problem-based learning
The patient as text: a challenge for problem-based learning Nuala P Kenny1 & Brenda L Beagan2
OBJECTIVES To explore the values and assumptions underlying problem-based learning (PBL) cases through narrative analysis, in order to consider the ways by which paper cases may affect student attitudes and values. METHODS Randomly chosen PBL cases from the first year curriculum at Dalhousie University medical school (n ¼ 10) were coded by 3 independent reviewers attending to narrative components. RESULTS The cases generally used spare, objective language, used the passive voice, eliminated agency, and employed linguistic markers to encode scepticism about patient reports. There was almost no sense of the presence of the patient as person in these cases in terms of their words, feelings, or their social and cultural context. The almost complete exclusion of the preferences and priorities of the patient was striking. CONCLUSION The sample is small, the results only suggestive. Yet it appears that the cases used in PBL may unnecessarily, even unintentionally, encourage student detachment from the messiness of real patients’ lives and emotions. Positioning a particular way of seeing – the doctor’s gaze – as normative renders less visible the choices that are being made whenever an account is constructed. Including multiple voices in a case would complicate that tidy reduction of choices. Ongoing attempts to enrich the case format should be encouraged. At the same time,
1 Department of Bioethics, Dalhousie University, Halifax, Nova Scotia, Canada 2 School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
Correspondence: Nuala P Kenny OC, MD, FRCP(C), Department of Bioethics, Dalhousie University, 5849 University Avenue, Halifax, Nova Scotia B3H 4H7, Canada. Tel: 00 1 902 494 3801; E-mail:
[email protected].
students may benefit from being taught the skills for critical analysis of the case itself. KEYWORDS education, medical undergraduate ⁄ *methods; problem-based learning ⁄ methods; medical records ⁄ standards; students, medical. Medical Education 2004; 38: 1071–1079 doi:10.1111/j.1365-2929.2004.01956.x
INTRODUCTION ÔIt is a safe rule to have no teaching without a patient for a text, and the best teaching is taught by the patient himself.Õ1 Problem-based learning (PBL) has become a standard feature of contemporary medical education.2 The goals of PBL curricula include improving the learning environment of medical school, improving lifelong learning skills and clinical performance, and enhancing the humanistic skills of teamwork and attention to patients.3–6 While the exact format of PBL varies considerably, certain key features are consistent: an emphasis on learner-focused exploration of casebased patient problems, and the use of patient case histories to help students identify learning issues that become the focus of individual and group problem solving. The patient ÔcaseÕ is central to PBL on the understanding that: Ôstudents should be exposed to some professionally meaningful problems or situations that have a strong resemblance to the problems they will be confronted with in their future profession.Õ7 (p 186) The hope is that mapping the problem solving to the context of ÔrealÕ practice will enhance learning.6 Much of the impetus behind the adoption of PBL pedagogy stems from the fact that it is rooted in ÔrealÕ medical cases and experiences. Yet there has been
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Overview What is already known on this subject Case histories used in rounds employ language, structure, voice and perspective that socialise medical trainees into underlying assumptions, values and beliefs. Cases frequently depersonalise both the patient and the doctor.
The structure, language, voice and perspective in the case history frame particular representations of the situation, based on the choices and perspectives of the author. When used as a pedagogic tool in PBL, cases similarly convey particular values and perspectives. and they do so much earlier in the learner’s training: students often first meet patients as paper cases. We offer some suggestions for enriching PBL cases for medical students, but more importantly we argue that students need to learn ways to critically assess PBL cases as narratives, as stories that are simply particular representations of events.
What this study adds This study explores the implications of PBL curricula that introduce medical students to the decontextualised patients of some paper cases. The paper case may encourage students to avoid the ÔmessinessÕ of real patients’ lives and emotions, enhancing tendencies toward detachment. Suggestions for further research Future research should examine the generalisable narrative analyses of PBL cases, explore the impact of different types of cases on students and investigate tutor training to develop skills for critical analysis of cases.
insufficient attention given to the implications of using paper cases as students’ introduction to patients and their problems. Have we created a very different text than that envisioned by Osler? What values are embedded in the form, structure and language of the paper case – values conveyed intentionally or unintentionally to students? Might the format of the case history impart information and values that medical educators would be loath to teach explicitly? This paper reflects on the values embedded in the paper case, utilising insights from literature on professional socialisation and narrative analysis. We argue that, while the medical case history has a key role to play in clinical practice, along with the transmission of information it also conveys attitudes, values and assumptions that help to socialise new members into the culture of professional medicine.
THE CASE HISTORY IN MEDICAL CULTURE: LANGUAGE, VOICE AND PERSPECTIVE Medical training is a site of professional socialisation, a site where students learn normative rules regarding behaviour and emotions.8 Role modelling and informal interactions teach the norms, values and expectations that constitute the community of practice students are entering.9 The medical case history is a pervasive vehicle through which a unique set of shared values may be imparted. In clinical practice, the case history serves specific purposes: to obtain in a focused way and communicate efficiently the essential facts necessary for proper diagnosis and treatment. Cast in a ritualised format, however, the language, structure, voice, perspective and content not only impart information but also reveal underlying assumptions, values and beliefs into which medical trainees are socialised.10 A communication vehicle for health professionals, the case history is not intended to be meaningful to the patient. Doctors listen to a patient’s story through the defined discourse of the case history; pertinent details are captured in the case while ÔextraneousÕ information is deleted.11 Case histories depersonalise the patient, separating biological processes from the person10 while excluding many facets of the patient’s story because they are seen as having no bearing on diagnosis. While the past medical history of the patient may be taken into account, if deemed clinically relevant, the case history primarily chronicles a discreet medical event, occurring in the present. The language used in case histories is noteworthy. The case, typically, is spare and objective. The patient’s concern is termed a complaint; his or her
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voice is not heard; his or her words are not used and personal information is scant. Use of the passive voice eliminates agency: for example, Ôthe patient was treated with...Õ and Ôthe patient was noted on physical examination to have...Õ. This makes invisible the persons making observations and decisions and performing procedures. As Rene´e Anspach notes: Ô...using the passive voice while omitting the observer seems to imbue what is being observed with an unequivocal, authoritative factual status.Õ10 (p 367) At the same time, specific linguistic markers encode scepticism about patients’ accounts, with phrases such as Ôthe patient reportsÕ or Ôthe patient claimsÕ denoting these portions of the case as subjective perceptions which may or may not be factual. The perspective dominating the account is that of the doctor, for the case history is not the patient’s story. It is the doctor’s highly structured rendering of certain aspects of the patient’s experience. The case history is a story, an account, a narrative. The values expressed through the case history can be brought into sharp relief by analysing the components of the narrative: plot, point of view, character, structure, convention and dialogue. The identity and perspective of the storyteller, the revelation or concealment of information, the sequence of events and their conclusion shape the account to reflect what the author – a doctor – deems important. In the medical encounter the patient’s uniquely personal story is transformed as it is structured into the medical case: Ôthe transformed and medicalised narrative may be alien to the patient… the patientÕs account of the experience of illness is distorted and flattened, almost obliterated.’11 (p 13) In clinical practice, although transmitting information is clearly a function of the case history, the ritualised format of the narrative also has other less obvious consequences.10 It establishes a hierarchy of information in which the findings of diagnostic technology are paramount, followed by doctors’ observations and, lastly, by patients’ accounts. It grants ultimate authority to the voice of the doctor, excluding the voice of the patient. It constructs medical observations and interpretations as incontestable facts while devaluing patient observations as subjective and fallible. These Ôside-effectsÕ of the case format may or may not affect doctors’ attitudes toward patients; more importantly, when case histories are used as a tool for educating and evaluating doctors-in-training – as they have long been used in rounds, conferences, consultations and
charting – they serve to socialise trainees into particular values of the professional culture.
