Teaching Tips


Medical Education TEACHING TIPS: TWELVE TIPS FOR MAKING CASE PRESENTATIONS MORE INTERESTING* ____________________________________________________________________________
1.   SET THE STAGE Prepare the audience for what is to come. If the audience is composed of people of mixed expertise, spend a few minutes forming them into small mixed groups of novices and experts. Explain that this is an opportunity for the more junior to learn from the more senior people. Tell them that the case to be presented is extremely interesting, why it is so and what they may learn from it. The primary objective is to analyze the clinical reasoning that was used rather than the knowledge required, although the acquisition of such knowledge is an added benefit of the session. A "well organized case presentation or clinicopathological conference incorporates the logic of the workup implicitly and thus makes the diagnostic process seem almost preordained". Example A psychiatry resident began by introducing the case as an exciting one, explaining the process and dividing the audience into teams mixing people with varied expertise. He urged everyone to think in 'real time' rather than jump ahead and to refrain from considering information that is not normally available at the time: for example, a laboratory report that takes 24 hours to obtain be assessed in the initial workup. 2.   PROVIDE ONLY INITIAL CUES AT FIRST Give them the first two to live cues that were picked up in the first minute or two of the patient encounter either verbally, or written on a transparency. For example, age, sex race and reason for seeking medical help. Ask each group to discuss their first diagnostic hypotheses.  Experts and novices will learn a great deal from each other at this stage and the discussions will be animated. The initial cues may number only one or two and hypothesis generation occurs very quickly even in the novices. Indeed, the only difference between the hypotheses of novices and those of experts is in the degree of refinement, not in number. Example It is Saturday afternoon and you are the psychiatric emergency physician. A 25-year-old male arrives by ambulance and states that he is feeling suicidal. Groups talked for 4 minutes before the resident called for order to commence step three. 3.   ASK FOR HYPOTHESES AND WRITE THEM UP ON THE BLACKBOARD Call for order and ask people to offer their suggested diagnoses and write these up on a board or transparency. Example The following hypotheses were suggested by the groups and the resident wrote them on a flip chart: depression, substance abuse, recent social stressors-crisis, adjustment disorder, organic problem, dysthymia, schizophrenia, bipolar affective disorder. The initial three or four bits of information generated eight hypotheses. _____________________________________________________________________________________ *Craig J, Kopala L. Medical Teacher 1995;17(2):161-6. 4.   ALLOW THE AUDIENCE TO ASK FOR INFORMATION After all hypotheses have been listed instruct the audience to ask for the information they need to confirm or refute these hypotheses. Do not allow them to 'jump the gun' by asking for a test result, for example, that would not have been received within the time frame that is being re-lived. There will be a temptation to move too fast and the exercise is wasted if information is given too soon. Recall that the purpose is to help them go through a thinking process which requires time.       Teachers participating in this exercise will receive much diagnostic information about students' thinking at this stage. Indeed, an interesting teaching session can be conducted by simply asking students to generate hypotheses without proceeding further. There is evidence to suggest that when a diagnosis is not considered initially it is unlikely to be reached over time,  Hence it is worth spending time with students to discuss the hypotheses they generate before they proceed with an enquiry. Example Directions to the group were to determine what questions they would like to ask, based on gender, age and probabilities, to support or exclude the listed diagnostic possibilities. A sample of question follow: ·         Does he work? No, he's unemployed. ·         Does he drink? one to three beers a week. ·         Why now? He's been feeling worse and worse for the last 3 weeks. ·         Social support? He gives alone. Has no girlfriend. ·         Appearance? Looks his age. Not shaved today. No shower in 3 days. ·         Cultural background? Refugee from Iraq. Muslim. ·         How did he get here? He spent 4 years in a refugee camp after spending 4 months walking to Pakistan from Iraq. He left Iraq to avoid military service. ·         Suicide thoughts? Increasing the last 3 weeks. He was admitted in December and has been taking chloral hydrate. This step took 13 minutes. 5.   HAVE THE AUDIENCE RE-FORMULATE THEIR LIST OF HYPOTHESES After enough information has been gained to proceed, ask them to resume their discussion about the problem and reformulate their diagnostic hypotheses in light of the new information. Instruct them to discuss which pieces of information changed the working diagnosis and why. Call for order again and ask people what they now think. Example After allowing the group to talk for a few minutes, the resident asked them if there was enough information to strike off any hypotheses or if new hypotheses should be added to the list. One more possibility was added, post-traumatic stress disorder (PTSD). One group's list of priorities was major affective disorder with psychosis, schizophrenia, personality disorder. Another group also placed affective disorder first followed by organic mood disorder.       