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As you work through this web site you will see that cases can be used in several ways. For instance, one case may form the focus of a whole week’s work, or it may be used as the basis of one tutorial discussion.
Here is the first part of a case that can form the basis of one week’s study in the curriculum for the School of Medicine:
POST-OPERATIVE PROBLEMS: MRS LUCK
CONTEXT
Dr Swift is a new intern on his first night shift. He has just sat down on the sofa to rest his feet an no sooner has he got himself comfortable than the pager goes off again. CASE DETAILS A nurse on ward 5B sounds very worried about the lack of urine output for the entire day in a 70yo woman who was day 3 after a reduction of a spiral fracture of her humerus. When Swift gets to the ward he checks the patient’s chart. She is Mrs Luck, a widow, who was found by a neighbour 10 hours after falling on the floor and complaining of a painful right arm. She had simply tripped, and there were no prior neurological or cardiovascular symptoms. Mrs Luck has a history of Htn, SOB and ankle swelling on frusemide; chronic back pain and arthritis. She doesn’t smoke or drink. Her other meds are captopril and aspirin. Because it was a compound fracture she was taken to theatre and given gentamicin and flucloxacillin for the antibiotic cover. Postoperatively she was not placed on IV fluid for fear of exacerbating the CCF. She was given regular narcotic analgesia and the regular meds were continued except for aspirin. PRN celocoxib and paracetamol were also prescribed. LEARNING TASKS
- What is striking about the medications pre- and post- operatively?
- What does Dr Swift look for now?
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(The case is further developed in stages describing the progress of Mrs Luck and her treatment and posing questions at each stage.)
- This case is presented to a class who have done some pre-reading on post-operative problems.
- They discuss the questions as a whole group and decide what further information they need to know in order to arrive at the best answers.
- The class breaks into several work groups to research identified needs.
- The class later reconvenes to share new knowledge and agree best answers to case questions.
The students are in charge of identifying their own learning needs. The lecturer acts as facilitator to clarify issues, assist with learning resources and moderate at class meetings (if required).
- The lecturer/facilitator will then provide the next part of Mrs Luck’s case history and the next set of questions for group investigation.
The information provided on the patient's progress and test data reported at each stage provide the basis for analysis and research. Students base their recommendations for investigation and treatment on the evidence they are provided with, as they would in a 'real' patient-doctor situation.
This is an example of a case method that makes a documented case and its progress the central focus of the week's learning. Other activities - lectures and practical sessions if they are held - will be designed to assist with the relevant physiology, pharmacology and differential diagnosis of this case. There are other ways of using cases central to the teaching process, and examples can be accessed from the link at the bottom of this page.
ALTERNATIVE PRESENTATIONS OF A
'CASE'
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In our example above, students have been presented with a paper-based case - a written narrative that may be based on a real patient or fabricated to match the set learning outcomes. This is quite adequate when it is the analysis of the content and progress of the patient's physical condition that is central to the learning outcomes.
A theoretical case like this can be much improved by the inclusion of relevant evidence in the form of test results, X-ray images, ECGs to interpret, etc. |
| If it is the process of the practitioner-client communication that is significant, then it might be better to present the case with a trained actor playing the part of the client, primed to respond appropriately (or even primed to be a 'difficult' patient to further test the coping skills). But the use of actors for every case is time-consuming and expensive, so is usually reserved for cases that would benefit particularly from this method. |
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Of course, within correct ethical guidelines real patients can be used to present their own cases if they are willing to assist in this way. They do tend to be somewhat unpredictable and don't necessarily present at the appropriate times in the curriculum, but this is the best way of providing a 'real' experience for the students. This method should only be included after basic skills have been aquired. |
| A compromise could be the incorporation of a role-play exercise in the investigation of the case. After the class has discussed the case and tackled significant learning tasks, one pair from each group might act out a practitioner-client interraction for group critique - a particularly useful method for approaching sensitive issues. You might provide the 'client' with relevant background information that the 'practitioner' has to elicit by appropriate investigation. |
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Working with a Template
When designing a teaching program around the case method - and especially when several people are writing the cases - it can be useful to agree on a standard format that everyone will use. This won't mean that all the cases are taught in the same way or use the same presentation method, but it will ensure a degree of commonality and prompt all those who contribute to consider all necessary components of a 'good' case.
This is the process that has been followed in the design of the 'new curriculum' for the School of Medicine at the University of Tasmania. A template has been provided to lecturers asking them to specify learning outcomes for each case they write; student activities or 'learning tasks' are included at appropriate breaks in the case history; ancillary learning resources are listed; the preferred teaching approach is specified (small group discussion, role play, individual research, etc.). Professor Peter Stanton from the School of Medicine says:
| Given this rather free-form model of teaching with cases, it is obviously a considerable challenge to make sure that a complete syllabus is covered over the course of a year's cases, but I don’t see that as an insuperable obstacle especially with good documentation of the cases and a clear understanding by the planners of each case as to the objectives that they are trying to meet through these variable and no doubt innovative activities. (personal communication) |
The School of Medicine's Case Writing Handbook is provided on-line, and includes the Case Writing Template which is followed. This is a good example of a case-based curriculum process that is currently in progress.
You will find other suggestions to assist with planning case teaching below.
 Other examples of case teaching from FHS
PBL or CBL – what’s the difference?
Planning your case teaching
Further reading and resources
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