Cultivating Cultural Humility

by Amy Ly-Ha, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

Growing up in the Vietnamese culture, whenever I had a minor illness, my parents engaged in the practice of cạo gió, also known as coining. The intent of the practice is to dispel negative energy from a sick individual.  Coining involves spreading medicated oil onto the skin and rubbing a coin over this area until a red abrasion mark forms. To those who are unfamiliar with the practice, these marks may look frightening and can be mistaken as abuse. As a child, I did not pay much attention to these marks on my body. Once, I came home from school feeling feverish. My mother performed coining and brought me to the doctor’s office the next day. Upon conducting a physical examination, the physician noticed the red stripes on my back. Rather than making accusations of abuse, the physician skillfully interviewed my mother and listened to her explanation. Looking back, I now recognize the significance of this encounter. Not only did the physician display a willingness to listen to my parents, but she also demonstrated an openness to my family’s cultural traditions. This physician modeled cultural humility, a concept that I believe all healthcare professionals should possess to create an environment conducive to optimal patient care.

The widespread implementation of cultural diversity training in various health professions education aligns with the growing diversity of our patient populations. There are many aspects to cultural diversity training. Commonly taught in health professions degree programs today, cultural competency embodies the ability to provide care to people with diverse values, beliefs, and behaviors.¹ Cultural competency requires several skills, including recognizing the unique needs of every patient, realizing that culture impacts health beliefs, and respecting cultural differences. A culturally competent healthcare professional is able to negotiate and restructure therapeutic plans in response to a patient’s cultural beliefs and behaviors.² And while cultural diversity training is clearly important, health professionals must also demonstrate cultural humility.

Cultural humility, a term first coined in 1988, is a lifelong process of ongoing self-reflection and self-critique.³ It emphasizes awareness of one’s possible biases and a willingness to be taught by patients. Unlike cultural competency, the goal of cultural humility involves “relinquish[ing] a provider’s role as a cultural expert and adopt[ing] patient-centered interviewing to create a mutual therapeutic alliance.”² One barrier to teaching cultural humility includes the difficulty of assessing students’ growth in this area. Despite this, I recommend that educators implement the following elements to foster cultural humility in their students.

Element 1: Develop Culturally Relevant Curricula

A culturally relevant curriculum incorporates aspects of culture throughout a curriculum, thus valuing various cultures and encouraging intercultural understanding.⁴ Introducing students to different cultures throughout their education, in and outside the classroom, enables students to learn how to navigate through diversity. By embedding cultural diversity training at strategic times throughout a curriculum, educators can include reflective exercises intended to build cultural humility. 

When developing and implementing a culturally relevant curriculum, one must be aware of the potential to introduce unconscious bias in lessons and assessments. For example, a recently published research study investigated the presence of unconscious bias in student assessments at a Doctor of Pharmacy program.⁵ Assessing questions from the academic year of 2018 to 2019 for first-, second-, and third-year pharmacy classes, the investigators examined 3,621 questions. Only a small fraction of these questions referenced race (N=40); however, race was relevant to only two questions. The study also found that specific races were more often associated with specific health conditions. For example, in the analyzed set, the researchers found that all questions related to human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) were associated with African-Americans. Thus, as this study documents, the routine use of race as a descriptor in instances where it lacks significance may propagate racial bias.⁵ Therefore, providing culturally relevant curricula requires educators to acknowledge their own biases, mitigate them, and display intentionality as they develop and implement instructional materials.

Element 2: Create Opportunities for Cultural Socialization

Cultural socialization is the process in which individuals learn about the customs and values of other cultures. Within the classroom, instructors can create simulations that foster cultural humility. For example, scenarios that prompt students to confront challenging situations and recognize their own biases can help facilitate cultural humility. Furthermore, instructors can create discussion boards to encourage students to share their cultural practices, values, and beliefs.

Immersive experiences outside of the classroom can reinforce direct instruction. These opportunities include community outreach events, introductory and advanced practice-based experiences, and international service trips. Placing students in these environments encourages students to go outside their comfort zone and strengthen their confidence. By creating and introducing experiences for cultural socialization, educators can broaden their students’ perspectives.

Element 3: Promote the Practice of Self-Reflection

The emphasis on introspection sets cultural humility apart from cultural competency. Instructors should encourage students to regularly reflect on and learn from their experiences. Activities that promote reflective practices include journaling and meditation. Online resources like the Implicit Association Tests can also serve as tools to help students recognize their unconscious biases.⁶ By encouraging reflection and providing opportunities to talk about experiences, educators are developing the habits of mind needed for learners to continue this practice throughout their careers.

