Medical Teacher, Vol. 17, No. 2, 1995 161

Twelve tips for making case presentations more interesting

JENNIFER CRAIG’ & LILI KOPALA’, I Department of Family Medicine, Department of Psychiatry, University of British Columbia, Canada

SUMMARY A common method of presenting cases is to provide a passive audience with patient information that has been analyzed and synthesized and with all conclusions drawn so that the audience is not required to think or participate in any way. This paper presents 12 tips for a more active and interesting method which follows the line of reasoning in which clinicians engage. Each step is followed by an example taken from a real case presentation given by a psychiatry resident.

Introduction

Instead of being challenging and thought provoking, many case presentations are a recitation of facts about a patient often delivered in a monotone and with no audience participation whatsoever. Audio-visual aids frequently consist of over- head transparencies covered in tiny green writing which display every known fact about the patient down to where their grandmother lived. At the end of 30-45 minutes of this, the presenter asks, “Are there are any questions?”. At this point the more noble of the audience rouse themselves to try and think of something intelligent to say. Yet the study of patient conditions and their outcome is the very meat of medical teaching. In this paper we describe 12 tips for making case presentations thought provoking, enjoyable and useful for everyone. These tips may be followed by physicians when they are teaching students or residents (or equivalent), or taught to the latter as a way of giving their own presentations. Each step description is followed by an example taken from a recent case presentation by a resident in psychiatry to other residents, staff and students.

It is a well-known maxim that adult learners like to solve problems. When patients are first seen they present with a problem which a physician is challenged to solve. Such challenges are the enjoyable aspect of medicine, and only after several years of meeting similar problems do physicians become bored. So the

0142-159)3/95/020161-06 0 1995 Journals Oxford Ltd

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.

162 J. Craig & L. Kopala

whole challenge when presenting a case is to allow the audience to go through the thinking process that took place when the patieent was first seen. Patients do not arrive with a transparency covered in green writing pinned to them, so prior to any case presentation one must reflect on each step of the decision making and determine the information available at the time, what information was needed and the puzzles at each decision-making juncture.

Tip one: set the stage

Prepare the audience for what is to come. If the audience is composed of people of mixed expertise, spend a few minutes forming them into small mixed groups of novices and experts. Explain that this is an opportunity for the more junior to learn from the more senior people. Tell them that the case to be presented is extremely interesting, why it is so and what they may learn from it. The primary objective is to analyse the clinical reasoning that was used rather than the knowledge required, although the acquisition of such knowledge is an added benefit of the session. As Kassirer (1 983) points out, a “well organized case presentation or clinicopatholog- ical conference incorporates the logic of the workup implicitly and thus makes the diagnostic process seem almost preordained”.

Example

The resident began by introducing the case as an exciting one, explaining the process and dividing the audience into teams mixing people with varied expertise. He urged everyone to think in ‘real time’ rather than jump ahead and to refrain from considering information that is not normally available at the time: for example, a laboratory report that takes 24 hours to obtain cannot be assessed in the initial workup.

Tip two: provide only initial cues at first

Give them the first two to five cues that were picked up in the first minute or two of the patient encounter either verbally, or written on a transparency. For example, age, sex, race and reason for seeking medical help. Ask each group to discuss their first diagnostic hypotheses. Experts and novices will learn a great deal from each other at this stage and the discussions will be animated. The initial cues may number only one or two and hypothesis generation occurs very quickly even in novices. Indeed, the only difference between the hypotheses of novices and those of experts is in the degree of refinement, not in number (Barrows et al., 1978; Elstein et al., 1978; Gale & Marsden, 1983).

Example

It is Saturday afternoon and you are the psychiatric emergency physician. A 25-year-old male arrives by ambulance and states that he is feeling suicidal. Groups talked for 4 minutes before the resident called for order to commence step three.

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.

Case presentations 163

Tip three: ask for hypotheses and write them up on the blackboard

Call for order and ask people to offer their suggested diagnoses and write these up on a board or transparency.

