Medical Teacher, Vol. 9, No. 3, 1987 28 1

The Case Presentation: teaching medical students writing and communication skills

LARRIE W. GREENBERG 81 LESLIE S. JEWETT, ChiMren’s Hospital National Medical Center and George Washington University School of Medicine and Health Sciences, Washington D. C.

SUMMARY This paper describes a program in which the focus is on improving medical students’ writing and communication skills as part of a paediatric clerkship. Based on the quality of students’perjimance and their evaluation of the exercise, this has been a successful innovation.

Introduction

Two of the most important objectives for medical students to learn during their undergraduate education are presenting a case effectively and recording their observa- tions in an organised and succinct manner. Although these skills may be periodically stressed within the context of daily activities such as rounds, few programs in the clinical years have reported the formal incorporation of writing and communication skills into their curricula (Zack, 1982; Weinhole, 1983; Anderson et al., 1984; Roland 81 Cox, 1976). The purpose of this report is to describe a successful program developed for third year medical students on a pediatric clerkship.

Methodology

Since 1978 all third year medical students rotating through the Children’s Hospital National Medical Center (CHNMC) are required to select and perform an in-depth study of an interesting patient with whom they have worked, record this information and orally present before their peers and a faculty preceptor within a finite time period. Students select disease-oriented topics or those involving well child/baby care. Three to four students are randomly assigned to present their case from the second through the eighth Thursday afternoon of the rotation. Guidelines provided to the students on the first day of the rotation include the following:

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282 Larrie W. Greenberg & Leslie S. Jewen

(1) The case abstract may not be longer than three and one-half typed pages,

(2) The case history should include all relevant clinical and laboratory data, with

(3) The abstract should incorporate appropriate literature specific for the focus of

(4) A list of three to ten pertinent recent references regarding the case in addition to

(5) Tables and graphs are not included in the three and one-half pages. (6) Audio-visual aids are suggested. An example of an actual previous case presentation is provided in student folders at

orientation for reference purposes. Students are encouraged to choose topics from the core curriculum and have an opportunity to consult with the clerkship director or other faculty about their topic.

The oral presentation is limited to 30 minutes and the presentors are expected to reserve some of this time for answering questions and clarifying points. There is no standard format for presenting although each presentation should include a pertinent history and physical examination, an assessment and plan in addition to an in-depth discussion about the chosen topic.

A core group of eleven faculty have volunteered to precept cases and have each been orientated to the format and responsibilities prior to the first assignment. Preceptors receive the cases the day prior to the presentations to allow time to read and evaluate the abstract.

The case presentation is weighted 20% of the final clerkship evaluation in the form of a letter grade given by the faculty preceptor and a randomly selected group of three to four student peers. Comments and grades are assigned by the preceptor and peers as each student finishes hidher presentation. At the conclusion of the session, students and the faculty preceptor discuss the evaluations, with these being weighted 25% and 75%, respectively of the case presentation grade. The faculty preceptors then have the responsibility of meeting individually with each presentor to provide feedback.

The criteria used to evaluate each presentor are the following: (1) skill of presenta- tion including eye contact, appropriate audio-visual aids and ability to elicit audience participation; (2) case history summary, including pertinent positives and negatives, relative lab data and the clarity and logic of the presentation; (3) knowledge of the caseldisease, specifically the prognosis, complications, treatment, emotional aspects and handling of peer questions; (4) case abstract, including a concise and logical presentation, relevant to the learning of junior students, syntax and completeness in covering the specified area; (5) references, including a review article and relevant and up-to-date articles.

Students have the opportunity to evaluate this exercise at the end of the rotation as part of the overall evaluation of the clerkship. A scale of one to five is used, with one contributing minimally or nothing to one’s learning and five representing the maximal contribution.

including references and may be single spaced.

pertinent negatives.

the case.

a review article is recommended.

Results

Student performance on the case presentations has been very good and of high quality, reflecting significant student input into the process (Table I).

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Learning Case Presentation 283

TABLE I. Comparison of preceptor and faculty evaluations

Grade Faculty Students*

A 63 64 B 72 73 C 4 2

*Represents compilation of student evaluators.

At the conclusion of the clerkship, students related this exercise 4.0 on a scale of 5.0. Student comments were very positive about the experience, with 30% stating that they were happy to have the opportunity to present to their peers and another 6% commenting that this was one of the most valuable educational experiences of the rotation. Twelve per cent rated it as an excellent learning exercise. Fifteen per cent thought that faculty preceptors were helpful, fair and provided positive feedback to presentors; but 12% felt evaluators were too inconsistent and there was too much subjectivity in grading. Only five students (4%) commented that they received no feedback or that the preceptors contributed little to the presentations. Less than 10% felt that peer and faculty evaluations were too critical. Other comments included that the exercise was too stressful (3%), a waste of time (2%), and there should be either no grading or less emphasis on grading.

Discussion

Although few medical students are expected to write a scientific paper during their undergraduate training, they do have the responsibility of mastering the fundamentals of good communication (Roland i? Cox, 1976). Writing skills should also not be taken for granted nor should it be assumed that students are well-rounded in the art of English syntax. In the educational experience described in this paper, students have to focus on a topic and then survey the literature in that area, making certain the subject matter is not too broad in scope. Reading the literature critically, choosing pertinent information and eliminating non-contributory facts are skills the student has to master in this exercise. Writing the abstract with space constraints also teaches the student self-discipline and encourages him/her to further eliminate extraneous material. An added benefit is to stimulate students to be more self-directed learners as advocated in the GPEP report.

Preceptor feedback to each student presentor is an important aspect of this experience. Students are evaluated on their skill of presentation, case history summary, knowledge of the case/disease, case abstract and references. Student performance has been very good, with the main deficiencies being the following: choosing too broad a topic to cover in the allotted spaceltime; poor organisation of the abstract and/or oral presentation; and rarely, not enough preparation.

Most students have rated the experience as very important in their learning experiences. Their major complaint was that faculty preceptors were inconsistent in the evaluations, with some expecting higher levels of performance than others. This is a valid criticism but is not different than subjective faculty evaluations of students in

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284 La& W. Greenberg & Leslie S. Jewett

the ambulatory or inpatient settings. Most of the other criticisms, related to different aspects of grading, i.e., students should not grade, grading is too critical, etc.

REFERENCES

ANDERSON, WIUW A., BRIDGHAM, ROBBRT G., ALGKJ~RE, PATRICK C. & MAYLB, JAMES E. (1984) Improving medical students' clinical case presentation skills A n n d Meeting of the American Educational Research Association, April, 1984, New Orleans.

ROLAND, CHlw~s G. & Cox, BARBARA G. (1976) A mandatory course in scientific writing for undergra- duate medical students, Journal of Medical Educ&n, 51, pp. 89-93.

WBINHOLTZ, Do" (1983) Directing medical student clinical case presentations, Medical Education, 17, pp.

ZACK, BRIAN G. (1982) A guide to pediatric case presentations, Resident and S&z#Physiciun, 28, pp. 71-80. 364-368.

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