Abstract
ABSTRACT
Integrative Case-Based Applied Pathology (ICAP) cases form one component of learning and understanding the role of pathology in the veterinary diagnostic process at the Faculty of Veterinary Science, University of Sydney. It is a strategy that focuses on student-centered learning in a problem-solving context in the year 3 curriculum. Learning exercises use real case material and are primarily delivered online, providing flexibility for students with differing learning needs, who are supported by online, peer, and tutor support. The strategy relies heavily on the integration of pre-clinical and para-clinical information with the introduction of clinical material for the purposes of a logical three-level, problem-oriented approach to the diagnosis of disease. The focus is on logical diagnostic problem solving, primarily using gross pathology and histopathological material, with the inclusion of microbiological, parasitological, and clinical pathological data. The ICAP approach is linked to and congruent with the problem-oriented approach adopted in veterinary medicine and the case-based format used by one of the authors (PJC) for the teaching and learning of veterinary clinical pathology in year 4. Additionally, final-year students have the opportunity, during a diagnostic pathology rotation, to assist in the development and refinement of further ICAPs, which reinforces the importance of pathology in the veterinary diagnostic process. Evidence of the impact of the ICAP approach, based primarily on student surveys and staff peer feedback collected over five years, shows that discipline-specific learning, vertical and horizontal integration, alignment of learning outcomes and assessment, and both veterinary and generic graduate attributes were enhanced. Areas for improvement were identified in the approach, most specifically related to assistance in the development of generic teamwork skills.
In the Faculty of Veterinary Science (FVS) at the University of Sydney, there has been significant curriculum development over the past six years to ensure enhanced vertical and horizontal integration, greater emphasis on student-centered approaches to learning, increased use of online learning to support face-to-face learning, and alignment with a developed list of graduate attributes.1 One of these major graduate attributes relates to research and enquiry, with an emphasis on the student's ability to apply understanding and knowledge across the curriculum to the diagnosis of disease. This has led to many study units implementing case-based studies for some portion of their didactic program to encourage linkages with veterinary medicine. A year 3 unit of study, Veterinary Pathology, was one of the units of study to engage in that process, and in 2002 a case-based approach to the teaching of veterinary pathology for a component of the didactic program was implemented. This approach uses both online and face-to-face methodologies and is called Integrated Case-Based Applied Pathology (ICAP). ICAP is founded on the fundamental role of veterinary pathology in the diagnosis of disease and is aligned to the diagnostic approach used in the teaching of veterinary medicine and clinical pathology in the latter part of the curriculum.
This article documents the evolution of the ICAP methodology over the past six years, from a paper-based to an online modality, in response to student and peer feedback. In addition, it discusses the impact of ICAP in relation to developing problem-solving capacity in a group situation, developing an understanding of the role of veterinary pathology in the diagnostic process, and promoting vertical and horizontal integration with clinical and other para-clinical disciplines.
In veterinary science, an important graduate attribute is the ability to undertake an investigative approach2 to a disease problem in individual animals or groups of animals to enhance both scientific understanding and clinical acumen.3 This incorporates the generic attributes of critical evaluation, adoption of a problem-solving approach, and application of discipline-based technical skills. This learning environment can also foster the acquisition of generic attributes for building a body of knowledge in the field, applying that knowledge in unfamiliar circumstances, developing the ability to use information technology, communicating effectively in spoken and written English, developing the ability to work with others, and developing planning skills.4
In the traditional veterinary science curricular model, the pre-clinical sciences are taught didactically, followed by the para-clinical sciences (also taught, to a lesser extent, didactically), with final application of this knowledge in the practical environment of the clinic.5 In response to the recognition that veterinary practice requires certain graduate attributes such as critical thinking, problem solving, and analytical skills, problem-based learning (PBL) has been adopted to various degrees by veterinary schools across North America.6
An understanding of structural and functional abnormalities is vital to the clinical disciplines of veterinary science. The para-clinical discipline of veterinary pathology provides the conceptual knowledge base that allows veterinarians to formulate strategies of diagnosis, treatment, control, and prevention of disease. Traditionally, this has been achieved through didactic presentation of the five basic pathological processes (cell injury, degeneration, and necrosis; inflammation and repair; circulatory disturbances; disorders of growth; and tissue pigmentations and deposits) in a general pathology unit of study, followed by a systemic pathology course focusing on etiology, pathogenesis, and appearance of diseases affecting specific organs or tissues. The rationale for this approach is to draw the learner from an understanding of normal structure and function, through the limited manifestations of tissue dysfunction, to an understanding of disease that allows appropriate treatment and prognosis of clinical medicine. Although the merits of such an approach are well accepted, the traditional didactic discipline-focused methods mean that the role of veterinary pathology and veterinary pathologists in the investigative diagnostic process for clinical practice may not be adequately perceived by students. Evidence-based medicine has led to an increased emphasis on identifying clinically significant problems through an investigative process of diagnosis (i.e., a problem-oriented approach) and a lesser emphasis on specific disease pattern recognition. The traditional didactic learning environment of general and systemic pathology may easily be misconstrued by the student to encourage only a pattern-recognition approach. As a result, upon exposure to a problem-oriented approach in the clinical disciplines, the student is likely to disregard the pre-clinical and para-clinical knowledge that he or she has previously acquired.
