Author Archives: ebrock

Constructivism and Case Based Learning

Simulation is a form of case based learning.

Case based learning grew out of the problem based learning discipline. PBL employs an open inquiry approach, in which students independently discover knowledge within a domain. Self directed learning is central to a PBL curriculum. The knowledge base is integrated through the discovery of its applicability across cases and problems. Barrows argues that the core of problem based learning lies in allowing students to “analyze and resolve the problem as far as possible before acquiring any information needed for better understanding.”(1)

PBL’s proponents have argued that it encourages lifelong learning, fosters the development of superior problem solving skills, and is firmly grounded in adult learning theory (self-directed, building on prior experience, relevant to the lives and work of learners). Critics of problem-based learning have argued that the open inquiry approach is inefficient, wastes faculty time, and leads to sometimes inaccurate or erroneous constructs which the learner establishes out of inexperience or lack of knowledge. Despite its theoretical strengths, learning outcomes in problem based learning curricula are mixed, leading educators to speculate on and attempt to mitigate the shortcomings of PBL and the reasons for the disconnect between theory and outcome.(2)

Case based learning leverages the theoretical underpinnings of PBL, but adopts a guided inquiry approach, in which the expertise of the instructor is used to guide the discussion toward relevant and accurate knowledge, and to mitigate group dysfunction that inhibits learning. Case based teaching requires both content expertise and expertise in group facilitation.

Case based learning has its critics as well, and they argue that the “guided” nature of CBL stifles creativity, and that the guidance may well be ineffective unless there is adequate attention to faculty development.

In a comparison of satisfaction and perceived value of PBL vs. CBL at two medical schools, Srinivasan et al reported that students and faculty overwhelmingly preferred CBL. Students felt that CBL was more efficient, provided better opportunity for applying skills learned, and provided valuable feedback.(3)

Simulation is grounded in the philosophies of case based teaching and learning, using the experience of the simulation to provide active engagement with the case, and guided inquiry to achieve the reflective observation necessary for learning.

In her primer on cases based teaching, Colich(4) reviews attributes and advantages of case based teaching. At its best, simulation will share these attributes. Learners will make and implement decisions by sorting out pertinent information from irrelevant information, they will apply prior knowledge to identify core problems, and they will formulate narratives about problems and strategies to address them. The learning outcomes (knowledge, skills and attitudes) match the ability of the case to challenge students in these areas.

Case based learning is a constructivist approach. Constructivism relies on the notions that learning is based on interactions with the environment, that cognitive puzzlement is a powerful stimulus for learning, and that social negotiation is an important contributor to knowledge acquisition.(5) Simulation is grounded in these ideas and in the principles of designing an authentic task, anchoring the learning in a larger problem, and providing opportunity for guided reflection. The idea of social negotiation is particularly interesting in its application to the desired learning for the simulation. Teaching the need to “speak up”, to avoid assumptions and to engage in error correction are substantial challenges for medical educators. The collaborative learning process gives us an opportunity to reinforce the notion that lack of comment or question implies agreement.

1. Barrow HS. Problem based Learning in Medicine and Beyond: A Brief Overview. New Directions for Teaching and learning 1996; 68: 3-12
2. Onyon C. Problem-based learning a review of the educational and psychological theory. The Clinical Teacher 2012; 9: 22-26
3. Srinivasan M. Comparing problem-based learning with case-based learning. Acad Med 2007; 82(1): 74-82
4. Golich C. The ABC’s of Case Based Teaching. International studies perspectives 2000; 1: 11-29.
5. Savery J and Duffy T. Problem based learning: An instructional model and its constructivist framework. in Wilson, BG. Constructivist learning environments: case studies in instructional design. Educational Technology Publications Inc., Englewood Cliffs, NJ. 1996

Feedback, assessments and more…

What is feedback in clinical education? van de Ridder JM, Stokking KM, McGaghie WC, ten CateOTJ.  Medical Education 2008; 42:189-97

The purpose of the research is to establish an operational definition of “feedback” for purposes of research and improved communication.  The authors reviewed the general, social science and medical education literature for conceptual formulations of and approaches to feedback.   Three concepts dominating definitions of feedback in the literature are:  feedback as information, feedback as a reaction, and feedback as a cycle.

The authors construct a definition of feedback in clinical education as “Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance.

Looking at the elements of this definition allows one to categorize feedback as week or strong (this is different from effective or ineffective).  Strong feedback, for example, includes specific information gleaned from observations of tasks or elements for which there is an explicit standard.  It derives from personal observation by experts with the aim of performance improvement.

This paper was published 7 years ago.  During that time the feedback attributes defined as “strong” have become the foundation of how we think about performance feedback in simulation.

So that’s STRONG feedback.  And effective feedback has to be strong, but strong feedback is not necessarily effective.  What’s the difference?

Linking Simulation Based Educational Assessments and Patient Related Outcomes: A systematic review and meta-analysis. Brydges R, et al. Acad Med 2015:90:246-256

First review of its kind trying to evaluate the evidence linking educational surrogates with corresponding assessments in the workplace — looking to examine the relationship between simulation based and patient related assessments — and furthermore if there is validity evidence for these outcomes, and what is the quality of methods and reporting in this body of research.

Almost 12 thousand articles screened, only 33 included in the review; these articles in total included 1203 participants. Patient related outcomes defined as provider behaviors and patient outcomes.

This is a long article.. If I think about what the message is – there seems to be suggestion that provider behaviors and time behaviors and patient outcomes each to varying degrees (higher to lower respectively) correlate with simulation outcomes. However – there are multiple instruments used to define/rate simulation outcomes and not all of these are validated.

Concerns from the writers about publication bias for the results – but no real way to exclude this…

Future ideas – contain recommendations to work these educational trials like we would drug trials, about consistency in ratings/assessment, sample sizes, etc.