Collaboration + DxR Clinician = Enhanced Learning Opportunity

Collaboration + DxR
Clinician = Enhanced
Learning Opportunity
Presented by:
Natalie Walkup, MPAS, PA-C
Vivian Moynihan, MD, MPH
Disclosures
• Although Dr. Moynihan serves as an ARC-PA
commissioner, her opinions and remarks during this
workshop/presentation represent her own views and
not those of the ARC-PA.
Objectives
At the conclusion of this session, participants will:
• Identify opportunities for curricular collaboration
among faculty members and courses
• Examine the relationship between use of computer
case-based interactive learning and student
confidence in forming differential diagnoses
• Analyze options for assessment of critical thinking
by student teams
Overview
• Aligned Clinical Medicine I and Diagnostic and
Therapeutics I (cardiology, respiratory, ENT,
infectious disease, hematology)
• Assigned a total of 8 DxR Clinician cases over the
course of the semester
• Students worked in groups to complete virtual cases
in 2 hours
• Each group was responsible for a case presentation
DxR Clinician
• http://www.dxrgroup.com/clinician/
• Pre-authored virtual patient cases
• Student responsibilities:
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Obtain complete history
Perform a virtual physical exam
Order appropriate laboratory testing
Establish a plausible and broad differential diagnosis
Establish and justify (using pathophysiology) a final
diagnosis
Incorporating DxR Clinician
• Chose cases that were relevant to the lecture
material, but may or may not be presented in lecture
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Dissecting Aneurysm
Acute Coronary Syndrome
Myelodysplastic Syndrome
Periorbital Cellulitis / Sickle Cell Crisis
Cholesteatoma
Multilobar Community Acquired Pneumonia
COPD with Cor Pulmonale
Infective Endocarditis
Incorporating DxR Clinician
• Freed up class time for cases by placing some
lectures on Lecture Capture for students to review
on their own time
• Total of 8 DxR Clinician cases to be completed in
groups in a 2 hour timeframe
• 8 total student groups with 5-6 students per group
Incorporating DxR Clinician
• Students completed cases unsupervised and were
provided a laptop and projector / screen
• 4 cases went toward Clinical Medicine I grade and 4
cases went toward D&T I grade
• Each group was responsible for one assigned case
presentation per semester. Presentations were very
in-depth covering history, physical, labs, Ddx,
assessment, and plan
• Students were provided the grading rubric for the
cases and presentation
Student Competencies
• Medical knowledge – students were expected to
incorporate medical knowledge derived from
didactic course and learning from case work
• Patient Care – student presentations had to provide
detailed patient education and care plan
• Communication – expected students to be able to
collaborate with each other in order to work through
the cases as well as provide patient education
Student Competencies
• Professionalism – collegial teamwork and
presentation skills
• Systems-based practice – forced students to consider
cost of resources and risk of patient exposure
• Practice-based learning – for presentations students
were expected to use valid research to support their
assessment and plan
Student Perception
• 2 surveys were submitted – mid-semester and end of
semester
• Assessed student confidence in DxR Clinician in the
following areas:
• Developing differential diagnoses
• Understanding of physical exam findings
• Identifying appropriate laboratory tests in specific
patients / diseases
• Enhance lecture based learning
Student Perception
• Responses were assessed using a traditional Likert
Scale (strongly agree, agree, disagree, strongly
disagree)
• Students were also able to provide feedback
• Surveys were computerized and completely
anonymous to both instructors
• Mid-semester survey provided a positive response.
Program was continued and evaluated by end of
semester survey.
