Case-Based Learning

CBL = case-based learning; this is the type of teaching which my university is using to deliver its information to us medical students.

I find this such a great way of learning and it's very useful because it keeps all the information together. Each cycle is the same, just with a different system. So far for this year, we have studied the musculoskeletal system, cardiovascular system, respiratory system, gastrointestinal system and the urinary system. After the holiday, in term 3, we will be studying the neuro system and finally the endocrine system.

The cases are taught in two week cycles. These two weeks contain three facilitation sessions, one day of labs (and one session in the anatomy dissection room), one day of placement (GP or hospital, these are rotated) and ten lectures that deliver information on this section.

At the beginning of the cycle, we are given a case (of around 500 words) which will introduce us to a condition or complaint being presented by a patient regarding the cycle. So for cardiovascular, we had a patient with high blood pressure. In the musculoskeletal case, we looked at the use of anabolic steroids to develop muscle mass. In the urology case, we looked at two people who drank a certain amount of water before a marathon and the effects of dehydration etc. The problems described in the case will then be explored in our lectures for this case.

As an example, I will be using the respiratory case:

• Three facilitation sessions where we discuss the current case that has been presented to us. We sit and go through the learning objectives in the first facilitation session at the beginning of the cycle. We can identify parts of the case we don't understand that may not be or fully covered in lectures, so we will distribute and delegate presentations to each other and present them in the following facilitation session. We have another facilitation session mid-cycle to work out where we all are, and then a final session to conclude the case and clarify any final information we are struggling with or want help with (from the guidance of our facilitator who supervises us).
• 10 lectures - all delivered on the respiratory system but divided up across the two weeks. In these lectures, we learnt about the anatomy of the lung, how the lungs ventilate to provide gaseous exchange, what is gaseous exchange and the respiratory and metabolic responses within the body (at a cellular and organ level).
• One lab session in anatomy where we used cadavers to study the respiratory anatomy. In this session, we located the lungs, the pleura and other structures in the chest and mediastinum. But we also learnt about reading and interpreting x-rays of the chest and an introduction to taking a chest examination.
• I had placement in the GP, which meant I had the opportunity to do a home visit and meet a patient who had severe asthma. On the home visit, I was able to use my history taking skills to listen to the patient and understand the difficulties she experiences, but also apply the knowledge I had learnt in this cycle about the pathology and physiology causing her symptoms.
• People that had placement at the hospital for this cycle had the opportunity to practise percussion (banging your fingers on the chest to produce a sound which can signify hollowness [from air] or dullness [from a build-up of fluid]). There was also the chance to auscultate the chest (use a stethoscope to listen to the different lobes of the lung) and where to place the stethoscope.
• One lab session using the simulation patient to look at the effects of hyperventilation and climbing in altitude on the patient's respiratory rate, consciousness and oxygen saturation levels.
• One lab session on the effects of exercise on respiration (so doing an exercise activity and measuring the increase in respiratory rate etc).

This is the same structure for all of the cases.

Labs - about talking?

This might be hard to understand, but we do have labs...not in labs...and not a pipette in sight!

These labs are based on consultation skills. They are endorsed with our placements, either in the GP or the hospital, which in turn strengthen the lectures and tutorials on a particular aspect of the consultation.

The consultation is broken up into different elements. These elements obviously craft together to make the perfect consultation with the purpose of finding out what is wrong with the patient (by taking a history and an examination) and then interpreting your findings to come to a conclusion and then a plan of action (such as medication).

If we are given a part of the consultation, like examining the complaint which is being presented to us by the patient, we will have a lecture on this. In the lecture, we will be taught about the purpose of taking a history of a presented complaint, and the type of questions we will have to ask. We can even hear of examples of when this goes wrong, or poor practice in doctor consultations that leads to poor outcome for the patient.

After the lecture, we meet in our small tutorial groups of around eight peers and discuss what we have learnt from the lecture. These are our "labs".

These labs involve a lot of role play. Such as acting out particular consultation scenarios, structured by a plan that has been prepared for the session. For example, we could be pretending to be Mr Smith who has a family history of cardiovascular disease and I have just presented very high blood pressure and need to answer my peer's questions (as the doctor) to help them breakdown my presented complaint to build up a possible diagnosis and plan of action.