Implementing the three elements can promote cultural humility within students. Fostering cultural humility and incorporating cultural competency training in health professions education is critical to achieving accessible and comprehensive healthcare for all.

 

Sources:

1. American Hospital Association [Internet]. Becoming a Culturally Competent Health Care Organization. AHA; 2016 Jun [cited 2022 Sep 16].
2. Rockich-Winston N, Wyatt TR. The Case for Culturally Responsive Teaching in Pharmacy Curricula. Am J Pharm Educ 2019; 83(8): Article 7425.
3. Tervalon M, Murray-García J. Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. J Health Care Poor Underserved 1998; 9(2):117-25.
4. International Bureau of Education [Internet]. Culturally Responsive Curriculum; [cited 2022 Sep 16].
5. Rizzolo D, Kalabalik-Hoganson J, Sandifer C, Lowy N. Focusing on Cultural Humility in Pharmacy Assessment Tools. Curr Pharm Teach Learn 2022;14(6):747-50.
6. Project Implicit [Internet]. Select a Test; [cited 2022 Sep 30].

Should Feedback be Given Verbally or in Writing?

by Mariam M Philip, PharmD, PGY1 Community Pharmacy Practice Resident, Walgreens Pharmacy

Learners thrive in a safe environment where they can freely express their thoughts and opinions. At the heart of learning is feedback.¹ Feedback is critical in the classroom, in clinic, at work … indeed, anywhere learning occurs. It is crucial to knowledge acquisition, patient care, personal development, and growth. As educators, it's critically important to strive to give effective feedback.  Many agree it gets easier to provide over time. Feedback received is not always predicted, positive, effectively delivered, or correctly interpreted. Generally, the feedback provided should be based on direct observations and understood by the learner. Feedback should be provided in a safe environment where learners can discuss the feedback, express their concerns, and participate in developing an action plan.

Feedback is different from an evaluation, and it should be delivered in a conversational yet descriptive manner. When it’s done effectively and periodically, the formal evaluation (which typically occurs at the end of the course or experience) should not be a surprise.¹ Evaluations are more formal and done to determine the learner’s grade (or, in the case of employees, pay raises or promotion decisions).

Feedback can take two forms: verbal or written.  Is one delivery method better than another?  The goal of feedback is to influence the learner and either motivate the continuation of their good work or point out what needs improvement, or both. One of the advantages of verbal feedback is that can lead to a “real-time” discussion and provides an opportunity for both the educator and student to elaborate more with examples. On the other hand, written feedback is often clearer, can be referenced later (e.g. when constructing the final evaluation), and (perhaps) reduces the chance of miscommunication or misinterpretation.

In 2017, a randomized controlled trial that enrolled 44 nursing students assessed the effectiveness of oral and written feedback.  The students were divided equally into two groups. The students filled out a questionnaire after the feedback to determine their reactions, perceptions, and responses to the different forms of feedback. The questionnaire showed no statistical differences between the two groups, and the results were similar. Although there was no statistical significance between the groups, the study might have been underpowered due to the small sample size. Nonetheless, the authors offer some interesting points of view.²

Based on the students’ responses to the questionnaire, 21.3% of the oral feedback group experienced negative reactions; 75.8% were classified as mild, and 24.2% were classified as severe reactions. Conversely, only 14.4% of the students in the written feedback group had a negative reaction; most were classified (92.3%) as mild and 7.7% were severe. While the difference was statically significant, the oral feedback group had a higher percentage of students who experienced negative responses such as arguing, crying, insulting, denying, and inattention. The written feedback group had a higher rate of intimidation, undue self-defensiveness, and confrontation. The satisfaction rate was higher (but not significantly so) in the written feedback group (77.1% indicated high satisfaction with the feedback vs. 50% in the oral group). Lastly, when the delivery of the feedback was assessed, the students in the oral feedback group gave it a higher delivery score.²

Additional studies conducted with medical students who received “well done” feedback showed similar satisfaction from both oral and written methods of communication.³ A similar study was conducted with medical residents from two university-based clinics. To diversify the participants and results, the residents that participated were assigned to medical clinics of various specialties. Sixty-eight internal medicine residents were randomly assigned to receive either written or “face-to-face” feedback. They were then given a questionnaire to assess their overall clinic experience, in which eight of the 19 questions asked about feedback. Six five residents completed the questionnaire. The results showed no differences in the residents’ perceptions of oral and written feedback.³

