THE WAY WE TEACH...
The Cardiovascular System Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
D. A. POWIS and R. L. B. NEAME D.A . Powis,
is Lecturer, and R . L. B. Neame, MA, PH.D, MB, B.CHIR, is Senior Lecturer in H u m a n Physiology, Faculty of Medicine, The University of Newcastle, New South Wales, Australia. B.SC, PH.D,
In the last issue of this journal an approach to the construction of integrated, multidisciplinary course units was described (Neame 1981). This approach is illustrated in relation to the cardiovascular system course unit developed for use early in the second year of the five-year curriculum at the Faculty of Medicine, The University of Newcastle, New South Wales. A fully integrated course of medical studies centred around organ systems is necessarily constructed and presented rather differently from its conventional counterpart. Traditionally, the various medical, paramedical and basic science disciplines construct independent courses to teach all those facts and concepts which they consider a prospective medical graduate should know. At the time of presentation of each course the student usually has little or no idea of how this knowledge will be of use to him as a practising doctor: all too often, when its relevance finally is appreciated, the detailed information has long since passed from memory. The fully integrated approach practised at Newcastle is the antithesis of the traditional. Here, the course is built around a series of ‘priority’ clinical problems (Neame 1981); the disciplinary input for each of these is restricted to that information necessary to allow the students to understand and be able to manage that condition. For example, a clinical problem based on an acute myocardial infarction would require consideration of the anatomy of the chest and mediastinal contents, the physiology of the coronary circulation, the biochemistry and physiology of tissue respiration and pain mechanisms, the anatomy of pain referral, the pathology of ischaemic change, inflammation and repair, the pharmacology of morphine and anti-arrhythmia, the epidemiology of ischaemic heart disease as well as other discipline-based material encompassed in the study of an acute myocardial infarction. Problem-based learning in medicine owes much to the developments originally undertaken at McMaster University: the concept is elegantly explained in a recent book by Barrows and Tamblyn (1980). The potential advantages of the approach to learning developed by Newcastle University have been described previously (Neame
Medical Teacher V o l 3 No 4 1981
1981), but from the point of view of the student two aspects must be emphasized. First, the interdisciplinary approach to the construction of the problems leads to a softening of the arbitrary boundaries between disciplinary territories and may promote unity between clinical and preclinical smdies. Second, the relevance of all material to be studied is clear at the outset since the student sees its immediate application: this makes it easier for him to comprehend and remember its essential significance. It is clear that for such a course as this to be an effective means of training the prospective medical practitioner, the ‘priority’ problems must be selected with care so as to provide appropriate coverage of subjects and embrace as many as possible of the concepts considered essential by the disciplines.
The Cardiovascular System
Although at Newcastle the main thrust of learning about the cardiovascular system occurs in Term 4 (first term, second year) of the medical course, in parallel with studies on the respiratory system, the subject is really studied on a ‘spiral’ throughout the whole five years of the course. The students are confronted repeatedly with problems of the cardiovascular system in the context of units whose primary orientation is towards other body systems. At each successive ‘turn’ of the educational spiral students are exposed to material covering the same basic principles but requiring them to deal with it in greater depth, and with emphasis upon the more complex concepts and inter-relationships. The importance of the cardiovascular system to whole body function is introduced in Term 1 by a problem about blood loss and trauma resulting from a road traffic accident. Other problems in the first two terms of the course introduce the cerebral circulation (in a patient who has suffered a stroke) and the peripheral circulation (in a patient who suffers a femoral arterial embolism). In the third year many of the basic principles are re-emphasized and some new concepts introduced when detailed study is made of various emergencies (cardiac arrest, burns, 131
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
anaphylactic shock) and of chronic systems failure (congestive cardiac failure, hypertension). In the fourth year students encounter a number of problems relating to cardiovascular system dysfunction in pregnancy, the foetus, the newborn and in children. Throughout the course, and particularly in the fifth and final year, the ward-based clinical attachments bring the student into contact with a variety of patients suffering from cardiovascular ailments, some of which they will have studied previously. In this way the student is required to apply familiar concepts to new situations, thereby increasing the breadth and depth of his understanding of the cardiovascular system. Content of the Cardiovascular System Unit-Term
4
The time available for the study of each organ system unit is about four to five weeks and so careful planning of the course material is essential to ensure that there is an adequate and comprehensive exposure to the essential underlying principles, concepts and mechanisms pertinent to the system. For example, choosing a cluster of problems all based on functional disorders of the heart would not be satisfactory since much essential material relating to the structure and function of the peripheral vasculature and to concepts of the circulatory system as a whole would be missed. Selection of material to achieve an adequate and comprehensive exposure to the essential underlying principles, concepts and mechanisms is something that cannot be undertaken by one individual; it is an issue of vital importance to all disciplines and interests represented in the school. The negotiation and consultation mechanism whereby these interested parties have their input into the planning and preparation of each course unit has been described in some detail (Neame 1981). The outcome of such discussions is an agreed list of objectives for the unit (Figure l ) , which specifies the knowledge, understanding and skills that the student should acquire in relation to the cardiovascular system. The reader will note a relative deficiency of process objectives therein, that is of objectives which specify skills relating to communication, ability to solve problems, attitudes or professionalization etc. Process skills are acquired over a much longer time scale than the five weeks allocated to this unit and therefore feature more prominently in the longer term objectives such as those for the whole programme (Faculty Working Paper No. VI).
