How can I learn medical meta-analysis

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A win-win situation for research, teaching and treatment

Sebastian Ertl

1Clinic for Psychoanalysis and Psychotherapy and Postgraduate Unit, Teaching Center, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria

Laurenz Stastka

2Department of Internal Medicine II, Department of Angiology, Medical University of Vienna, Vienna, Austria

Henriette Löffler-Stastka

1Clinic for Psychoanalysis and Psychotherapy and Postgraduate Unit, Teaching Center, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria

1Clinic for Psychoanalysis and Psychotherapy and Postgraduate Unit, Teaching Center, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria
2Department of Internal Medicine II, Department of Angiology, Medical University of Vienna, Vienna, Austria
Corresponding author.
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Abstract

A modern “case-based” e-learning is an excellent aid to train skills and communication, since “diagnostic reasoning” is seen as a schematic problem solving. We present a patient case on the subject of coagulation disorders in chronic substance abuse, in which adequate success can only be achieved through an interdisciplinary approach. In this regard, it should be mentioned that there is still little evidence on this topic and more research is needed.

Additional material online

In the online version of this article (10.1007 / s00739-020-00655-3) you will find further literature on the topic.

Keywords: E-learning, case-based learning, embolism, interdisciplinary, teaching

Abstract

Modern case-based eLearning is an excellent tool for skills and communication training, as diagnostic reasoning can be seen as schema-based problem-solving. We report on a patient with coagulation disorder due to chronic substance abuse, in whom reasonable success can only be achieved with an interdisciplinary approach. In this regard, it should be mentioned that there is still little evidence and that more research is needed on this topic.

Keywords: eLearning, Case-based Learning, Embolism, Interdisciplinary, Teaching

introduction

Increasing numbers of patients, complex patient cases, documentation requirements for every treatment step and a gigantic production of knowledge that needs to be implemented and applied are confronting aspiring specialists with ever greater hurdles in their training. According to the Cochrane Directory, there have been a million completed randomized controlled trials to date. Around 20,000 studies were published in 2019 alone.

How can this enormous knowledge be adequately conveyed and taught?

How should the knowledge transfer be designed in practice?

Case-based teaching

There can be worlds between recognized theory and practical application. This gap can be found in many areas and is mostly seen as a massive challenge by those working on the front lines. In order to be able to develop a modern postgraduate curriculum and to do justice to the further developments in specialist training, the basics of "lifelong learning" (LLL) as well as current research results from medical didactics must be taken into account. The integration of new state-of-the-art treatment options and their training in education and training, such as psychotherapeutic medicine in psychiatry, should be mentioned here as an example.

Knowles et al. like many other authors, published various aspects that are essential in postgraduate teaching. As early as the 1980s, Merriam grouped these into the 3 important pillars of "lifelong learning": the change in learning, living conditions and a change in consciousness in adulthood.

For Knowles, intrinsic motivation is the most important drive for adults. In the learning process, time management, influenced by deadlines, work and everyday life, is significantly different from that of adolescents. If the content to be learned is seen as not meaningful enough or if it does not reflect one's own interests, this in turn influences the motivation of the further education students.

E-learning, the perfect solution for everyone?

E-learning is a tool, not a teacher

E-learning is often seen as the ideal solution for every type of learner and content.

Coffiedl et al. published over 70 different parameters in their meta-analysis that were used in the literature to describe different learning types and teaching methods. However, many papers lack evidence or valid measurement methods to present significant results.

"Blended learning"

Twenty years ago, blended learning (BL) was identified by the American Society for Training and Development as the most important way to teach students. Ross & Gage described BL as the new gold standard in teaching and Garrison et al. as: "Simple and easy at the same time - to teach the new art".

“Blended learning” requires a combination of face-to-face teaching and e-learning. The focus, however, is mostly geared towards the institution and little or no adaptation to the needs of the students or the content to be conveyed. Despite good didactic methods, this often leads to worse results compared to conventional teaching. The current situation of the SARS-CoV-2 crisis also taught us to switch to online work, therapy and teaching if possible and to have useful distance learning methods at hand.

