Using online environments for case-based learning in the health sciences
Opportunity
Working with colleagues, both within and external to the University of Toronto, Dr. Leila Lax, an Assistant Professor in Biomedical Communications at the University of Toronto Mississauga and the Institute of Medical Science at the University of Toronto, has applied the theory of Knowledge Building to enhance student learning and engagement in courses in the health sciences.
Knowledge Building theory, defined by Drs. Marlene Scardamalia and Carl Bereiter of the Institute for Knowledge and Innovation and Technology, at the Ontario Institute for Studies in Education/University of Toronto, involves the creation of an environment that supports cognitive collaboration and the intentional improvement of knowledge, ideas, and practice. Dr. Lax has created a number of award-winning courses for individual and collaborative online learning in undergraduate and graduate health sciences education and continuing medical education.
Innovation
For each course, opportunities for online Knowledge Building are designed around providing authentic experiences through the use of clinical case studies. The objective is to retain the complexity of clinical situations to support authentic student decision-making. Patient videos are created and pedagogically integrated in the online programs through a unique set of Knowledge Building scaffolds or learning process tools designed by Dr. Lax and colleagues. The actors and film-makers from the Faculty of Medicine Standardized Patient Program, who are involved in the production of the patient videos, are experienced at portraying both patients and health care professionals and in teaching communication skills.
Medical Legal Visualization Course: The University of Toronto offers the only two-year Master of Science in Biomedical Communications (BMC) program in Canada. BMC is an interdisciplinary program in the design and evaluation of visual media in medicine and science. Online Knowledge Building was integrated into the second-year Medical Legal Visualization course, using the Knowledge Forum® platform, to extend the opportunities for case-based discussion, collaborative critique, and formative evaluation of student images beyond the classroom. Knowledge Forum is an electronic group workspace designed to support the process of knowledge building. Students upload consecutive iterations of their medical legal visualizations on Knowledge Forum so that classmates, instructors, and external experts can comment and contribute to improvement. With only 16 students in the class, mentorship becomes a collective process; students learn through providing and receiving assessments and building-on each other’s ideas.
End-of-Life Care Distance Education Program: The End-of-Life Care Distance Education Program was designed as an online collaborative Knowledge Building environment to help family physicians in the Toronto, York, and Simcoe regions improve their knowledge and understanding of palliative care and support better care for their dying patients and their families. The End-of-Life Care Distance Education Program is a 22-week, accredited continuing medical education course made up of five multimedia online case studies for asynchronous Knowledge Building and two face-to-face or videoconference sessions for synchronous discussion. Each module is conducted online for one month so that physicians can work together, anywhere and at any time. The course is case-based and employs a problem-based approach; video case studies feature actors who depict patients with symptoms and issues common in the last days of life. The physicians watch the videos online, research the symptoms and treatments, and then discuss management and care options online, facilitated by a palliative care expert from a local hospital.
Web-Based Communication and Cultural Competence Program: Internationally trained graduates of medical programs often lack an understanding of the cultural context and patient-centred care as practiced in Canada. This online program has been developed, with support from the Government of Ontario, to incorporate the Medical Council of Canada`s objectives concerning communication and culture, as well as legal, ethical, and organizational aspects important to practicing medicine in a Canadian context. The educational design stresses Knowledge Building, but unlike the previous two web-based examples, the students are not mentored nor do they work collectively online; thus, support for accuracy, deep understanding, and reflection had to be built into the resources. Five design strategies were developed for use in this program:
- Video Vignettes: Five problem-based modules and a communication skills module were developed with authentic cases that simulate doctor/patient interaction in video vignettes with text support. The students are offered choices of directions that the cases might take.
- Reflective Exercises: After the students make their choices for treatment or response to each stage of a case, videos show the strengths, weaknesses, and consequences of different decisions. None of the case studies has one clear answer; they illustrate ethical issues and clinical dilemmas doctors face in daily practice. The reflective exercises include commentaries to encourage consideration of the choices made and the processes students used to make those choices.
- Commentaries: In addition to the Reflective Exercises, commentaries provide information on case interpretation, learning application, and supportive mentoring and guidance.
- Concurrent Feedback: Knowledge checks, tests with online formative feedback, were embedded throughout the modules. Correct answers are supplied after a second try, along with in-depth explanations and links to resources and guidelines for practice.
- Contextualized Resources: Links to resources are offered throughout the modules, in the case studies, the reflective exercises, and the knowledge checks – wherever students need to connect to content.
Outcomes and Benefits
Medical Legal Visualization Course: The students have incorporated online Knowledge Building as an essential part of their learning. Knowledge Forum is used for formal feedback and communications, but the students have expanded online group interaction and building of ideas to other technologies that they use more readily, such as Twitter, wikis and Google docs. Structuring group feedback is no longer the sole responsibility of the professor but an intrinsic component of the learning. In a formal evaluation study, all of the students assessed the educational value of the process of online Knowledge Building as excellent or good. The students identified numerous advantages to using Knowledge Forum for collaborative learning:
- More egalitarian student participation;
- Creation of a record of the process for development of medical visualizations;
- More varied specialist/instructor participation, including outside experts; and
- More in-depth and analytical student-to-student critiques and comments.
