Writing a teaching case
A teaching case makes learners apply new knowledge by taking them through a patient's story to a series of decision points. Writing one well depends on knowing what the case is for, planning and researching it before drafting, telling it as a short story whose decision points rest on evidence, and getting its images and dosing details right.
What a teaching case is for
Case studies encourage adult learners to apply new knowledge or skills rather than simply regurgitate facts, and case-based education also helps learners integrate previous experience and creates a sense of immediacy during the learning process. For these reasons, many continuing medical education (CME) providers incorporate case studies in face-to-face and online learning activities. The ability to craft compelling case studies is a marketable skill for medical writers in CME. Two experienced CME writers hold that a good case study does not simply write itself: skill is required to make the learning exercise engaging, accurate and appropriate to the learner's level of expertise. In one CME writer's view, perfecting the art of writing case studies is worth the hours it takes.
For many clinicians, the most memorable learning comes from patients. Textbooks are a poor substitute for observing the effects of drugs or procedures in an individual, which is why reading a good case report can be an effective way of reinforcing learning. A case can also be designed to encourage students to apply their knowledge and skills in a structured way to one patient with a particular set of characteristics, rather than generically to a general patient population. A case written to teach need not be unusual: the patient can be an excellent example of a common or rare disease presentation without any particularly unusual response to standard treatment, and sometimes the more normal the better.
The particular value of a teaching case is that, as in clinical care, there is rarely one clear answer: where drug therapy is indicated there may be several viable options, from different drug classes or from different drugs within a class, so students can learn to evaluate them for an individual patient. A case studied in groups can prompt valuable discussion of the optimal management strategy, which should change over time as the evidence moves on, so studying a case can encourage critical appraisal of the literature and its application to patient care.
Planning and research before drafting
The key to planning a successful case study is to ask plenty of questions beforehand. They include whom the case is for (physicians, nurses or pharmacists, a particular group of clinicians, or multidisciplinary use), what the learners already know and what new information the narrative must supply, and what the case is meant to achieve, including the key learning objective it will address. Teaching with a case at undergraduate level should be very different from teaching with one at master's level: at undergraduate level the learning outcomes may be that the student can describe and manage a patient with a specific disease or monitor a variety of therapies, whereas at master's level a case may highlight the more controversial aspects of care and encourage the student to appraise a variety of management options critically. A case can stand alone, for instance to help a practitioner become familiar with the type of patient they will be caring for, or be embedded in text or lectures to consolidate formal teaching and illustrate or reinforce key learning points.
A writer should expect ample research before beginning to write: seeking expert input, searching the Internet for other cases published in the same therapeutic area, consulting current clinical practice guidelines, and becoming familiar with pertinent laboratory tests and standard and abnormal laboratory values. A freelance writer should ask the client whether a template is available. In one CME writer's view, peer-reviewed guidelines on writing case reports align well with two experienced CME writers' advice on writing case studies.
The narrative and its decision points
The typical teaching case proceeds through a series of stages. The narrative first describes the history and symptoms of a patient. A decision point follows, often conveyed as a multiple-choice question that sparks further discussion and moves the case to the next stage. The narrative then describes how the decision affects the patient, and subsequent events lead to the next decision point, another multiple-choice question. The case may end there, or the pattern may continue with more decision points.
In organising a case, the writer should make sure it answers the basic questions journalists answer in a news story: who, where, when, why and how. A case essentially tells a short story, so it needs a cast of characters and a plot. A teaching case probably needs no introduction, and the case itself should be merely a factual description of its details in the order presentation, medical history including relevant family and social history, medication history, physical examination, test results, diagnosis, treatment and outcomes. Narratives usually follow a logical time sequence to avoid confusing learners, but more complicated cases might include flashbacks. The case should carry enough human-interest detail to be engaging, while carefully avoiding red herrings that distract learners. It should also give enough detail for the student to understand the issues raised and reach appropriate conclusions.
Questions can follow the narrative or appear at stages as the case unfolds, with the answers directly after them or provided separately. Asking the student to choose a management strategy from several options at points through the case means different scenarios may emerge depending on the option chosen, an approach computer-based learning packages have used very successfully. The correct answer to each decision-point question should be evidence-based, supported by clinical practice guidelines and tied to specific learning objectives. Answers can be supported by references within each answer or by articles offered as general reading. There is usually a time lag between the writing of a case and its use, and new evidence that has emerged by the time a student reads the prepared answers may alter them, so the case needs a statement to that effect.
Images and dosing details
Photographs and medical images add realism and visual appeal. X-ray films, magnetic resonance imaging, positron emission tomographic or computed tomographic scans, and three-dimensional computer models can enhance the learning experience. So can snapshots of laboratory reports or treatment diaries, but if they come from patient records, all identifying information must be removed.
One collection of memorable cases presents a rare or extraordinary image on one page, asks the reader to draw on their own background to make a diagnosis, and gives the actual diagnosis on the next page. Its images are of patients its author saw in 53 years of practice and as a full-time medical educator, and its reviewer imagines this is how such patients would typically appear in an emergency room, clinic or doctor's office. The collection seeks to restore bedside diagnostic skills. Many of its cases are rare and are ones that few people may see. Its reviewer, writing in 2008, describes conditions in it that a physician may encounter in practice when so many people are coming from countries that have endemic diseases.
Information on drug dosing must be accurate and appropriate: there is no quicker way to lose credibility with learners than to draft a multiple-choice question in which the correct answer involves a dosing schedule or route of administration that clinicians never use.