The Problems Each problem is constructed to follow the course of a patient through his entire illness, from presentation to resolution, and is presented to the students through a sequence of trigger materials (Neame 1981). It is our preference to have such trigger materials resemble as closely as possible the format of actual doctor/patient encounters. Since the students at this point in their medical careers have relatively little detailed knowledge of the subject matter, each problem initiates learning on a large range of new topics, with the consequence that a
132
substantial time allocation must be made for their study. It has become our practice therefore to work on the principle that each completely new problem will require about one week of study time. Thus there is time for a total of only four problems in the cardiovascular system unit: the rest of the 11-week term is taken up with study of a similar number of respiratory system problems, one week for consolidation of learning and one week for assessment and evaluation of the term’s activities. T o obtain a relatively comprehensive coverage of the major concepts relating to the cardiovascular system in health and disease within the limits defined by the Block Objectives, the following problems have been developed:
1. Collapse in a young adult due to vasovagal syncope.
2. Palpitations due to a supraventricular tachycardia in a 35-year-old woman. 3. Chest pain and collapse in a middle-aged businessman due to acute myocardial infarction. 4. Transient hemiplegia due to cerebral embolism, together with heart failure consequent upon severe mitral stenosis in a middle-aged woman.
A brief survey of these problems will give the reader some idea of the content of the unit; in addition, a detailed description of problem number three follows, to illustrate how the system works in practice. Problem 1. A videotaped introduction shows a young soldier on parade in the sun who is seen to collapse. H e is taken to the sick bay where he recovers without any ill effects other than feeling rather ‘washed up’. A f e w d a y later he collapses again, this time when he is about to have a blood sample takenfor analysis. Although no specific cause f o r his tendency to fainting can be identified, it transpires that he does have some personal troubles which are making him anxious. This problem introduces the student to the basic principles of the circulatory system, and the structure and function of the arterioles, capillaries and veins. The concepts of cardiac output, venous return and autonomic nervous control of blood vessel diameter are outlined; and the influence of posture, external environment and emotional upset on cardiovascular function through nervous and hormonal systems is discussed. The opportunity is taken to introduce the concept of electrocardiography as an investigative tool.
Problem 2. A young lady presents to her new general practitioner complaining of occasional attacks of an irregular heartbeat as a result of which she feels weak and distressed to an extent sufficient to be unable to work. The patient is treated with quinidine, but this causes a gastrointestinal upsets and so a P-adrenoceptor blocking agent is substituted. Little improvement is observed; indeed she reports an increasing frequency of attacks and requests progressively more medical certificates of unfitness to work, culminating in a request f o r pensioner status due to chronic ill health. The doctor is unable to confirm the truth of her claims and begins to suJpect that, apart from anything else, she may well not be taking her medication. This problem introduces the concept of regulation and synchronization of the heart contraction, the ways in
Medical Teacher V o l 3 N o 4 1981
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Figure 1. Objectivesfor the cardiovascular y t e m course unit. which this may become deranged, and the interrelationship between cardiac output and circulatory homeostasis. Approaches to the pharmacological, medical and behavioural management of this condition are discussed, with details of the ways in which the various therapies outlined are believed to work. The issue of'drug compliance is discussed in some detail. The reasons for the deterioration in 'the working relationship between the patient and the doctor are outlined, together with an analysis of how Medical Teacher Vol3 No 4 1981
the problem might have been avoided. The cost to the community (in terms of sickness benefit) of the illness of this patient is reviewed, together with the ethical, moral and legal obligations of the doctor, in relation to the issue of medical certificates. The attitude of an employer to employees in poor health is also raised.