Student Perception
• Final Survey Results:
• Final survey had 34/41 responses (82.9% response rate)
• 100% agreed that the DxR Clinician cases helped to
improve skills in developing Ddx
• 97% agreed DxR Clinician cases improved overall
understanding of course concepts
• 97% agreed DxR Clinician cases improved
understanding of physical exam findings
• 94% agreed DxR Clinician cases improved ability to
appropriately order and interpret laboratory results
Student Perception
• 100% agreed that using DxR Clinician cases improved
overall understanding of course concepts
Student Perception
• Reinforcement of didactic material
• “Reinforced what I have learned in class”
• “I liked that the cases were mostly pertinent to something we
had gone over (or were about to cover in the near future)”
• “It really helps to connect the big picture between the two
classes (and pathophysiology)”
• “I learn more when the illness or condition has already been
presented to us in lecture, it reinforces material and actually
gives a disease / illness a person that I can identify or
associate with”
• “Excellent supplement to lecture and individual study”
Student Perception
• Critical thinking, analysis, application
• “It was a great way to incorporate what we have learned in the
classroom into real life scenarios”
• “It (DxR) gave us the opportunity to apply our knowledge in a realworld way. I don’t know that I would feel comfortable seeing
patients for the first time without having the practice of critical
thinking / forming a differential / ordering labs that was provided
in DxR”
• “Researching the case helped me discover medical resources and
further information regarding testing and differential diagnoses
than I would have learned in class as we had an opportunity to go
deeper into one specific illness.”
• “The opportunity to coalesce my class subjects (Clin Med Pharm,
D&T, PE…) into an applicative process further enhanced my
understanding and reinforced the integrative process of learned
knowledge and hands-on training.”
Student Perception
• Student collaboration
• “It was helpful to talk out the pathophysiology for the dx that
explain symptoms and lab findings. I like working in groups.
I felt like my classmates taught me and the information that I
knew was re-informed when I explained something.”
• “Working as a team is very important and I think it is a good
way to teach collaboration.”
• “Everyone pulls different information from lecture, some of
us struggle with lecture more than another – but when we are
all together working on a case we teach each other and help
each other learn in a way that is better than lecture for
some.”
• “We were able to work together efficiently to solve the case.”
Student Perception
• Relevant “real-life” experience
• “This experience (DxR), as well as the simulation scenarios are
so helpful for me to see medicine in action. While I sit in class
(especially Clin Med) I sometimes have a hard time imagining a
patient with some of the conditions, especially with the overlap
of conditions and how sometimes conditions do not present
quite like the textbook would suggest.”
• “Being able to put a certain illness / disease to a real life
situation helped me remember little details about the disease
(which would have been hard to remember just studying the
notes alone).”
• “I would rather begin learning differential diagnosis, physical
exam, and laboratory testing in a case by case situation on a
computer program where the mistakes or trials I make WILL
NOT have impact on a human being.”
Faculty Perception
• Significantly improved student ability to
appropriately develop differential diagnoses
• Forced students to apply anatomy, physiology and
pathophysiology in a real concrete situation
• Improved student critical thinking skills
• 100% pass rate for both D&T I and Clinical
Medicine I
Future Use
• Used DxR Clinician again in summer semester for first
year students in D&T II. Cases supported topics covered
in Clinical Medicine II.
• Allowed 4 hours to work on cases. Increased
requirements to include treatment and patient education
for each case.
• Student requirements matured with students
• Required complete H&P, SOAP note and pathophysiology to
be submitted
• Identified areas that were weak in write-ups
Future Use
• Limitations:
• Grading rubric was limited and time intensive for
faculty
• DxR Clinician software requires some significant
adjusting for certain cases in order to ensure cases are
plausible and at an appropriate level for the first year
PA students
Questions ?
Natalie Walkup, MPAS, PA-C
University of Toledo
Assistant Professor, D&T I, II, III
natalie.walkup@utoledo.edu
Vivian Moynihan, MD, MPH
University of Toledo
Assistant Professor, Clinical Medicine I, II
vivian.moynihan@utoledo.edu
References
• Lilienfield LS, Broering NC. Computers as teachers: learning
from animations. Am J Physiol. Jun 1994;266(6 Pt 3):S47-54.
• Maldonado R. The use of multimedia clinical case scenario
software in a problem-based learning course: impact on faculty
workload and student learning outcomes. J Physician Assist
Educ. 2011;22(3):51-55.
• Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of
health care team training and the state of practice: a critical
review. Acad Med. Nov 2010;85(11):1746-1760.
• Gordon JA, Oriol NE, Cooper JB. Bringing good teaching
cases "to life": a simulator-based medical education service.
Acad Med. Jan 2004;79(1):23-27.
Evaluation Rubric for Presentations
Team members: (You will be assessed as a team)
_____ - All students on the team communicated in a clear and understandable way
_____ - PowerPoint presentation was well organized and free of error
_____ - Presentation was focused on development of a well-reasoned differential
diagnosis which was supported by the patient’s history, physical exam and
laboratory results
_____ - All laboratory results that were pertinent to the patient’s differential
diagnosis were justified as to what the expected result of each test would be
based on differential diagnosis
_____ - Strengths and limitations of all pertinent laboratory tests were presented
_____ - Clear explanation and reasoning of any change in differential diagnoses after
laboratory results received
_____ - Clear justification and support of final diagnosis based on patient’s
presentation and laboratory results
_____ - Pathophysiologic explanation of disease process was logical and wellreasoned
_____ - All acceptable treatment options were discussed and presented in a logical
manner
_____ - A final proposed treatment plan was logical and supported by medical
literature
_____ - Any necessary health education and/or prevention measures were discussed
_____ - A thorough discussion of the final diagnosis was delivered in a manner that
would provide an understanding of the disease processes epidemiology,
occurrence rate, causes, prevention, etc.
_____ - Presentation was at least 30 minutes but not more than 60 minutes.
Comments:
DxR Grading Rubric
Team Number:______
Grading
Criteria
Unsatisfactory
Satisfactory
Excellent
Was the Ddx
appropriate for the
H&P? (1pt)
Ddx was not supported by the
group’s findings in the H&P
(0pt)
Ddx was somewhat supported by
the group’s findings in the H&P
(0.5pt)
Ddx was fully supported by the
group’s findings in the H&P (1pt)
Were the laboratory
tests properly
justified in ordering
them? (2pts)
Group did not provide a
reasonable justification for
ordering tests (0pt)
Group provided a somewhat
reasonable justification for
ordering tests (1pt)
Group provided a reasonable
justification for ordering tests (2pts)
Were the laboratory
tests appropriately
interpreted, if
interpretation was
required? (1pt)
Group demonstrated no
reasonable lab interpretation
(0pt)
Group demonstrated reasonable
lab interpretation on some labs
(0.5pt)
Group demonstrated reasonable lab
interpretation (up to skill level) on
all required labs (1pt)
Did the group
demonstrate
appropriate use of
laboratory
resources? (1pt)
Group order many unnecessary
and potentially harmful tests
(0pt)
Group order a few unnecessary
tests, but did not pose any harm
to patient (0.5pt)
Group ordered tests that were
focused on their Ddx, with patient
safety in mind (1pt)
Group did not order the
necessary tests to support final
diagnosis (0pt)
Group ordered some, but not all
necessary tests to support final
diagnosis (1pt)
Group ordered necessary testing to
support final diagnosis (2pts)
Was the final
diagnosis justified
by the H&P and
Laboratory results?
(2pt)
Final diagnosis was not justified
by group (0pt)
Final diagnosis was justified by
either H&P or lab testing but not
both (1pt)
Final diagnosis was justified by both
H&P and lab testing (2pts)
Was the final
diagnosis explained
by pathophysiology?
(1pt)
Final diagnosis was not
explained using
pathophysiology (0pt)
Final diagnosis was somewhat
explained using pathophysiology
(0.5pt)
Final diagnosis was well explained
using basic pathophysiology (1pt)
Were the laboratory
tests needed to
support the
diagnosis ordered?
(2pts)
Total Points from Rubric: ________/10
DxR Evaluation Form
DxR Case: ______________________________________________________________________________
Team Number: ________
Team Members:
1.
2.
3.
4.
5.
6.
Ddx:
Laboratory tests ordered:
Final Diagnosis: __________________________________________________________________
DxR Rubric score: _________/10
Comments: