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Pathology - Global Challenges in Education |
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Key Words: veterinary pathology • case-based learning • online learning • deep approach to learning • diagnostic reasoning
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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This article documents the evolution of the ICAP methodology over the past six years, from a paper-based to an online modality, in response to student and peer feedback. In addition, it discusses the impact of ICAP in relation to developing problem-solving capacity in a group situation, developing an understanding of the role of veterinary pathology in the diagnostic process, and promoting vertical and horizontal integration with clinical and other para-clinical disciplines.
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PHILOSOPHY AND PEDAGOGICAL PRINCIPLES UNDERLYING THE DEVELOPMENT OF ICAP |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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In the traditional veterinary science curricular model, the pre-clinical sciences are taught didactically, followed by the para-clinical sciences (also taught, to a lesser extent, didactically), with final application of this knowledge in the practical environment of the clinic.5 In response to the recognition that veterinary practice requires certain graduate attributes such as critical thinking, problem solving, and analytical skills, problem-based learning (PBL) has been adopted to various degrees by veterinary schools across North America.6
An understanding of structural and functional abnormalities is vital to the clinical disciplines of veterinary science. The para-clinical discipline of veterinary pathology provides the conceptual knowledge base that allows veterinarians to formulate strategies of diagnosis, treatment, control, and prevention of disease. Traditionally, this has been achieved through didactic presentation of the five basic pathological processes (cell injury, degeneration, and necrosis; inflammation and repair; circulatory disturbances; disorders of growth; and tissue pigmentations and deposits) in a general pathology unit of study, followed by a systemic pathology course focusing on etiology, pathogenesis, and appearance of diseases affecting specific organs or tissues. The rationale for this approach is to draw the learner from an understanding of normal structure and function, through the limited manifestations of tissue dysfunction, to an understanding of disease that allows appropriate treatment and prognosis of clinical medicine. Although the merits of such an approach are well accepted, the traditional didactic discipline-focused methods mean that the role of veterinary pathology and veterinary pathologists in the investigative diagnostic process for clinical practice may not be adequately perceived by students. Evidence-based medicine has led to an increased emphasis on identifying clinically significant problems through an investigative process of diagnosis (i.e., a problem-oriented approach) and a lesser emphasis on specific disease pattern recognition. The traditional didactic learning environment of general and systemic pathology may easily be misconstrued by the student to encourage only a pattern-recognition approach. As a result, upon exposure to a problem-oriented approach in the clinical disciplines, the student is likely to disregard the pre-clinical and para-clinical knowledge that he or she has previously acquired.
The problem-oriented approach to diagnosis focuses on developing a list of prioritized evidence-based problems for further investigation on the basis of signalment, history, clinical signs, and physical examination. Clinical problems can be, and usually are, commonly distilled to describe organ-system or tissue involvement. The logical clinician then uses some consideration of the limited manifestations and causes of tissue dysfunction (general pathology) to create a differential diagnostic list of broad, and sometimes specific, possibilities. The key to effective clinical case management is to detect, describe, and then deduce the significance of the disease changes to formulate a plan for further investigation and finally attempt to arrive at a specific diagnosis. The plan aims to delineate problems and accumulate evidence for identification of a specific disease. Invariably, laboratory aids and the veterinary pathologist are used in that deductive process. The question arises, then, if this is the role of the veterinary pathologist in the diagnostic process, why not attempt to teach students veterinary pathology in the context of the diagnostic process? This is the first stage of curriculum alignment.
Using Problem-Based Learning (PBL) and a Deep Approach to Learning in the Teaching of Veterinary Pathology
Teaching the diagnostic process, however, ideally requires a case-based approach rather than the traditional didactic approach in order to have a major impact on students’ learning and understanding. This strategy uses real-life cases of animal disease to enhance the learning process by establishing relevance and logical direction through true curriculum alignment among graduate attributes, learning outcomes, and assessment tasks.7 When students are engaged in a learning task, they usually adopt one of two basic learning strategies: a surface learning approach, involving attention only to verbatim memorization of facts, or a deep learning approach, involving understanding and critical analysis of the underlying concepts within a task.7–9 Students reporting a deep approach are more likely to understand the meaning of a written task, apply the principles, and remember the content over an extended period of time. The perception of a task influences the learning approach adopted by the student. Tasks that require comprehension, critical thinking, and problem-solving skills will encourage the use of deep cognitive learning approaches. Curriculum design offers a good opportunity for the teacher to influence students’ learning approach.7, 9–11 By its very nature of high relevance, a case-based approach has the capacity to enhance student-centered opportunities for learning, encouraging a deep approach both in discipline-specific problem solving and in the development of a specific knowledge base.
