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| ORIGINAL RESEARCH PAPER |
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| Year : 2013 | Volume
: 26
| Issue : 1 | Page : 21-24 |
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Case vignette: A promising complement to clinical case presentations in teaching
Jeyashree Kathiresan1, Binod K Patro2
1 Senior Resident, School of Public Health, PGIMER, Chandigarh, India
2 Associate Professor, Department of Community Medicine & Family Medicine, AIIMS, Bhubaneswar, India
| Date of Web Publication | 31-May-2013 |
Correspondence Address:
Binod K Patro
Associate Professor, Department of Community Medicine & Family Medicine, AIIMS, Bhubaneswar - 751019
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1357-6283.112796
Introduction: Case studies are widely used in medical education. They help students recognise and interpret important data coming from the patient's problem thereby enabling students to arrive at a correct diagnosis and best treatment course. We have used the case vignette method, a variant of the case study method, for teaching family medicine residents, and here we assess their perceptions of its advantages and limitations. Methods: In the case vignette method, residents studied a particular case of interest from the community. Before presenting it to peers, they prepared and circulated a brief case vignette outlining the salient features of the case, the preferred line of management and suggested discussion probes. Structured notes were taken by programme faculty during the presentations, and feedback was obtained from residents. Results: Major advantages perceived by residents were that the case vignette method demanded their active participation in the preparation and presentation of the case. The need to prepare a vignette helped them better organise their thinking and experience peer teaching. However, some felt that the exercise was time consuming and the discussion sometimes wandered from the intended course. Conclusions: The case vignette method helps meet specific learning objectives in teaching sessions. Residents feel that it improves their skills as physicians and teachers. This study finds that case vignettes are a promising complement to existing methods of teaching medicine. Further research is required to more firmly establish this method's value. Keywords: Case vignette, family medicine, peer teaching, problem based learning
How to cite this article:
Kathiresan J, Patro BK. Case vignette: A promising complement to clinical case presentations in teaching. Educ Health 2013;26:21-4 |
| Introduction | |  |
Case studies have been widely used as a teaching tool in various disciplines especially medicine, engineering and law. When students engage with cases, learning takes place: they analyse, synthesise and apply knowledge. The case study method allows for multiple viewpoints, encourages discussion and fosters greater understanding. [1] There are many models of case-based teaching described for teaching clinical medicine, including case-bedside, case-lecture and case-iterative teaching. [2] It has been found that these methods help solidify students' understanding as they have to find the solutions to their cases rather than relying passively on the instructor to provide the answers. [3]
Beyond teaching, case studies can be used to evaluate a learner's ability to recognise and interpret important data to support their decision making pertaining to the case's management. Case studies also allow faculty to evaluate learner's ability to organise and communicate their ideas. [4] They are also used as a method for measuring the competence of physicians and the quality of their actual practice. [5]
However, case-based methods, like all methods of teaching clinical medicine, have shortcomings. They are perceived as lengthy and time consuming, allowing little student participation and are sometimes repetitive. [6] There is a need for additional teaching methods that enable medical students and residents to make appropriate use of what they have studied for improving the quality of patient care. [7],[8] In teaching family medicine residents, we have used a new variant of the case-based study method called the case vignette method. This study aims to document the strengths and limitations of the case vignette method of teaching medicine.
| Methods | | |
The study was conducted among Doctor of Medicine (MD) Community Medicine resident physicians of the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Family medicine is one of the major concentrations of the curriculum of the MD Community medicine course under which resident doctors are trained as family physicians. One of the training methods used in our family medicine training programme is case presentations. Every week one case identified in the community/hospital is presented by a resident physician at a departmental education session moderated by the faculty in charge. The patient is not typically present during the session.
A new method of conducting these sessions was conceived [Table 1]. The residents were instructed to prepare in writing a vignette on the case that they propose to present for discussion, and they were first briefed on how to do this. [9] They were instructed to have the vignette describe briefly the major features of the case including history and examination findings, and they were asked to suggest a line of management at the primary, secondary and tertiary levels of health care delivery. The residents were instructed to raise probes at the end of the vignette to focus the discussion on the points they find most important for the group. The complete case vignette including the probes/discussion points were not to be more than 400 words long.  | Table 1: Instructions given to the resident under the new case vignette method of teaching
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Case vignettes were to be communicated to all residents and the faculty-in-charge 3 days prior to the case discussion to allow time for adequate preparation to promote a meaningful discussion. During the session, a brief presentation of the case history and examination findings was followed by a discussion along the lines of the probes/questions prepared by the resident. Structured notes were taken during the session tabulating the major probes that the resident had proposed for the session against the discussion that actually took place in the session. Schmidt [10] proposes a framework for evaluating problem-based learning methods. The teaching method should be able to use the students' prior knowledge of the subject optimally, provide a context of learning similar to that for application of knowledge and allow opportunities to elaborate on the knowledge gained. We evaluated the case vignette method against these criteria.