These lectures and tutorials can be delivered either in the university or the hospital I'm doing my placements in.

The labs also involve developing communication. My university's Medicine course was updated last year (I'm the first cohort) to provide more teaching on the communication aspect of being a doctor. Imagine having a doctor who didn't know how to talk to you or deliver the information correctly or understandably. Therefore, this year they are focusing on providing more teaching on this! So in the labs, we learn how to use vocal cues in our consultations to give better understanding (eg. the importance of paraphrasing to show understand and using it as an opportunity to make sure you've collected all of the relevant points).

For example, we ask patients "What is your past medical history?" and they often think only of diseases and illnesses. They'll tell you about their pneumonia or chest pain ... but they always forget surgery! So make sure you ask whether or not the patient has had any recent surgery, as this can explain symptoms. Abdomen pain can sometimes be explained by previous surgery in this region creating weakness in the bowel.

Postmortem?!

I had an amazing opportunity to observe a postmortem this week! I am lucky that my facilitator is a pathologist who works in a coronary court to carry out postmortems on patients who have died 'suspiciously' (not like forensic murder!)

So what is a 'suspicious' death? According to my facilitator, this is where a patient has died unexpectedly, but hasn't seen a GP in the past two weeks before their death. This tends to be when a body has been found at home, and the death has come as a shock.

I was really shocked to how the postmortems are carried out. They are nothing like how they are portrayed in the media. The body is examined in a brightly lit lab - there is no small light dangling in a dark room with four people surrounding the body with their tools. In fact, there are four bodies being examined at the same time with one person doing it.

I won't go into the details in my blog, as I understand there is a line. But I would recommend you look at how they examine the body. They remove every organ from the body before examining each organ in detail. This is important to identify any health issues which may not be directly obvious from the outside as you are after all identifying the cause of death. For example, it is hard to look at a body that has been found, and see that the person died of a cardiac arrest. A postmortem will reveal hard crunchy coronary suggesting atherosclerosis that could've resulted in a myocardial infarction that killed the person. I would recommend you looking at the method they use to remove these body parts as I found it particularly fascinating.

This is an experience I was delighted to have the opportunity to take part in. I feel it endorsed my anatomy, as it was the most recent view I have seen of the internal anatomy of a human. Especially when the organs were removed, it was amazing to relate them to how close they appear in standard anatomy labelled diagrams! The liver is that red/purple colour in real life, despite it appearing greyer in the anatomy labs.

What's harder than searching for the phrenic nerve? Searching for a house for next year!

This is something very crucial that, I feel, was very masked from all my Year 1 preparation for university! You must be prepared to start house viewing, basically from November.

Yes, you read that correctly. You will start university in September. You will enjoy the beginning of term, all the way through to October. Then in November, you should be getting prepared to start accommodation hunting ready for Year 2!

This is my flatmate, from Year 1 and now Year 2, signing the tenant forms and confirming our house for next year!

This is because all of your peers and other students at university will roughly be looking all at the same time. The student letting agencies will be releasing properties slowly, but will be turning them over very very quickly.

Here is my little nifty guide to help prepare you for this, because house hunting was everything but enjoyable (to an extent!) and easy!

