Development, implementation and evaluation of consultation case-based learning course to improve the interdisciplinary clinical reasoning ability-a pilot study from nephrology

Abstract

Background

In modern clinical settings, interdisciplinary clinical reasoning skills and associated education are pivotal and should be encouraged for residency training.

Methods

An interdisciplinary course on clinical reasoning was developed for residents based on ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model. We collected frequently encountered consultation cases as our teaching resources with the methods of scenario case-based learning. Finally, consultation case-based learning (CCBL) method was established. At the end of the course, summative evaluations were carried out to test the overall effects with the Kirkpatrick’s evaluation model.

Results

The ten-week interdisciplinary course were successfully implemented according to the planned training schedule. 26 residents from different majors were included, and 24 of the residents completed the modules and evaluation. Over 90% participants were satisfied with our course, and over 79.2% participants achieved improved interdisciplinary skills. Furthermore, 80% participants reported behavior changes in professional clinical practice after the completion of the course.

Conclusions

The interdisciplinary course based on consultation scenario case-based learning received positive feedback from most residents.

Introduction

At present, the mainstream of clinical reasoning is discipline-specific disease centered, which focuses on the clinical manifestations, diagnosis, differential diagnosis, and treatment [1]. However, clinical settings are inherently complicated and interdisciplinary. For example, oncologists were required to recognize and treat anti-tumor medication associated renal injury, while cardiologists need to evaluate the risk of contrast-induced nephropathy before coronary angiography. To achieve better healthcare outcomes, the multidisciplinary team format has gained popularity in recent years. In order to adapt to the transformation of medical models, clinical education should also keep pace with this expanding multidisciplinary approach.

Interdisciplinary education (IDE) and interprofessional education (IPE) are the most common educational approaches involving the integration of knowledge and methods from multiple disciplines. Interdisciplinary education (IDE) is defined as [2]: An interaction involving collaborations between students from differing subject areas in pooling their disciplinary knowledge in addressing complex and significant, real-world problems [leading to] the ability to understand and be understood by a diverse group of specialists.

In contrast, IPE refers to occasions when students from two or more professions learn with, from, and about each other, enhancing collaboration and the quality of care and services [3]. While both IDE and IPE emphasize the necessity of collaboration and knowledge integration to tackle complex issues, IDE specifically focuses on cultivating students' critical and creative thinking skills across disciplinary boundaries to solve given problems [4, 5], aligning closely with the objectives of medical education. Furthermore, prior studies have demonstrated that IDE could enhance students' ability to handle real-world clinical problems, such as asthma [6], palliative care [7], and pain management [8]. Besides, interdisciplinary training programs might cultivate physicians' ability to conduct scientific research by developing interprofessional abilities [9]. Therefore, interdisciplinary courses should be encouraged in medical education.

Standardized residency training for physicians is a crucial part of graduate medical education with a clinical competence orientation, which cultivates residents’ clinical reasoning abilities. Clinical reasoning is a series of thinking activities that involve investigating, analyzing, synthesizing, judging, and inferring about disease phenomena. Solid medical knowledge, rich clinical practice, and networking ways of thinking are foundations for clinical thinking cultivation. Considering the importance of interdisciplinary education, as we mentioned above, interdisciplinary clinical reasoning competency should be emphasized in residency training to fit for the new medical model.

Here, we plan to design a course for Chinese residents to enhance interdisciplinary clinical reasoning skills. The case-based learning (CBL) method uses clinical cases to simulate real-world scenarios, and guides students in critical thinking, analysis, and problem-solving, thereby enhancing academic performance and fostering rigorous logical reasoning [10, 11]. Considering that the main objective of this training is to improve the participants' ability to diagnose and treat interdisciplinary clinical problems, consultation cases could be suitable cases for CBL in interdisciplinary education. Due to the importance and complexity of renal physiological functions, kidneys are involved in many kinds of multidisciplinary diseases. Renal insufficiency, abnormal serum electrolytes, and edema are common manifestations in these interdisciplinary clinical settings. Therefore, we selected frequent consultation cases from the nephrology department as teaching resources, forming a modified CBL method, referred to as consultation case-based learning (CCBL) method, to fulfill our teaching objectives. Like any other educational modality, the development of CCBL in interdisciplinary education needs instructional design to guarantee more efficient and positive teaching outcomes. ADDIE (Analysis, Design, Development, Implementation, and Evaluation) is a widely used instructional design model in medical education, beneficial to construct a learner-centered and competence-oriented design [12]. We utilized the ADDIE model to plan, design, implement, and evaluate an interdisciplinary course based on the CCBL method combined with scenario simulation teaching, aiming to comprehensively and systematically cultivate clinical thinking, analysis, and problem-solving abilities in interdisciplinary conditions.