This step took 25 minutes. 6.   FACILITATE A DISCUSSION ABOUT REASONING Alter the original lists of hypotheses on the board in light of the discussion, or allow one member from each group to alter their own lists. By the use of open-ended questions encourage a general discussion about the reasons a group has for preferring one diagnosis over another. Example A general discussion ensued about reasons for these priorities.  Then the list was altered so that it read: schizophrenia, personality disorder, PTSD, major affective disorder with psychosis, organic mood disorder. 7.   ALLOW ANOTHER ROUND OF INFORMATION SEEKING Continue with another round of information and small-group discussion or else allow the whole group to interact. By giving information only when asked for and only in correct sequence, each person is challenged to think through the problem. Example More information was sought, such as: form of speech? eye contact? affect? substance use? After 5 minutes the resident asked if there were only lab tests they would like. The group asked for thyroid stimulating hormone, T4, electrolytes and were given the results. They also asked for the results of the physical examination and were told that the pulse was 110 and the thyroid was enlarged. At this point some hypotheses were removed from the list. 8.   ASK GROUPS TO REACH A FINAL DIAGNOSIS When there is a lull in the search for information, ask the groups to reach consensus on their final diagnosis, given the information they have. Allow discussion within the groups. 9.   CALL FOR EACH GROUP'S FINAL DIAGNOSIS On each group's list of hypothesis, star or underline the final diagnosis. Example The group decided that the most likely diagnosis was affective disorder with psychosis, the actual working diagnosis of the patient. 10. ASK FOR MANAGEMENT OPTIONS If there is enough time, ask them to form small groups again to discuss treatment options, or conduct the discussion as a large group. Again ask for the reasons why one approach is preferred over another. Particularly ask the experts in the room for their reasoning so that the novices can learn from them. 11. SUMMARIZE By the time the end is in sight the audience will be so involved that they will not wish to leave. However, 5 minutes before time, call for order and summarize the session. Highlight the key points that have been raised and refer to the objective of the session. Example We are now at the end of our time. You have all had the opportunity to use your clinical reasoning skills to generate several hypotheses which are shown on the board. Initially you thought it possible that this man could have any one of a number of diagnoses including depression, substance abuse, adjustment disorder with depressed mood, organic mood disorder or post-traumatic stress disorder. With further information the possible diagnosis shifted to include schizophrenia and personality disorder as well as depression with psychotic features. Finally the diagnosis of depression or mood disorder with psychosis was most strongly supported because of the history of consistently depressed mood over several months, along with disturbed sleep, poor appetite, weight loss, decreased energy and diminished interest in most activities. The initially abnormal thyroid test proved to be a red herring so organic mood disorder related to hyper- or hypo-thyroidism was excluded. Additionally absence of vivid dreams involving a traumatic event made a diagnosis of post-traumatic stress disorder unlikely. Although a diagnosis of schizophrenia could not be totally excluded, this seemed less likely given the findings. 12. CLOSE THE SESSION WITH POSITIVE FEEDBACK In some respects, but only some, teaching is like acting and one should strive to leave them not laughing as you go, but feeling that they have learned something. Example The more novice members of the group have learned from the more experienced and all your suggestions have been valid. It has been interesting for me to follow your reasoning and compare it with mine when I actually saw this man. You have given me a different perspective as you thought of things I had not, and I thank you for your participation. SUMMARY Although case presentation should be a major learning experience for both novice and experienced physicians they are often conducted in a stultifying way that defies thought. We have presented a series of steps which, if followed, guarantee active participation from the audience and ensure that if experts are in the room their expertise is used. Physicians have been moulded to believe that teaching means telling and, as a consequence, adopt a remote listening stance during case presentations. Indeed the back row often use the time to catch up on much needed sleep! Changing the format requires courage. We urge you to try out these steps so that both you and your audience will learn from and enjoy the process.


