Effective Case Based Teaching

The end of medical school is an interesting time.  Although I am still technically (and intellectually) a medical student, preceptors are beginning to expect me to be more responsible and know how to approach and manage patients.  During a particularly vigorous pimping session with my preceptor this week I was praised with the interesting sentiment “see, you’re not as stupid as you think”.   However, despite how stupid I sometimes feel, I am on the precipice of becoming a resident who will be responsible on some level for imparting knowledge to the next generations of medical students.  At times I still feel woefully unprepared to leave the comforting label of “student” myself and have been focused on my own learning during these last few weeks of medical school, the final chapter of my medical education. 

 Like many medical students, I like case based teaching and learning.  A story is worth something to me; it is memorable.  Case based teaching is commonplace in internal medicine from morning report to lunch time rounds.  Instead of “good morning”, every day of my core internal medicine rotation started with “This is a case of a __ year old ___ presenting with ____”.  I enjoyed that but found these exercises to be more intellectual than real.  There was no real patient in front of me.  I wanted to learn, yes, but I also wanted to know what happened, something that was not always available for these reports.

On my current rotation I am exposed to exclusively outpatient clinics.  Most of the patients are follow-ups.  At the start of my clerkship, I would have been disappointed, thinking that there was little I could learn from follow-up appointments.  At the beginning of clerkship the objective is often to see new things for yourself.  To do the history and physical.  To make the first attempt at diagnosing managing disease on your own.  To see people that were sick.  Now, as I prepare for a career in family medicine, follow-ups are suddenly cast into a different light.  My preceptor has been encouraging me to read the chart first.  He tells me about these patients when they were sick or unwell.  Using his signature style, he often shows me pictures of their condition when he first met them.  He wants me to understand their journey.  He wants me to learn the full story so that I can recognize familiar tales if I come across them again.  He tells me how these patients presented initially and makes me talk through a logical work-up with him before he shows me what tests were done in real life and what they showed.  

This form of case based teaching is extremely valuable to finishing medical students.  My preceptor is allowing me to benefit from the best: the beginning and the end of a particular patient’s medical story.  He encourages me to think about how I would fill in the middle of this story, before showing me what was done to our current patient.  There is no guesswork or hypothesizing.  We go over real stories, real results, real notes, and finally talk to the real patients.  It is some of the most complete case based teaching I have ever been exposed to throughout medical school. 

 

I emphasize that for effective case based teaching, it is helpful to know the end instead of just the beginning.

-Julia