Portraying Social Constructs that Influence Health in Patient Cases

by Jewlyus Grigsby PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

One of the most common ways health profession programs assess students’ knowledge is through patient cases intended to mirror real-life practice scenarios. These cases are meant to place students in a “what would you do?” simulation and facilitate the development of their critical thinking and clinical skills. These cases are used during in-class discussions, on exams, in clinical skills competitions, in interviews, and for professional development. When designing these cases, faculty consider a variety of factors such as the severity of the patient’s symptoms, lab values, comorbidities, allergies and intolerances, and even family history. One set of factors that must be carefully considered when creating a case is the patient’s race, ethnicity, nationality, and socioeconomic status. These factors are social constructs, and therefore influence perception, decision making, and (all too often) health outcomes. In August 2021, the American Medical Association published updated guidelines about how to report race and ethnicity in the medical literature. These guidelines state that the words and terms used must be, “accurate, clear, and precise and must reflect fairness, equity, and consistency.”¹ Furthermore it also provides guidance on how to address sex and gender, sexual orientation, age, and socioeconomic status in research reports, review articles, and case reports. The goal of these guidelines is to reduce unintentional bias within the medical and scientific literature. However, despite now having a guideline instructing health care researchers and educators on how best to include these social constructs, how should this be done in the classroom setting and during experiential courses?

Ensuring the appropriate portrayal of diversity in patient cases should start with a careful reflection on the objectives of the lecture or topic being taught. This is especially important because test questions are often developed from the learning objectives. When writing learning objectives, one must ask what participants should be able to do as a result of the lecture, what the audience needs to know, and communicate the take-home message. By including objectives that relate to the social determinants of health, diversity can be introduced into the patient cases, and assist students in practicing disease state management with patients from diverse backgrounds. Here are three examples of how to structure objectives that include some of these social factors:

1. Create a treatment plan for patients within the confines of the state’s Medicaid medication formulary.
2. Design a medication regimen that accounts for and is consistent with a patient’s religious beliefs and practices.
3. Compare and contrast the prevalence of medication allergies and intolerances present in specific racial and ethnic groups.

These objectives challenge students to analyze a patient’s financial status, religious beliefs, and race/ethnicity in the context of the treatment regimen and medication characteristics.

After establishing the objectives for a presentation and determining whether specific social factors should be incorporated, the next step is to design the cases that will be used during the in-class activities and on exams. The cases should highlight the medical conditions under consideration but also highlight how political, economic, and social factors contribute to the patient’s o vernal health outcomes. It is also important to ensure the case does not reinforce biases and avoids stereotypes. This can be challenging because there is a fine line between something that might be more common in a particular population and a stereotypical patient presentation. For example, psoriasis is more common in Caucasian patients and diabetes is more common in African Americans. However, not all diabetes-related cases should be about an African American patient, and not all psoriasis cases should feature a Northern European! These diseases occur in people of all racial and ethnic backgrounds, but there may be some differences in presentation, clinical features, and severity that can be explored by featuring patients from various backgrounds.

One group, a non-profit organization, produces cases for courses in medical schools in the United States. They design their cases using an approach called “structural competency” defined as: 

the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health.²

Based on this definition, the group produced a guide to assist educators in the implementation of the cases and how to discuss race and culture in the classroom.²

Using our learning objectives above, we could construct a patient case to explore a range of issues.  Here is an example of a patient case that a teacher might create:

RS is a 30 YO bisexual African American male with type 2 diabetes, hypertension, and dyslipidemia. He is coming to clinic for the first time since being hospitalized due to diabetic ketoacidosis. His diabetes is uncontrolled and he probably doesn’t have health insurance. His family history includes type 2 diabetes, stroke, and heart failure. He states that he drinks very little water and because he works all the time in a factory, he eats a typical Southern diet: high calorie and high carbohydrates with little to no vegetables. What medication regimen would you recommend in this case? What are some non-pharmacological interventions would you suggest?

