|Year : 2007 | Volume
| Issue : 1 | Page : 15
Applying the Case Method for Teaching within the Health Professions - Teaching the Students
M Stjernquist1, E Crang Svalenius2
1 University Hospital MAS, Malmö, Sweden
2 Lund University, Lund, Sweden
|Date of Submission||10-Mar-2007|
|Date of Web Publication||19-Apr-2007|
Se-205 02 Malmö
Source of Support: None, Conflict of Interest: None
Context: When using the Case Method in teaching situations, problem-solving is emphasized and taught, in order to acquire the skills and later be able to apply them in new situations. The basis of the learning process is the students' own activity in the situation and is built on critical appraisal and discussion.
Objectives: To explain what the Case Method is, what it is not and to describe when and where to use the Case Method. The objective is also to describe how to write a 'case', how to lead a 'case' discussion and how to deal with problems. Why one should use the Case Method is also highlighted.
Application The case used should be founded on a real life situation, containing a problem that must be handled. The structure and use of the white board plays a central part. It is important that the setting allows the teacher to interact with all the students. Groups of up to 30 students can be handled with ease, though larger groups are feasible in the right physical setting. Within the health professions, the Case Method can be used at all levels of training and to a certain extent the same case can be used - the depth with which it is addressed depends on the student's prior knowledge. Different professions and specialists can take part. A whole curriculum can be built up around the Case Method, but more often it is used together with other pedagogic methods.
Conclusion: The Case Method is a well-structured, student-activating way of teaching, well-suited to hone problem-solving skills within health education programmes.
Keywords: Teaching, Case Method, Health Professions
|How to cite this article:|
Stjernquist M, Crang Svalenius E. Applying the Case Method for Teaching within the Health Professions - Teaching the Students. Educ Health 2007;20:15
The Case Method is a student active teaching form that assists students to develop, discuss and test their ‘train-of-thought’ regarding a problematic situation. Group discussions help participants to elaborate their individual knowledge and hone their problem-solving abilities. Cognitive research currently being undertaken also supports the theory that active educational methods result in both better learning and better retention of knowledge (Spencer, 2003).______________________
Despite the fact that problem based learning (PBL) has been used more extensively in medical education than the Case Method has, its history is shorter (Harden & Davies, 1998). The pioneer of PBL was the Faculty of Health Sciences at McMaster University, Ontario, Canada (Neufeld & Barrows, 1974). At McMaster, a curriculum based on PBL was introduced in 1969. The method was also launched at an early stage in universities in the Netherlands (Maastricht), Australia (Newcastle) and the USA (Michigan State University and the University of New Mexico).
Case methodology was created in the first decades of the 20th century at the Harvard Business School in Boston. The school was founded in 1908 and the aim with the Case Method was to give the students professional and academic training based on actual situations and problems (Christensen, 1981). During the 1960s, the method spread to other schools of economics, both in and outside North America. The Richard Ivey School of Business, Western Ontario, Canada adopted it from the Harvard Business School in the 1970s and has developed the method to suit the needs at Western Ontario (Erskine et al., 1998). In Sweden, the National Centre for Case Methodology was formed in1992, primarily for education within the area of Social Sciences. Since 1998, the Case Method has been introduced successively as one of the teaching methods used within the Medical Faculty of the University of Lund (Crang-Svalenius & Stjernquist, 2005). The need arose to educate the teachers/tutors at the Medical Faculty, University of Lund/Malmö, Sweden regarding use of the method in a teaching situation. Short courses have been initiated (Crang-Svalenius & Stjernquist, 2005). In the medical school at Lund University, PBL is used predominantly during the first five terms (mainly pre-clinical) where “why” is more a question than “how.” The Case Method is successively introduced during the sixth term, when the clerkship is also introduced and the question of “why” is replaced by “how.” The Case Method is then used substantially more than PBL during the last five clinical terms. In nursing and midwifery training, the Case Method is one of the teaching methods used throughout training.
What is ‘case’ and what is not ‘case’?
