Why Consider Using Small Group Case Based Learning

Knowledge: Facts, information, and skills acquired by a person

through experience or education; the theoretical or practical

understanding of a subject.

Much of “Knowledge” is a transient

(What is right today can be wrong tomorrow)

The volume of information is increasing exponentially

“...the meaning of knowing has shifted from being able to remember and

repeat information to being able to find and use...” Simon, 1996

Small group case based learning is about………

• Learning content information in the same context of its use• Learning to develop a systematic strategy to approach problems• Learning to develop a critical and creative reasoning process• Learning self-directed acquisition of evidenced-based

knowledge from relevant sources

• Learning self assessment

Learning: The act of acquiring new, or modifying and reinforcing

existing knowledge, behaviors, values and preferences, through

synthesizing one or more types of information.

Specific Goals for Patient Cases in SGCBL

• Present new material that integrates with contents of one or

more previous courses• Challenge students to identify and hypothesize explanations

for problems presented by a patient • Stimulate students to find evidence in support of hypotheses

using relevant databases and reference sources

• Incorporate patient interactions in the context of ethics,

socioeconomic factors, availability of insurance, etc.

Basic Format and Presentation of Patient Cases

• Cases are presented over two or more class sessions.

• Disclosed to students in discrete segments (1 or more per class session), each with new information about the patient.

• After each segment is presented, students work

collaboratively in class to consider and record what they

already know, what they need to know, to generate

hypotheses and to develop a set of learning issues (i.e.,

learning goals).

Basic Format and Presentation of Patient Cases

• Between class sessions, students individually research

information to address each learning issue, helping to test

hypotheses and understand the case.

• Select students present their research at the beginning of the

next group session, with discussion, narrowing of hypotheses

and development of new learning issues.

• The learning objectives for the case are revealed to students at

the end of the case, with students responsible for each

learning objective.  

Elements of a Small Group Session

• The group lists chief complaints, test results, other facts

provided.• Propose hypotheses to explain issues/problems potentially

associated with the chief complaints.- Initially use broad categories until more information is

obtained

• Consider if one hypothesis explains several issues/problems.

• Provide initial rationale for each hypothesis.

• Create a Concept Map that outlines general hypotheses of

biomedical and non-biomedical nature.

Elements of a Concept Map

Red: Potential broad areas to consider initial hypotheses.

As the case progresses, the group explores potential mechanisms and adds them, along with new facts, to refine the map and to support or eliminate a hypothesis.

Elements of a Small Group Session

• In further refinement of the concept map:- Consider basic mechanisms which may explain how each

hypothesis leads to problems.

- The group reaches the limits of their existing knowledge.• The group then decides what are their gaps in knowledge to

further test each hypothesis (i.e., Knowledge Gaps).

• Compile these into a group of Learning Issues.

• Individual research between class sessions.

• Select students present their research at the beginning of the

next group session, with discussion, narrowing of hypotheses

and development of new learning issues.

What is the Role of the Facilitator?

• The facilitator is a guide, asking students to explain their

thinking or to challenge their ideas.

• Insist on students provide sources of evidence for statements

made and questions the validity of different sources.

• Facilitator’s interaction with students is to promote thinking,

not to provide information!

• Facilitate the following self-questioning by students:- Do I understand the scenario?- Have I thought of all the possibilities?- What’s the best way to manage the problem?- Is there another way of thinking about the- problem?- Do I know enough about this?- What facts do I still need to know?- Where can I find the information?

What is the Role of the Facilitator?

• Challenge students, both when correct and when wrong:

- Are you sure you’re right?- Is everyone comfortable with a particular stated idea or

decision?• Encourage comments between/among students.• Promote participation by all members.

• Encourage consensual decision making by the group.• The facilitator should ultimately become unnecessary as the

students begin to understand the process and take control of

their own learning.

What is the Role of the Facilitator?

• Handles potential interpersonal problems.

• Understands that not all groups go in the same direction or at

the same rate.

- Variability in coverage of case objectives by different

student groups.• Assesses each student’s contributions to case discussions.