The problem-oriented approach to diagnosis focuses on developing a list of prioritized evidence-based problems for further investigation on the basis of signalment, history, clinical signs, and physical examination. Clinical problems can be, and usually are, commonly distilled to describe organ-system or tissue involvement. The logical clinician then uses some consideration of the limited manifestations and causes of tissue dysfunction (general pathology) to create a differential diagnostic list of broad, and sometimes specific, possibilities. The key to effective clinical case management is to detect, describe, and then deduce the significance of the disease changes to formulate a plan for further investigation and finally attempt to arrive at a specific diagnosis. The plan aims to delineate problems and accumulate evidence for identification of a specific disease. Invariably, laboratory aids and the veterinary pathologist are used in that deductive process. The question arises, then, if this is the role of the veterinary pathologist in the diagnostic process, why not attempt to teach students veterinary pathology in the context of the diagnostic process? This is the first stage of curriculum alignment.
Teaching the diagnostic process, however, ideally requires a case-based approach rather than the traditional didactic approach in order to have a major impact on students’ learning and understanding. This strategy uses real-life cases of animal disease to enhance the learning process by establishing relevance and logical direction through true curriculum alignment among graduate attributes, learning outcomes, and assessment tasks.7 When students are engaged in a learning task, they usually adopt one of two basic learning strategies: a surface learning approach, involving attention only to verbatim memorization of facts, or a deep learning approach, involving understanding and critical analysis of the underlying concepts within a task.7–9 Students reporting a deep approach are more likely to understand the meaning of a written task, apply the principles, and remember the content over an extended period of time. The perception of a task influences the learning approach adopted by the student. Tasks that require comprehension, critical thinking, and problem-solving skills will encourage the use of deep cognitive learning approaches. Curriculum design offers a good opportunity for the teacher to influence students’ learning approach.7, 9–11 By its very nature of high relevance, a case-based approach has the capacity to enhance student-centered opportunities for learning, encouraging a deep approach both in discipline-specific problem solving and in the development of a specific knowledge base.
The need to encourage a deep learning approach in students has led to the implementation of new teaching strategies such as the problem-based learning (PBL) method. PBL, in its most fundamental sense, represents all parts of the spectrum in the use of real cases to drive the development of problem-solving skills and the integration and acquisition of knowledge. PBL is characterized by the use of real-life examples as a context for students to learn problem-solving skills and acquire knowledge.12 This implies self-directed learning in which the students decide what and how they will learn. The interpretation of PBL varies, and the terms “problem-based learning,” “case-based learning,” and “problem-orientated learning” are often used interchangeably. However, the difference between case-based learning and PBL is that in PBL the problem is presented before any knowledge of basic principles or basic science has been acquired and the problem drives the acquisition of those basic principles; in case-based learning, cases are used in conjunction with traditional didactic methods. More recently, terms such as “inquiry-based learning” (IBL) have been implemented to describe the engagement of students in their learning process by means of integrating methods such as problem solving with more traditional didactic teaching methods such as practical laboratories and lectures.13
Although the case-based approach is second nature for clinical academics teaching veterinary medicine, both in the lecture theatre and the clinical setting, academic pathologists are traditionally less skilled in applying this approach to the teaching of veterinary pathology in the lecture theatre. The teaching and learning that take place in the necropsy room and laboratory, on the other hand, rely on real cases to emphasize that detection, description, and deduction are fundamental for understanding gross and microscopic pathological changes. How, then, can case-based approaches to learning be extended to other components of the teaching of veterinary pathology?