Problem 4. A middle-aged howewzze is taken to hospital suffmhg j+om hemiplegza and difFincltr with speaking (the students stdied 133
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Figure 2. Tutor guide to problem No. 3 on chest pain. ThisJow diagram outlines t h way the patient is presented to the students (lej column), the issues which the group should consider as a result (centre column) and the disciplines contributing relevant resource materials (right column). Medical Teacher V o l 3 No 4 1981
135
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
a similar ‘stroke’ problem in Term 1). She recovers rapidly from this crisis, but examination reveals heart failure, consequent upon mitral stenosis with atrial fibrillation, and tricuspid incompetence. She has a history of rheumaticfever as a child. Cardiac catheterization reveals that the condition is moderatelg, severe; elective mitral valve replacement is undertaken, following which she is put on long-term anticoagulants. This problem introduces the structure and function of the valves of the heart, the way in which they are affected by rheumatic fever and the concept of cardiac failure. The detailed mechanism of action of digitalis, and of the anticoagulants heparin and warfarin are discussed. The cardiac catheter,results serve as a basis for study of the intracardiac and pulmonary pressures. The concept of chronic illness is discussed, with particular emphasis on the effects on the family and the attitude of employers to such persons (as a follow-on to problem two). The various factors which may improve the prognosis of open heart surgery by lessening distress and risks are also considered. The above problems cover a wide range of disciplinary knowledge in relation to the cardiovascular system and, as indicated by the summaries, serve to introduce many of the essential basic principles and concepts for further detailed development later in the course and, indeed, after graduation.
A Problem in Detail- Working Problem 3: Chest Pain This problem is introduced to the students, in groups of eight with a tutor, through a videotaped scene showing Nick Mason, a busy executive under extreme pressure, who is seen at his office desk complaining of severe chest pain. A pause in this videotaped sequence allows the students to discuss what they have seen, and analyse its meaning and implications. At this stage the tutor encourages them to hypothesize about the cause of the pain. The videotape continues with the arrival of the doctor, who examines Mr Mason, administers an injection, reassures him, and calls an ambulance. The role of the tutor is to facilitate the ensuing discussion, maybe with a cue from his tutor guide which maps the suggested course of the development of the problem (Figure 2). Further prepared material is injected to maintain the progress of the group discussion, to emphasize particular points and to develop the story. Handout 1 summarizes the data which the doctor elicits by questioning the patient and Handout 2 lists the physical examination findings which leads the doctor to take the various steps (reassurance, morphine intravenously, transport and admission to hospital) which are summarized in Handout 3. Each of these items of trigger material is designed to lead the students into specific discussion areas: the general aim of their introduction is indicated to the tutor on the flow chart or tutor guide (Figure 2 ) . During their discussion the students note those areas in which they perceive the need for further study. The problem continues with Handout 4 which shows M r Mason’s monitor electrocardiogra and outlines the 134
emergency management instituted. This introduces a discussion on the merits of coronary care units and of continuous patient monitoring in cases of cardiac instability and the psychological impact of these events on the seriously ill patient and his family. Finally, the progress of the patient at 24 hours after admission is presented in Handout 5 which records the therapy given, the physical examination findings and the results of tests and investigations which have been carried out. These show that the patient has mild heart failure and that his ECG and plasma enzyme studies confirm a moderate anterior myocardial infarction. At this point the students summarize the learning they need to undertake before the next group meeting and they each receive a ‘package’ of materials prepared by academic staff from each discipline designed to fulfil most of their needs; the disciplines contributing to this package are indicated in the right hand column of Figure 2. Typically, a package consists of about 40 pages of commentary written in an interactive style and including relevant references, suggested practical activities and formative (self-) assessment questions. The students, working individually or as a group, use these materials, together with the detailed problem objectives (Figure 3), as a basis for their subsequent study. As a result they come to the next group meeting able to resolve issues raised in the first session and, in addition, to discuss as a group formative assessment questions which, individually, they may have found difficult. The tutor guide for the second session (Figure 2) raises some issues to which the students may not have paid sufficient attention, for example, ‘risk’ factors in the aetiology of heart disease, management of cardiac emergencies, rehabilitation, long-term management and prognosis after heart attack and the impact of this disease on the patient, his family and the community. A role-play is suggested to bring out some important behavioural aspects of the effect of this sort of incident on the patient (“will I live?”; “why was it me?”) and his spouse (“when can I see him?”; “will he live?”; “what can I do?”) so that the student can understand the central role of explanation, reassurance and support. Other Activities Although much of the student’s time is spent on problemrelated study, he also has a simultaneous involvement in clinical activities which, as far as possible, are made relevant to the problems being studied at that time. Thus, he would also be seeing patients with diseases of the cardiovascular system and, in p a r t h l a r , visiting and studying the activities in a coronary care unit. Assessment Each course unit has objectives (Figure 1) which are further expanded through provision of detailed objectives for each problem (Figure 3). Assessment is based on these and it is the responsibility of the students to ensure that they have achieved the competences defined; it is up to them to seek remedial help if they experience difficulties. Medical Teacher Vol 3 No 4 1981
.. .