THE USE OF THE CASE AS A PEDAGOGICAL TOOL With the introduction of PBL, while medical students may also encounter real patients early in their training, many if not most of their first encounters with patients are mediated through the format of the paper case. Under traditional curricula, when students encountered patients in their clinical years, one of their major tasks was to learn to pare away the ÔextraneousÕ information in a patient’s story to focus on the clinically relevant.12 They needed to learn to distil the complexity of the person into the format of the case. In PBL curricula, many of the first patients students encounter have already been distilled for them. They are exposed much earlier to the unintentional lessons embedded in the format and language of the case history. As we wanted to know if the cases used for teaching purposes shared the attributes previously documented in clinical case histories, we conducted a systematic review of a random selection of the PBL cases used in our own medical school (at Dalhousie University, Halifax, Nova Scotia, Canada). We randomly chose 1 case from each unit in the first year curriculum in which cases are used (total n ¼ 10). Two reviewers independently read and coded each case, asking of the narrative the questions noted in Table 1. Another reviewer read each case, specifically attending to assignment of agency, treatment of objective or subjective accounts, and the use of linguistic markers to encode scepticism about patient accounts. On the whole, the teaching cases tended to replicate the problems noted above for clinical cases. Cases were presented from the perspective of the doctor, language was generally spare and objective. The use of the passive voice to eliminate agency – both the patient as agent and the doctor as agent – was striking. For example, in 1 case, after a patient Ôwas referred to a respirologistÕ, he Ôunderwent bronchoscopyÕ. Shortly afterwards a Ôchest X-ray showed a 50% pneumothoraxÕ so Ôa chest tube was insertedÕ. He Ôwas admitted to hospitalÕ where Ôthe chest tube continued to bubbleÕ. Here no one performed the bronchoscopy (let alone cleaned the bronchoscope, wheeled the patient into the room, or cleaned up afterward); no one took the X-ray, or
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problem-based learning read it; no one inserted the chest tube; no one admitted the patient, nor did the patient enter the hospital himself. The most active agents here were the X-ray showing, and the chest tube bubbling! Only in a single case was the doctor present as an active agent – it stood out for its unique voice. In it, rather than the typical Ôfundal height was 34 cmÕ, the case read: ÔYour examination of her abdomen reveals a fundal height of 34 cm.Õ Again, rather than, ÔNo fetal heart beat was detectedÕ, this case read: ÔYou are unable to hear a fetal heartbeat.Õ The change in language makes it very clear that an actual person is observing and assessing: there is agency.
As Anspach10 notes with clinical cases, the accounts given by patients in these teaching cases were usually ÔmarkedÕ with words that denote doubt. For example, when describing the patient ÔcomplaintÕ the language used was Ôshe thinksÕ, Ôshe notesÕ, Ôhe feelsÕ, Ôhe claimsÕ. (Interestingly, in 2 cases this was not even necessary, as the patient really never appeared as a person. Such cases start by presenting specific symptoms already couched in medical terms; the patient has already been translated into a set of symptoms.) The markers of subjectivity in patient accounts are especially striking when they are followed by the results of examination and diagnostic tests. Suddenly the language is that of fact: ÔShe was alert… She had
Table 1 Analysis of PBL cases Narrative component
Suggested questions
Language
Is the language used in the case that of the patient or is it medical terminology?
Voice
Is the active or passive voice used? Who is ÔspeakingÕ? Are there any direct quotes from the patient?
Audience
Is the ÔaudienceÕ identified? Who does the case seem to be written for?
Perspective (point of view)
From whose perspective or Ôpoint of viewÕ is the case told? Is there any direct reference to the patient’s perspective or point of view?
Time course
What is the time frame and course of the case? How much information is there on the patient’s previous health? How much information is there on the patient’s experience with this symptom?
Point of ÔcrisisÕ (resolution)
How does the case unfold? Is there a resolution? Is there an account of the patient after the diagnosis is made (outcome)? Is there any sense of a ÔheroÕ or ÔvillainÕ in the story?
Dialogue
Is there any explicit dialogue in the case? Any use of the patient’s words as quotes? Any commentary about the patient’s communication during the diagnosis and initiation of treatment? Is there any dialogue between health care team members?
Character development
To what extent are ÔcharactersÕ other than doctor and patient present? Other health care professionals? Family or loved ones of the patient? How much do you get to know about who the patient is? Do you get to know their family, family relationships? Do you get to know their emotions? How much do you get to know who the patient is in terms of: social class background, education level? cultural, religious or ethnic background? (and how important this is to them?) employment status ⁄ type?