Methods

We used ADDIE (an instructional design paradigm) (Fig. 1) as the process model for training course development. The ADDIE model includes analysis, design, development, implementation, and evaluation stages. Evaluation is the guarantee for the success of the whole course.

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Analysis

The first step of the analysis was an electronic questionnaire for demand survey, namely, the demand to improve clinical reasoning ability in interdisciplinary settings. There were twelve questions in the questionnaire, including age, major, gender, educational background, the grades of the residency program, the difficulty in solving interdisciplinary clinical problems, the expectation to attend the course, the experience of interdisciplinary problems in clinical practice, and the previous pathways to obtain interdisciplinary knowledge. The questionnaire was shown in supplemental Table 1. Then, an extensive review of the literature was performed to identify the common types of interdisciplinary training programs and the limitations of previous programs. Finally, the content of literature review and questionnaire was discussed by a group of six professional clinicians. After the discussion, the faculty believes that it is necessary to develop a new course for interdisciplinary clinical reasoning. The overall aim is to improve the interdisciplinary abilities of residents in clinical practice. The participants were residents from the First Affiliated Hospital, Medical School of Zhejiang University.

Design

After clarifying the objectives and goals of the course based on the preliminary analysis, the faculty team began to design the course. A course syllabus was designed. As the complexity of renal physiological functions and its network with muti-disciplinary, we chose nephrology consultation issues as the teaching content in the pilot course. After the course syllabus had been drawn up, the learning strategy was determined in reference to CBL. To effectively achieve our objectives—improving interdisciplinary clinical reasoning competency—the course content was established by analyzing the consultation issues, the main sources of interdisciplinary problems. For instance, cases of chemotherapy-associated kidney injury from the oncology department require knowledge of oncology, pharmacology, and nephrology. Similarly, cases related to severe hyperlipidemic disorders in the endocrinology department necessitate understanding lipid metabolism, dialysis principles and procedures, and nursing science. Thus, we selected ten consultation topics as our teaching materials, which encompass essential renal pathophysiology while also reflecting common interdisciplinary issues encountered in the nephrology department. Finally, the teaching plan, the profile of the participants, and the total number of study hours, and distance-learning segment were determined (Fig. 2).

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Development

In the design part, the ten key topics (refined from consultations) were determined to be the main teaching content, and ten corresponding lessons were set up. Considering the convenience of the interactive online platform, we adopted an online teaching platform. Then, in order to facilitate the learning topics, the faculty summarized knowledge points and structured questioning guidelines. Besides, learning activities such as on-site investigations, group discussions, and case analyses were designed. Finally, a series of course supporting materials were developed, including course schedule, slides, course feedback form, course certificate, course logo, and poster, etc. Before the beginning of the course, the instructors conducted trial lectures. With the feedback from trial lecture, we continuously improved the curriculum development.

Implementation

The ten-week course was implemented according to the schedule. The participants were given introduction of the cases, related guidelines and reference papers for self-study before each lesson. Each lesson started with the instructor providing a brief introduction of the topic, the class agenda, and the learning objectives. Then a consultation case was introduced by the instructor and sequential questions were proposed. Then, a group discussion was carried under the instructor’s guidance. The participants were encouraged to choose the right answer by their own after the discussion. The main content was carried out with structured questioning provided by the instructor. After going through the main content, we rechecked the quoted case at the beginning of the class. Both the instructor and participants shared their opinions on the quoted case. Finally, the instructor summarized the class. At the end of these online activities, participants were asked to complete a post-class quiz. They were also asked to complete a survey about their perceptions and experiences with the course (Fig. 3).