Figure 3. Objectivesfor Working Pro61m 3 on chert $ a h due fa a myocardial infarction.
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Medical Teacher VoE 3 N o 4 1981
D
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
The assessment of each course unit is by criterionreferenced Modified Essay Question (Knox 1972); this has been described elsewhere (Engel et al. 1980). Most of the items require the students to apply their newly acquired knowledge to a different clinical situation. This is a high-level cognitive skill (Bloom 1956) and as such the assessments are demanding. Each assessment instrument is subjected to analysis with regard to its reliability (internal consistency among items, or alpha score), the nature of the items (data gathering, hypothesis generation, hypothesis refinement, patient management, incidental) and various other aspects before being considered acceptable. However, few students (one or two out of 64 per year) have been unable to satisfy the assessors of their mastery of the course unit objectives by the end of the year. The students undergo no special prior preparation for the course, neither have they had previous exposure to much of the relevant basic science. All disciplinary learning is initiated by the problems studied: there are no formal disciplinary lecture courses, but the total learning in each discipline is the sum of its contributions to the problems studied throughout the five-year curriculum. Assessment results to date confirm that this course unit enables the students to achieve a satisfactory standard of competence in their knowledge of the cardiovascular system.
and principles essential to the understanding of cardiovascular medicine. Each year, every such unit is evaluated by staff and students as a basis for revision, i n order to ensure that the unit is acceptable, comprehensive, accurate, up to date and appropriately reflects community trends.
References Barrows, H. S. and Tamblyn, R . M . , Problem-based Learning: A n Approach to Medical Education, Springer Series on Medical Education, vol. 1 , Springer, New York, 1980. Bloom, B. S. (Ed), Taxonomy .f Educational Objectiues: The Cognitiue Domain, McKay. New York, 1956. Engel, C . E., Feletti, G . I . and Leeder, S. R., Assessment of medical students in a new curriculum, Assessment in Hipher Education, 1980, 5 , 279-293. Knox, J. D. E., The ModiJid Essay Question, Association for the Study of Medical Education, Dundee, 1972. Neame, R. L. B., How to Construct a Problem-based Course, Medical Teacher, 1981, 3, 94-99. Working Papers of the Faculty of Medicine, No. VI, Undergraduate Programme Objectives, University of Newcastle, NSW, 1976.
Acknowledgement
Conclusion We have described a totally integrated, problem-based course unit designed to introduce students to the concepts
We thank all our colleagues in the Faculty of Medicine, University of Newcastle, who have collaborated in the construction of this course unit and, in particular, D r B. Chapman and the late D r D. Wallace of the Royal Newcastle Hospital.
Training Activities for Women Organized by INSTRAW In collaboration with WHO and other United Nations agencies, the United National International research and Training Institute for the Advancement of Women (INSTRAW) is organizing training activities in health in many parts of the world. Projects have been started in Africa, Asia and- the Pacific, Latin America, and Western Asia, and there are also a number of interregional projects designed to benefit women in more than one region. The WHO-assisted projects cover such activities as: training of health personnel in maternal and child health and family planning; teachers’ workshops on health education; training of village health workers; instruction in paediatric care and laporoscopic techniques; in-service training courses for nurses and midwives; and the granting of fellowships. The decision to establish INSTRAW was taken in December 1975 by the General Assembly of the United Nations, when it endorsed a resolution adopted by the World Conference of the International Women’s Year, held in Mexico City six months earlier. This resolution
Medical Teacher Vol 3 No 4 1981
recognized the need for specific programmes to eliminate impediments to the advancement of women -such as inadequate training opportunities and information on their situation-and called for the creation of an international research and training institute. INSTRAW, which will be located in the Dominican Republic, is financed through voluntary contributions to a United Nations trust fund. Its fundamental responsibility is to collaborate with the various organjzations of the United Nations system and other international organizations engaged in planning and implementing programmes for women. Among its plans for future activities is a study of the need for further research on the extent to which present health care services are geared to women’s special health problems. This study is to be undertaken in collaboration with WHO and the United Nations Fund for Population Activities.
WHO Chronicle, 1981, 35, 65.
