A. Overview
1. Problem-Based Learning Process
The dermatology integrative competency experience
is designed to work best in a small group setting with
four to twelve participants. If your group is larger or
smaller than this, take note: it has been successfully
used by individuals for independent study or in larger
groups of 15 to 25. In this case-based curriculum, cases
are chosen in an order that meets appropriate dermatology
residency curriculum goals. The schedule is similar to
the general topic outline of the weekly integrated basic
and clinical science conference series created by Dr Ponciano
Cruz and colleagues. Cases can also be chosen in an order
that best suits the interests of the group (for example,
if a pediatric resident is rotating on service with the
group, the case that is chosen might be a pediatric dermatology
case). At the end of this content there is a reference
section which provides a PDF of a sample schedule of weekly
dermatology integrative competency curriculum case topics.
The dermatology integrative competency curriculum involves
case-based learning that uses the patient problem as a
stimulus for learning appropriate subjects. The patient
problem is encountered first in the learning process and
serves as a focus or stimulus for learning. The role of
the teacher in the dermatology integrative curriculum
process is much different than in traditional teacher-centered
styles of learning. The teacher’s focus is no longer
on lecturing, but rather serving as a group facilitator.
This curriculum process will now be described, including
the resources needed, the group setting, and the process
the group goes through with each case.
2. Resources
There are two kinds of resources necessary to
participate in the web-based dermatology integrative competency
curriculum. One type of resource is needed to participate
in the online curriculum, and the other type of resource
is needed to answer case questions and objectives that
are assigned during the case. To participate in the online
curriculum, it is important to understand that each residency
site serves as an independent autonomous group of learners.
Groups are not connected across the country with other
programs simultaneously participating. This allows maximum
small group learning and interaction.
Rather than having a group participate by crowding around
one computer monitor, it is recommended that the group
have one computer with web access connected to an overhead
projector, such as an LCD projector, to project an enlarged
version of the computer web page. Individual case pages
can be printed and distributed to members of the group,
but this is not necessary.
Resources to fulfill completion of post-session case questions
and objectives are also very important. Residents and
other dermatology learners should be given access to the
online resources available at each institution. In addition,
free world-wide-web resources for medical literature searching
and medical information gathering are available to users.
Each department should provide access to an updated set
of core dermatology texts including general, medical,
pediatric, procedural dermatology, and dermatopathology.
Organized dermatopathology and clinical photo libraries
are an added bonus, allowing learners to review an institution’s
set of case-related teaching slides in an integrative
and meaningful way. Each program should take inventory
of their available resources and work to integrate them
into the context of the integrative competency learning.
3. Room Set-Up
A comfortable conference table setting works best so that
learners may share eye contact as they communicate with
one another. Classroom style setups sometimes hinder the
adult learning process. The facilitator may choose to
sit among the group or off to the side. Comfortable chairs
and minimal outside distraction would be ideal. Indicating
to others in the department the sanctity of this academic
time is also recommended.
4. Participants Including Facilitator
The dermatology integrative competency curriculum
group consists primarily of dermatology residents at all
levels of training. In addition, rotating medical students,
rotating non-dermatology residents or other healthcare
providers can participate as group members. There may
also be a role in the near future for community dermatologists
participating as group members for CME credit. A junior
or senior faculty member serves as the case facilitator.
It is the facilitator that will assess the quality of
the discussions of the group. It is not necessary for
the facilitator to have special expertise in the particular
case being discussed. Once the group is present, the facilitator
calls the session to order. The case then begins.
B. The Case
1. Starting the Case
During each case session after the facilitator
activates the online session and documents the group members
present, the facilitator selects one member of the group
to read the case aloud from the projected web page. In
this curriculum, the problem in each case presents as
it would in reality, with the patient’s chief complaint
and a thorough or partial history. All of the pertinent
information, including medications, allergies, social
history, past medical history, and pertinent family history
are read aloud. The group then typically proceeds to the
physical examination of the patient. Here, a series of
digital photographs of pertinent clinical findings are
projected. The case is read aloud until a series of questions
is encountered on the web screen. Whenever such a set
of questions is encountered during a case, the group halts.
2. Case Questions
The questions that occur throughout the case
serve as a stopping point for discussion. These questions
are designed to probe the clinical reasoning process.
They are discussed by the group. Determining what further
information gathering is needed, generating differential
diagnoses on what is known, selecting or describing procedural
techniques or diagnostic testing, and discussing therapeutic
options and expectations are among the topics addressed
by these questions. Often the questions are tiered by
level of difficulty so that various members of the group
can be selected by the facilitator to participate. Through
these discussions, the teacher is able to evaluate the
resident’s clinical reasoning process and communication
skills. The case does not proceed until all members including
the facilitator are satisfied with the level of discussion,
since the following web link often reveals the actions
taken and potentially some answers to the questions on
the previous page.
Throughout the case, further question sets are encountered
followed by further discussion. Each question is designed
to probe a resident’s competency in one or more
of the six ACGME-defined competencies. If the group thoroughly
and competently discusses the objectives as determined
by the faculty facilitator, then the question is marked
as being competently discussed on the interactive web
page. If further discussion would be necessary to consider
the question competently discussed, then the question
is converted to a learning objective for the group to
be further researched and discussed at a later session.
If this is the case, the group is not assigned competence
with that learning issue until competently discussed.
3. Proceeding Through The Case
In addition to the history and physical examination,
each case includes a clinical course including follow-up
care and management of complications, when appropriate.