End-of-Life Care Distance Education Program: The physicians cover not only the learning objectives in their online discussion, but also address additional issues and concerns, beyond the formal curriculum, such as religious and cultural issues around death and dying. Collaborative online Knowledge Building enables participant identification of real-world issues and collective problem-solving of current practice problems.
Web-based Communication and Cultural Competence Program: Although the students were initially uncomfortable with having no ‘right’ answers to the medical and ethical problems presented in the case studies, many of them consequently worked through all the options for each case so as to gain a deeper understanding of medical practice in Canada. The capacity of web-based resources to support learning about nuances of culture and communication was demonstrated through the student success and response to the program.
Challenges and Enhancements
For busy students and professionals, the biggest challenge of working collaboratively online often relates to time. For example, in the Medical Legal Visualization Course, some of the students indicated that the time to read, write, and respond in text was the greatest impediment to participation in Knowledge Forum critiques, although this did not seem to affect their participation. The physicians in the End-of-Life Care Distance Education Program commented on the quality of the course, but also noted the difficulty they had in finding the two to three hours a week to participate fully.
The development of each of the Knowledge Building courses, outlined above, requires a considerable investment in resources – personnel, infrastructure, and funding, with expertise needed in pedagogy, content areas, evaluation, and technology.
Potential
Medical Legal Visualization Course: This initial application within the Biomedical Communications Program provided the experience and the model for future adaptations of Knowledge Forum within the health sciences.
End-of-Life Care Distance Education Program: The End-of-Life Care Distance Education Program could be re-conceived to respond to interprofessional continuing education so that various health professionals who deal with palliative care can share perspectives and approaches to assessment and patient management. Interprofessional collaboration is a growing trend in health professional education and a reality of clinical practice; online learning can facilitate wider sharing among professional groups and help overcome geographical challenges.
Web-based Communication and Cultural Competence Program: This award-winning program is available for use by international medical graduates throughout Canada on the Medical Council of Canada web site at http://bmc.med.utoronto.ca/bmc/.
Dr. Leila Lax has published extensively on Knowledge Building pedagogy and is happy to share her publications, expertise, and models with others who are interested in building these experiences into their own courses.
For Further Information
Leila Lax
Assistant Professor
Biomedical Communications
Department of Biology
University of Toronto Mississauga and
Institute of Medicine, University of Toronto
[email protected]
Resources
Masters of Science in Biomedical Communications Program, Medical Legal Visualization Course: http://www.bmc.med.utoronto.ca/bmc/index.php
Lax, L., Taylor, I., Wilson-Pauwels, L., and Scardamalia, M. (2004). Dynamic Curriculum Design in Biomedical Communications: Integrating a Knowledge Building Approach and a Knowledge Forum® Learning Environment in a Medical Legal Visualization Course. Journal of Biocommunications. 30:1.
Lax, L., Singh, A., Scardamalia, M., & Librach, L. (2006). Self-Assessment for Knowledge Building in Health Care. QWERTY: Journal of Technology and Culture. Vol.1 (2) 19-37.
http://www.ckbg.org/qwerty/index.php/qwerty/article/view/11/11
Web-Based Communication and Cultural Competence Program: http://bmc.med.utoronto.ca/bmc/
Lax, Leila R., M. Lynn Russell, Laura J. Nelles, and Cathy M. Smith, Scaffolding knowledge building in a web-based communication and cultural competence program for international medical graduates. Academic Medicine, Vol. 84, No. 10, October 2009 supplement.
Nelles, Laura Jane, Cathy M. Smith, Leila R. Lax, and Lynn Russell. (2011). Translating face-to-face experiential learning to video for a web-based communication program. The Canadian Journal for the Scholarship of Teaching and Learning, Vol. 2, No. 1.
http://dx.doi.org/10.5206/cjsotl-rcacea.2011.1.8
Program Committees and Research Partners
End-of-Life Care Distance Education Program
Dr. Anita Singh
Course Content Co-ordinator
Palliative Care Consultant
Temmy Latner Centre for Palliative Care
Mount Sinai Hospital & Faculty of Medicine
University of Toronto
Dr. Leila Lax
Course E-Learning Co-ordinator
Assistant Professor
Biomedical Communications
Department of Biology
University of Toronto Mississauga and Institute of Medicine, University of Toronto
Dr. Lawrence Librach
Director
Joint Centre for Bioethics
University of Toronto
Dr. Anoo Tamber
Palliative Care Consultant
Sunnybrook Health Sciences Centre
Dr. Hyon Kim
Palliative Care Consultant
Sunnybrook Health Sciences Centre
Dr. Paolo Mazzotta
Palliative Care Consultant
Sunnybrook Health Sciences Centre
Web-Based Communication and Cultural Competence Program
Dr. Lynn Russell
Former Director Wighman-Berris Academy
Medical Education Consultant
Faculty of Medicine, University of Toronto
Dr. Leila Lax
Assistant Professor
Biomedical Communications
Department of Biology
University of Toronto Mississauga and Institute of Medicine, University of Toronto
Dr. Cathy Smith
Standardized Patient Program
Faculty of Medicine, University of Toronto
Laura Jane Nelles
Standardized Patient Program
Faculty of Medicine, University of Toronto