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The Cardiovascular System Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
D. A. POWIS and R. L. B. NEAME D.A . Powis,
is Lecturer, and R . L. B. Neame, MA, PH.D, MB, B.CHIR, is Senior Lecturer in H u m a n Physiology, Faculty of Medicine, The University of Newcastle, New South Wales, Australia. B.SC, PH.D,
In the last issue of this journal an approach to the construction of integrated, multidisciplinary course units was described (Neame 1981). This approach is illustrated in relation to the cardiovascular system course unit developed for use early in the second year of the five-year curriculum at the Faculty of Medicine, The University of Newcastle, New South Wales. A fully integrated course of medical studies centred around organ systems is necessarily constructed and presented rather differently from its conventional counterpart. Traditionally, the various medical, paramedical and basic science disciplines construct independent courses to teach all those facts and concepts which they consider a prospective medical graduate should know. At the time of presentation of each course the student usually has little or no idea of how this knowledge will be of use to him as a practising doctor: all too often, when its relevance finally is appreciated, the detailed information has long since passed from memory. The fully integrated approach practised at Newcastle is the antithesis of the traditional. Here, the course is built around a series of ‘priority’ clinical problems (Neame 1981); the disciplinary input for each of these is restricted to that information necessary to allow the students to understand and be able to manage that condition. For example, a clinical problem based on an acute myocardial infarction would require consideration of the anatomy of the chest and mediastinal contents, the physiology of the coronary circulation, the biochemistry and physiology of tissue respiration and pain mechanisms, the anatomy of pain referral, the pathology of ischaemic change, inflammation and repair, the pharmacology of morphine and anti-arrhythmia, the epidemiology of ischaemic heart disease as well as other discipline-based material encompassed in the study of an acute myocardial infarction. Problem-based learning in medicine owes much to the developments originally undertaken at McMaster University: the concept is elegantly explained in a recent book by Barrows and Tamblyn (1980). The potential advantages of the approach to learning developed by Newcastle University have been described previously (Neame
Medical Teacher V o l 3 No 4 1981
1981), but from the point of view of the student two aspects must be emphasized. First, the interdisciplinary approach to the construction of the problems leads to a softening of the arbitrary boundaries between disciplinary territories and may promote unity between clinical and preclinical smdies. Second, the relevance of all material to be studied is clear at the outset since the student sees its immediate application: this makes it easier for him to comprehend and remember its essential significance. It is clear that for such a course as this to be an effective means of training the prospective medical practitioner, the ‘priority’ problems must be selected with care so as to provide appropriate coverage of subjects and embrace as many as possible of the concepts considered essential by the disciplines.
The Cardiovascular System
Although at Newcastle the main thrust of learning about the cardiovascular system occurs in Term 4 (first term, second year) of the medical course, in parallel with studies on the respiratory system, the subject is really studied on a ‘spiral’ throughout the whole five years of the course. The students are confronted repeatedly with problems of the cardiovascular system in the context of units whose primary orientation is towards other body systems. At each successive ‘turn’ of the educational spiral students are exposed to material covering the same basic principles but requiring them to deal with it in greater depth, and with emphasis upon the more complex concepts and inter-relationships. The importance of the cardiovascular system to whole body function is introduced in Term 1 by a problem about blood loss and trauma resulting from a road traffic accident. Other problems in the first two terms of the course introduce the cerebral circulation (in a patient who has suffered a stroke) and the peripheral circulation (in a patient who suffers a femoral arterial embolism). In the third year many of the basic principles are re-emphasized and some new concepts introduced when detailed study is made of various emergencies (cardiac arrest, burns, 131
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
anaphylactic shock) and of chronic systems failure (congestive cardiac failure, hypertension). In the fourth year students encounter a number of problems relating to cardiovascular system dysfunction in pregnancy, the foetus, the newborn and in children. Throughout the course, and particularly in the fifth and final year, the ward-based clinical attachments bring the student into contact with a variety of patients suffering from cardiovascular ailments, some of which they will have studied previously. In this way the student is required to apply familiar concepts to new situations, thereby increasing the breadth and depth of his understanding of the cardiovascular system. Content of the Cardiovascular System Unit-Term
4
The time available for the study of each organ system unit is about four to five weeks and so careful planning of the course material is essential to ensure that there is an adequate and comprehensive exposure to the essential underlying principles, concepts and mechanisms pertinent to the system. For example, choosing a cluster of problems all based on functional disorders of the heart would not be satisfactory since much essential material relating to the structure and function of the peripheral vasculature and to concepts of the circulatory system as a whole would be missed. Selection of material to achieve an adequate and comprehensive exposure to the essential underlying principles, concepts and mechanisms is something that cannot be undertaken by one individual; it is an issue of vital importance to all disciplines and interests represented in the school. The negotiation and consultation mechanism whereby these interested parties have their input into the planning and preparation of each course unit has been described in some detail (Neame 1981). The outcome of such discussions is an agreed list of objectives for the unit (Figure l ) , which specifies the knowledge, understanding and skills that the student should acquire in relation to the cardiovascular system. The reader will note a relative deficiency of process objectives therein, that is of objectives which specify skills relating to communication, ability to solve problems, attitudes or professionalization etc. Process skills are acquired over a much longer time scale than the five weeks allocated to this unit and therefore feature more prominently in the longer term objectives such as those for the whole programme (Faculty Working Paper No. VI).
