| | Teaching Diagnostic Decision Making: Student Evaluation of a Diagnosis UnitAbstract ObjectiveThe aim of the study was to report on chiropractic students' response to a changed learning format and on how the students fared in their final examination. MethodsA 13-week year-4 diagnosis unit that used a structured self-study guide, a prescribed text, classroom clinical simulations, WebCT-based learning, and self-assessment tasks is described. After 4 weeks of study, a questionnaire was used to assess the chiropractic students' interim evaluation of the various learning experiences. The ability of students to meet unit objectives was assessed in a summative examination. ResultsMost students found the learning experiences acceptable and believed the learning options provided would enable them to meet the unit aims. This belief was confirmed both on formative and summative student assessment. ConclusionDiverse classroom teaching/learning opportunities combined with self-learning guides provide a viable alternative to more traditional teaching formats for introducing chiropractic students to differential diagnosis. There is a trend in Australian University education to reduce face-to-face didactic classroom teaching in favor of more independent learning modes. This trend is the result of a multiplicity of factors ranging from a tightening of government purse strings to advances in educational technology, from acute awareness of the rapid “turnover” time of information to the necessity of graduating independent learners. Courses training health professionals are increasingly incorporating structured self-learning formats that encourage independent learning, problem solving, and use of the Internet. Computers with Internet access are replacing pen and paper, whereas problem solving scenarios are supplanting the traditional didactic lecture.1, 2, 3 In a problem-based spiral curriculum, the learning continuum moves from theoretical learning, economically conveyed as factual information in standard lectures or texts, to a variety of problem- and task-based scenarios in which knowledge and skills are applied in a clinical context. Courses designed to encourage independent learning include formats that range along a continuum from problem-oriented, through problem-assisted, problem-solving, problem-focused, problem-initiated, problem-centered, and problem-centered discovery to, finally, problem-based learning.4 As the student progresses through the learning continuum, previous learning is increasingly activated in a quest to discover new clinically relevant relationships. Rote learning is superseded by experiential learning as students are increasingly challenged to solve problems in a real-world clinical context. The underlying ethos of new age education is problem solving, and the success of student learning is strongly influenced by the quality of the cases presented. The 7 principles of case design that influence the efficacy of problem-based learning are as follows: the content of the case should be relevant to the student's prior knowledge; the case should contain several cues that stimulate student elaboration; a problem relevant to the student's future professional role should be presented; presentation of relevant basic science concepts should be couched in the context of a clinical problem; and self-directed learning should be stimulated.5 The more authentic the problem and how closely the “classroom” activity resembles a future practice scenario, the more effective learning is likely to be. Students have been found to value practical learning experiences with a clinical focus.6 A problem-based learning approach offers such a learning opportunity and creates scenarios in which activation of prior knowledge in a meaningful context provides opportunities for elaboration and organization of knowledge.7 Indeed, students in a problem-based curriculum appear to perform particularly strongly in the clinical situation.8 Problem-based learning refines reasoning skills; however, such reasoning can only be effective if based upon sound factual information. Concern that those in a problem-based curriculum may fail to assimilate sufficient factual information appear groundless.9, 10 On the contrary, students in problem-based curricula demonstrate enhanced reasoning skills in applying science-based concepts to their explanations11 and are more enthusiastic about self-study than lecture-based groups.9, 12 Furthermore, graduates from a problem-based medical curriculum perceive their ability to work independently and solve problems as greater than that of their conventionally trained colleagues,13 and chiropractic students educated using a problem-based learning curriculum were found to outperform the traditional lecture-based curriculum students on the National Board Examination. 