Case-Based Learning in Athletic Training
INTRODUCTION
The National Athletic Trainers' Association (NATA) Executive Committee for Education has emphasized the need for proper recognition and management of orthopaedic and general medical conditions through their support of numerous learning objectives and the clinical integrated proficiencies.1 These learning objectives and integrated clinical proficiencies are designed to prepare athletic training students to become competent professionals. In fact, the educational competencies and integrated proficiencies related to orthopaedic clinical assessment and diagnosis are just one of the vital links in becoming either a successful or an unsuccessful athletic trainer. However, this success is not accomplished overnight; rather, it is accomplished gradually over time, as students progress through the higher levels of Bloom's taxonomy.2
Students should be challenged to comprehend, apply, analyze, synthesize, and then evaluate (Bloom's taxonomy) properly to competently diagnose an injury or illness and make rational, clinically appropriate medical decisions in the patient's best interests. These decisions include: (1) appropriate medical referrals, (2) return-to-play decisions, and (3) knowing when and how to initiate a rehabilitation or reconditioning plan. Without an accurate understanding of the condition's pathophysiology, pathomechanics, or etiology, it is difficult for the athletic trainer to develop an appropriate prevention program to reduce the likelihood of reinjury. Finally, there may be times when incorrectly diagnosing a condition may have significant repercussions, possibly increasing a patient's morbidity or mortality.
Unfortunately, in many circumstances the educational competencies taught and evaluated in the classroom are done as fragmented pieces rather than as a whole process. Students tend to learn orthopaedic and general medical assessments as a stepwise process rather than learning how to integrate and synthesize the information to generate a logical diagnosis and then act appropriately to manage the situation. To use a jigsaw puzzle analogy, athletic training students have (ie, learned the cognitive knowledge) all the puzzle pieces, but then they try to complete the puzzle by placing random pieces in the middle rather than putting the borders together first and working towards the middle. This approach places students at a disadvantage because they lack the ability to use a systematic approach (ie, to see the bigger picture) to acquire and interpret information and make clinical connections between classroom theory and clinical practice. Therefore, the purpose of this column is to examine the use of case-based learning (CBL) as a pedagogical tool to assist students in the learning process by allowing them to step into the role of a certified athletic trainer to acquire and interpret information and make appropriate clinical decisions using critical decision making and problem solving, using classroom theory (ie, knowledge and comprehension) and clinical reality (clinical integrated proficiencies) in order to become competent entry-level athletic trainers.
PRINCIPLES OF CBL
Case-based learning, or case study teaching, is a long-established pedagogical method.3 Case-based learning typically involves the use of short and/or long, detailed events or stories that describe a fairly well-defined situation, commonly involving a decision, challenge, opportunity, problem, or issue faced by a person (or persons) in an organization.3–6 Sometimes analogous to problem-based learning, CBL is a form of inquiry-based learning and fits on the continuum between structured and guided learning. It provides an opportunity to prepare students for clinical practice through the use of authentic clinical cases by linking theory to practice, through the application of knowledge to the cases3,7 as well as through exposing students to new academic content.4
Case studies used by educators as part of CBL are typically fictional, virtual (online CBL), researched, actual patient experiences, or other situational experiences designed by educators or commercially prepared (ie, textbooks and textbook supplemental material). They may provide a snapshot of a specific moment in time, or they may examine a patient's condition from the onset of the condition to its final resolution (eg, case reports found in peer-reviewed journals). Different types of case study methods can be used to place students in contact with different learning3,8 experiences or, in the case of athletic training, different practice analysis performance domains or work settings. Whether the case study method is used to focus on clinical reasoning, to focus on specific content, or to practice medical histories and physical examinations, it can be a useful method to prevent boredom in the classroom.3,9
For many athletic training educators CBL is likely a combination of actual patient experiences encountered during an educator's professional career, modifications of case reports found in the literature, and/or fictional situations created to simulate what a certified athletic trainer may experience in his or her professional career. And although many case studies are detailed, describing fairly well the defined problem(s), they can be written to contain limited information to allow students to enhance the relevance of their learning while promoting their understanding of the course concepts. Occasionally vital information may be intentionally left out, inaccurate, or designed to create ethical dilemmas, forcing students to challenge the clinical competence and decision-making skills of the athletic trainer. Some case studies provide clear learning objectives, asking students to address only one concern, whereas others are written using a variety of qualitative and quantitative information to allow students to learn and practice how to systematically approach a situation and make correct clinical decisions.10 Finally, some case studies require students to think beyond the injury assessment process and incorporate other educational competencies, ethical dilemmas, and communication challenges, and allow for speculation, interpretation, contrasts, and comparisons, all of which are tools necessary to function as a competent professional.4,9
SO WHY USE A CASE STUDY?
