Integrating Basic Science into Clinical Teaching Initiative (IBS-CTI): Preliminary Report
Article Outline
Concern regarding the rapid accumulation of new medical knowledge and the lack of incorporation of this knowledge into clinical teaching and clinical practice has challenged medical educators.1, 2 Advances in molecular biology, functional imaging, and the Human Genome Project have greatly accelerated our understanding of the significance of the dynamic interactions among genes, environment, and timing on human biology. Pediatricians in particular have long been concerned with these developmental issues as they relate to normal/abnormal behavioral, cognitive, and somatic growth. In recognition of this, the National Research Council and Institute of Medicine's Children's Health: The Nation's Wealth3 proposes a new conceptualization of children's health as a developmental model, emphasizing that each period of life and the interactions occurring during that period influence subsequent periods.
But the explosion of evidence from functional imaging, genetic, and behavioral studies regarding the unique importance of specific developmental stages on subsequent health and functioning has stood in marked contrast to the paucity of information on this topic presented in clinical training for medical students and pediatric/family medicine residency training. Pediatric chairs and educators around the country are challenged by this gap, leaving some to believe that much of current pediatric training may be unconnected to both the significant advances in knowledge in the basic sciences and to emerging clinical realities.
Accordingly, the aim of this collaboration was to develop a case-based educational activity using our current state of knowledge of the disease presented, with an emphasis on the influence of the specific developmental stage, and to use this knowledge in developing a parsimonious approach to diagnosis and treatment of the disease. This approach emphasizes an understanding of the basic science that drives the clinical presentation and the use of that understanding for clinical problem solving. This is a preliminary report of data from a single site from this multicenter effort.
Methods
Initially, 10 interested pediatric residency programs were represented, 7 of which eventually participated in the study. This preliminary report represents data from 1 of these sites, Wayne State University.
The participating centers agreed on a case discussion format that emphasizes an understanding of the basic science that explains the clinical presentation at the given developmental stage. This format emphasizes a parsimonious approach to diagnosis and treatment based on a clear understanding of the physiology involved. The format calls for a relevant and focused history and physical examination, presenting all relevant data without extraneous information, followed by identification of the primary problem (eg, wheezing) and subsequent development of a focused differential diagnosis list given the patient's clinical presentation, inclusive of the breadth of possible organs and/or organ systems involved. Specific emphasis was given to the influence of developmental stages on the presenting problem. The remainder of the case involved discussing and gaining insight into the biological factors responsible for the presenting symptoms, and narrowing the differential diagnoses based on this understanding. Additional clinical data were introduced only when necessary to arrive at the diagnosis, again emphasizing how additional information allows a narrowing of the differential diagnoses based on an understanding of the physiology involved. In some cases, treatment of the clinical problem was then reviewed in the context of the relevant physiology.
Investigators from the original 10 sites were involved in finalizing the format and also in generating a list of wide-ranging general pediatric topics to be used. A total of 30 case discussions were developed to cover a wide range of pediatric topics, including wheezing, hyperbilirubinemia, altered mental status, and sexual abuse (Table I; available at www.jpeds.com). Many of these topics allowed 2 or 3 separate 30-minute case discussions, each focusing on a different aspect of the underlying disease mechanisms. The 30 cases were chosen to allow sites discussions that meet the institutions' educational needs, while allowing presentation of at least 20 discussions throughout the academic year, to allow for a reasonable contrast with current case discussion activities. The cases were distributed to each site for incorporation into their established educational activities, either as a substitute for the traditional morning report or as a novel educational activity.
Table I. Case discussions
1. Sexualabuse |
| 2.Shakenbabysyndrome |
| 3.Alteredmentalstatus |
| 4.Cardiogenicshock |
| 5.Cyanoticinfant |
| 6.Hypertension |
| 7.Hyperammonemia |
| 8.Hypocalcemia |
| 9.HemophiliaA |
| 10.Maintenancefluidtherapy |
| 11.Jaundice |
| 12.Vomiting |
| 13.VitaminB12deficiency |
| 14.Lymphadenitis |
| 15.Pallor |
| 16.Persistentpneumonia |
| 17.Respiratorydistresssyndrome |
| 18.Wheezing |
Both residents and presenters were queried anonymously with Likert-type questionnaires before exposure to the case discussions (preintervention) and at 1-month intervals postintervention (Figure; available at www.jpeds.com). Responses were identified only by site and level of training and were collected by study personnel not involved in resident clinical or educational evaluation. The case discussions were delivered over a 3-month period. Data from the Wayne State University pediatric residency program year-end resident evaluations also were included in this portion of the study.
Figure.
Likert preintervention and postintervention questionnaire.