One exciting feature of the curriculum is the incorporation
of pertinent dermatopathology into the cases. During the
case, when the patient has a biopsy performed, the group
is provided with realistic, web-based virtual dermatopathology
sections of the unknown patient slide. This is a tremendous
clinical pathologic correlation learning opportunity.
Throughout each case are other digital patient photos
of pertinent skin findings as well, including follow-up
clinical findings. Other images might include diagnostic
test findings, including dermoscopy, Wood’s lamp,
KOH prep, and Tzanck smear findings. The group views and
discusses the relevant photographs and virtual dermatopathology
slides when prompted to do so by the case. As the clinical
course of the patient proceeds, further question sets
are encountered followed by further discussions.
4. Objectives
There are two types of objectives encountered
with each case: learner-defined and expert-defined. Typically,
during the course of the case, there will be some questions
which the group as a whole cannot competently answer without
seeking more information. As questions are encountered
that the group cannot competently discuss, a running list
of group-defined learning objectives are identified. Usually,
the first case session ends before completion of the entire
case. At the end of the session, the group divides these
learning objectives among the members as homework assignments
to be completed. At this point, an evidence-based preparation
period occurs. The group begins the next session by first
discussing those learning objectives from the proceeding
session prior to resuming and subsequently completing
the case. The facilitator can then go back to the questions
which triggered each learning objective and decide whether
the objective has now been competently discussed among
the group.
Typically in the second session the case is completed.
At the end of the case, in addition to any further group-defined
learning objectives, the group also encounters a set of
expert-defined learning objectives from the faculty creators
of the case. Often, these are also tiered in level of
difficulty: those for which the entire group including
medical students and non-dermatology residents should
be familiar, and those more detailed objectives aimed
at upper level dermatology residents. The objectives typically
include basic science, epidemiology, pathophysiology,
clinical features, histopathology, and therapeutics relevant
to the case. Objectives may also include diseases related
clinically or histologically for review by the group.
Expert-defined learning objectives are designed to identify
all pertinent learning that should be encountered by the
group.
In addition, the group is able to add any group-defined
objective relevant to the problem but not listed on the
expert-defined list. The objectives are divided appropriately
among the group members. Each member then spends the self-directed
learning and review interval preparing to lead a discussion
on the assigned objective or objectives at the next scheduled
PBL session, the objectives session. Reference text, journals,
expert interviews and online sources are just a few of
the possible resources used to prepare. Evidence-based
preparation is encouraged and is one factor in the facilitator’s
evaluation of competence. By the end of the three years
of dermatology residency training, all residency-training
topics are covered. Cases representing certain dermatology
problems are given adequate yearly coverage. These include:
1. Problems, conditions or diseases that have the greatest
frequency in the usual practice setting.
2. Problems that represent urgent or life-threatening
situations.
3. Problems with potentially serious outcomes in terms
of morbidity or mortality.
4. Problems most often poorly handled by health providers
in the community.
5. Problems that emphasize or underlie important concepts
and basic science.
5. Session Number
In a typical week there will be three resident
learning sessions. The first session usually begins midweek.
In this session, the patient’s history, physical
exam, initial assessment and plan is discussed. Learner-defined
objectives relating to case questions are identified by
the group as the session progresses. The second session
of the week usually occurs within the next one to two
days, allowing a brief objectives preparation interval.
During the second session, the case continues through
its conclusion, ending with the assignment of the competency-based,
expert-defined learning objectives. Between the second
and third sessions, the group is typically given a longer
period of time to complete their learning objectives in
a thorough and evidence-based fashion, as this is often
a more rigorous workload. The third session typically
follows the weekend. During the third and final session,
learners lead the discussion of their individual objectives
and provide information to the group.
Each session lasts 45 minutes to an hour. Some shorter
cases may require fewer than three sessions to complete.
Some complex cases or complex discussion topics may require
more than 3 sessions to complete. Since each participating
resident group acts as an independent entity, longer or
additional sessions can occur without jeopardizing the
effectiveness of the curriculum. The facilitator should
avoid rushing the group through a case just to keep a
rigid curriculum pace. The facilitator will extend when
necessary the number of sessions for a particular case.
6. Integrating the Competencies
As the name implies, this curriculum integrates
the teaching and assessment of dermatology core competencies
in the context of group discussions. The case creators
design questions to assess one or more areas of resident
competence. Each case question and each expert-defined
objective is followed by a Roman numeral. Roman numerals
I through VI correspond to the six ACGME competencies.
It is the responsibility of the faculty facilitator to
interpret the competency assignments of each question,
then to recognize and assess the competence of each group
discussion.
7. Competency Tally
Each question and learning objective designated
as competently discussed is summarized at the end of each
case in a competency report. Information from each question
is linked to a competency report statement in one or more
of six sections in the competency report. Each section
in this report corresponds to one of the six ACGME core
competencies. For instance, if a case question is designed
to assess a patient care objective and it is competently
discussed by the group, then at the end of the case when
the competency report is generated, a statement under
the Patient Care section will appear summarizing the competence
displayed in that discussion. If at the end of the case
the facilitator decides that more discussion would be
necessary to be competent with this particular case question,
then no statement would appear under the patient care
section corresponding to this question.
Competency reports can be generated for any designated
time period, whether this is every week, every quarter,
every semester, every year in training, or even as a summary
of all competent discussions in which a learner took part
during his or her residency. Because the facilitator is
entering the individual learners taking part in each session,
competency tally reports can be generated for any individual
learner.
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