PBL medical students tend to adopt a deep approach to learning,14, 15 and, although a highly strategic reproductive learning behavior can be invoked,16 the strength of PBL is the contextual framework that is applicable to real life. The mental organization of knowledge encouraged by a learning environment determines successful integration and application in the environment in which it needs to be used and is closely related to contextual learning theory.12
In the past decade or so there has been a revolution in the field of information and communication technology. This revolution has allowed the development of learning-management systems (LMS) that enhance the student experience (e.g., WebCT and Blackboard) and commonly support the face-to-face teaching components of a curriculum. While this has been occurring there has been a serious move from teacher-centered to student-centered learning modes,7 and LMSs contribute to this process, with their emphasis on engaging students through questioning and other strategies. The key to ensuring the success of online learning is to link it with other forms of teacher–student interaction and to emphasize its congruence with assessment.
The ICAP approach relies on group problem solving, with the formation of a collaborative approach supporting enhanced student learning and the development of professional skills required of veterinary graduates, such as leadership, communication, and interpersonal skills.17–19 Students who analyze case-based evaluations as a group have a performance advantage and display deeper understanding, in terms of improvement in areas such as the ability to conduct complete differential diagnostic lists, over those who analyze them as individuals.20 Pickrell et al., in their study, particularly noted the improved capacity of groups over individuals to discriminate among diagnostic differentials in specific cases. In addition, it was shown that training provided as part of a group helped students to perform better on similar problems in the future, whether performance was analyzed subsequently in a group or on an individual basis.
Three versions of ICAP have evolved in response to annual surveys and learner comments (see Tables 1 and 2), as well as to peer feedback and the increased availability of information technology. The ICAP component of the veterinary pathology curriculum represented 15–20% of the final assessment and built on the traditional didactic teaching methods of lectures and practical classes. While students had previously been exposed to general principles of pathology and pathophysiology of body systems, the introduction of the ICAPs meant exposure to new diseases and the diagnostic process as applied to novel cases.
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| Survey Item | SD | D | U | A | SA | |
|---|---|---|---|---|---|---|
| 1 | The ICAPs allowed me to integrate pathology with the other disciplines in the course, especially the clinical sciences and clinical pathology. | |||||
| 2 | The ICAPs promoted teamwork. | |||||
| 3 | The ICAPs promoted independent study and accessing information about diseases of animals. | |||||
| 4 | The ICAPs encouraged me to critically evaluate information. | |||||
| 5 | The ICAPs promoted understanding of disease processes and their impact on specific organs as well as on the whole animal. | |||||
| 6 | Providing feedback to my peers enhanced my learning and provided exposure to a greater range of cases. | |||||
| 7 | The ICAP resources were easily understood and allowed me to develop a logical approach to disease. | |||||
| 8 | The ICAP format within WebCT allowed me to explore the cases in a way that enhanced my understanding. | |||||
| 9 | Online access to the ICAP cases promoted my learning. | |||||
| 10 | Group time allocated to the ICAPs was wasted and would have been better spent having more lectures. | |||||
| 11 | The workload in preparation for the ICAPs was manageable. | |||||
| 12 | The group assessment process was fair and well explained. | |||||
| 13 | The methods by which ICAPs were assessed allowed me to demonstrate my diagnostic approach to cases. | |||||
| 14 | Receiving feedback from my peers was useful and improved my learning. | |||||
| 15 | The generic feedback on the cases was adequate and allowed me to better understand the case material. | |||||
| 16 | The resolution sessions helped me to understand the cases and would have been useful for all cases. | |||||
| 17 | ICAPs helped me to develop a diagnostic approach that has been useful in my clinical subjects including extramural rotations. | |||||