The means of the responses to each question both preintervention and postintervention, as well as the mean score for residency program evaluation, were compared using the Student t-test. The study design was approved by Wayne State University's Human Investigation Committee.
Results
A total of 26 IBS-CTI case discussions were administered to the pediatric residents during the second half of their 2007 academic year. Ninety-three out of a possible 117 pediatric and combined internal medicine/pediatrics residents participated in the study by returning the evaluation questionnaire on at least 1 of the 4 time points.
Using the 5-point Likert-type scale (Figure), the satisfaction with traditional morning report case discussions preintervention was high (mean scores of 4.4 to 4.6 for questions 1 to 5). Although the scores remained high at each postintervention time point, no statistical improvement was demonstrated for any of the 7 outcome questions (Table II; available at www.jpeds.com). However, the mean scores for questions 6 and 7 on the postintervention questionnaire (which ask about satisfaction with the IBS-CTI format and the usefulness of the information contained in them) ranged from 4.3 to 4.5, suggesting high satisfaction with the format. Data were obtained regarding presenter satisfaction with the format, including ease of preparation for the discussion and usefulness of the information contained in it for use in clinical practice. Although presenter (ie, our chief residents) satisfaction was high, the amount of data was small, and these data will be pooled with data from other sites and presented in a future report.
Table II. Mean response scores for each of the 6 preintervention and 8 postintervention questions
| Question | Preintervention | Postintervention 1 | Postintervention 2 | Postintervention 3 |
|---|---|---|---|---|
| 1 | 4.4 | 4.4 | 4.4 | 4.5 |
| 2 | 4.6 | 4.5 | 4.6 | 4.7 |
| 3 | 4.2 | 4.3 | 4.4 | 4.4 |
| 4 | 4.5 | 4.4 | 4.6 | 4.6 |
| 5 | 4.4 | 4.2 | 4.5 | 4.5 |
| 6 | 3.3 | 4.3 | 4.4 | 4.5 |
| 7 | 4.4 | 4.4 | 4.4 | |
| 8 | 3.0 | 3.2 | 2.9 |
In addition, although this was not initially included in the data collection, each resident was required to fill out a program evaluation at the end of the academic year, including evaluation of all regularly scheduled educational activities. Of the 11 recurring educational activities, the residents ranked the IBS-CTI morning report first, significantly higher than the traditional morning report.
Discussion
It is generally agreed that the amount of medical knowledge that exists is vast and increasing at a rapid pace. Thus, maintaining a current knowledge base is becoming increasingly difficult for trainees and clinicians alike. This presents a challenge for medical educators. The ability to continually translate new, clinically relevant scientific information into medical education is becoming both more difficult and more important.
Based on this preliminary data and the outcomes selected, the present attempt at improving the understanding and use of state-of-the-art basic science for clinical problem solving was at least partly successful. Although no difference was demonstrated between satisfaction with our traditional morning report and IBS-CTI morning report, our residents demonstrated a clear preference for the IBS-CTI morning report based on the ranking of educational activities. This likely is due to the very high satisfaction scores with our traditional morning report and the insensitivity of our outcome scale to determining a true difference.
The subjective comments that accompanied the outcome questions were nearly universally positive. Some examples are as follows:
Negative comments consisted of concern over an excessive amount basic science in a single session to fully grasp, and displeasure with the manner in which a specific presenter discussed a specific point.
The outcomes in this study were chosen because they were easy to obtain and provide insight into how the intervention was received by the participants. They do not allow assessment of the effectiveness of the intervention in improving basic science knowledge or clinical practice. The goal of IBS-CTI is to increase current knowledge of clinically relevant basic science and to teach it in way that makes that knowledge useful for clinical problem solving. But measuring the effectiveness of patient care is difficult and involves multiple confounding factors, making this type of assessment of our intervention prohibitive. As a surrogate for clinical effectiveness, clinical decision making would be a logical evaluation tool. We hope to be able to use this in the form of structured case discussions, medical simulation, or monitored clinical care in future studies.
In conclusion, the institution of an IBS-CTI format case discussion series as part of the educational curriculum for our pediatric residency program was found to be useful and was well received by the residents and chief residents.
References available at www.jpeds.com.
IBS-CTI Working Group
References
- . National efforts to reform residency education in surgery. Acad Med. 2007;82:1200–1210
- . Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007;82:1211–1219
- . Children's Health, the Nation's Wealth: Assessing and Improving Child Health. Washington, DC: National Academies Press; 2004;p. 210
Supported by the Commonwealth Fund, the Josiah Macy, Jr Foundation, and the American Board of Pediatrics. The authors declare no potential conflicts of interest.
PII: S0022-3476(08)00601-X
doi:10.1016/j.jpeds.2008.07.020
© 2008 Mosby, Inc. All rights reserved.