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normal eye movements… There was normal muscle bulk…Õ Lastly, there is almost no presence of the patient as person in these cases. Hardly any of them include quotes from the patient; the patient’s feelings are condensed to statements like ÔShe is understandably upsetÕ; we know little or nothing about the patients’ loved ones or their feelings or concerns, about the patient’s fears, or even who they are in terms of sociocultural characteristics. The story begins with the presenting complaint and ends with its resolution (or non-resolution). No other health care professionals are present in the cases, and there is no discussion at all about the impact of the health event on the patient’s life. For example, a terrifying incident of paralysis concludes: ÔShe was transferred to a rehabilitation unit where she remained for 2 months.Õ Nowhere is the impact on the patient or her husband raised, nor are students given any questions to urge them to think about that impact. The questions in these cases are used as tools for helping students focus on what is relevant – the science. As if stripping away the patient’s reality is not sufficient, the questions further narrow the gaze. For example, in a case where a 32-year-old has a cancerous growth on his neck for the fourth time in 10 years, students are not asked how that might feel for this young man and his family; rather they are solely directed to concentrate on the anatomy of the neck, the cervical spine, the larynx, the muscles used in chewing and so on. Our sample of cases is small, and drawn from a single school, thus our results can only be suggestive. Nonetheless, like the case histories used in clinical practice, it appears that many PBL cases used as teaching tools also proceed from the point of view of the doctor. The narrative stance and perspective of the doctor shape the case narrative. Cases may use a structure and language that grants primacy to the observations of medical staff, and to the interpretations of diagnostic tests, while devaluing or eliminating the patient’s interpretations of reality. They are exemplars of communication between doctors, constructing a plot and timeline that make sense only within the medical encounter; from the patient’s perspective, the timeline may well start much earlier, go on long after the official case narrative has concluded (cf. 13), and involve a range of other characters. We are not suggesting that cases could address everything, and obviously as teaching tools for medical content, they must explicitly address that content. Nonetheless the almost complete exclusion
of the experience and perspective of the patient is striking.
THE PBL CASE AS SOCIALISING AGENT Problem-based learning cases need not be as depersonalised as we have described above. The theory underlying PBL suggests the use of highly contextualised scenarios to aid students in attaching their learning to real people. The best PBL case writers undoubtedly achieve this goal. Nonetheless, there is often an importation of the 2dimensional cases commonly seen in rounds. When used in PBL, such paper cases impart to students a distorted view of the patient’s life in which past and future are, essentially, severed from this medical episode. When teaching medical students, the pressure is great and the temptation to reduce the complexity of the social aspects is strong, allowing medical-scientific complexity to be foregrounded. In these instances, a tremendous onus rests on the PBL tutors to contextualise the case, to add nuance. Tutors may or may not have such skills, or sufficient professional development to fulfil this role. With the use of 2-dimensional paper cases, gradually a Ôstripped downÕ version of the patient’s experience becomes normal, natural, Ôthe only reasonable way to thinkÕ.14 (p 99) The process of transforming a novel set of values and norms into something natural, taken for granted, is the process of socialisation. Problem-based learning cases, then, are part of the process through which medical students are socialised into the world of doctoring. Just as students absorb the worldview of the doctor, they become inured to the absence of the patient’s story in the case history. The very learning tools used in medical education convey a sense of what is vital to the doctor. Social theorists argue that language is the foundation of a shared or social reality. Language allows for abstract categorisation of experiences, which in turn enables communication. At the same time language creates semantic zones of meaning that are Ôlinguistically circumscribedÕ, that determine what we notice and what we do not, what we remember and what we forget.15 In short, language establishes particular relevance by allowing some things to matter and some not. The language of the PBL case, with its embedded values about what matters, facilitates student adoption of a very
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problem-based learning particular worldview by establishing as valid the relevances of medicine. By constructing paper cases and fictitious patients for the express purpose of enabling students to identify predetermined objectives, PBL methods may hasten a tendency toward depersonalisation. With no real person present at the encounter, students avoid the messiness associated with eliciting relevant information and do not have to contend with the patient’s hopes, fears or anger. The cognitive goals of the exercise are achieved and the problem solved without emotional baggage. There is ample evidence that medical education can cause erosion of ethical sensitivity.16 Students learn to adopt a position of Ôdetached concernÕ for patients.12,17 Professional norms suggest there is no room for emotional involvement or feelings in medicine: Ôthe greatest challenge facing medical students today is not the mental incorporation of daunting volumes of biomedical information and scientific ways of thinking, but rather the need to remain humanised.Õ18 (p 1387) Paper cases, which simply cannot convey emotion, body language or non-verbal cues, may speed the process of emotional detachment and hinder the development of caring and empathy in doctors – especially in the absence of strong tutor training. At the same time that paper cases may facilitate the depersonalisation of patients, and the dehumanisation of medical students, they may also entrench the belief that doctors are (or should be) unaffected by their personhood, by all the biases, assumptions and perspectives attendant upon their own social locations.19 Medical students strive for a stance of professional neutrality where their knowledge and skills matter but not their persons – as if they were not humans interacting with humans, in a social world where every aspect of our beings has social and cultural meaning. Students who ÔmeetÕ patients initially through paper cases may be even more strongly encouraged to deny the impact of the self; they are introduced from the beginning to a medicine devoid of personal engagement with the patient.