The Problems Each problem is constructed to follow the course of a patient through his entire illness, from presentation to resolution, and is presented to the students through a sequence of trigger materials (Neame 1981). It is our preference to have such trigger materials resemble as closely as possible the format of actual doctor/patient encounters. Since the students at this point in their medical careers have relatively little detailed knowledge of the subject matter, each problem initiates learning on a large range of new topics, with the consequence that a
132
substantial time allocation must be made for their study. It has become our practice therefore to work on the principle that each completely new problem will require about one week of study time. Thus there is time for a total of only four problems in the cardiovascular system unit: the rest of the 11-week term is taken up with study of a similar number of respiratory system problems, one week for consolidation of learning and one week for assessment and evaluation of the term’s activities. T o obtain a relatively comprehensive coverage of the major concepts relating to the cardiovascular system in health and disease within the limits defined by the Block Objectives, the following problems have been developed:
1. Collapse in a young adult due to vasovagal syncope.
2. Palpitations due to a supraventricular tachycardia in a 35-year-old woman. 3. Chest pain and collapse in a middle-aged businessman due to acute myocardial infarction. 4. Transient hemiplegia due to cerebral embolism, together with heart failure consequent upon severe mitral stenosis in a middle-aged woman.
A brief survey of these problems will give the reader some idea of the content of the unit; in addition, a detailed description of problem number three follows, to illustrate how the system works in practice. Problem 1. A videotaped introduction shows a young soldier on parade in the sun who is seen to collapse. H e is taken to the sick bay where he recovers without any ill effects other than feeling rather ‘washed up’. A f e w d a y later he collapses again, this time when he is about to have a blood sample takenfor analysis. Although no specific cause f o r his tendency to fainting can be identified, it transpires that he does have some personal troubles which are making him anxious. This problem introduces the student to the basic principles of the circulatory system, and the structure and function of the arterioles, capillaries and veins. The concepts of cardiac output, venous return and autonomic nervous control of blood vessel diameter are outlined; and the influence of posture, external environment and emotional upset on cardiovascular function through nervous and hormonal systems is discussed. The opportunity is taken to introduce the concept of electrocardiography as an investigative tool.
Problem 2. A young lady presents to her new general practitioner complaining of occasional attacks of an irregular heartbeat as a result of which she feels weak and distressed to an extent sufficient to be unable to work. The patient is treated with quinidine, but this causes a gastrointestinal upsets and so a P-adrenoceptor blocking agent is substituted. Little improvement is observed; indeed she reports an increasing frequency of attacks and requests progressively more medical certificates of unfitness to work, culminating in a request f o r pensioner status due to chronic ill health. The doctor is unable to confirm the truth of her claims and begins to suJpect that, apart from anything else, she may well not be taking her medication. This problem introduces the concept of regulation and synchronization of the heart contraction, the ways in
Medical Teacher V o l 3 N o 4 1981
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Figure 1. Objectivesfor the cardiovascular y t e m course unit. which this may become deranged, and the interrelationship between cardiac output and circulatory homeostasis. Approaches to the pharmacological, medical and behavioural management of this condition are discussed, with details of the ways in which the various therapies outlined are believed to work. The issue of'drug compliance is discussed in some detail. The reasons for the deterioration in 'the working relationship between the patient and the doctor are outlined, together with an analysis of how Medical Teacher Vol3 No 4 1981
the problem might have been avoided. The cost to the community (in terms of sickness benefit) of the illness of this patient is reviewed, together with the ethical, moral and legal obligations of the doctor, in relation to the issue of medical certificates. The attitude of an employer to employees in poor health is also raised.