This is a suitable case to evaluate a patient newly diagnosed with diabetes however, it does perpetuate stereotypes and can reinforce some implicit biases that many practitioners have. First, in the introductory sentence, it states the patient’s sexual orientation. This information really isn’t necessary to answer the key questions. Nonetheless, patients sometimes disclose personal information during a clinic visit or hospital stay. Although it does not contribute information that is useful when addressing the key questions in the case, it might be an opportunity to introduce students to a patient whose sexual orientation may be different than their own. However, the manner in which the patient’s sexual orientation is included doesn’t flow with the narrative of the case. Also, the case alludes to the possibility that this patient is uninsured, but based on the objectives, we should indicate that the patient is on Medicaid. Lastly, the patient’s diet is described in a stereotypical manner. Instead of labeling this a "southern diet" that all African Americans in the south consume, it would be better to describe the patient’s diet without ascribing it to the patient’s race or ethnicity. So here’s a way to change the case without perpetuating these biases and stereotypes:

RS is a 30 YO African American male with type 2 diabetes, hypertension, and dyslipidemia. He is coming to the clinic for the first time after being hospitalized for diabetic ketoacidosis. He has trouble getting his medications because his Medicaid plan’s limited formulary and normally his boyfriend helps him pay for his medications. His family history includes type 2 diabetes, stroke, and heart failure. When ask about what he has eaten over the past 24-hours, he indicates he did not eat breakfast, he ate a chicken sandwich meal from Chick fil A for lunch, and had fried chicken with bread for dinner. What medication regimen would you recommend in this case? What are some non-pharmacological interventions you would suggest?

The new case removes the patient’s sexual orientation from the introductory statement but its still alluded to it later in the case.  The case introduces access to medications as a potential problem. Also, there is specific information about the patient’s eating habits, rather than sweeping generalizations. These changes do not alter the case entirely, but they do remove some of the stereotypical elements and biases. In order to introduce students to the social determinants of health, social constructs need to be included in patient cases but must be constructed in such a way to reduce biases while reflecting the diversity in the patients we serve.

References

1. Flanagin, A., Frey, T. and Christiansen, S., 2021. Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals. JAMA 2021; 326(7): 621. Available at: <https://jamanetwork.com/journals/jama/article-abstract/2783090> [Accessed 28 April 2022].
2. Krishnan A, Rabinowitz M, Ziminsky A, Scott S, and Chretien K. Addressing Race, Culture, and Structural Inequality in Medical Education. Academic Medicine 2019; 94(4): 550-555.

Cased-based Learning From Two Perspectives: Learner and Teacher

by Madison Parker, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Who enjoys being proved wrong or having to learn the hard way? The rhetorical answer is no one! However, in the last couple of months, it has happened to me time and time again. I recently graduated from pharmacy school. I matched for a PGY-1 pharmacy residency at the medical center associated with my alma mater. Wanting to be a well-rounded pharmacist and a successful preceptor, I decided to participate in an elective academia rotation. I quickly learned how different things are on the “other side.” As a student, I never understood the time commitment and detail that went into teaching a class and developing cases.

As a student, I did not enjoy the “case-based approach.” I did not understand why we were going to school if we were essentially just teaching ourselves. What I didn’t realize at the time was how much I was learning and growing as a health professional by grappling with cases. Hindsight always seems to be 20/20! Case-based learning made me dig far deeper than typical lectures ever did during pharmacy school. I was no longer just memorizing a drug side effect to regurgitate it back on a multiple-choice test. It was challenging, and it made me think well beyond “the right answer.” I had to learn how to pivot when a treatment was contraindicated or what to do next if a patient suffered a side effect.  Essentially, I learned how to contingency plans to better take care of my future patients.