| 18 | The diagnostic approach that I developed through the ICAP modules will help me in my professional activities after graduation. |
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| Survey Item | Year 3 Cohort 2002 | Year 3 Cohort 2003 | Year 3 Cohort 2004 | Year 3 Cohort 2006 | Year 4&5 Cohort (2006)** | Topic Addressed |
|---|---|---|---|---|---|---|
| The ICAPs allowed me to integrate pathology with the other disciplines in the course, especially the clinical sciences and clinical pathology. | 4.2 | 4.4 | 4.4 | 4.3 | 4.3 | Integration |
| The ICAPs promoted teamwork. | 3.9 | 3.8 | 3.9 | 3.8 | 3.7 | Teamwork |
| The ICAPs promoted independent study and accessing information about diseases of animals. | 3.9 | 3.9 | 3.8 | 3.8 | 4.1 | Independent learning |
| The ICAPs encouraged me to critically evaluate information. | 3.9 | 4.1 | 4 | 3.9 | 3.8 | Critical evaluation |
| The ICAPs promoted understanding of disease processes and their impact on specific organs as well as on the whole animal. | 4.2 | 4.3 | 4.3 | 4 | 4.1 | Understanding pathology |
| The tutorials were well-structured and presented in a logical manner. | 3.4 | 3.7 | 3.7 | 3.7 | 4.3 | Resolution session |
| The ICAP resources were easily understood and allowed me to develop a logical approach to disease. | 3.7 | 3.7 | 3.8 | 3.6 | 3.7 | Investigative approach |
| The workload in preparation for the ICAPs was manageable. | 3.6 | 3 | 3.8 | 3.3 | 3.6 | Workload |
| The group assessment process was fair and well explained. | 3.5 | 3.2 | 3.3 | 3 | 3.5 | Assessment |
| I was allowed to have adequate involvement in the tutorial sessions. | 3.9 | 3.9 | Resolution session | |||
| The feedback on the group's progress was adequate and allowed me to better understand the case material. | 3.5 | 3.2 | 3.3 | 3 | 3.4 | Feedback |
| The ICAP format within WebCT allowed me to explore the cases in a way that enhanced my understanding. | 3.8 | 3.9 | 3.9 | 3.7 | Online format | |
| Online access to the ICAP cases promoted my learning. | 3.8 | 3.9 | 4 | 3.9 | Online access | |
| Class time allocated to the ICAPs was wasted and would have been better spent having more lectures. | 1.9 | 1.9 | 2 | 2.2 | ||
| Providing feedback to my peers enhanced my learning and provided exposure to a greater range of cases. | 3.2 | 2.6 | 3.1 | Providing peer feedback | ||
| Receiving feedback from my peers was useful and improved my learning. | 2.8 | 2.4 | 2.8 | Receiving peer feedback | ||
| The methods by which ICAPs were assessed allowed me to demonstrate my diagnostic approach to cases. | 3.3 | 3.5 | Diagnostic approach—current | |||
| ICAPs helped me to develop a diagnostic approach that has been useful in my clinical subjects including extramural rotations. | 3.6 | Diagnostic approach—current | ||||
| The diagnostic approach that I developed through the ICAP modules will help me in my professional activities after graduation. | 4 | 3.7 | Diagnostic approach—future |
*Responses are on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree).
**Students in this cohort would have been in year 3 in 2004 or 2005.
An interactive, investigative learning module was developed in early 2002 as a component of the Systemic Pathology unit of study at the FVS. This module, the first Integrative Case-Based Applied Pathology (ICAP) unit, consisted of a group learning exercise based on a set of clinical and pathological data from a real case and a series of questions for groups to consider (see Figure 1). Students were placed in groups and asked to consider the scenario. No timetabled events were allocated for this exercise, and students were required to prepare for a large-group tutorial session within two weeks. Two case scenarios were considered during every two-week period, and all groups worked on the same scenarios. Questions were designed to lead the students through a logical pathological process–based approach to the case. While reports were submitted every two weeks, and feedback provided to the group as formative assessment, two cases were used as summative assessment toward the end of the unit of study. At the one-hour resolution session, additional case data in the form of images (including ultrasonographic, radiographic, gross pathology, and histopathology images) were provided and discussed.
Figure 1: An example of ICAP version 1. As this figure shows, this model requires student cooperation to make a staggered delivery. The type of information provided to the student is limited to text.