14 Problem-based learning would seem to be well suited to vocational education. This article describes a problem-based unit in differential diagnosis that has reduced face-to-face lecturer-student teaching and has made use of the Internet in providing alternative teaching/learning formats. It describes the students' response to a changed learning mode and reports on how well the unit objectives were met. Methods  Primary Practice III: Differential Diagnosis 1 is a subject taught in the fourth year of a 5-year chiropractic program at Murdoch University. It is offered over one 13-week semester and consists of two 4-hour classroom sessions per week for 6 weeks accompanied by 13 weeks of directed self-study. The unit has been designed in a problem-based active learning format with self-assessment opportunities. The broad aims of the unit are listed in Figure 1. The unit covers conditions affecting the eye and the cardiovascular, respiratory, and gastrointestinal systems. Students are provided with 2 schedules. One schedule is a 6-week classroom schedule that provides a breakdown of the topics and learning formats to be covered each day that class is convened. The other is a 13-week structured self-study schedule that suggests the topics to be covered each week. The Self-Learning Guide Guidance for the 13-week structured self-learning component is provided in the form of a learning guide, the content of which has been divided into 11 topics. The paper-based information provided in the learning guide is complemented by WebCT, a computer-based learning platform used for delivering online learning experiences. The first 7 topics focus on how anatomical, physiologic, and pathologic changes present clinically. The emphasis is on becoming familiar with the signs and symptoms characteristic of various conditions frequently encountered in primary practice. Figure 2 depicts the template used in the structured self-directed learning guide for the first 7 topics. Some examples have been included displaying the content for topic 2. There are several guidelines for studying the first 7 topics. First, students are to read the learning objectives and then refer to the prescribed text and study the characteristics of the prevalent conditions listed in the table provided. They then read the study questions and either review the prescribed reading or attempt the listed tasks. Tasks listed in the basic science review located on WebCT are attempted; Figure 3 provides an example of how basic knowledge can be used in a clinical context. Students then attempt the tasks listed under the conditions review located on WebCT; Figure 4 provides an example of how students are provided with an opportunity to review their guided reading and check their understanding of the content of topic. Students then review the study questions, check the key concepts, and assess their progress by completing the self-test challenge that is located on WebCT. This provides an opportunity to evaluate the success of the learning experience through the use of multiple-choice questions. The first 7 topics in the learning guide are constructed to meet the first and second aims of the unit by applying their prior knowledge of anatomy, physiology, and pathology in a clinical context. It is necessary to have a good grasp of the signs and symptoms of disorders affecting each of these systems before proceeding to the final 4 topics. The final 4 topics examine disorders from a clinical perspective (Fig 5). The emphasis is on gathering information from the patient, integrating the clinical data, and differentiating various conditions to make an appropriate diagnosis. Topics such as the differential diagnosis of chest pain, dyspnea, and abdominal pain are considered. The WebCT basic science review and tasks are replaced in this section by case study questions (Fig 6). The WebCT challenge questions for these topics also concentrate on patient presentations. The final 4 topics have been constructed to meet the third and fourth unit aims to apply problem solving in a clinical context and ensure that conditions with a serious prognosis are actively confirmed or excluded. The objectives, study questions, and key concepts provided for each of the 11 topics in the study guide and on WebCT clarify the relative importance of various aspects of each topic. The self-directed learning package along with the WebCT is structured to provide students with new information in a format that encourages active learning while permitting them to study at their own pace. The tasks offered in WebCT encourage deep learning by challenging students to integrate previous with new learning in a context relevant to their professional needs. The challenges offered in WebCT give students an opportunity to assess their progress and prepare for formal examination. Classroom Teaching The self-directed learning package can be used in isolation. However, this unit also offers face-to-face learning opportunities in the form of PowerPoint presentations, student case presentations, and group case differential diagnosis sessions. PowerPoint presentations revert to a didactic teaching mode, and lectures are used to highlight various aspects of diagnostic decision making and differential diagnosis. The objective is to enhance understanding of the diagnostic decision-making process and highlight important processes in making a differential diagnosis. With respect to student case presentations, each student is allocated a particular condition and required to prepare and demonstrate a simulation of the clinical consultation. The presentation is to include a detailed differential diagnosis and review of the signs and symptoms of each condition considered. The presentation contributes 20% to the final grade. This requirement ensures that each student has independently considered the various dimensions of diagnostic decision making from both the patient's and physician's perspective. Group case differential diagnosis sessions involve students working in groups of 4 to 6 people. Students are challenged