The Facilitator is Not an Expert on Case Material

• Provided a guide with:- List of earning objectives for the case.- Expert explanation of the main points of the case that

students are expected to cover, written in language that

faculty, in general, should understand.

- Includes biomedical, behavioral and socioeconomic

information. - An orientation meeting of facilitators prior to the case.

Using CBL in DEN 5221

• Current situation– Exceedingly difficult to obtain non-traditional acting talent

• Adolescents• Child/parent pairs• Culturally diverse

– Talent doesn’t always “look” the part– Mental health issues such as eating disorders and depression

are hard to simulate in SP cases.– SP encounter is 10” in length– not long enough to bring in

subtle cues and difficult topics.– SP actor is trained in case subtleties, but also independent.– Feedback is retrospective.

Dodd 1/10

Using CBL in DEN 5221

• Advantage of CBL if the ability to increase the depth of the case.– Provides students with a stronger background

from which to approach the patient interview.– Allows for introduction of multiple people into the

patient/provider communication process (child/parent).

Dodd 2/10

“Don’t Tell Anyone!”

• 16 year old female patient• Has not been seen by the doctor for 18

months• Parents have recently divorced• Reason for visit: – teeth are extremely sensitive to cold, especially

her upper teeth (desensitizing toothpaste has not helped);

– Bad breathDodd 3/10

“Don’t Tell Anyone!”

• Oral exam findings:– Bilateral parotid enlargement– Generalized enamel erosion– Dental caries– Generalized pocket depths of 4mm to 5mm with

BOP• OHI debris score 3• OHI calculus score 1

– Tongue mildly sore- reddish purple in color– Mild bilateral angular chelitis

Dodd 4/10

“Don’t Tell Anyone!”

• Patient reports– Brushing 1x daily in morning– Sipping on Pepsi Max and Gatorade during the day to

relieve hunger– Oral contraceptive use began 4 months ago

• Mother is unaware

– Concerned that she may be at risk for oral cancer because she has engaged in unprotected oral sex

• Patient is adamant that this information not be placed in her dental chart.

Dodd 5/10

“Don’t Tell Anyone!”

• Patient reports– Use of OTC diet pills• Rx drug for ADD contradicts use

– Consumes calorie dense foods in the evening before bed• No brushing before bed

• Dr. wants a consult with pediatrician and nutritionist

Dodd 6/10

“Don’t Tell Anyone!”

• Case ends with students role-playing the dentist’s presentation of findings, suspicions, diagnosis, and treatment plan to patient and mother.

Dodd 7/10

Experiential Learning

• Students move through the case by experiencing the situation through dialogue.

• Each section of the case is discussed immediately- learning gaps are acknowledged and information exchanged.– Students must exchange information

• Acknowledge the strengths and weaknesses of one another

• Termination of case can require students to act-out the scenario as they see it taking place.– Students role play the case and characters.– Feedback is immediate and corrections can be made.

• Cases can be written to “reappear” in future courses. • Allows psychosocial aspects of the case to be considered in treatment planning

and other courses.

Dodd 8/10

Learning goals met through CBL

• Describe and contrast etiology, symptoms, and treatment of oral, physical, and mental health conditions and disorders.– Application to a specific case enhances memory and later

recall.• Case can be continued in later courses.

• Become familiar with factors and processes relating to appropriate referral and consultation with other health professionals.

• Illustrates complexity of dealing with “sensitive” patient information.

Dodd 9/10

Learning goals met through CBL

• Requires consideration of ethical and legal duties when dealing with adolescent health information.

• Demonstrate patient/provider communication skills– Interview– Case presentation

• Illustrate the effects of patient/provider personality differences on communication and case acceptance– Introduce complexities of communicating with adolescents

• Demonstrates complexities that can present in clinical practice.

Dodd 10/10

Recap of Case-Related Issues

• Adolescent behavior• Divorce• Sensitive teeth• Mechanism of action-

toothpaste for sensitive teeth

• Bad breath• Poor parent/child

communication

• Issues of confidentiality• Legal vs. ethical issues of

disclosure• Communicating with

adolescent about sexuality• Weight loss/body image

issues• Eating disorder• Immediate vs. future

treatment planning

Dodd 11