In 2003, the ICAP learning module was modified to a Web-based version delivered to students through the university's LMS (WebCTa). The cases were individually transferred to static HTML pages for Web delivery by IT support staff, allowing for the delivery of clinical data in the form of text and images. This delivery format allows exploration of all the clinical information, available in the order in which each student chooses to access it. The reporting template had 11 parts and was designed in such a way as to guide the learner from the general to the specific, beginning with an exercise linking clinical signs to body-system involvement and progressing to the consideration of pathological processes likely to be involved, significant findings on diagnostic data, interpretation of the data, and, ultimately, through to a list of specific differential diagnoses. The final two parts of the reporting template asked the learner to learn independently about the pathogenesis of the two most likely differential diagnoses decided upon. It was expected that the learner would access various reference sources, including journal articles, textbooks, and Web sites. In this format, the learner report output is a word-processor template that is added to and submitted electronically to a drop box in the LMS. Fortnightly resolution sessions were used to discuss the approach to investigation and interpretation of diagnostic data.
A further evolution of the learning system was embarked upon in 2004 and 2005. The format and appearance of Web delivery remained essentially the same (see Figure 2). The major advance made at this point was the building of a dynamic Web site run from a database called CaseBuilder (created by the Faculty of Veterinary Science, University of Sydney), with seamless links provided from the LMS. While making no perceptible difference to the student, this change made it quick and easy for teaching staff to upload text and image data to the database, choose an output template, and then automatically populate the template with case-specific data.
Figure 2: A screen grab of the construction view of CaseBuilder. The edit format is extremely user friendly, with the edit view mirroring the learner view and a quick link to the actual student view. For the tutor, there is a short description of the case used, and each field and field heading can be edited or deleted. Screen layout is currently not editable in this version of CaseBuilder. Image files, Web links, data tables, forms, and text can all be inserted. Delivery of material is at the learner's discretion, allowing exploration and enquiry.
Within the Veterinary Pathology unit of study there are many activities that involve groups of various sizes. The ICAP group is the basic building block of all groups. For different activities, two or more ICAP groups come together to form larger groups, depending on the activity; for example, for necropsy classes two ICAP groups work together, whereas in laboratory practical classes (gross pathology and histopathology) six to eight groups work together.
For ICAP Version 1, groups of four to six learners were formed alphabetically (by surname) by the unit-of-study coordinator; for Version 2, groups were still formed by the unit-of-study coordinator but were assigned randomly rather than alphabetically; in Version 3, groups are formed by the learners themselves during an introductory exercise.
For ICAP Versions 1 and 2, feedback was provided during the fortnightly resolution sessions (six times in the semester, 12 cases) and in written form to each group on their case report. For Version 3, feedback is given online as generic case feedback and written comments on group case reports with monthly resolution sessions.
Discussion and resolution of each case was achieved in large-group tutorial sessions involving six to eight ICAP groups, facilitated by a teaching member of the veterinary pathology staff.
For ICAP Version 3, a system of peer feedback was incorporated into the learning module. This peer feedback is a part of the formative assessment process whereby participation is required; however, it does not form part of the summative assessment for the unit of study. The requirement is that peer feedback be short (200–400 words), and students are encouraged to be supportive and constructive.
The bulk of the cases form part of the formative assessment program, while two cases provide the bulk of the summative assessment for this component of the unit of study. A summative assessment mark is provided for each group, based on one case report. This group mark is modified for each individual within the group, based on their attendance at ICAP sessions and their participation in group work. Group-work participation is judged to be either satisfactory or unsatisfactory by members of the group. The ICAP component makes up 15–20% of the overall assessment of the unit of study.
Upon completion of the unit of study, learners were asked to participate in a survey to give feedback on learner perceptions of the modules. The surveys used a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), and opportunities for additional student comments were provided. These surveys evolved over the period between 2002 and 2006, some questions being removed and others added during that time. The 2002, 2003, 2004, and 2006 year 3 cohorts were surveyed, in addition to the 2006 year 4/5 cohort. The 2005 year 3 cohort was not surveyed as a result of logistical difficulties. Table 1 shows the most recent survey form.
The three authors evaluated the student survey results each year in relation to ICAP's effectiveness in delivering learning outcomes: namely, the perceptions of developing problem-solving capacity in a group situation, an appreciation of the importance of staff feedback and peer feedback, an understanding of the role of veterinary pathology in the diagnostic process, and the promotion of vertical and horizontal integration with clinical and other para-clinical disciplines. One of the authors (PJC) has significant input into a later clinical unit of study (Veterinary Medicine and Clinical Pathology) and was able to evaluate the impact of ICAP learning outcomes on year 4 students directly.