Problem 4. A middle-aged howewzze is taken to hospital suffmhg j+om hemiplegza and difFincltr with speaking (the students stdied 133
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Figure 2. Tutor guide to problem No. 3 on chest pain. ThisJow diagram outlines t h way the patient is presented to the students (lej column), the issues which the group should consider as a result (centre column) and the disciplines contributing relevant resource materials (right column). Medical Teacher V o l 3 No 4 1981
135
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
a similar ‘stroke’ problem in Term 1). She recovers rapidly from this crisis, but examination reveals heart failure, consequent upon mitral stenosis with atrial fibrillation, and tricuspid incompetence. She has a history of rheumaticfever as a child. Cardiac catheterization reveals that the condition is moderatelg, severe; elective mitral valve replacement is undertaken, following which she is put on long-term anticoagulants. This problem introduces the structure and function of the valves of the heart, the way in which they are affected by rheumatic fever and the concept of cardiac failure. The detailed mechanism of action of digitalis, and of the anticoagulants heparin and warfarin are discussed. The cardiac catheter,results serve as a basis for study of the intracardiac and pulmonary pressures. The concept of chronic illness is discussed, with particular emphasis on the effects on the family and the attitude of employers to such persons (as a follow-on to problem two). The various factors which may improve the prognosis of open heart surgery by lessening distress and risks are also considered. The above problems cover a wide range of disciplinary knowledge in relation to the cardiovascular system and, as indicated by the summaries, serve to introduce many of the essential basic principles and concepts for further detailed development later in the course and, indeed, after graduation.
A Problem in Detail- Working Problem 3: Chest Pain This problem is introduced to the students, in groups of eight with a tutor, through a videotaped scene showing Nick Mason, a busy executive under extreme pressure, who is seen at his office desk complaining of severe chest pain. A pause in this videotaped sequence allows the students to discuss what they have seen, and analyse its meaning and implications. At this stage the tutor encourages them to hypothesize about the cause of the pain. The videotape continues with the arrival of the doctor, who examines Mr Mason, administers an injection, reassures him, and calls an ambulance. The role of the tutor is to facilitate the ensuing discussion, maybe with a cue from his tutor guide which maps the suggested course of the development of the problem (Figure 2). Further prepared material is injected to maintain the progress of the group discussion, to emphasize particular points and to develop the story. Handout 1 summarizes the data which the doctor elicits by questioning the patient and Handout 2 lists the physical examination findings which leads the doctor to take the various steps (reassurance, morphine intravenously, transport and admission to hospital) which are summarized in Handout 3. Each of these items of trigger material is designed to lead the students into specific discussion areas: the general aim of their introduction is indicated to the tutor on the flow chart or tutor guide (Figure 2 ) . During their discussion the students note those areas in which they perceive the need for further study. The problem continues with Handout 4 which shows M r Mason’s monitor electrocardiogra and outlines the 134
emergency management instituted. This introduces a discussion on the merits of coronary care units and of continuous patient monitoring in cases of cardiac instability and the psychological impact of these events on the seriously ill patient and his family. Finally, the progress of the patient at 24 hours after admission is presented in Handout 5 which records the therapy given, the physical examination findings and the results of tests and investigations which have been carried out. These show that the patient has mild heart failure and that his ECG and plasma enzyme studies confirm a moderate anterior myocardial infarction. At this point the students summarize the learning they need to undertake before the next group meeting and they each receive a ‘package’ of materials prepared by academic staff from each discipline designed to fulfil most of their needs; the disciplines contributing to this package are indicated in the right hand column of Figure 2. Typically, a package consists of about 40 pages of commentary written in an interactive style and including relevant references, suggested practical activities and formative (self-) assessment questions. The students, working individually or as a group, use these materials, together with the detailed problem objectives (Figure 3), as a basis for their subsequent study. As a result they come to the next group meeting able to resolve issues raised in the first session and, in addition, to discuss as a group formative assessment questions which, individually, they may have found difficult. The tutor guide for the second session (Figure 2) raises some issues to which the students may not have paid sufficient attention, for example, ‘risk’ factors in the aetiology of heart disease, management of cardiac emergencies, rehabilitation, long-term management and prognosis after heart attack and the impact of this disease on the patient, his family and the community. A role-play is suggested to bring out some important behavioural aspects of the effect of this sort of incident on the patient (“will I live?”; “why was it me?”) and his spouse (“when can I see him?”; “will he live?”; “what can I do?”) so that the student can understand the central role of explanation, reassurance and support. Other Activities Although much of the student’s time is spent on problemrelated study, he also has a simultaneous involvement in clinical activities which, as far as possible, are made relevant to the problems being studied at that time. Thus, he would also be seeing patients with diseases of the cardiovascular system and, in p a r t h l a r , visiting and studying the activities in a coronary care unit. Assessment Each course unit has objectives (Figure 1) which are further expanded through provision of detailed objectives for each problem (Figure 3). Assessment is based on these and it is the responsibility of the students to ensure that they have achieved the competences defined; it is up to them to seek remedial help if they experience difficulties. Medical Teacher Vol 3 No 4 1981
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Figure 3. Objectivesfor Working Pro61m 3 on chert $ a h due fa a myocardial infarction.