The Case Method should not be confused with typical clinical “case discussions” or “rounds”. In ordinary “case discussions” the focus is more on the details of the individual (patient) problem and often on how to handle an unusual, problematic situation that results in a treatment plan.
According to the National Centre for Case Methodology in Sweden, the Case Method has certain core points and typical attributes but the use of it can vary greatly (Kjellen, 1994). A ‘case’ is built up around a real situation although it should be written in an unidentifiable way, to protect confidentiality. The situation contains a problem that must be solved and requires decision-making. A number of people take part in the situation and have different roles and interests in the scenario. The problem should also be of a type where there is no obvious correct or incorrect answer. The basis of the learning process is the students’ own activity in the situation and is based on critical appraisal. The teacher’s role is to act as an initiator/moderator/facilitator for the group discussions (Kjellen, 1994).
An example of the Case Method is presented in Appendix 1 to this paper.
The Case Method requires a certain amount of time (45-90 minutes) and, in a learning situation, usually only one case can be addressed per sitting. It is thus not feasible to deal with “multiple cases” during one session, as described by Tärnvik (2002), as there would be too little time available for the teaching of problem-solving skills.
The structure and use of the white board is a central part in the Case Method. The headings on the white board are important and give structure to the problem solving process, necessary for the health professions. These headings are similar to the ones used in patient files/notes and are recognisable in a clinical situation – for example, they might include: background/facts, main problem, prognosis if nothing is done, possible explanations, additional information, suggested measures, expected effects, ethical/legal/economical/organisational, psychological aspects and issues/learning goals.
Where to use the Case Method – the best location
A room with a large whiteboard is strongly recommended as a setting for the Case Method, although other solutions are possible - e.g. a flip-chart. The students should be able to see one another, so variations of a U-formation (straight tables) work well and also allows them to form ‘beehives’. The whiteboard and the teacher should be at the open end, to allow the teacher to move easily in the centre of the room and interact with all the students, while also having easy access to the whiteboard. This works well with groups of up to 20-30 students, depending on the size of the room. Even larger groups are feasible in the right physical setting. It is a disadvantage to use a room that only allows traditional classroom layout (cinema-setting) as the students cannot see one another and the teacher is also far from the students at the back. This does not facilitate teacher/student interaction. A café-setting with round tables, in one or more rows, can be an acceptable solution for larger groups. With some type of cases, it can be an advantage to allow the students to discuss it in small groups of 5 to 7 students, in smaller rooms, before starting work on the whiteboard with the large group.
How to write a case for the Case Method
The teachers choose a situation, preferably one of which they have personal experience (Christensen, 1981). It is important to make it anonymous. If necessary, other adjustments can be made so the case is suitable for the level of the course, e.g. confusing facts can be omitted. In the following, the ‘case’ is described in three parts.
The first part presents the situation and is roughly equivalent to a referral, a first consultation or a ward report. This part of the case should be as open as possible, yielding numerous potential explanations. It is given to the students to first read through and then discuss in small groups (beehives). The situation should be experienced as challenging and requiring action. The ‘case’ should be given a name, which should not be the same as the problem - e.g. “Labour ward – 1 am.” The description should include several actors with whom the group could identify themselves, and to make the situation more realistic, it is advisable to provide them with fictitious names. In health professions, the central object harbouring the problem is a patient, while the subject supposed to find solutions is a health professional (e.g. a doctor or nurse). The student groups identify themselves with this health professional and try to act as this person would, when suggesting investigations and treatment. Thus, it is logical that this doctor or nurse is professionally at a level close to the students. For example, in a medical school case it could be a junior houseman and within nursing training, a young staff nurse, while in post-graduate training a more senior actor is suitable.
The second part of the ‘case’ is often shorter than the first one and provides more information, matching some of the suggestions and answering questions raised by the students when working with the first part. The introduction of the second part unavoidably “narrows” the case down and reduces the possible explanations and solutions to the actual problem. Often the second part does not yield such a long and intense discussion as the first part. In medical/nursing cases, one or more diagnoses now are plausible while a number can be excluded. The discussion is focused towards different reasonable actions or treatment, of varying applicability.