1. From September/October, this is the perfect opportunity to start flatmate-hunting! You should be using this time to work out who you should and shouldn't be living with next year. This is crucial stuff, because it's ridiculous how you're house hunting so early yet you're not sure whether or not these people are still wearing their "first impressions count!" masks and could actually change as the year progresses. Personally, I feel living with your current flatmates is a safe option as you can address problems fairly early on (eg. "Please can you start washing up after you've cooked?" or "Please don't use my tray if you're not gonna wash it?" etc) ready for next year.
2. Some people do choose to keep medic-orientated. So if you've made some great friends in the course, or even across other courses, then maybe consider living with them next year! Either way, I have found in my city that finding accommodation for a larger house (ie. 6/7 people) is a lot easier than a smaller house (ie. 3/4 people).
3. Book as many viewings as you can in different properties - don't go by the photos! This works in two ways: don't judge a property by it's naff photos because the 'small' bedroom photographed could turn out to be the best in the house and the one you want! And, don't judge a property by the way it looks in the photograph without seeing it for yourself. If I'm honest, I didn't practice what I'm currently preaching as this is what I've done. I have put down a deposit and paid the agency fees to a house I haven't seen, my flatmates went to the viewing whilst I was on placement so I haven't seen my house!
4. Booking as many property viewings will educate you on what you should be looking for: mould, condensation, cleanliness, washing facilities etc. Make a list of things that are important to you, such as en suite bathrooms or a living space, and help this to refine your searches when booking different property viewings.
5. If current tenants are in the property as you are viewing, use them as accurate reviewers of the landlord! Use it as an opportunity to ask questions for honest answers, like how quick are repairs done and what are the catastrophic disadvantages of living here? Like neighbours that hate noise or a leaky roof in the winter may not be highlighted in the paperwork or leave the estate agent's mouth whilst she's giving you the viewing. It's also the perfect time to ask about how much the bills are for the property as you will need to factor this into rent.
6. Review your estate agent that you're using to buy the property before you go ahead. We did this after - just to find that our estate agent is currently rated 1/5 stars because of their inconsistency, poor professionalism and reliability. For example, the tenancy agreement that was emailed to us was full of awful spelling and grammar mistakes.
7. Have your deposit and the agency fees at the ready. Be prepared to make a payment of around £1,000 in the November-January period if you have currently secured yourself a property. I had to pay £500 in agency fees, and then the deposit of around £485. Obviously this was the greatest shock, because I did not have £1,000 ready to transfer towards the beginning of my first year in university!
8. Finally, you need to be quick. My flat were fairly quick on the ball. We started searching in November and got the house sorted in January/February. My friend however only secured their house towards the end of March, he was very worried he wouldn't have a house for next year! But also, you will be viewing the property alongside other students who are viewing at the same time. In every property, I feel I was viewing houses with three other groups. In one property, we were looking at the larger bedroom and walking downstairs when the estate agent then told us that the other group had already signed the paperwork and had just bought this property and she 'apologised' we were too late.

You have been warned! Make sure you are prepared to go house hunting, and have £1,000 (roughly) ready to be able to put a deposit down on the next house for Year 2. And of course, make sure you choose the right flatmates to live with!

If you can't, and find yourself struggling, my social media at the moment is full of people advertising for new flatmates. For example, someone who has had to dropout of university for unseen circumstances, and is looking for a new flatmate to replace them. So if you do miss out, or can't find the suitable people to live with, keep your eyes peeled on the social media platforms!

Exam Results

When I left you before Christmas, I described about my stresses of exam revision over the holidays but also the structure of the exams I took part in.

I can happily say I have passed both exams! Thankfully, I have clearly revised what I had needed to for my advantage and have managed to somehow score greater than that pass percentage so that my grade sits in "green".

We were sent a generic email prior to our exam release time (which is set at a certain time and date, so we had to wait until 1:00pm for our results to be released). In the email, it was detailed what the pass mark was for both exams, and a general average. As it appears in the email, on average everyone has passed which is great for the year group!

But now that these exams are over, we get to move on and knuckle down more into the case-based learning aspect of our course.

A small side note though, I did take part in a fairly difficult consultation while completing my GP placement. While sat in the GP surgery, the GP I was shadowing met a patient who was battling with depression. He had progressed to a serious stage, where he contemplated ending his life and his value in this world. I found it very interesting to observe how the GP approached the patient's feelings to help break down the presented complaint in a comfortable matter.

To be honest, the appointment really hit me as I sat there. Hearing how the patient was describing his own worth, I realised how important mental health and wellbeing really is. Its significance is often suppressed. I, myself, have battled with mental health issues in the past with low mood (but I am grateful for the prescription medication which helped me get back on track). But today I witnessed when medication isn't the answer as the complaint is far more serious.

My partner and I from the placement then went home to discuss how we felt. Sometimes it is very important to speak openly but privately (respecting confidentiality) if you are struggling to cope. Many universities, including mine, have specialised student support which is readily available for you to approach and seek help if you do need it.

I feel for the situation you are going through right now, as I have experienced it myself. Whether it be application stress or exam stress, you can pull through this! Don't let it affect your mood, and if it does, monitor it closely. If you notice your mood deteriorating fast, whether it be a personality change (for the worse) or your attention/concentration being very weak, seek help and support and you'll be back to normal. Remember though, talk and use these support networks.

It was nice to sit down and enjoy a bottle of wine with a friend in the bar conservatory, talking about our results.