The need to encourage a deep learning approach in students has led to the implementation of new teaching strategies such as the problem-based learning (PBL) method. PBL, in its most fundamental sense, represents all parts of the spectrum in the use of real cases to drive the development of problem-solving skills and the integration and acquisition of knowledge. PBL is characterized by the use of real-life examples as a context for students to learn problem-solving skills and acquire knowledge.12 This implies self-directed learning in which the students decide what and how they will learn. The interpretation of PBL varies, and the terms "problem-based learning," "case-based learning," and "problem-orientated learning" are often used interchangeably. However, the difference between case-based learning and PBL is that in PBL the problem is presented before any knowledge of basic principles or basic science has been acquired and the problem drives the acquisition of those basic principles; in case-based learning, cases are used in conjunction with traditional didactic methods. More recently, terms such as "inquiry-based learning" (IBL) have been implemented to describe the engagement of students in their learning process by means of integrating methods such as problem solving with more traditional didactic teaching methods such as practical laboratories and lectures.13
Although the case-based approach is second nature for clinical academics teaching veterinary medicine, both in the lecture theatre and the clinical setting, academic pathologists are traditionally less skilled in applying this approach to the teaching of veterinary pathology in the lecture theatre. The teaching and learning that take place in the necropsy room and laboratory, on the other hand, rely on real cases to emphasize that detection, description, and deduction are fundamental for understanding gross and microscopic pathological changes. How, then, can case-based approaches to learning be extended to other components of the teaching of veterinary pathology?
PBL medical students tend to adopt a deep approach to learning,14, 15 and, although a highly strategic reproductive learning behavior can be invoked,16 the strength of PBL is the contextual framework that is applicable to real life. The mental organization of knowledge encouraged by a learning environment determines successful integration and application in the environment in which it needs to be used and is closely related to contextual learning theory.12
The Application of Information and Communication Technology (ICT) for Student-Centered Learning
In the past decade or so there has been a revolution in the field of information and communication technology. This revolution has allowed the development of learning-management systems (LMS) that enhance the student experience (e.g., WebCT and Blackboard) and commonly support the face-to-face teaching components of a curriculum. While this has been occurring there has been a serious move from teacher-centered to student-centered learning modes,7 and LMSs contribute to this process, with their emphasis on engaging students through questioning and other strategies. The key to ensuring the success of online learning is to link it with other forms of teacher–student interaction and to emphasize its congruence with assessment.
The Use of Group Work to Enhance the Learning Experience
The ICAP approach relies on group problem solving, with the formation of a collaborative approach supporting enhanced student learning and the development of professional skills required of veterinary graduates, such as leadership, communication, and interpersonal skills.17–19 Students who analyze case-based evaluations as a group have a performance advantage and display deeper understanding, in terms of improvement in areas such as the ability to conduct complete differential diagnostic lists, over those who analyze them as individuals.20 Pickrell et al., in their study, particularly noted the improved capacity of groups over individuals to discriminate among diagnostic differentials in specific cases. In addition, it was shown that training provided as part of a group helped students to perform better on similar problems in the future, whether performance was analyzed subsequently in a group or on an individual basis.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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ICAP Version 3 (CaseBuilder)- A further evolution of the learning system was embarked upon in 2004 and 2005. The format and appearance of Web delivery remained essentially the same (see Figure 2). The major advance made at this point was the building of a dynamic Web site run from a database called CaseBuilder (created by the Faculty of Veterinary Science, University of Sydney), with seamless links provided from the LMS. While making no perceptible difference to the student, this change made it quick and easy for teaching staff to upload text and image data to the database, choose an output template, and then automatically populate the template with case-specific data.
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For ICAP Version 1, groups of four to six learners were formed alphabetically (by surname) by the unit-of-study coordinator; for Version 2, groups were still formed by the unit-of-study coordinator but were assigned randomly rather than alphabetically; in Version 3, groups are formed by the learners themselves during an introductory exercise.
Feedback- For ICAP Versions 1 and 2, feedback was provided during the fortnightly resolution sessions (six times in the semester, 12 cases) and in written form to each group on their case report. For Version 3, feedback is given online as generic case feedback and written comments on group case reports with monthly resolution sessions.
ICAP Resolution Sessions- Discussion and resolution of each case was achieved in large-group tutorial sessions involving six to eight ICAP groups, facilitated by a teaching member of the veterinary pathology staff.
Peer Review- For ICAP Version 3, a system of peer feedback was incorporated into the learning module. This peer feedback is a part of the formative assessment process whereby participation is required; however, it does not form part of the summative assessment for the unit of study. The requirement is that peer feedback be short (200–400 words), and students are encouraged to be supportive and constructive.
