In this study, we demonstrated that CPs improved student performance on unit examinations and comprehensive final examinations when compared to students who did not experience CPs (). This study also revealed an improvement in student self-perceptions in regards to their abilities to analyze patient and laboratory data and to arrive at a correct diagnosis (). A qualitative analysis of the students’ self-reflections following the last CP in the ID course demonstrated that a large number of students perceived improvements in their ability to rule-in and rule-out answer choices and to present pertinent patient information (). Our findings suggest that the CP exercises increased our students’ ability to recall microbial facts, strengthened the relevance of our MM and ID courses, and enhanced our students’ clinical thinking skills.
Several factors likely contributed to the significant improvements seen in exam scores earned by students who participated in the CP exercises versus those who did not. First, active engagement with course material has been shown to enhance learning and content recall (11
). Students took responsibility for organizing their study materials and learning the information in a way that would help them arrive at a correct diagnosis without consulting external references during the CPs. Second, providing students with feedback that allowed them to gauge their learning (13
) and strategically placing the CP exercises a few days before an examination allowed deficiencies to be identified and addressed proactively. Third, peer pressure undoubtedly provided motivation to perform well during the CPs. Although very few points were awarded for successfully completing the CPs, several students mentioned in their reflections that they wanted to avoid appearing deficient in their understanding and knowledge while in front of their peers and facilitator. Finally, others have demonstrated that learning is enhanced when the student becomes the teacher (14
). The students in the CPs served as teacher when they described their patients’ history, physical examination data, laboratory findings, and discussed how they ruled in the correct diagnosis/disease and ruled out the other choices. They were also required to answer questions from their colleagues and a faculty member. Frequently, discussions occurred during the question and answer time as students realized deficiencies in their knowledge or wanted to know more about a particular subject. Lack of preparation for the CP exercises did adversely affect their ability to function as a teacher in these settings and may have motivated them to improve their preparation and performance during the next CP. The self-described improvement in organizing and presenting their patient cases may, in part, have resulted from their desire to do a better job of informing their colleagues and faculty about their patient ().
It is widely perceived that content without context has a negative impact on student learning because the content lacks relevance (4
). In this case, the CPs appeared to provide students with the context they needed to improve their learning of MM and ID content. In fact, 30% of the students felt that CPs would be helpful to them during their third and fourth year clinical rotations, residency, or as a physician ().
Case presentations have been used extensively in outpatient and inpatient settings to communicate patient information between physicians (16
). Case presentations have also been used by attending physicians to assess student physicians’ medical knowledge and diagnostic abilities (17
) and to assess the cognitive skills required of a physician while they care for their patients. Several of these skills require critical thinking. One critical thinking skill requires the physician to take patient data and use it to develop a differential diagnosis. This skill is demonstrated by the ability to organize the data in some fashion and to determine which data are pertinent in regards to the patient's chief complaint. The physician then needs to communicate the patient information in writing, and in some cases, orally. A large number of the students felt that the CPs helped them to be more organized, concise and pertinent when they presented information from their patient (42.6%; ). The students were not required to develop a differential diagnosis list; however, they were required to present patient data that was organized, pertinent and timely in regards to the patient's chief complaint. It appears from the student self-reflection comments that the students felt their abilities to organize patient data had improved.
Another critical thinking skill physicians must develop is the ability to rule-out and rule-in the diagnoses they list after organizing the patient data. Over 46% of the students stated that the rule in/rule out portion of the CPs helped them to apply the material they were learning and required them to think critically (). Since multiple choice examinations test the ability to rule-out and rule-in the answer choices, improvement in this critical thinking skill may have also helped them on the multiple choice MM and ID examinations.
One limitation of this study is the use of required student self-reflections to determine improvements in student perceptions of the relevance of the MM and ID courses to their progress towards becoming physicians. While taking our courses, students may be inclined to give glowing remarks concerning their progress in a non-anonymous self-reflection essay. To test the validity of our conclusions from self-reflection data, we reviewed the results of an anonymous post-COMLEX-USA Level 1 questionnaire, which is offered by the College to all students to obtain their opinions regarding how well first and second year courses prepared them for the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA); Level 1. The Level 1 exam, which is taken approximately seven months after the end of our ID course, is largely devoted to assessing basic science knowledge presented in a clinical vignette format. All students are required to pass this exam to graduate from our medical program, and passing it is the first of four required steps to eventually obtain their medical licenses. The class that took our courses in 2008 ranked both ID and MM second (94%) out of 21 courses (scoring range was 32–95%; data not shown). The class that took our courses in 2009 ranked MM first (98%) out of 22 courses (scoring range was 26–98%; data not shown). The ID course, for reasons unknown to the authors, was omitted from the questionnaire for the 2009 class. However, for the 2010 class, students scored ID and MM at 99 and 98%, respectively. With these scores, our courses ranked first and second out of 24 courses (scoring range was 25–99%; data not shown).
Although helpful to student learning, small group activities have been difficult to implement when student class sizes are large and the number of faculty is small. The exercises described here were implemented with a small faculty using relatively few physical resources. We have conducted CPs with as few as four facilitators and with as many as six students per small group. Even though the student-to-faculty ratio for our department was nearly 35:1, the CPs were completed in a well-coordinated and timely fashion, thanks in large part to skillful planning by staff and the cooperation between faculty, staff, and students.