Semi structured feedback was obtained from the residents regarding their experience in preparing vignettes of their cases and framing probes for discussion. Feedback was obtained via email to encourage critical views. A moderated focus group discussion was also held with the resident physicians to understand their perceptions of the advantages and shortcomings of the case vignette method of teaching. Structured notes were taken during the focus group discussion. Textual analysis of the feedback was performed to arrive at an organised list of residents' suggestions and comments. The study was conducted in compliance with the ethical regulations for research on human subjects and approved by the peer review committee of the department.
| Results | | |
At the end of 3 months, 7 out of our 10 residents had completed at least one case vignette preparation and discussion. One of the model case vignettes presented by a resident is shown in [Table 2]. The major advantages as perceived by the residents were that the method demanded that they actively engage in the preparation and presentation of the case, which fostered a thorough understanding of the case. The need to prepare a vignette helped them organise their thinking better. They were also able to place themselves in the teacher's position thus helping them practice and experience peer teaching. The probes helped them design and moderate a discussion about the case to meet specific learning objectives. The disadvantages they perceived were that compared with the earlier method, where they had to only present the case from their notes, the new method was more time consuming, as it required the preparation of a vignette and discussion probes. The residents also found that sometimes, the probes did not generate the expected discussion when residents did not understand the intended meaning of the probe, and the planned learning objectives consequently suffered.
The extent to which the case vignette method fulfils Schmidt's criteria for an effective Problem Based Learning (PBL) tool is presented in [Table 3]. The method enables the student to apply his clinical reasoning skills in real life contexts in the community. It also motivates self learning and communication of the knowledge gained.  | Table 3: Assessment of the case vignette method of teaching as an effective problem-based learning tool based on Schmidt's criteria
Click here to view |
| Discussion | | |
Case-based discussion and teaching that follows the presentation of the details of a case is a commonly used method of teaching in medicine. We discuss a variant of the case-based study method for use in family medicine teaching - the case vignette method. Here, the resident doctor was required to study in depth a particular case of interest from the community and prepare a brief case vignette listing the salient features of the case and a proposed line of management, and suggesting probes for discussion.
Most literature on case vignettes addresses the use of hypothetical case studies that are designed to pursue a particular learning objective. In contrast, our method requires study of real cases from the community, and the discussion centres on the diagnosis and comprehensive management. Another modification of our method was that the resident assumes the role of the teacher. The faculty instructor restricts himself/herself to only moderating the discussion and contributing specific points when necessary. Hence, our approach is more of a peer teaching style, which encourages more active discussion than traditional didactic teaching. Irby [2] points out that a good clinical teacher should be able to relate to three cognitive connections at the same time, namely the students' knowledge base, the case specific details and the general principles of medicine. The teacher should also be able to convey a few selected learning points for a discussion in an inductive manner through questions and discussions. Our method allows the teacher to be flexible in deciding his/her extent of involvement in the case vignette discussion.
Many studies in the medical and non-medical literature have highlighted the need for teaching methods to raise new information for learners and enable them to practice applying it appropriately. The effectiveness of an instructional method can be assessed by analysing what students are able to do with the information they receive. The case vignette method, as we have used it, was found to satisfy all the three of Schmidt's criteria.
One disadvantage perceived by the residents was that the discussion of the vignette sometimes takes a different course from that planned by the resident. However, appropriate moderation by both the resident presenting the case and the teacher can help keep the conversation on the planned course. We have not yet assessed how case vignettes affect the resident doctor's actual health care practice. [5] However, it is expected to both directly and indirectly improve the quality of care residents provide: directly for the particular case that is discussed, as the best line of management of the case is decided upon based on the suggestions and guidance of peers and the teacher, and indirectly by the overall effect on the resident's skills as a physician. Thus with many desirable features, the case vignette method seems a promising complement to the existing methods of teaching medicine.
| References | | |
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| 2. | Irby DM. Three exemplary models of case-based teaching. Acad Med 1994;69:947-53.
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| 9. | Writing a Clinical Vignette (Case Report) Abstract. Philadelphia: American College of Physicians; 2012. Available from: http://www.acponline.org/residents_fellows/competitions/abstract/prepare/clinvin_abs.htm. [Last cited on 2012 Aug 9].
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| 10. | Schmidt HG. Problem-based learning: Rationale and description. Med Educ 1983;17:11-6.
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[Table 1], [Table 2], [Table 3]
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