An extensive, systemic review examining the effectiveness of CBL in health professional education programs demonstrated inconclusive results as to the effects of CBL on learning when compared with other types of learning activity.3 As a teaching strategy, though, students enjoy the use of CBL and believe this method of learning enhances their educational experiences and understanding of the course content; thus, this method creates a more active and collaborative learner.3,11 Educators also enjoy CBL, reportedly because CBL fosters effective learning in small groups, possibly through the effect of having more attentive and engaged learners, but perhaps also through having more structured learning activities closely linked to authentic learning12 and clinical practice scenarios that potentially makes better use of the available teaching time.3
As a pedagogical method used in a variety of health related professional education programs, case studies create a safe, simulated learning environment that can address a wide array of learning objectives (Figure 1). Students can learn to acquire, analyze, and judge the correctness of the information presented in the case, compare and evaluate optional solutions, decide how to handle the actual or hypothetical situation, and react to and communicate the appropriate clinical decision making that connects classroom theory and clinical practice.3,4,6,8,10–12 This experience creates an opportunity to facilitate active and reflective learning, which is necessary to identify and select care options and set patient priorities13 as well as for developing self-directed lifelong learners.14
Citation: Athletic Training Education Journal 8, 3; 10.4085/080374
Case-based learning is not helpful in assisting students remember specific details and/or specific recall facts learned as part of a normal lecture,11,14,15 but rather it enhances students' critical thinking and clinical decision making.3,8,11,15,16 Case studies enhance critical thinking and clinical decision making by offering students an opportunity to examine and reexamine complex clinical situation actions (or inactions) from a variety of perspectives17 by allowing for (1) analyzing, (2) applying standards, (3) discriminating, (4) information seeking, (5) logical reasoning, and (6) predicting and transforming knowledge.10
Educators may utilize CBL to demonstrate achievement of a wide variety of Board of Certification18 role delineation/practice analysis performance domains and NATA educational competencies,1 specifically those related to orthopaedic injuries and general medical illnesses.4 This method also offers educators an opportunity to maintain consistent learning objectives for tracking simulated patient encounters. Case studies used as part of CBL can expose students to situations and patient experiences not always encountered during clinical education experiences,3,19 which again allows for consistent learning (and tracking of learning and learning outcomes) and ensures all students have had the opportunity to be exposed to a variety of patient encounters.4
Another benefit of CBL is the ability to provide for safe experimentation and reflection without concern for the impact on real organizations or patients.19 Using classroom theory and clinical practice experiences, students can make clinical decisions without any risk of harm to their patients and then reflect upon these experiences to determine the appropriateness of their actions and whether or not they actually completed the jigsaw analogy discussed above. When these reflective behaviors are taught as part of the curriculum, the potential to professional practice behavior change is also increased19 and students learn how to engage in lifelong self-assessments and reflection, a necessary component in becoming a competent, self-directed lifelong learner and professional later in life.14,19
Self-Reflection Using the WHAT Model
A modification to the “WHAT” framework is one method of assisting students in becoming reflective practitioners20 and encompasses 3 phases, “What,” “So What,” and “Now What.” Students begin the WHAT framework by carefully reading through a case study. The “What” phase begins with an individual returning to the case and describing in his or her own words exactly what occurred and how he or she would have handled the situation. This is similar to reflection on action, which occurs when individuals contemplate an event (a case in this context) in order to gain insight into their current level of knowledge and understanding.21 Once an individual has identified what happened and responded to the situation (often in the form of a clinical decision), either verbally or in a written format, he or she now moves on to “So What.” The So What is an opportunity for a student to examine his or her feelings regarding the case, determine the effects of what he or she did or did not do to handle the situation, and finally determine if these decisions, actions, or responses are in line with those of others and, more importantly, learn from these actions or decisions. The “Now What” phase takes what has been learned and allows a student to apply it to his or her professional practice by asking, “What can I do differently when I am confronted with this particular situation?”
Role-Playing
Case-based learning demonstrates that in some situations there may be no easy answers and that often there is not one correct answer. The cases can also be assigned to individual students, teams, or a class to promote student-to-student exchanges and peer learning19 through role-playing. Role-playing deals with problems or situations where students must analyze and interpret information, act out the problem or situation, and then reflect and discuss the consequences of these actions,22 using the “WHAT” framework. When role-playing is used in conjunction with the prepared cases, students are able to see a live sample of human behavior that serves as a vehicle for students to: (1) explore their feelings; (2) gain insight into their attitudes, values, and perceptions; (3) develop their problem-solving skills and attitudes; and (4) explore subject matter in varied ways.22 When case studies do not provide students with all of the necessary clinical evaluation or management information, students and educators alike can embellish upon the cases and alter them to address a variety of cognitive and psychomotor skills as part of the role-playing.
UTILIZING CASE STUDIES
As previously mentioned, case studies used in health-related professional education programs are often fictional, virtual (online CBL), researched, actual patient experiences/medical conditions, or other situational experiences. Case studies are often developed by faculty to meet specific learning objectives; commercial case studies4 can also be used and modified as needed, again based on learning objectives.