The challenge of "blended learning" is a well-thought-out integration and coordination. The proportion of face-to-face appointments associated with higher resources must be combined with the more time-consuming e-learning area based on current guidelines.

"Case-based blended learning"

The wealth of information at the beginning of their clinical career poses a major challenge for prospective specialists.

"Case-based blended learning" helps in the search for essential findings

"Case-based blended learning" is a good opportunity to learn how to deal with this flood and to search for the essential findings in a targeted manner.

Case-oriented teaching - "clinical reasoning" and "clinical decision making"

In our course we use the concept of case-based “blended learning” with a focus on online “distant learning”. Due to years of research and development work as well as our internationally well-networked working group, which has already been able to present its research results at numerous congresses at home and abroad, we were able to adapt relatively quickly to the current circumstances. We were able to do justice to the current situation quickly, because we were prepared and have been internationally networked for a long time.

structure

In terms of content, interdisciplinary cases as well as cases relating to the following specialist areas are offered:

Psychiatry (including psychotherapy and interviewing), internal medicine, dermatology, traumatology (with trauma surgery and orthopedics), emergency medicine (interdisciplinary cases with trauma surgery and anesthesia), pediatrics (with a focus on emergencies and acute care in the clinic) and general medicine (with a strongly interdisciplinary Character).

The course is divided into two parts, in the first part patient cases must be solved from the included areas. The following specialist areas are covered, among others: psychiatry, psychotherapy, neurology, anesthesia and intensive medicine, internal medicine and surgical subjects, etc. Each case is designed as a scenario to simulate a virtual situation in a hospital. Interactive questions in multiple-choice format lead to the solution of a case. In the second part, the participants have to create their own patient case themselves based on selected criteria and then anonymously evaluate cases from colleagues in a peer review. The aim here is to present the situation of a "teacher" and to provide insight into the perspective of a supervising student.

The structural structure of all teaching cases follows a standardized scheme. This is illustrated in more detail using our case study, which has, however, been greatly shortened.

Case report: embolism after substance abuse

The inpatient admission of the patient takes place via the ZNA (Central Emergency Admission) after referral from the general practitioner.

anamnese

The patient reports that her right hand was squeezed between a door handle and the wall. The family doctor describes a pulseless radial artery and ulnar artery with a sufficiently perfused and equally warm extremity. For further clarification, she will be transferred to the Angiology Department.

status

The patient presents herself in a reduced general condition and adipose nutritional condition.

Previous illnesses include hypertension, post-gastric bypass surgery, post-tonsillectomy, post-cholecystectomy, and nicotine, alcohol and cannabis abuse.

In a detailed anamnesis discussion, the significantly increased vulnerability in the negative range of the scale is noticeable. The patient stated that she suffered from difficulty sleeping through the night, felt less hungry and viewed food as a burden. At the time of admission, the patient is looking for work and takes care of the mother 3 times a week. The patient begins to cry while telling the social situation.

Apparative diagnostics

Findings of the duplex sonography: the right subclavian artery freely continuous with proximal pendulum flow. The distal area of ​​the subclavian artery shows a low, prstenotic flow profile. The axillary and brachial arteries as well as the forearm arteries are completely closed. There is a large caliber collateral in the area of ​​the axillary artery.

An MRI scan is performed for further clarification: the right subclavian artery is regularly contrasted and normal. The right axillary artery is also displayed with regular contrasts. There is a long occlusion of the brachial artery from its departure. This shows a strongly contrasted collateral vessel on the upper arm. The brachial artery is reconstructed for a short distance on the distal upper arm. The brachial fork cannot be depicted with sufficient contrast.

An imaging of the upper abdomen performed as part of MR angiography also reveals a short KM recess and a missing “flow void” of the portal vein, which suggests a portal vein thrombosis.

therapy

  • Anticoagulant therapy with enoxaparin sodium 100 MG 1-0-1 and prostaglandin E1

  • Coagulation consultation by the laboratory medicine department

  • Medical consultation by the department of psychiatry

  • Coagulation consultation: There is no indication of a congenital or acquired coagulation disorder that could be the cause of the occlusions.