2006-06-09

Selection of Medical Students and its Implication for Students at King Faisal University


SELECTION OF MEDICAL STUDENTS AND ITS IMPLICATION FOR STUDENTS AT KING FAISAL UNIVERSITY Baher A. Kamal, MD,FRCS, Department of Urology, College of Medicine, King Faisal University, Dammam, Saudi Arabia. ______________________________________________________________________ إن أعداد المتقدمين لإلتحاق بكليات الطب فى إزدياد مضطرد لا يتناسب مع الأماكن الموجودة فعليا فى هذه الكليات لإستيعابهم ولذلك فإن قواعد اختيار المتقدمين للقبول فى كليات الط بهامة وحساسة.  إن  تقييم المتقدمين للدراسة بكليات الطب تعتمد فى المقام الأول على المهارات المعرفية ويتم قياس هذه المهارات عند المتقدمين عن طريق معدلات إمتحان شهادة إتمام الدراسة الثانوية وإمتحان القبول الذى يجرى لهم عند التقدم ، ويأتى فى المقام الثانى للتقييم المهارات الشخصية التى لا تعتمد على ما تعلمه الطالب ومنها الذكاء والمرونة الذهنية وحب الأستطلاع والتفكير المنطقى والقدرة على التحمل وحل المشكلات.،ولا يقل أهمية عن ماسبق فى خصائص المتقدمين المنظر العام والشخصية اللذان من شأنهما أن يعكسان العلاقة المستقبلية بين الطبيب والمريض، وعلى العكس من ذلك فإن العوامل الشخصية مثل العمر والنوع والجنس والديانة والحالة الإحتماعية لابد أن لاتؤثر على قبول الطلبة من عدمه فى كليات الطب.   إن قواعد إختيار الطلبة للدراسة بكلية الطب بجامعة الملك فيصل تعتمد فى المقام الأول على تقييم المهارات التعليمية ، ويؤخذ فى الإعتبار بعد ذلك تقييم باقى الخصائص عن طريق المقابلة الشخصية وتعبئة  إستبانه مفتاح الكلمات:   إختيار المتقدميين ، التعليم الطبى ، طلاب الطب. ________________________________________________________________________ The appropriate selection of medical students is a challenging task. It requires that important assessment criteria principally based upon cognitive skills that include the matriculation and admission test scores of the applicants be fulfilled. Non-cognitive skills are  also important, but  used to a lower degree include intellectual flexibility, inquisitiveness, critical reasoning, logical thinking, tolerance, ability to cope with uncertainty and problem solving. Other criteria that are also considered important for selection include personal qualities and attitudes of the applicants that reflect directly on doctor-patient relationship. In contrast, such demographic factors as age, gender, race, religion, socio-economic status and schooling should not influence the selection process. The admission criteria adopted at King Faisal University Medical College focus basically on cognitive criteria. Other criteria whether non-cognitive or personal quality assessment are also taken into account through interviews and completed questionaires. Key Words: Admission selection, medical education, medical students.______________________________________________________________________________ Download full article


2006-06-09

Prevention of Breast Cancer


PREVENTION OF BREAST CANCER Ali M. Al-Amri, MD Department of Internal Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia __________________________________________________________________ مقدمة : إن الوقاية هي خير وسيلة لعلاج السرطان بشكل عام و سرطان الثدي بشكل خاص. الوقاية الأولية و تشمل تعزيز الصحة و تقليل نسبة حدوث السرطان بين عامة النا س مما يؤدي إلى منع نشوء و تطوراالسرطان التوسعي. من عوامل الوقاية الأولية التوقف عن التدخين , التكيف في الأسلوب الحياتي و الغذائي مع تناول كميات من الفيتنامينات و العناصرالمعدنية. إن تحديد العامل الوراثي و فهم العوامل التي تساعد على نشوء السرطان وتطور الوسائل التشخيصية الفعالة و تجنب العومل المسببة و تحديدها مع وجود العلاج الكيميا ئي النا جح يمكن أن تؤدي إلى تناقص عدد الوفيات و المضاعفات الناتجة عن السرطان بشكل عام وسرطان الثدي بشكل خاص. الوقاية الثانوية هي تحديد و علاج الأورام والحالات التي لها قابلية التحول إلي خلايا  سرطانية والتي تكون غير واضحه سريرياً و من الأمثلة النموذجية لهذه الوقاية هو التصوير الإشعاعي للثدي. الوقاية الثالثة تم تعريفها بالتحكم في الأعراض و المضاعفات الناتجة عن الأمراض السرطانية مع إعادة التأهيل. إن هذه التعريفات يمكن أن تصبح أقل فائدة في المستقبل بحيث لا يمكن أن تتسع للعلوم و المعارف الجديدة كالبيانات الجزيئية مثلاً. _________________________________________________________________________ The best therapy for cancer is prevention. Primary prevention involves health promotion and risk reduction in the general population so that invasive cancers do not develop. These primary preventive measures include the cessation of smoking, lifestyle and diet modification, vitamins and micronutrients supplementation. Identification of genetic risk, understanding of carcinogenesis, development of effective screening tools, avoiding risk factors and effective chemoprevention can lead to decreased morbidity and mortality of cancers in general and more importantly breast cancer. Secondary prevention is the identification and treatment of premalignant or subclinical cancers. Screening by means of mammography is a typical example of secondary prevention. Tertiary prevention is defined as symptoms control and rehabilitation. These definitions may become less useful in the future as they do not account for the new incoming data such as molecular data. Key Words: Prevention, Cancer, Breast. ____________________________________________________________________________________ Download full article