Both forms of feedback are acceptable and can be effective when delivered following best practice principles. There are advantages to each method of communication when providing feedback. Oral feedback is often less formal and more conversational, which will allow the student to feel safer expressing their concerns or participating in planning for the future. While less efficient, written feedback often promotes deeper reflection. The student can reflect on the given feedback and refer to it periodically. Thus, a teacher should focus on the quality and frequency of the feedback rather than the delivery method.⁴

I believe health professional students benefit from written and oral feedback in both the didactic and experiential settings. Both delivery methods serve a purpose that is important to students’ growth. The thoroughly thought-of written feedback will allow the student to digest the feedback and reflect on their own time. This will increase autonomy and promote self-assessment and planning. Meanwhile, oral feedback allows students to explain themself, ask questions, and brainstorm with the preceptor on the next steps.

A healthy balance between verbal and written feedback should exist between the two forms of communication.  Both should be used to help the student grow. I find oral informal feedback more engaging, which helps build the teacher-learner relationship. It can help shift the “formal meeting” nerves to a mentorship mindset. Periodic written feedback can reinforce verbal discussions and make constructing the end-of-course evaluations easier.

References:

1. Jug R, Jiang X, Bean Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine 2019; 143 (2): 244–250. https://doi.org/10.5858/arpa.2018-0058-RA
2. Tayebi V, Armat MR, Ghouchani HT, et al. Oral versus written feedback delivery to nursing students in clinical education: A randomized controlled trial. Electron Physician. 2017;9(8):5008-5014. Published 2017 Aug 25. doi:10.19082/5008
3. Elnicki DM, Layne RD, Ogden PE, et al. Oral Versus Written Feedback in Medical Clinic. J Gen Intern Med. 1998;13(3):155-158. doi:10.1046/j.1525-1497.1998.00049.x
4. Dobbie A, Tysinger JW. Evidence-based strategies that help office-based teachers give effective feedback. Fam Med. 2005;37(9):617-619.

"Blended Learning” Models and Their Effectiveness

by Hannah Black, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Health-North Mississippi

Many of us are familiar with the term, “blended learning.” While it is easy to assume that this teaching model simply involves a combination of in-class and online instruction, there are lots of different ways of accomplishing it. Although blended learning models are now commonplace (thank you COVID-19), there has been a lot of research published in medical education journals over the last 4 decades.¹ Many studies have documented the effectiveness of blended learning in health professions education but given that blended learning methods vary very substantially, what strategies are most effective?

The Journal of Medical Internet Research published a systematic review and meta-analysis examining the effectiveness of blended learning compared to traditional learning in health professions education.¹ Blended learning was stratified into different types of learning support, defined as follows:

• Offline Learning - the use of personal computers to assist in delivering stand-alone multimedia materials without the need for internet.
  • Videos and audio-visual learning materials (as long as the learning activities did not rely on internet connection)
• Online Support – all online materials used in learning courses.
  • Educational platforms (learning management system, LMS like Blackboard)
• Digital Education – a wide range of teaching and learning strategies exclusively based on the use of electronic media and devices
  • Facilitates remote learning for training purposes
• Computer-Assisted Instruction – the use of audio-visual material to augment instruction.
  • Multimedia presentations, live synchronous virtual sessions via a web-based learning platform, synchronous or asynchronous discussion forums
• Virtual Patients – interactive computers simulations of real-life clinical scenarios

The primary outcome of this study was to evaluate the effectiveness of blended learning to achieve knowledge outcomes compared with traditional teaching strategies.¹ Of the 3,389 articles identified in MEDLINE, 56 studies met the inclusion criteria with a total of 9,943 participants. Most of the participants were students in medical schools. Other participant subgroups included nursing, pharmacy, physiotherapy, dentistry, and interprofessional education.

Offline Blended Learning vs Traditional Learning

Some benefits of offline learning have been suggested, such as unrestricted knowledge transfer and enhanced accessibility. This type of learning gives students more flexibility to learn at a convenient pace, place, and time, which can improve retention of content. However, this study showed no significant difference in knowledge outcomes when compared to traditional teaching methods. It was noted that the majority of studies in this group were in nursing. These results were consistent with a previous meta-analysis on offline digital instruction.²

Online Blended Learning vs Traditional Learning

Online blended learning gives students more experience building competency in things that require repeated practice, such as EKG and imaging interpretation. The internet has provided students with an abundance of resources that can be used with the click of a button, so why not use it to the learner’s advantage? As expected, this study did show a significant advantage in knowledge outcomes of online blended learning versus traditional learning alone. Using the internet to deliver instruction does not come without challenges. Learning is highly dependent on the student’s ability to cope with technical difficulties and comfort using computers and navigating the internet.