Assessment- The bulk of the cases form part of the formative assessment program, while two cases provide the bulk of the summative assessment for this component of the unit of study. A summative assessment mark is provided for each group, based on one case report. This group mark is modified for each individual within the group, based on their attendance at ICAP sessions and their participation in group work. Group-work participation is judged to be either satisfactory or unsatisfactory by members of the group. The ICAP component makes up 15–20% of the overall assessment of the unit of study.
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EVALUATION OF ICAP |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The three authors evaluated the student survey results each year in relation to ICAP's effectiveness in delivering learning outcomes: namely, the perceptions of developing problem-solving capacity in a group situation, an appreciation of the importance of staff feedback and peer feedback, an understanding of the role of veterinary pathology in the diagnostic process, and the promotion of vertical and horizontal integration with clinical and other para-clinical disciplines. One of the authors (PJC) has significant input into a later clinical unit of study (Veterinary Medicine and Clinical Pathology) and was able to evaluate the impact of ICAP learning outcomes on year 4 students directly.
Peer Evaluation
There has been ongoing dialogue with two para-clinical and five clinical colleagues over the usefulness of ICAP in achieving the desired learning outcomes, especially in promoting vertical and horizontal integration. Written comments were sought from these colleagues in mid-2006. Moreover, the authors have the opportunity to evaluate the success of ICAP in achieving the desired learning outcomes through their teaching of veterinary clinical pathology to year 4 (PJC) and an elective rotation in diagnostic veterinary pathology to year 5 (all authors).
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RESULTS |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Promotion of Understanding in Veterinary Pathology- Another key survey question investigating the effectiveness of ICAP on the promotion of understanding in veterinary pathology showed 91% agreement among cohorts of respondents (see Table 2) and provoked numerous positive comments revolving around engagement with the discipline (see Table 3).
Online Format- Approximately three-quarters of respondents agreed that the online format and Web access were a positive part of their learning process, while only 8% agreed that time would have been better spent on didactic lectures.
Workload- Almost two-thirds of students over all cohorts agreed that the workload was manageable. The response was remarkably consistent over the four-year period, despite a marked reduction in workload over the same period. Other students commented that the workload was too high.
Generic Attributes- Importantly, measures of more generic attributes appear to show favorable responses in the context of this learning activity, with 80% of respondents agreeing that the ICAP format promoted independent learning and critical evaluation.
Teamwork/Group Work- The survey results show that three-quarters of learners across all cohorts recognized the importance of teamwork as a generic skill and agreed that the process helped engagement in teamwork.
There were, however, a number of references to difficulties with group work (see Table 4); students identified problems including domination by certain group members, lack of organizational skills, difficulties with conflict resolution, the unfairness of group assessment, and lack of workload equity. Some students perceived that having their groups chosen for caused an unequal distribution of work.
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Personally I had some trouble with members of my group so my impression of group learning was not overly pleasant (my own fault for choosing these people to work with).
Some process issues received variable responses, with respondents equivocal on mode and fairness of assessment. Judging by the students’ comments, such feedback is mostly driven by angst about group marks.
Student Peer Feedback- Students were less enthusiastic about peer feedback, with only 37% agreement overall that providing feedback enhanced their learning and 28% agreement that receiving feedback enhanced their learning.
Peer Evaluation (see Table 5)
The success of this innovation has been recognized by our peers to some extent, with three colleagues, one clinical and two para-clinical, adopting similar online case-based programs from the ICAP model on the basis of ongoing discussions regarding the effectiveness of ICAP in providing contextual relevance and delivering desired learning outcomes. These initiatives are in veterinary microbiology (Case-Based Applied Veterinary Microbiology On Line, or CAVMOL) and ruminant production (Teaching Innovation Livestock Health and Production, or TILHAP). As a result, the students are familiar and comfortable with the format.