2006-06-09

Health Education Resources Availability for Diabetes and Hypertension at Primary Care Settings, Aseer Region, Saudi Arabia


HEALTH EDUCATION RESOURCES AVAILABILITY FOR DIABETES AND HYPERTENSION AT PRIMARY CARE SETTINGS, ASEER REGION, SAUDI ARABIA Yahia M. Al-Khaldi, MBBS, ABFM,* Abdullah I. Al-Sharif, MBBS, FCCU† *Department of Primary Health Care, Health Affairs, Aseer Region, †Assistant Deputy of Curative Medicine, Ministry of Health, Riyadh, Saudi Arabia ________________________________________________________________________________________________________ هدف الدراسة: تهدف هذه الدراسة إلى التعرف على توفر الموارد اللازمة للقيام بالتوعية الصحية لمرضى السكري والضغط المرتفع بمراكز الرعاية الصحية الأولية بمنطقة عسير  واقتراح الحلول العملية لكيفية توفير البنية الأساسية ذات العلاقة. طريقة الدراسة:  تم إجراء هذه الدراسة من خلال توزيع استبيان صمم بواسطة الباحثين إلى جميع مراكز الرعاية الصحية الأولية بمنطقة عسير ، وقد اشتمل هذا الاستبيان على بعض المعلومات عن المراكز الصحية كعدد السكان وعدد مرضى السكري والضغط  ومدى توفر الأجهزة السمعية والبصرية والمثقفين الصحيين والمواد التثقيفية كالكتيبات والمطويات والملصقات وبرامج التوعية الصحية بالمراكز الصحية . تم تعبئة الاستبيان من قبل المشرفين الفنين بالمراكز الصحية خلال عام 2001م  . تم إدخال المعلومات السابقة إلى حاسب آلي مزود ببرنامج إحصائي وتم استخدام الاختبارات الإحصائية المناسبة. نتائج الدراسة :  بلغ عدد المراكز التي استجابت للاستبيان  242 مركز من أصل 245 مركز ، أي بنسبة مقدارها  99%.   بلغ عدد المراكز التي يوجد بها مثقفون صحيون مؤهلون  20 مثقفاً صحياً أي بنسبة 8% من إجمالي المراكز.  تفاوتت نسبة توفر الأجهزة السمعية والبصرية والمواد التثقيفية بين 10-50% ، أما برامج التوعية الصحية فقد  كانت موجودة في أكثر من 90% من المراكز الصحية لكل من مرض السكري والضغط المرتفع على حد سواء. الاستنتاج:  رغم انتشار مرض السكري والضغط بمنطقة عسير فإن معظم المراكز الصحية تفتقد إلى البنية الأساسية المطلوبة للتوعية الصحية بهذين المرضين، مما يحتم أهمية دعم هذه المراكز بالموارد الأساسية للتوعية الصحية سواءً من خلال إدارة التوعية بالمديرية الصحية بالمنطقة،القطاع الخاص ، شركات الأدوية أو اللجان الصحية المحلية. الكلمات المرجعية: التوعية الصحة ، توفير ، السكري ، الضغط المرتفع ، منطقة عسير. _______________________________________________________________________ Objective: The aim of this study was to evaluate the availability of health materials and means on diabetes and hypertension at PHCCs in Aseer region, Saudi Arabia. Materials and methods: This study was carried out in PHCCs in Aseer region. A questionnaire was distributed to all PHCCs in the region. The questionnaire elicited information on the total population served, the number of diabetic and hypertensive patients, and the availability of health materials for diabetes and hypertension. Data were entered and analyzed by using SPSS. Results: A total of 242 PHCCs out of 245 responded to this questionnaire. There were 20 health educators (8%).Availability of health education materials ranged between 10 to 50%. Health education programs for Diabetes and hypertension were available in more than 90% of PHCCs. Conclusion: This study revealed that most of PHCCs in Aseer region lacked essential health education materials and means for diabetes and hypertension and, therefore were in urgent need of these materials from the Health Education Department, private health sectors and drug companies. Key Words: Health education, availability, Diabetes, Hypertension, Aseer Region. ______________________________________________________________________________ Correspondence to: Dr. Yahia M. Al-Khaldi, P.O. Box 2653, Abha, Saudi Arabia E-mail: yahiammh@hotmail.com Download full article