The third part of the ‘case’ often gives the solution and explanation to the problem dealt with and ends the session. It is possible to leave this part more open so that the students are not provided with the answer, which is thought, by some schools, to facilitate learning but can also be experienced as frustrating.
How to lead a case discussion
When leading a case the students should be given time to read through part one. They may have received it beforehand so they can prepare for the group discussion or it can be handed out at the start of the session. This depends on the size and the subject of the case and how far the students have come in their training. After time for small group discussions, the teacher starts the session with an open question - e.g. “what is this all about?” - inviting all the students to participate. The students should then reach consensus about the actor with whom they will identify (e.g. nurse, doctor, etc.). At this stage all given suggestions are written down on the whiteboard by the teacher, under relevant headings and without censorship. More information is required, which is also noted on the whiteboard, but the answers should be withheld until the next part of the case is given out. The students should be able to identify, and motivate, further investigations (e.g. x-ray or blood tests), with anticipated outcome. As many students as possible should be involved in the discussion, one at a time. This part of the session can take up to an hour, depending on the complexity of the case and the student’s knowledge and grasp of it. Discussions might occur between students, periodically allowing the teacher to observe students in action.
When no further discussion is forthcoming, part two can be given out and the process repeated, though this part usually takes less time as the problem has been narrowed down and some answers given. When noting suggestions from part two on the whiteboard, a new colour should be used to emphasise the temporal development of the case. Some of the earlier ideas can be rejected, though these should be left crossed out, but readable. The most relevant suggestions can be underlined, to enable everyone to keep track. Arrows can be drawn between suggested action and expected outcome. Part two usually takes less time than part one, but can take up to half an hour. The third part, which usually is the final part of the case and can provide the solution, should be given out when the discussion is finished.
Dealing with problems
As in all student groups, some students are very verbal and some are quiet. The quiet or shy students can be invited to give their contribution by asking a non-controversial question. In some situations, it is necessary to have a “speakers list” in order to prevent the dominant students from taking over. We try to get the un-interested students to take part in the discussion, not always successfully, but the most important thing is that they do not disturb the group process. Occasionally, a student is disruptive and threatens the whole process. In these cases, which seldom occur, the session is stopped and the student confronted with his/her behaviour then and there. In stable groups (i.e. when the same group has had the Case Method together on several occasions) the students usually manage to take care of this sort of problem between themselves, which is, of course, a better solution. These problems are not specific for the Case Method and we have only commented on how we deal with them in this situation.
When to use the Case Method
Within the health professions, the Case Method can be used at all levels of training and to a certain extent the same case can be used - the depth with which it is addressed depends on the student’s prior knowledge. Different professions can take part, as well as different specialities. A case dealing with a labour and delivery can involve both medical and midwifery students, which is good for future professional interaction. Teachers with different specialities can also work together - e.g. a case dealing with abdominal pain could involve a general surgeon, a gynaecologist and an urologist. In cases involving several teachers, it is important that the teacher leading just the part of the case under discussion is also the one who writes on the whiteboard, otherwise it is difficult for the students to focus.
In post-graduate training, it can be an advantage if the participants submit their own cases. This is often one that has been problematic. The discussion at this level is often advanced and with a number of different aspects, as the participants do not all come from the same place of work, which is often the situation with undergraduate students.
Conclusion - Why use the Case Method?
Within the health professions, it is important to be able to apply factual knowledge to patient situations where problem-solving is essential. It can be used like PBL, alone or together with other teaching methods, to acquire knowledge and stimulate individual or group studies. An important feature is the problem-solving aspect of the Case Method, which can be used in many situations, not only involving patients. In contrast to PBL, the Case Method provides training in different courses of action and is also less expensive than PBL, as it is suitable for larger student groups. A whole curriculum can be built up around the Case Method, but more often it is used together with other pedagogic methods like lectures and seminars.
In our experience the Case Method is stimulating for the teacher and easy to implement. These facts, taken together, predict a favourable future for the use of the Case Method within the education of health professionals.
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