Example

The following hypotheses were suggested by the groups and the resident wrote them on a flip chart: depression, substance abuse, recent social stressors-crisis, adjustment disorder, organic problem, dysthymia, schizophrenia, bipolar affective disorder. The initial three or four bits of information generated eight hypotheses.

Tip four: allow the audience to ask for information

After all hypotheses have been listed instruct the audience to ask for the infor- mation they need to confirm or refute these hypotheses. Do not allow them to ‘jump the gun’ by asking for a test result, for example, that would not have been received within the time frame that is being re-lived. There will be a temptation to move too fast and the exercise is wasted if information is given too soon. Recall that the purpose is to help them go through a thinking process which requires time.

Teachers participating in this exercise will receive much diagnostic information about students’ thinking at this stage. Indeed, an interesting teaching session can be conducted by simply asking students to generate hypotheses without proceeding further. There is evidence to suggest that when a diagnosis is not considered initially it is unlikely to be reached over time (Bordage & Allen, 1982). Hence it is worth spending time with students to discuss the hypotheses they generate before they proceed with an enquiry.

Example

Directions to the group were to determine what questions they would like to ask, based on gender, age and probabilities, to support or exclude the listed diagnostic possibilities. A sample of questions follows:

Does he work? No, he’s unemployed. Does he drink? one to three beers a week. Why now? He’s been feeling worse and worse for the last 3 weeks. Social support? He lives alone. Has no girlfriend. Appearance? Looks his age. Not shaved today. No shower in 3 days. Cultural background? Refugee from Iraq. Muslim. How did he get here? He spent 4 years in a refugee camp after spending 4 months walking to Pakistan from Iraq. He left Iraq to avoid military service. Suicide thoughts? Increasing the last 3 weeks. He was admitted in December and has been taking chloral hydrate.

This step took 13 minutes.

Tip five: have the audience re-formulate their list of hypotheses

After enough information has been gained to proceed, ask them to resume their

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.

164 J. Craig & L. Kopala

discussion about the problem and reformulate their diagnostic hypotheses in light of the new information. Instruct them to discuss which pieces of information changed the working diagnosis and why. Call for order again and ask people what they now think.

Example

After allowing the group to talk for a few minutes, the resident asked them if there was enough information to strike off any hypotheses or if new hypotheses should be added to the list. One more possibility was added, post-traumatic stress disorder (PTSD). One group’s list of priorities was major affective disorder with psychosis, schizophrenia, personality disorder. Another group also placed affective disorder first followed by organic mood disorder.

This step took 25 minutes.

Tip six: facilitate a discussion about reasoning

Alter the original lists of hypotheses on the board in light of the discussion, or allow one member from each group to alter their own lists. By the use of open-ended questions encourage a general discussion about the reasons a group has for preferring one diagnosis over another.

Example

A general discussion ensued about reasons for these priorities. Then the list was altered so that it read: schizophrenia, personality disorder, PTSD, major affective disorder with psychosis, organic mood disorder.

Tip seven: allow another round of information seeking

Continue with another round of information and small-group discussion or else allow the whole group to interact. By giving information only when asked for and only in correct sequence, each person is challenged to think through the problem.

Example

More information was sought, such as: form of speech? eye contact? affect? substance use? After 5 minutes the resident asked if there were any lab tests they would like. The group asked for thyroid stimulating hormone, T4, electrolytes and were given the results. They also asked for the results of the physical examination and were told that the pulse was 110 and the thyroid was enlarged. At this point some hypotheses were removed from the list.

Tip eight: ask groups to reach a final diagnosis

When there is a lull in the search for information, ask the groups to reach consensus on their final diagnosis, given the information they have. Allow discussion within the groups.

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.

Case presentations 165

Tip nine: call for each group’s final diagnosis

On each group’s list of hypotheses, star or underline the final diagnosis.

Example

Each group decided that the most likely diagnosis was affective disorder with psychosis, the actual working diagnosis of this patient.

Tip ten: ask for management options

If there is enough time, ask them to form small groups again to discuss treatment options, or conduct the discussion as a large group. Again ask for the reasons why one approach is preferred over another. Particularly ask the experts in the room for their reasoning so that the novices can learn from them.