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Evaluation

During the implementation stage, the formative evaluation questionnaire was used to regularly evaluate each participants’ satisfaction and to suggestions for improving the training content, methods, and schedule. Meanwhile, the online interaction records, learners’ online learning processes, and behaviors (recorded by the online platform) were all analyzed as part of the formative evaluation for refining the course. The summative evaluation was used at the end of the course. The summative evaluation contained two parts, a subjective questionnaire and an objective knowledge test. The subjective questionnaire was in reference to previous literature [13] and was created by the investigators. The questionnaire was showed in Table 2. This form contained 12 items categorized into three blocks, aimed at evaluating the first three levels of Kirkpatrick’s evaluation model. The evaluation of the first level was about the participants’ reactions to the course, including their motivation, interest and feedback of the participants for the course. The second level is about what the participants have learnt. The evaluation of the third level is to determine if their behavior and procedures have been changed after the course. The questions were scored on a Likert-type scale, with the following options of response: “I strongly agree”, “I agree”, “I neither agree nor disagree”, “I disagree” or “I strongly disagree”. The questionnaire was shown in supplemental Table 2. The objective knowledge test of summative evaluation consists of single-choice questions and short-answer questions. Both of two types of questions set clinical cases as background.

Results

The analysis of demands for interdisciplinary course before the course

Analysis of demands for interdisciplinary clinical reasoning was done through the questionnaires. 40 residents in our hospital completed the questionnaires. 95% of the responders agreed or strongly agreed that many patients presented interdisciplinary clinical problems, reflecting the objective demands for interdisciplinary clinical abilities. Furthermore, 95% of the responders agreed or strongly agreed that it is difficult to manage interdisciplinary problems in real clinical settings (Table 1). We also investigated the current situation to deal with the interdisciplinary problems (Fig. 4). Consultation is the leading way to deal with interdisciplinary problems, followed by guidance by superior doctors, a reference/textbook, and internet searching. As to the pathway of obtaining interdisciplinary knowledge, specific training course ranked lastly. Only 20% of the responders have previously received training in interdisciplinary skills after graduation. Most of the responders (97.5%) expected to attend interdisciplinary training courses (Table 1).

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Course performance of participants

The recruitment of the course lasted for two weeks, and finally 26 residents were enrolled. The average age was 27 years old. Their majors were internal medicine (n = 13), surgery (n = 5), infectious disease (n = 6), and critical care medicine (n = 2). In China, residency training typically spans two to three years. Over half of the participants (16/26) were in their first year, while 10 were in their second or final year. The ten-week course was implemented according to the training process models and the planned training schedule. The courses were scheduled on every Thursday evening. The data for formative evaluation were analyzed and used to improve the course during the implementation stages. Finally, 24 participants (92.31%) completed the modules and received their certifications.

Post-course evaluation of participants using Kirkpatrick’s evaluation models

All these 24 participants who completed the course were then invited to complete a subjective questionnaire and objective test for post course evaluation. All the 24 participants passed the objective test. The subjective questionnaire had three parts, including satisfaction, learning, and behavior change, the first three levels of the Kirkpatrick evaluation model. All the questionnaires were completed anonymously (Table 2).

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In the first level of Kirkpatrick’s model, all satisfaction statements were rated “strongly agree” or “agree”, which showed the participants’ high rate of satisfaction with the educational intervention. In the second level of the Kirkpatrick model, more than 87% of the responses were categorized as ‘strongly agree’ for the first three statements, showing that the majority of participants recognized that they had developed interdisciplinary skills in the course. For the fourth statement in the second level, the statement of ‘I am able to analyze my patients with renal disorder’, which asked for higher levels of Bloom’s taxonomy of learning domains, received responses of ‘strongly agree’ from 79.2% responders. In the third level of the Kirkpatrick model, more than 87% of the responses were categorized as ‘strongly agree’ for the first three statements, in aspects of behavior change from self-evaluation and colleagues’ feedback.

