bowel. 2. Consider some of the structural etiologies of bowel obstructions.


3. Become familiar with physical examination signs and symptoms in the surgical abdomen. 4. Become familiar with viewing abdominal films, recognizing the difference between small and large bowel.

Questions 1. Draw a diagram of the anatomical divisions of the abdomen, i.e., RUQ, RLQ, LLQ, LUQ, epigastric, umbilical, and hypogastric (aka. suprapubic) regions. 2. What major structures lie in the RUQ? RLQ? LLQ? LUQ? epigastric region? umbilical region? hypogastric region? 3. With the history of abdominal distention, increased tympany, inability to keep food down, and no bowel movement for 5 days, but presence of flatus, let’s as- sume for now that this is a bowel obstruction, probably partial. Why? 4. What anatomical causes can you think of which would obstruct or partially obstruct the small bowel? Large bowel? 5. Think about the intestines as hollow tubes with fluid and air flowing through them. Remember Bernoulli’s principle? What will the bowel sounds be like in early bowel obstruction? total obstruction? diarrhea? 6. What nerves relay the pain in early bowel obstruction, i.e., what nerves are related to pain from visceral distention? Where does the patient feel the pain, i.e., where does the pain refer to? 7. Why is bowel obstruction a surgical emergency? What are the complications of a bowel obstruction? 8. What is rebound tenderness? What does it make one suspicious of? 9. What do the following terms mean? hematemesis: bilious: non-feculent: dysuria: anorexic: hysterectomy : salpingo-oophorectomy : tympany: Murphy’s sign:

REFERENCES Bates B. 1991 A Guide to Physical Examination and History

Taking, fifth edition. Philadelphia: J.B. Lippincotr Company. Calkins, B.M. and A.I. Mendeloff 1986 Epidemiology of in-

flammatory bowel disease. Epidemiol. Rev., 860 . DeGowin R.L. 1987 DeGowin and DeGowin’s Bedside Diag-

nostic Examination, fifth edition. New York: Macmillian Publishing Co.

Schwartz S.I., Editor. 1989 Principles of Surgery, fifth edition. New York: McGraw-Hill, Inc.

(This case modified from original case written by Jennifer Epp, M.D., Class of 1992)

APPENDIX B: HINTS FOR STUDENT FACILIIIATORS: FOURTH YEAR FACILITATORS 1. Prepare in advance. You will serve as a resource to the group; all students should read the case.

Read the case. Review references, texts. Meet with other student leaders and faculty to

Prepare visuals, handouts. plan.

2. Present clinical correlations. Cite clinical examples that apply basic science to “real life” situations.

3. Take responsibility for the learning process, not content.

Encourage group members to grapple with the

Don’t “present” the answer in a mini lecture. - Let group members uncover the answers them-

Challenge group members to present their own

Respond to students’ ideas with counter examples

Offer data their ideas will not explain. Offer new information that will help shape

Challenge students’ assumptions and probe their

“Why did you saylask that?” “What does this mean?” “What would you do next?” “How do you know?” “How does this relate to previous findings?” - Serve as a resource, but not as the source for all the

Back up and support contemporaneous leaders. Answer questions preclinical students can’t answer. - Bring in references or clinical examples that may

Clarify answers or information when you can, but

questions.

selves.

thinking.

that would result from these ideas.

thinking.

reasoning process with questions like,

answers.

illustrate the case.

don’t feel you must know all the answers.

4. Guide, facilitate discussions. Do not dominate discussions. Suggest group members interact with one another,

Don’t sit in the center of the group. - Involve all students in the group. Ask open-ended questions that stimulate clarifica-

not with the leader.

tion and discussion.


Call on students. Ask for alternative points of view. Ask for group consensus on issues. Provide structure to keep discussion focused. Set agendas to guide and direct the session. Intervene if necessary to keep the group on track. Summarize as you go along.

Establish a comfortable learning climate. Support positive interpersonal relationships within

Encourage students to be candid. Don’t be critical of wrong answers. Be flexible and willing to explore new areas.

the group.

Documents

The use of small group case-based exercises in human gross anatomy: A method for introducing active learning in a traditional course format