to produce a working and definitive diagnosis and suggest how simulated patients may be managed given their presenting complaint. Each group is required to submit 3 patient presentations/complaints and list the criteria used to differentiate between 2 prevalent conditions with a similar presentation. For example, the group may chose to compare asthma and an inhaled foreign body in a child presenting with the sudden onset of dyspnea. Each patient presentation is allocated a possible 5% of the final grade. In contrast to the self-learning guide where the emphasis is on encouraging students to use and add to prior knowledge in a clinically relevant context, the focus in the classroom is on problem solving. The PowerPoint presentations emphasize the principles and processes used in unraveling patient data and arriving at a working and ultimately definitive diagnosis. The student case presentations and group differential diagnosis sessions simulate the clinical consultation and challenge participants to integrate data derived from the patient's presentation, formulate a differential diagnosis, select a working diagnosis, and then gather the additional information required to propose a definitive diagnosis. The outcome of the unit was assessed both at the level of student acceptance and with respect to having met the unit aims. In the case of the former, the response of students to the unit was ascertained both with respect to their use of various learning options and their comments/perceptions of various learning options. The latter was formally assessed in the form of student presentation, their formative assessment, their end of semester examination, and their summative assessment. Results Student Responses During the first week of the unit, a time during with both classroom and self-learning guide were operating, class attendance was approximately 100%. By the second week, students had become selective about the classroom experiences they attended. Inclusion of certain compulsory assessment requirements ensured that all students did actively participate in differential diagnosis exercises at both a group and individual level. After 4 weeks, of a class of 60 students, a total of 49 students chose to attend. These students were asked to complete a questionnaire to ascertain their opinion of what was a novel learning experience (Fig 7). Twenty-one students selected lectures as their most preferred learning style, 15 chose discussion, and 8 reading or self-study. When ranked preferences were analyzed on a Likert-type scale, lectures emerged as the overall preferred learning format. Discussion and reading ranked an equal second. Student partiality for a lecture type rather than an independent learning format was further emphasized by some respondents requesting lecture notes and additional lectures. Other evidence of discomfort with a structured self-directed learning environment included the request for class quizzes rather than those provided as self-assessment on WebCT, and the suggestion that more controls be imposed to persuade students to complete the learning tasks provided on WebCT. Overall, although 1 student considered the unit a “terrible” learning experience and another an “excellent” learning experience, most students (25) regarded it as average on par with their other units. Two students considered it below average and 16 above average. The information was further refined by ascertaining which of the learning experiences students perceived as most valuable. A Likert-type scale was used. Students who indicated they had not performed or who had attended less than half of the sessions offered for a particular activity were deemed unqualified to comment and excluded from analysis of that activity. A score of 5 per student was allocated to each activity rated as an excellent learning experience, 4 was allocated for an activity rated as good, 3 for a fair learning experience, and 2 per student for activities rated as a waste of time. The score derived was then divided by the number of respondents to that item, and the final score was used to rank learning experiences. On this arbitrary scale, the most valued learning experience, WebCT challenge, achieved a total of 4.027; the least appreciated, PowerPoint presentation, a value of 3.04. Figure 8 describes how the learning experiences were ranked. The first 8 items listed scored 3.8 and higher. Only 1 student felt WebCT case studies were time wasted. On the open question that requested the best aspect of the unit be identified, the group case differential diagnosis and subsequent class discussion were regarded by many as the most valuable of the learning experiences provided; 5 students felt these activities were time wasted. Nine students felt the same way about class discussion after student case simulation/presentations and 6 regarded the student case simulation/presentations as wasted time. The learning experience most students regarded as a “waste of time” was the PowerPoint presentation. Although almost 60% found the presentations useful, close to 40% found them too detailed and 4 students found them confusing. A further criticism was that the presentations were interrupted by interactive student tasks in which students were challenged to apply information provided. Most respondents felt that both principles and factual information should be included is these sessions. The length of the class (2 sessions of 4 hours each) was