Tip eleven: summarize

By the time the end is in sight the audience will be so involved that they will not wish to leave. However, 5 minutes before time, call for order and summarize the session. Highlight the key points that have been raised and refer to the objective of the session.

Example

We are now at the end of our time. You have all had the opportunity to use your clinical reasoning skills to generate several hypotheses which are shown on the board. Initially you thought it possible that this man could have any one of a number of diagnoses including depression, substance abuse, adjustment disorder with depressed mood, organic mood disorder or post-traumatic stress disorder. With further information the possible diagnosis shifted to include schizophrenia and personality disorder as well as depression with psychotic features. Finally the diagnosis of depression or mood disorder with psychosis was most strongly supported because of the history of consistently depressed mood over several months, along with disturbed sleep, poor appetite, weight loss, decreased energy and diminished interest in most activities. The initially abnormal thyroid test proved to be a red herring so organic mood disorder related to hyper- or hypo-thyroidism was excluded. Additionally absence of vivid dreams involving a traumatic event made a diagnosis of post-traumatic stress disorder unlikely. Although a diagnosis of schizophrenia could not be totally excluded, this seemed less likely given the findings.

Tip twelve: close the session with positive feedback

In some respects, but only some, teaching is like acting and one should strive to leave them not laughing as you go, but feeling that they have learned something.

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.

166 J. Craig 63 L. Kopala

Example

The more novice members of the group have learned from the more experienced and all your suggestions have been valid. It has been interesting for me to follow your reasoning and compare it with mine when I actually saw this man. You have given me a different perspective as you thought of things I had not, and I thank you for your participation.

Summary

Although case presentations should be a major learning experience for both novice and experienced physicians they are often conducted in a stultifying way that defies thought. We have presented a series of steps which, if followed, guarantee active participation from the audience and ensure that if experts are in the room their expertise is used. Physicians have been moulded to believe that teaching means telling and, as a consequence, adopt a remote listening stance during case presentations. Indeed the back row often use the time to catch up on much needed sleep! Changing the format requires courage. We urge you to try out these steps so that both you and your audience will learn from and enjoy the process.

Acknowledgments

The authors wish to thank Dr Sean Flynn, a psychiatry resident, who actually presented this case.

Notes on contributors

JENNIFER CRAIG is an Educational Consultant and Honorary Associate Pro- fessor in the Department of Family Medicine, University of British Columbia. She is the Regional TIPS Director for Canada and the Commonwealth and UBC TIPS site director.

LILI KOPALA is an Assistant Professor in the Department of Psychiatry, Univer- sity of British Columbia. She is the Director of Communication Skills for medical students and a member of the TIPS workshop faculty.

Correspondence: Dr Jennifer Craig, Division of Educational Support and Development, 400-2 194 Health Sciences Mall, University of BC, Vancouver, BC, V6T 123, Canada. Tel and fax: 604 352 6436. E-mail: jcraig@awinc.com

REFERENCES

BARROWS, H.S., FEIGHTNER, J.W., NEUFELD, V.R. & NORMAN, G.R. (1978) An analysis of the clinical methods of medical students and physicians, report submitted to the Province of Ontario Department of Health and Physician Services Inc. Foundation, McMaster University, Hamilton, Ontario.

BORDAGE, G. & ALLEN, T . (1982) The etiologv of diagnostic errors: process or content? An exploratoy study, paper presented at the 2 1st Annual Conference on Research in Medical Education of the American Association of Medical Colleges, Washington, DC.

ELSTEIN, A.S., SHULMAN, L.S. & SPRAFKA, S.A. (1978) Medical Problem-Solving. An Analysis of Clinical Reasoning, Cambridge, MA: Harvard University Press.

GALE, J. & MARSDEN, P. (1983) Medical Diagnosis, Oxford, Oxford University Press. KASSIRER, J.P. (1983) Teaching clinical medicine by iterative hypothesis testing, New England Journal

of Medicine, 309, pp. 921-923.

Med

Tea

ch D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y N

yu M

edic

al C

ente

r on

11/

09/1

4Fo

r pe

rson

al u

se o

nly.