  • Psychiatric consultation: Moderately depressive episode as well as psychological and behavioral disorders due to alcohol and other substances.

  • Further procedure: Establishing an antidepressant therapy with trazodone hydrochloride starting with 150 MG 0-0-1 and increasing every 2 days up to a target dose of 300 mg.

  • With increasing subjective symptoms of withdrawal, start of Oxazepam 50 mg ½ ‑ ½-0 and taper off for at least 2 weeks if withdrawal symptoms cease. Connection to a specialist in psychiatry and psychotherapeutic medicine, motivate the patient to do so during the inpatient stay.

Recommended actions

  • Strict abstinence from nicotine, presentation to the resident specialist for psychiatry and psychotherapeutic medicine for further connection and care for moderate depressive episodes and substance abuse

  • INR control in the angiological outpatient department after 6 weeks

Summary

The reason for admission was an occlusion of the upper arm artery on the right in status post trauma on the right hand about 11 days before. An MR angiography of the affected vessel sections showed an occlusion of the right brachial artery. A blood-thinning drug and a vasodilator drug was established. The sonographic controls showed a clearly improved symptomatology in the course of the inpatient stay. Nicotine abuse since the age of 15 and cannabis use were identified as cardiovascular risk factors. At the time of discharge, anticoagulant therapy with phenprocoumon was established. The cause of the closure is considered to be continued cannabis use upon discharge.

Open test questions on the teaching case

  • Why was trazodone used for drug therapy versus an SSRI? (Please discuss the following publication on the effect of platelet serotonin on arterial and venous thrombosis in your consideration)

  • State your position on the patient's psychological situation (substance abuse, personality factors, social parameters). How do you see gastric bypass surgery?

  • Do you actively address destructive parts? If yes how?

  • How can the patient's protest for disappointment be interpreted and a sufficiently stable therapeutic relationship established?

  • How can optimal treatment adherence be achieved in the patient?

  • What role do protein S and protein C play? What study results do you know about this?

  • How do you organize your contact with the internist or in the interdisciplinary team?

Conclusion

Modern “case-based” e-learning is an excellent tool for training skills and communication, since “diagnostic reasoning” is seen as a schematic problem-solving process.

Kopp et al. postulated that teaching with examples conveys more lasting knowledge than the presentation of abstract information. This is due to different cognitive work demands. The educational benefit of mistakes should also be taken into account in the planning of teaching content; constant feedback on correct or incorrect steps encourages participants to deal more intensively with the content offered and consolidates the newly acquired knowledge in the long term. Likewise, new research questions often develop on the basis of difficult cases.

COVID-19

Due to the global COVID-19 pandemic, many universities and academies had to suspend their face-to-face courses. Many institutions therefore tried to implement “distant learning” in a relatively short time. Under these circumstances, our course was attended by up to 1,000 medical students at the same time and over 7,000 comments were written.

conclusion for practice

  • "Case-based blended learning" is a good opportunity to learn how to deal with the flood of information in everyday ward life and to search for the essential findings in a targeted manner.

  • E-learning is often planned and implemented without evidence-based research data on didactics.

  • The educational benefit of interactive questions should be considered in the presentation of each case report.

  • Complex patient cases require an interdisciplinary approach.

thanksgiving

The authors thank Ao Univ.-Prof. Dr. M. E. Gschwandtner and Dr. P. P. Wadowski (Clinic for Internal Medicine II, Department of Angiology, Medical University of Vienna) for their professional support and cooperation in treatment, teaching and research.

Funding

Open access funding provided by the Medical University of Vienna.

Compliance with ethical guidelines

Conflict of interest

S. Ertl, L. Stastka and H. Löffler-Stastka state that they have no conflict of interest.

This article does not contain any studies on humans or animals carried out by the authors. All patients who can be identified via images or other information within the manuscript have given their written consent.

Footnotes

Notice from the publisher

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