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Reflections of the Authors
Students’ acceptance of and involvement in a paper-based cased-based approach in veterinary clinical pathology in year 4, in operation since 1990, appeared to be facilitated by their prior exposure to ICAP in year 3 from 2002 on (PJC). This facilitation was expressed in decreased time spent working through cases, enhanced understanding of the importance of pathological processes in disease diagnosis, and a greater awareness of the role of histopathological examination and other laboratory procedures as diagnostic tools. Moreover, all authors had the opportunity to assess a limited number of students undertaking an elective rotation in veterinary diagnostic pathology in year 5 on their level of understanding of ICAP by allowing them to develop additional ICAPs online. While these students were obviously highly focused on diagnostic pathology, they did display an aptitude for the process of development of online ICAPs that reflected a high level of understanding.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The evolution of the ICAP model, although primarily driven by student and peer perception feedback and by our own reflections, has also been dependent on curriculum design, with an emphasis on vertical and horizontal integration. Clearly, ICAP has assisted this process, both by influencing the design of other online cased-based models within the curriculum and by encouraging continual dialog among para-clinical and clinical academics. However, evaluating the success of ICAP in achieving its goals of developing problem-solving capacity in a group situation and an understanding of the role of veterinary pathology in the diagnostic process is somewhat more difficult. Student and peer perception feedback has suggested varying degrees of success and emphasized the importance of reinforcing principles and approaches—despite the fact that all three authors teach across three years of both para-clinical and clinical units of study and, therefore, have ample opportunity to reinforce principles and approaches.
Student feedback identified two key issues: group-member interaction and peer assessment. It was clear from individual students’ comments (Table 4) that group dynamics often left much to be desired and that there was concern about unequal distribution of work within the groups. The issue of selection of group members was addressed in ICAP Version 3 when students were allowed to select their own groups (with varying degrees of success). However, the issue of group dynamics and the consequent unequal distribution of workload is one that the authors felt needed to be addressed in a generic way earlier in the curriculum. This conclusion was reinforced through student feedback for similar group-work activities in other units of study. Consequently, one of the authors (PJC) contributed to the establishment of a session on understanding teamwork for first-year veterinary students in a Professional Practice unit of study, which focuses on developing self-awareness, interpersonal skills, and leadership (a further example of vertical integration). This student-focused session takes students through reasons why teamwork succeeds or fails and offers them some insight into how they and others best work in a group via a simulated teamwork activity. These generic aspects are then reinforced in all group activities throughout the curriculum. Since the session was introduced only in 2006, its impact on student perceptions of ICAP sessions cannot be assessed until 2008.
It is well accepted that the success of group work is heavily dependent on members’ agreeing on common goals and, through self-awareness, developing trust and respect.22 Other factors necessary for success are usually subsidiary to these, but some, such as technical expertise, cooperation, and shared workload, may be equally important, depending on the teamwork exercise.22 The authors suspect that the difficulties in group work for ICAP sessions emanated from a lack of trust and respect rather than from disagreement on the goals of the project. This view was based on student comments that other group members were often "holding them back" or "didn't have the expertise required."
There is evidence that some students did not perceive the value of engaging in group activities. One student commented,
The main problem I believe was the grouping together of individuals to work together who may not necessarily chose to work together in real life. From that point of view I found the entire ICAP unconducive to learning. Any benefit gained from each exercise was based on my own individual research and collaborating with people from other groups.
For these students to accept the usefulness of group work, there must be an attitudinal paradigm shift, which can come about only through self-awareness and reinforcement of the importance of interpersonal skills. This conclusion is consistent with other studies of collaborative learning, in which student survey responses suggest that the students do not necessarily appreciate the benefits gained from the pedagogical approach of working in teams and that emphasizing how students gain from such assignments and identifying the skills developed would be advantageous.23 The global veterinary profession expects all graduates to have attributes based on leadership, communication, and interpersonal skills.18, 24 Teamwork, therefore, must remain an important component of the veterinary curriculum.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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ACKNOWLEDGMENTS |
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Footnotes |
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Dr. Mark Krockenberger, BSc(vet), BVSc, PhD, Grad. Cert. Ed. Stud, MACVSc (Pathobiology), MASM, is Senior Lecturer in Veterinary Pathology, Faculty of Veterinary Science B14, University of Sydney, NSW 2006 Australia. E-mail: mkrocken{at}mail.usyd.edu.au.
Dr. Katrina Bosward, BVSc, BSc (Vet), PhD, Dipl. VCS, Grad. Cert. Ed. Stud., is Senior Lecturer in Veterinary Pathology, Faculty of Veterinary Science B14, University of Sydney, NSW 2006 Australia. E-mail: kateb{at}camden.usyd.edu.au.
Professor Paul John Canfield, DVSc, PhD, Grad. Cert. Ed. Stud., FRCPath, FACVSc, MRCVS, is Professor of Veterinary Pathology and Clinical Pathology, Faculty of Veterinary Science B14, University of Sydney, NSW 2006 Australia. E-mail: p.canfield{at}vetp.usyd.edu.au.
a Blackboard, Inc., Washington, DC 20036 USA <http://www.webct.com>.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONPHILOSOPHY AND PEDAGOGICAL...MATERIALS AND METHODSEVALUATION OF ICAPRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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