2006-06-09

Giant Juvenile Fibroadenoma: Experience from a University Hospital


GIANT JUVENILE FIBROADENOMA: EXPERIENCE FROM A UNIVERSITY HOSPITAL Maha S.A. AbdelHadi, FRCSI, FACS,Department of Surgery, College of Medicine, King Faisal University, Dammam, Saudi Arabia _____________________________________________________________________________________________________________________ مقدمة : يعتبر الورم الغدي الليفي أحد أورام الثدي الحميدة الأكثر شيوعاً في العيادات الخارجية لدينا بالمستشفى. وأن الأورام الغدية الليفية الشبابية العملاقة هي الأقل تحديداً وتتميز بالنمو السريع والتشوه الكبير. طريقة الدارسة هي عبارة عن مراجعة لجميع حالات الأورام الغدية الليفية التي تم الكشف عليها بالعيادات الخارجية خلال فترة امتدت لمدة 14 عاماً من 1990-2004 م. تمت ملاحظة البيانات الديموغرافية ومدة الأعراض وحجم الورم عند المراجعة واستخدام الوسائل الإشعاعية والخلوية والنسيجية المرضية ( الباثولوجية ) والاستئصال الجراحي والمتابعة. تمت تشخيص 864 حالة ورم غدي ليفي بواسطة الفحوصات السريرية والإشعاعية وتم تأكيدها بواسطة الارتشاف بالحقنة الرقيقة. تمت متابعة حالات الورم الغدي الليفي والذي يقل حجمه عن 2 سم بصورة منتظمة في العيادات الخارجية بينما أجري استئصال جراحي للورم الذي يزيد حجمه عن 2سم وتم تحديد الأورام الغدية الليفية الشبابية العملاقة بتلك الأورام التي يزيد حجمها عن 5 سم. النتائج الدراسة : بلغ العدد الكلي لحالات الأورام الغدية الليفية التي تم استئصالها جراحياً 202 حالـة ( 23% ) بينما كانت بقية الحالات الأخرى والتي عددها 662 ( 77% ) ضمن الفئة التي تمت متابعة حالتها بالعيادات الخارجية. تم تشخيص الأورام الغدية الليفية الشبابية العملاقة في 9 مريضات وبما يعادل 5و4% من جميع حالات الأورام الغدية الليفية التي تم استئصالها جراحياً ، كانت أعمار المريضات تتراوح ما بين 14-23 سنة. الخلاصة: بالنظر إلى تاريخ التضخم الفجائي السريع للثدي كما موضح تقريباً في جميع المظاهر السريرية وعلى الرغم من أن الأورام يمكن أن تبدو حميدة إلا أن الاستئصال الجراحي يظل الطريقة الوحيدة في علاج مثل هذه الأورام مما يسمح للأنسجة الطبيعية المحيطة بالثدي والتي كانت مضغوطة سابقاً، بالتمدد واستعادة وظيفتها الطبيعية ومظهرها الجمالي. إن استخدام الوسائل الإشعاعية مثل الموجات فوق الصوتية والرنين المغنطيسي يمكن أن يساعد في التشخيص ومن ثم ترك التصوير الإشعاعي للثدي للمجموعة العمرية الكبيرة. الكلمات المرجعية : الورم الغدي الليفي. ______________________________________________________________________________ Objective: Fibroadenoma is one of the commonest benign breast lesions in our outpatient clinics. Giant Juvenile fibroadenoma (GJF) characterized with their alarming rapid growth and gross disfigurement is less frequently identified. Materials and Methods: A 14-year review (1990-2004) of all fibroadenomas presented to the Outpatient Department was undertaken. Demographic data, duration of symptoms, size at presentation, the use of radiological, cytological and histo-pathological modalities, surgical excision and follow up were all noted. Eight-Hundred-Sixty-Four cases were diagnosed as fibroadenoma by both clinical and radiological examinations and confirmed by FNAC.  Patients with fibroadenomas <2 cm in size were followed up regularly in the out patients department, while those 2 cm underwent surgical excision. GJF were defined as those with 5 cm in diameter. Results: The total number of excised fibroadenomas was 202 (23%), while the remaining 662 _____________________________________________________________________________________ Correspondence to: Dr. Maha SA AbdelHadi, Associate Professor and Consultant Surgeon, Department of Surgery, King Fahd Hospital of the University, P.O. Box 40293, Al-Khobar 31952, Saudi Arabia   E-mail: abdelhadi_m@hotmail.com Download full article


2006-06-09