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Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
Med Teach 1981.3:131-137. Downloaded from informahealthcare.com by Ohio State University Libraries on 12/06/14. For personal use only.
The assessment of each course unit is by criterionreferenced Modified Essay Question (Knox 1972); this has been described elsewhere (Engel et al. 1980). Most of the items require the students to apply their newly acquired knowledge to a different clinical situation. This is a high-level cognitive skill (Bloom 1956) and as such the assessments are demanding. Each assessment instrument is subjected to analysis with regard to its reliability (internal consistency among items, or alpha score), the nature of the items (data gathering, hypothesis generation, hypothesis refinement, patient management, incidental) and various other aspects before being considered acceptable. However, few students (one or two out of 64 per year) have been unable to satisfy the assessors of their mastery of the course unit objectives by the end of the year. The students undergo no special prior preparation for the course, neither have they had previous exposure to much of the relevant basic science. All disciplinary learning is initiated by the problems studied: there are no formal disciplinary lecture courses, but the total learning in each discipline is the sum of its contributions to the problems studied throughout the five-year curriculum. Assessment results to date confirm that this course unit enables the students to achieve a satisfactory standard of competence in their knowledge of the cardiovascular system.
and principles essential to the understanding of cardiovascular medicine. Each year, every such unit is evaluated by staff and students as a basis for revision, i n order to ensure that the unit is acceptable, comprehensive, accurate, up to date and appropriately reflects community trends.
References Barrows, H. S. and Tamblyn, R . M . , Problem-based Learning: A n Approach to Medical Education, Springer Series on Medical Education, vol. 1 , Springer, New York, 1980. Bloom, B. S. (Ed), Taxonomy .f Educational Objectiues: The Cognitiue Domain, McKay. New York, 1956. Engel, C . E., Feletti, G . I . and Leeder, S. R., Assessment of medical students in a new curriculum, Assessment in Hipher Education, 1980, 5 , 279-293. Knox, J. D. E., The ModiJid Essay Question, Association for the Study of Medical Education, Dundee, 1972. Neame, R. L. B., How to Construct a Problem-based Course, Medical Teacher, 1981, 3, 94-99. Working Papers of the Faculty of Medicine, No. VI, Undergraduate Programme Objectives, University of Newcastle, NSW, 1976.
Acknowledgement
Conclusion We have described a totally integrated, problem-based course unit designed to introduce students to the concepts
We thank all our colleagues in the Faculty of Medicine, University of Newcastle, who have collaborated in the construction of this course unit and, in particular, D r B. Chapman and the late D r D. Wallace of the Royal Newcastle Hospital.
Training Activities for Women Organized by INSTRAW In collaboration with WHO and other United Nations agencies, the United National International research and Training Institute for the Advancement of Women (INSTRAW) is organizing training activities in health in many parts of the world. Projects have been started in Africa, Asia and- the Pacific, Latin America, and Western Asia, and there are also a number of interregional projects designed to benefit women in more than one region. The WHO-assisted projects cover such activities as: training of health personnel in maternal and child health and family planning; teachers’ workshops on health education; training of village health workers; instruction in paediatric care and laporoscopic techniques; in-service training courses for nurses and midwives; and the granting of fellowships. The decision to establish INSTRAW was taken in December 1975 by the General Assembly of the United Nations, when it endorsed a resolution adopted by the World Conference of the International Women’s Year, held in Mexico City six months earlier. This resolution
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recognized the need for specific programmes to eliminate impediments to the advancement of women -such as inadequate training opportunities and information on their situation-and called for the creation of an international research and training institute. INSTRAW, which will be located in the Dominican Republic, is financed through voluntary contributions to a United Nations trust fund. Its fundamental responsibility is to collaborate with the various organjzations of the United Nations system and other international organizations engaged in planning and implementing programmes for women. Among its plans for future activities is a study of the need for further research on the extent to which present health care services are geared to women’s special health problems. This study is to be undertaken in collaboration with WHO and the United Nations Fund for Population Activities.
WHO Chronicle, 1981, 35, 65.
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