Effectiveness of a programme design for the development of competence in solving clinical problems

Figures & data

Table

Practice points

Instructional formats built on authentic work processes offer valuable opportunities to practice at preclinical level with clinical problem-solving. Just-in-time provision of case information can be used to raise case fidelity, while maintaining a level of complexity students can handle. Providing students with just-in-time case information as well as scaffolding the process requires teachers to manage roles and activities concurrently. Evident performance improvements concern the students’ fluency and speed of work, ability to handle processes concurrently, their scope of relevant aspects and the appropriateness of solutions.

Table 1  Key features of the clinical lessons’ course design (Ramaekers et al. 2011a)

Key features at the level of ‘separate meetings within the course’

1. (Authentic) cases are the unit of work

2. Activities and sequence: the problem-solving process during the meetings is based on the procedures underlying patient assessment and preventive screening

3. The required case-specific information is provided just in time

4. Role of students: the instructional formats require/build on a high level of self-directed learning and critical co-operation between peers

5. Role of teachers: teachers combine the provision of information with scaffolding students in their problem-solving process and assessing their performance

6. Regulation: between phases in the process and at the end of a case discussion, time is allocated specifically to reflection and feedback

Key features at the level of the ‘course as a whole’

7. The course covers a large variety of animals and conditions, representing the situations and problems that veterinarians are confronted with in their practice

8. As the course progresses, cases are placed in a sequence of progressive complexity and scaffolding support is gradually reduced

9. The different work formats have complementary strengths with regard to achieving the course objectives

10. Longitudinally repeated assessments are used to monitor progress and establish the achieved level of competence in clinical problem-solving

Table 2  Data structure in triangulation

Level	Processes	Instrument/method	Categories of variables	Outcomes
Case level	• Problem-solving process	Observations (B) throughout the course	Components of clinical problem-solving	Changes in approach to clinical problems
	• Learning process	Questionnaire (A2) at the end of case discussion	Qualities of cases, teacher performance and work format	Perceived effectiveness of single case discussion related to learning
Course level	• Development process	Script Concordance Test (SCT) (C)	Different problems, levels of complexity and different types of judgements and decisions	Improved accuracy of solutions to clinical problems
		Questionnaire (A1) at the end of the course	Opportunities to practise and support learning and development processes	Perceived effectiveness of course as a whole related to competence development

Note: The additions A1, A2, B and C refer to the three different methods of analysis.

Table 3  The coding scheme (main categories) for observations of the clinical lessons

Problem-solving phases	Supportive-learning phases
Initial case information (C-INFO) Checking vital functions (C-VITA) Anamnesis (C-ANAM) Initial problem description (C-PROB) General patient assessment (C-GENA) Initial diagnostic hypothesis (C-INIT) Specific patient assessment (C-SPEA) Differential diagnosis (C-DDX) Choice of treatment modalities (C-RX) Execution of treatment (C-EXEC) Review of effectiveness (C-EFF)	Instruction beforehand (E-INFO) Time-out (E-TO) Evaluation (E-EVAL) Teacher-guided discussion (E-COLL)
Teacher behaviours	Students’ reasoning (behaviours)
Providing answers (T-ANSW) Asking questions (T-QUES) Additional statements (T-ADDS) Scaffolding the process (T-PROC) Stimulating group interactions (T-GROU) Guiding reflection and feedback (T-EVAL)	Choice of strategy (R-STRAT) Gathering information (R-GATH) Organising information (R-ORG) Interpreting information (R-INTP) Making judgements (R-JUDG) Making decisions (R-DECI) Justifying judgements and decisions (R-JUST) Other (R-OTHR)

Table 4  Results questionnaire at the course level

N = 129	M	SD
Opportunities (α = 67)
The clinical lessons offered a valuable opportunity to:
• practise with solving clinical problems	4.39	0.64
• learn from instructive cases and patients	4.25	0.61
• extend and deepen my knowledge base	4.30	0.63
• practise with performing relevant clinical skills	3.83	0.85
Effects (α = 0.82)
The clinical lessons have increased my:
• ability to deal effectively with clinical problems	4.13	0.68
• ability to justify my clinical decisions	4.07	0.62
• awareness of my own competence level with regard to professional conduct	3.39	0.96
• motivation for this degree study	4.29	0.71
• understanding of how various subjects within this degree study relate to each other	4.04	0.70
• readiness for clinical clerkship	4.09	0.67

Figure 1. Example case in the SCT-VM.

Figure 2. Scatter plot showing student progress in the SCT.

Ramaekers SPJ, Van Beukelen P, Kremer WDJ, Van Keulen J, Pilot A. A proof-of-concept study of an instructional design for development of competence in solving clinical problems. J Vet Med Educ 2011a; 38(4)360–372

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