most consistently volunteered as the “worst” aspect of the unit by students. Based on the learning they had experienced during the first 4 weeks of the semester, students were asked whether they believed they would be familiar with the signs and symptoms of prevalent diseases, and able to use their basic science knowledge in the clinical context, generating a differential diagnosis, formulating a working and proposing a definitive diagnosis by week 13. Table 1 shows the proportion who believed continuing with this learning format would meet the unit objectives. Student Performance Student performance was evaluated using both formative and summative assessment. Formative assessment was undertaken through individual student presentations and group work. Assessment of individual student presentations involved simulation of a clinical consultation in which a “disorder” was provided and the presenting student was required to prepare a simulated patient and demonstrate a consultation that emphasized the decision-making processes used in differential diagnosis. All students satisfactorily completed this assignment, and feedback provided at each session resulted in the presentations becoming more sophisticated over time. Cases submitted for formative assessment of group work were also satisfactory with students providing documentation of how to integrate sign and symptom pictures to differentiate between conditions with a common presentation. Upon completion of the unit, a multiple-choice, end-of-semester examination was administered as a summative examination. Most examination questions were presented as case studies, and students were asked to select a working diagnosis from a list of possible conditions. A few examination questions were designed to ascertain whether students could use their basic science knowledge in a clinical context. All students successfully completed the end of semester examination. The average grade was 72% (range, 50%-90%). A marked similarity was noted between student results on the diagnosis paper and those on the radiology examination. Item analysis of diagnosis questions showed that students had some difficulty applying their basic science knowledge in a clinically relevant context. For example, when asked whether the third heart sound was caused by (a) closure of the atrioventricular valves, (b) closure of the bicuspid valves, (c) atrial contraction, (d) passive ventricular filling, or (e) active ventricular filling, only 44% of respondents selected the correct alternative. Overall, the average grade for this group of questions was 40% (range, 35%-47%) with one exception in which 90% of students selected the correct alternative. In contrast to those questions evaluating the application of basic science information, students were found to have fared fairly well on analysis of those questions ascertaining the students' knowledge of the clinical presentation of various conditions. These questions necessitated selecting a working diagnosis and were of more immediate relevance to their future clinical practice. Most students felt the assessment was well balanced. Suggestions to improve the learning experience included a better introduction into how to use the system, better guidance on how to prepare for individual classes, and access to WebCT during classes, such as the use of a computer laboratory. Some students also requested increased emphasis on a more traditional lecture-type format and provision of lecture notes. Discussion Different types of teaching clinics have been found to facilitate greater diversity in the patient population seen by chiropractic students, thereby broadening the clinical training of chiropractic students by providing diversity in clinical settings.15 This article describes how diversity in classroom and self-study settings can enhance the learning experience. The use of a structured self-learning guide, WebCT, and simulated clinical scenarios provides a novel approach to teaching differential diagnosis at Murdoch University. Students who, by their own admission, are comfortable with and prefer the more traditional lecture-type format are being confronted with a unit offering directed self-study and group work. Despite this dramatic change, most students did rate the learning experience offered by this unit as average or better. The structured self-study component forms the backbone of the unit and provides an integrated comprehensive approach. The students recognized this and valued many of the learning opportunities provided. The WebCT basic science review provided a problem-orientated approach to translating basic science information gleaned from anatomy, physiology, and pathology into a clinically relevant format for the first 7 topics in which the emphasis was on disease and its clinical presentation. Further opportunities to integrate previous with new learning acquired by completing the “essential reading” were provided by WebCT study tasks. Use of the notion of a spiral curriculum within the unit is deemed to enhance understanding and achieve deep learning. Table 1 reflects the students' perception of this learning experience. Both the classroom learning experience and the remaining 4 topics of the structured self-study guide emphasize patient complaints. The focus moves from signs and symptoms of disease to clinical presentations of patients. WebCT case studies, student presentations, and group work provide