Digital Learning vs Traditional Learning

Digital learning, or “eLearning,” is being used increasingly in health professional education for improvement of access to training and communication.³ However, the pooled effect for knowledge outcomes in this study suggests no significant difference.¹ This study was broken into subgroups, and the medicine subgroup showed digital learning had a positive effect when compared to the control group.¹ I feel this concept is not one to ignore because it facilitates remote learning, which could help in addressing the shortage of health professionals in settings with limited resources.¹

Computer-Assisted Instruction Blended Learning vs Traditional Learning

Computer-assisted instruction can provide students with innovative methods of instruction for things like physical examination techniques.⁸ The pooled effect for knowledge outcomes in this study suggested a significant improvement. Participants in one study reported difficulties accessing the course due to problems with the university’s internet, so the online discussion board was not used to its full potential.⁵ One could argue that similar problems could have emerged even in the traditional learning setting where students may choose not to or feel intimidated to engage in discussion. 

Virtual Patient Blended Learning vs Traditional Learning

Virtual patients are widely used in simulation-based instruction. These simulations can be used as a precursor to bedside learning, or to be used when direct patient contact is not possible. The groups with supplementary virtual patient learning support showed a significant improvement in knowledge outcomes compared to traditional learning.¹ These results reinforce the results found in a similar meta-analysis, showing that virtual patients have a positive impact in terms of skill development and problem solving.³

When combining all 56 studies, the pooled effect size reflected a significantly positive effect on knowledge acquisition in favor of blended learning versus traditional learning in health professions education.¹ A possible explanation could be that blended learning allows students to review materials at their own pace and as often as necessary. This reinforces the belief that the outcomes of blended learning is most dependent on student characteristics and motivation, rather than the instructional deliver method.

In my opinion, one of the most interesting findings from this study comes from the subgroup analysis. For the top 3 subgroups, the pooled effect difference in the medicine subgroup was 0.91, nursing studies was 0.75, and dentistry studies was 0.35.¹ This reiterates that the effectiveness of blended learning is complex and dependent on the learner characteristics and needs of the student population. One tool that can be used to develop and implement a personalized blended learning curriculum is the six step Kern cycle⁶, described below:

1. Problem identification – The first step begins with the identification and analysis of a specific healthcare need or group of needs. It could relate to the needs of the provider, or the needs of society in general.
2. Targeted needs assessment – The second step involves assessing the needs of your group of health professional students, which may differ from the needs of providers or society in general.
3. Formulating goals and learning objectives – Once the needs have been clearly identified, goals and objectives should be written starting with broad goals, then moving to specific, measurable objectives.
4. Selecting educational strategies – After objectives have been finalized, the content and methods can be selected that will help to achieve the educational objectives.
5. Implementation – In this step the finalized curriculum is implemented.
6. Evaluation and feedback – This final step is important to help continuously improve the curriculum and gain support to drive the ongoing learning of participants.

 Overall, this meta-analysis reinforces the notion that blended learning has a positive effect on knowledge outcomes in healthcare education. However, it also indicates that different methods of conducting blended courses could demonstrate differing effectiveness based on the student population, their needs, and the learning objectives.¹ When strategically developed and implemented, I believe blended learning enhances outcomes.

References

1. Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning compared to traditional learning in medical education: Systematic Review and meta-analysis. Journal of Medical Internet Research. 2020;22(8): e16504.
2. Posadzki P, Bala MM, Kyaw BM, et al. Offline Digital Education for Postregistration Health Professions: Systematic review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(4): e20316.
3. Kononowicz AA, Woodham LA, Edelbring S, et al. Virtual patient simulations in Health Professions Education: Systematic Review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(7): e14676.
4. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: Student perceptions of useful and challenging characteristics. The Internet and Higher Education. 2004;7(1):59–70.
5. Al-Riyami S, Moles DR, Leeson R, Cunningham SJ. Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar. British Dental Journal. 2010;209(11):571–6.
6. Kern D. Curriculum Development for Medical Education: A Six-step Approach. Baltimore, MD: Johns Hopkins University Press, 2022.
7. George PP, Papachristou N, Belisario JM, et al. Online elearning for undergraduates in Health Professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction. Journal of Global Health. 2014;4(1).
8. Tomesko J, Touger-Decker R, Dreker M, Zelig R, Parrott JS. The effectiveness of computer-assisted instruction to teach physical examination to students and trainees in the Health Sciences Professions: A systematic review and meta-analysis. Journal of Medical Education and Curricular Development. 2017 Jul 14;4:2382120517720428

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.