I have also learned about Bloom’s Taxonomy during my teaching experience and the “cognitive skills” that case-based learning requires. Lectures rely on regurgitating information and the goal is to have students “remember” and “understand” whereas case-based learning requires the student to “analyze,” “evaluate,” and “create.”¹

During case-based learning, the student is provided a detailed clinical case or scenario that they need to work through and discuss. This typically involves a small group rather than a large lecture hall. Case-based learning, like typical lectures, should still include learning objectives, but the teacher won’t always disclose all of the objectives before the case discussion occurs.¹ This non-disclosure allows the learner to think for themselves. Case-based teaching dates back to the early 1900s. Dr. James Lorrain, a professor at the University of Edinburgh, was thought to be the first teacher to use case-based teaching during his pathology course. 

One study surveyed health professional students about their opinions toward case-based learning. There were 520 students invited to participate. These students were from various professional schools including medicine, pharmacy, nursing, and social work.  Students were required to work through the cases as teams during the course. Students were given a nine-item survey that asked about their satisfaction with small-group, case-based learning format using a 7-point semantic differential scale. The students were asked to rank each point from 1-to 5 where 1 indicated ‘strongly disagree’ and 5 indicated ‘strongly agree.’ Ratings were reported as a mean: e-learning discussions (3.54 ± 0.99), small group learning experiences (3.94 ± 0.88), and panel discussions (3.76 ± 0.91). Based on student satisfaction scores, one can infer that case-based learning can be challenging but also rewarding for the learner.³

Another study examined medical students in their pre-clinical years from 2015-2018 at Stanford who chose to enroll in an optional case-based learning course. This course was led by a facilitator and involved a small group of students who would discuss a prospective patient case. At the end of the course, the medical students were asked to participate in a pre-and post-intervention study reflecting on their clinical skills. The control sample included medical students who did not participate in the course. Non-participants were encouraged to participate in pre-and post-intervention surveys as well. A 14 item survey was given to assess participants’ self-reported skills including the ability to report, interpret, manage, educate, and course-specific skills and objectives. A 5-point Likert scale was utilized with 1 indicating ‘strongly disagree’ whereas 5 indicated ‘strongly agree.’ Two surveys were administered; the first survey was completed within two weeks before the first session of the optional course, and the second survey was completed within 2 weeks after the final session. The difference between the post-intervention score and pre-intervention score was calculated. The intervention group resulted in a more positive change in the following categories: understanding how clinicians arrive at a diagnosis, using a step-by-step approach in a longitudinal primary care setting, and how to ultimately share information with their patients.⁴

There are many benefits associated with case-based teaching. It challenges health professional students to use their problem-solving skills before encountering real patients in their clinical years. This in turn allows students to practice and sharpen their skills so that they know how to grapple with real problems and challenges using the same resources that practitioners use when faced with the unknown.⁴ As a future preceptor, I am a big fan of case-based teaching!

In my opinion, cases should be created by experts in the field of practice. Cases should be constructed in a way that they spark students’ interest when hearing about “the real world.” Case-based learning should be facilitated, but by whom? In my experience, it doesn’t have be an expert in the field, just someone with a general knowledge of the subject matter. However, it is helpful for facilitators to have a guide created by the case author.  The case guide should clearly state the objectives the students should acheive and give “tips for success” in the written matters.

In summary, case-based teaching is effective and encourages higher order thinking. It is particularly effectives in health professions education, giving students a chance to practice in a safe environment where “no harm” will arise from a poorly conceived or ill-informed decision. Case-based learning should be extensively used in every health-related curriculum as the benefits and positive results are well established.

References:

1. Armstrong, P. Bloom’s Taxonomy. Vanderbilt University Center for Teaching. 2010.
2. McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. Journal of Medical Education and Curricular Development. 2016;3:JMECD.S20377.
3. Curran VR, Sharpe D, Forristall J, Flynn K. Student satisfaction and perceptions of small group process in case-based interprofessional learning. Medical Teacher. 2008;30(4):431-433.
4. Waliany S, Caceres W, Merrell SB, Thadaney S, Johnstone N, Osterberg L. Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC Med Educ. 2019;19(1):31.