Cases may vary from a paragraph or two to a dozen pages with supporting documentation such as patient medical notes and laboratory results, diagnostic imaging, and pain and functional outcomes instrument results. When developing case studies, as the instructor please note that students can become lost in the specific details and confused when there are more than a dozen pages.6 Elaborate cases should be distributed well in advance of class. Study questions, either instructor generated11 or found in commercially available case study textbooks,4 can facilitate preparation for the class discussion and can loosely outline the discussion.6,11 Short cases (1–2 paragraphs) can be distributed and reviewed in class to either reinforce a concept or introduce a new concept.4 Whether case studies are short or long, Leenders and Erskine23 identify 4 basic steps for writing cases: (1) planning, (2) writing, (3) cooling (ie, incubation period), and (4) revising.
When planning and writing the cases, remember that each case should meet a specific learning objective and each case study should have a storytelling quality (Table). The characters (ie, health care provider and patient) should be given names (remember diversity), and their titles (eg, certified athletic trainer), responsibilities (eg, head athletic trainer, team physician), and personalities should be articulated with each case. Providing a backstory or narrative helps to set the stage and identify the case's key characters. The characters should carry on a realistic dialogue with details, and the sequence of events (ie, mechanism of injury, emergent care, sideline care, medical referral) should be easy to follow in chronological order5 based upon age, gender, ethnicity, and occupation or sport. The case information should identify needed information, but not be so blatant that students are able to identify items such as the differential or clinical diagnosis with a little thought process, unless this is the learning objective.
Recommendations for Students
Once a case or series of case studies have been assigned to students, knowing where to start to make the best use of one's time is difficult. The simplest thing a student can do when assigned a case is to read through the case(s) assigned by the instructor once or twice. Reading the case(s) at least twice allows students to gather a better sense of the state of affairs expressed by the case. In the case of athletic training cases, specifically those associated with orthopaedic or trauma assessment, most cases should begin with a paragraph that sets the scene for the injury or illness (backstory). A history and physical examination may follow, which typically provide enough information to guide the assessment process. Depending on the learning objectives, students may need to analyze the case and determine what is missing, incomplete, or even inaccurate.
As students read the case(s), suggest using a highlighter to identify the information they believe is key. Have them restate what has just occurred in a way that is more meaningful for them to understand. Suggest to them to ask themselves how they might have acted and what might have been done differently if they were managing the case. Using different-colored highlighters may assist students in separating the information they have analyzed and interpreted by categories in order to allow them to piece together segments of information to make correct clinical decisions (Figure 2). Figure 3 offers several other suggestions for students to utilize CBL.
Citation: Athletic Training Education Journal 8, 3; 10.4085/080374
Citation: Athletic Training Education Journal 8, 3; 10.4085/080374
Recommendations for Instructors
Once the case and any associated questions have been written, the next most important role of the athletic training educator is that of facilitator and not of content-information source. Facilitators are responsible for creating an atmosphere that is open, safe, and nonthreatening to facilitate students' participation, especially during open discussions. In discussing case studies, multiple viewpoints need to be shared, increasing the learning for each student and encouraging professional development. Boundaries should be established as to purpose of the debriefing, interrupting speakers, speaking time allocation, rules for cooperative disagreement, etc. Because cases may not have one right answer, facilitators must be able to consider alternative responses and be able to say, “I had not considered that action; let's discuss further.” Facilitators also need to ensure that all students remain engaged in the learning activity. When necessary, multiple cases may be used to facilitate smaller, more manageable class discussions. Finally, summarizing the key points is essential to ensure that the students take away the most important concepts.
If you opt for a group discussion, focus on bridging classroom theory with clinical practice. What makes this case different from reality if students have had the opportunity to see the case? Again, determine why they did or did not answer a question a certain way. Ask students to identify what they have learned from the assignment and how this may change their practice behaviors. Ask them how they would handle the situation now if confronted with a similar case. Figure 4 offers suggestions based on personal experiences and are intended to help utilize the case studies to improve student learning and bridge classroom theory and clinical practice experiences so students can begin to make the appropriate clinical decisions.
Citation: Athletic Training Education Journal 8, 3; 10.4085/080374
CONCLUSION
Case-based learning is a pedagogical method used in a variety of health-related professional education programs. It creates a safe, simulated learning environment and can address a wide array of learning objectives and program outcomes. As a teaching strategy, students appear to enjoy using CBL, and this encourages increased active and collaborative learning. Within athletic training, CBL has the potential to be an integral component of the educational and clinical component of preparing athletic trainers. Case-based learning can be used in a variety of athletic training courses, including orthopaedic assessment, general medical, and clinical/practicum courses to prepare future students to become competent athletic trainers. In addition, CBL can be used for capstone courses or seminars during the final academic year or semester to bridge the gap between snapshots of content and actually applying or integrating all course content into one situation.
Case-based learning objectives and outcomes examples.
Example of reading and marking up a case study. Abbreviations: DIPJ, distal interphalangeal joint; WNL, within normal limits; MMT, manual muscle testing.
Recommendations for students when completing case studies.
Alternative case-based learning teaching strategies.
Contributor Notes
About the Column Editor: Dr Berry is currently an associate professor and the professional athletic training education program director at Saginaw Valley State University.