ENRICHING THE PAPER CASE Many authors of PBL cases have begun to find alternative structures, formats and modalities for the presentation of the case to tutorial groups. The most obvious way to counter the narrow perspectives of the paper case would be to use real patients. For example, Jane Dammers and her colleagues have described the use of real patients in a 7-week PBL
course with students in Newcastle.20 Student numbers were small in this general practice elective; the logistics would be far more complex with a whole class. Nonetheless, the richness of the experience was impressive. Students were presented with a case history, but were able to interview the patient (in pairs) and had access to the family, the general practitioner, hospital records and to other health professionals and community workers. Such a complex process would not have to be available to every student every week. Even if each PBL group was able to engage in a few such learning processes each year it would learn as the Newcastle students learned Ôthat people arenÕt textbook cases but far more complicated and interesting’.20 (p 30) Short of using live patients, which would be logistically complicated and possibly cost-prohibitive, many authors of PBL cases have begun to find alternative structures, formats and modalities for the presentation of the case to tutorial groups. ÔThickÕ cases, for example, while not typical in PBL, nonetheless portray a more complex view of the patient and their story. Such cases portray patients as multidimensional persons with hopes, fears and beliefs, for whom connections to family and loved ones are essential. They are generally long, richly detailed, messy and comprehensive.21 Alternatively, given that we are a very visually oriented society, video presentation of the initial encounter between doctor and patient may also be extremely effective.22 Video can capture more immediately the patient’s story and give visual and non-verbal cues. With fewer resources, cases could incorporate photographs of the patients and their loved ones, both before and during illness and treatment. This might help students to learn by fixing an actual face, a name, a person to an illness, although such outcomes would need to be assessed empirically. Non-pictorial methods of enhancing the reality of a patient in the minds of medical students might include incorporating a fuller biography of the patient in the case history or adding transcripts of communications between the doctor and the patient’s family members. Diary or journal entries recounting the patient’s reaction to their diagnosis and an ongoing account of physical and emotional sensations could be meaningful additions. More creatively still, interactive web-based technologies could help bring the paper case to life. Patient photos, and audio and video clips would be the bare minimum possible. Cases could be set up such that students encounter the case only by posing questions
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that reveal information through the patient’s own story, disclosing clinically relevant information interwoven with personal, social and cultural facts, as well as with emotions. The student responses and the questions they pose next would structure which parts of the complex, composite picture ⁄ person are revealed. Each student could end up with a different picture of the case, depending on how they directed the encounter. Some students could seek only the pertinent biomedical facts; others could trace hyperlinks in innumerable directions rippling out from the patient at the centre. Imagine linking to a conversation with a family member, or to a clip of the patient playing her or his favourite sport, or to a poem or diary entry written by the patient. Obviously, the potential for enriching the case is limited by time, money and technology. But not every case need be worked up in these ways – even a few would be a start. Most important, however, regardless of medium, is the inclusion of multiple voices, multiple perspectives. Pattison and colleagues23 argue that the power, and the danger, of using cases as teaching tools is that they appear to be drawn from Ôreal lifeÕ. Because of the immediacy and reality they appear to portray, the constructed, authored, edited nature of the case tends to be forgotten. The author of a case imposes an order, constructs a reality; then the author disappears from view. We are not arguing that the patient’s story is somehow closer to ÔrealityÕ than is the case as interpreted by the doctor.24 Rather, both versions of events are constructions, interpretations, stories. In each story, choices are made about what matters. Someone, some author, decides what to include and what to exclude; what to foreground and what to background.25 The problem with using cases (whatever the modality) as a way for students to encounter patients and their health concerns is not that the doctor-narrated case is Ôless trueÕ than the patientnarrated account, but rather that the prepackaged case constrains students’ choices about how to see events, privileging a particular account over all other possible accounts. There are always other ways of describing a situation; there are always other versions of reality.24 Positioning a particular way of seeing as normative renders less visible the choices that are being made whenever an account is constructed. Including multiple voices in a case would complicate that tidy reduction of choices. Students will have to learn soon enough to strip away the extraneous when producing their own accounts, their own case histories, throughout their careers; in their initial introduction to patients, in their PBL tutorials when
they are still learning, there still remains space for multiple voices.