problem-centered learning opportunities in which the objective is to differentially diagnose patient complaints prevalent in primary practice. The unit guide, used in conjunction with WebCT and the prescribed text, provides a stand-alone study module that lends itself to use as a distance education module. However, students are provided with the additional classroom learning opportunity. Exposure to and application of information in simulated clinical situations were deemed a particularly useful learning experience by many students. It is suggested that these sessions were largely responsible for the confidence many students felt with respect to their ability to make a diagnosis (Table 1). The confidence expressed by students in their ability to recognize sign and symptom complexes and arrive at a working diagnosis was substantiated by the results of the end-of-semester examination. This finding was consistent with the appreciation and preference students expressed for those elements of the unit that simulated clinical consultations and provided opportunities to undertake differential diagnosis. It was also interesting to note that, in spite of their positive perceptions, the relative inability to apply basic science knowledge in the clinical context correlates with the lower ranking accorded to basic science review opportunities and the lesser emphasis on this aspect of the unit. The aspect of the unit most criticized was the PowerPoint presentations. Future delivery of this material will be modified in the light of student feedback. The difficulties associated with this component may, at least in part, be attributable to differing expectations. Students who perceived these presentations as an opportunity to receive factual information, take lecture notes, and have a passive learning experience were disillusioned. The objective of the PowerPoint presentations was to provide perspective while encouraging active learning. The aim was to enhance understanding of principles, not to distribute factual information. The structure of the unit appears sound; however, delivery could be improved. As a result of student feedback, several changes are proposed for future years. These include modifications of the schedule from two 4-hour blocks to two 3-hour and one 2-hour blocks, more structured and detailed introduction as to how to use the system with a hands-on demonstration, and more even distribution of the PowerPoint presentations over the 6 weeks. Despite lectures being the preferred learning format of this student group, no substantial changes to the fundamental structure are proposed. Other educators who have noted that a problem-based learning approach was a cause of concern among students found that student test performance was equivalent to that of traditional students.16 Another study found chiropractic students scored below medical students on the primary care examination in every area except musculoskeletal conditions.17 In this study, student performance in diagnosis mirrored that in radiology. If chiropractic students' superior performance in musculoskeletal diagnosis is deemed to include radiology, then consistency of student results between visceral diagnosis and radiology in this study may be viewed as encouraging. Conclusion This study suggests that differential diagnosis can be successfully taught with fewer face-to-face lecture hours than traditionally scheduled in this program. This study demonstrates that by using a combination of different teaching/learning formats, it is possible to provide active learning opportunities in which exposure to factual information takes place in a variety of clinically relevant scenarios. Although the students' response to the unit would imply that more self-directed learning is acceptable to senior students, formal assessment suggests the unit objectives have been met. References 1. 1Hallgren RC, Gorbis S. Utilization of the Internet to deliver educational materials to healthcare professionals. J Clin Eng. 1997;22:413–418. MEDLINE 2. 2Woo CC. First aid and emergency care education for chiropractic students: a course at Macquarie University. J Manipulative Physiol Ther. 2000;23:645–651. Full Text |
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15. 15Morschhauser E, Long CR, Hawk C, et al. Do chiropractic colleges' off-campus clinical sites offer diverse opportunities for learning? A preliminary study. J Manipulative Physiol Ther. 2003;26:70–76. Abstract | Full Text |
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16. 16Bovee ML, Gran DF. Comparison of two teaching methods in a chiropractic clinical science course. J Allied Health. 2000;29:157–160. MEDLINE 17. 17Sandefur R, Febbo TA, Rupert RL. Assessment of knowledge of primary care activities in a sample of medical and chiropractic students. J Manipulative Physiol Ther. 2005;28:336–344. Abstract | Full Text |
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a Professor of Primary Care, Division of Health Sciences, School of Chiropractic, Murdoch University, Perth, Western Australia, Australia  Submit requests for reprints to: Jennifer R. Jamison, MBBCh, PhD, EdD, Professor of Primary Care, Division of Health Sciences, School of Chiropractic, GPO Box S1400, Murdoch University, Perth 6849, Australia.
PII: S0161-4754(06)00080-7 doi:10.1016/j.jmpt.2006.04.001 © 2006 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. | |
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