Discussion

This study designed and implemented an interdisciplinary training based on the CCBL method to improve clinical reasoning, analyzing, and problem-solving skills of residents in interdisciplinary clinical conditions. The summative evaluation results showed positive feedback and high levels of satisfaction, proving the effectiveness and necessity of interdisciplinary medical training.

Medical education includes college education and graduate education. The tasks of college medical courses are mainly focused on transmitting basic concepts of medical knowledge to build a foundation for future career, while graduate medical education is competence-oriented and requires trainees to handle clinical conditions. Standardized residency training for physicians is a typical and important pathway of graduate medical education. In China, trainees have already chosen their subspecialties before the beginning of residency training, most of which would like to lay particular emphasis on their specialties during the training but neglect other specialties. However, real clinical conditions are complicated, interdisciplinary clinical reasoning and problem-solving abilities are required. Previous studies have proven that interdisciplinary medical education is effective in improving knowledge of basic medical sciences and enhancing physicians’ competence in dealing with complex clinical scenarios. This was further proven by students’ positive evaluation results and in line with previous studies [4, 14, 15]. After the above literature review, we recognized the urgent need for interdisciplinary medical training. Thus, we utilized the ADDIE model to develop, implement, and evaluate an interdisciplinary clinical reasoning course for Chinese residents.

The content of our course is the first element that should be determined, because there were no standard teaching materials for interdisciplinary training. If a patient suffered from complex problems, consultations from different disciplines offer a team-work modality to make clinical decisions. Consultations are the most frequent interdisciplinary clinical scenario. Therefore, one of the key features of consultation cases is its multidisciplinary nature, which means that consultation cases should be proper teaching resources in interdisciplinary education. We analyzed consultation cases in the nephrology department and chose top ten frequently encountered consultation cases as our teaching contents, each case corresponds to a pathophysiological point. After the teaching content was determined, the next step is the determination of the learning method. Because improvements in clinical thinking and problem- solving abilities are the central objective of our interdisciplinary courses, we identified case-based learning as our teaching method, which simulated clinical scenes, encouraged participants to analyze and solve the clinical problems [10]. Finally, we combined traditional case-based learning method and consultation cases to build a CCBL method to suit our interdisciplinary training.

Overall, the feedback to the interdisciplinary training course was positive. Most participants reported high levels of satisfaction, improved interdisciplinary reasoning ability, and, most importantly, positive changes in career behaviors. The enhancement of interdisciplinary reasoning during the early stages of clinical career is very important and meaningful. It may reduce the rates of missed diagnosis and misdiagnosis, be favorable for developing harmonious doctor-patient relationships, and, finally, improve the quality of patient care. In addition to the improvement in the interdisciplinary capability, our course may provide other benefits. Unnecessary consultation is source-wasting in clinical practice [16, 17]. Besides, the research about the relationship between patient satisfaction and consultation waiting time revealed that the degree of patients’ satisfaction decreases by around 2% for every 10 min of waiting [18]. With basic interdisciplinary knowledge, some simple interdisciplinary problems can be solved immediately. Therefore, the improvement of interdisciplinary clinical skills after the completion of CCBL course could avoid unnecessary and simple consultations, speed up the clinical decision, improve the efficiency of clinical work, save clinical sources and improve patients’ satisfaction.

The study also had some limitations. Firstly, this study is absent of a control group for comparison. Secondly, the participants in the study were assessed up to level 3 of Kirkpatrick's evaluation model. However, level 4 of Kirkpatrick's evaluation model, which evaluates potential improvements in health indicators and overall outcomes, was not included. Level 4 could not be assessed due to limited follow-up period. The course only lasted ten weeks. It is difficult to observe obvious changes in feedback from patients’ health indicators in such a short time. Finally, it is only a pilot study in the nephrology department, and further courses cooperated with other specialties are needed to verify current results.

Conclusion

This study develops an interdisciplinary course based on consultation cases in real clinical settings and improves residents’ clinical reasoning, analyzing, and problem-solving skills under complex clinical conditions.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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