THE NEED TO TEACH CRITICAL ASSESSMENT OF CASES Anspach argues that the format of the case history as used by doctors, clinical students and residents serves as an effective instrument for professional socialisation precisely because so many of its underlying assumptions about what constitutes relevant knowledge are unexamined and unquestioned.10 (p 372) The same is likely true of cases as used in PBL. We suggest that a key step to help students avoid some of the unintended consequences of learning through cases involves teaching them the skills they need to critically analyse the narratives they encounter. Cases are powerful learning and teaching tools. As Pattison and colleagues23 (p 45) suggest, it is critical that we look closely at their construction and authorship in order to use them Ôin a more discerning and selfcritical wayÕ. Drawing on Pattison et al.23 and others, we offer a series of questions PBL tutors and students could learn to ask of any case they encounter (Table 2). These questions do not in any way invalidate the veracity of the information contained in the PBL case; they simply acknowledge the case as story, as narrative, opening up the possibility that there are other equally valid ways of knowing about and reporting on the same situation or events. Routinely addressing such questions could help students to see the choices that are made when cases are written, to be conscious of the choices they themselves make when they write up case histories, something they will do for the rest of their careers. Teaching students to examine cases critically as narratives could help enable them to see the potential implications of their choices of perspective, voice, language, structure.
CONCLUSIONS The format and structure of the case history in clinical practice are well established means for efficient transmission of essential information. Although less intentionally, and certainly less consciously, they are also effective means for transmitting the values and assumptions of medical culture. When used in PBL pedagogy, cases continue to convey particular values: they tend to depersonalise patients, privilege the observations and interpretations of
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Table 2 Questions for critical assessment of cases Questions 1 2 3 4 5 6 7 8
From whose perspective or point of view is the case told? Who is the author of this account? What are the author’s biases, prejudices, assumptions, blind spots, values, viewpoints? How has order been imposed on this account of events? How would the account differ if constructed from someone else’s point of view? What has been excluded here that might be relevant if the account were told from someone else’s point of view? (people, events, emotions, observations, sociocultural contexts etc.) For what audience does this account seem to be written? Whose language is used in the case? With what implications? What literary devices have been used in constructing this account, with what effects? (e.g. active ⁄ passive voice, sequencing of information, assignment of agency, language that marks objectivity ⁄ subjectivity etc.)
medical experts while devaluing those of patients, and exclude the experiences and perspectives of patients and other actors in favour of the medical worldview. Choices are made when narratives are constructed. When cases are being authored for the express purpose of training students in PBL tutorials, choices could be made that would systematically counter some of the problematic aspects of professional socialisation. Case authors could refuse to use language and rhetorical structures that depersonalise and devalue patients. They could refuse to privilege the voice of the doctor and the ÔfactsÕ of medical observations and technological findings. They could choose to include multiple contradictory voices, to highlight the constructed nature of cases. They could, in as many ways as possible, make the patient ÔpresentÕ to the students, to counter their socialisation into detachment, at least for a while. Most importantly, tutors and case authors could systematically teach students the skills needed to make a critical assessment of cases, to help them open up the narratives they will be presented with, and will construct, throughout their careers.
ETHICAL APPROVAL Not applicable.
REFERENCES 1
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CONTRIBUTORS
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NPK conceived the idea for this study and wrote the first draft of the paper. BLB contributed to subsequent drafts and carried out substantial revision to the final paper.
FUNDING No external funds supported this project.
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Received 31 December 2002; editorial comments to authors 25 February 2003, 25 November 2003; accepted for publication 6 January 2004
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