There has been ongoing dialogue with two para-clinical and five clinical colleagues over the usefulness of ICAP in achieving the desired learning outcomes, especially in promoting vertical and horizontal integration. Written comments were sought from these colleagues in mid-2006. Moreover, the authors have the opportunity to evaluate the success of ICAP in achieving the desired learning outcomes through their teaching of veterinary clinical pathology to year 4 (PJC) and an elective rotation in diagnostic veterinary pathology to year 5 (all authors).
Survey results are presented in Table 2 (average response rate: 72% of enrolled students). In addition, approximately 75% of respondents provided interesting written comments (see Table 3 for selected comments from individual students). Key questions about the discipline-specific features of the ICAPs received an overwhelmingly positive response.
|
| Topic | Student Comments |
|---|---|
| Integration | ICAPs made studying pathology much more interesting and were an excellent way of integrating knowledge from other subjects both this semester and previous years. ICAPs also gave us an excellent foundation for the diagnostic process that we will be using everyday in our future careers and also proved to us that not all cases are clear cut. |
| The ICAPs were a really good way of making us apply stuff we’d seen in lectures and pracs and helped us to see links between pathology and other subjects. | |
| ICAP was great for integrating the different topics and units of study | |
| ICAPs were great for assisting in getting a big picture view. | |
| Discipline-specific understanding | I really enjoyed the ICAP cases. ICAPs were the first activity I remember doing that really started to draw together knowledge learnt in other courses. It was also the first time I can remember working through a diagnostic work-up of a clinical case. This not only promoted enthusiasm for the activity and subject, but also provided the fundamental building blocks for the diagnostic approach used in later clinical subjects, 5th year rotations and beyond. I also feel that emphasis provided by ICAPs on developing differential diagnoses based on pathological processes can't be stressed enough, as in later clinical subjects/clinical rotations/work experience etc I have seen diagnoses missed/left out of ddx because of a tendency to jump to specific diseases before thinking about generic processes of disease. |
| The ICAPs promoted understanding of disease processes and their impact on specific organs as well as on the whole animal | |
| ICAPs … showed the relevance of what I was learning | |
| ICAP has given me confidence that one day I will be able to identify, treat (& diagnose) cases by myself | |
| ICAPs allowed me to work though a case and apply my understanding of diagnostics and pathogenesis | |
| Online format | I think the cases, the format they are delivered in, is very useful as a learning tool—it is very educating |
| The setup on WebCT (microscope slides, PMs, biochem and haematology reports) allowed us to practice the skills we had learnt in prac classes | |
| Workload | They were a good way to learn but it was too much work! |
| Generic attributes | ICAPs are good for research and group work skills |
| ICAPs were responsible for the development of most of the generic skill | |
| ICAPs enable self learning and drive to research cases | |
| ICAP cases allowed us to think critically | |
| Group work | ICAPs are good for … group work skills |
| ICAPs especially taught me how to work in a group setting | |
| I really liked the group I was in which made ICAP a lot better. Working with others made me at first feel like I had a poor understanding of applying things we’d only just been introduced to but it also encouraged me to try and be better prepared and look at things and different ways. I learnt a lot off the others so I found it really useful. | |
| Talking the cases through made me think more about the cases and helped my learning. | |
| I learnt a lot from the other people in my ICAP group and was surprised at the amount of information I knew too. | |
| Our team worked really well together. | |
| I learnt a lot off the others so I found it really useful |
The critical question referring to the learning modules encouraging integration of this para-clinical discipline with other disciplines vertically and horizontally was answered with agreement of 96% over all cohorts of students (including present students in the clinical years), indicating that the teaching initiative was understood by learners to integrate disciplines within the veterinary science curriculum (see Table 2).
Another key survey question investigating the effectiveness of ICAP on the promotion of understanding in veterinary pathology showed 91% agreement among cohorts of respondents (see Table 2) and provoked numerous positive comments revolving around engagement with the discipline (see Table 3).
Approximately three-quarters of respondents agreed that the online format and Web access were a positive part of their learning process, while only 8% agreed that time would have been better spent on didactic lectures.
Almost two-thirds of students over all cohorts agreed that the workload was manageable. The response was remarkably consistent over the four-year period, despite a marked reduction in workload over the same period. Other students commented that the workload was too high.
Importantly, measures of more generic attributes appear to show favorable responses in the context of this learning activity, with 80% of respondents agreeing that the ICAP format promoted independent learning and critical evaluation.
The survey results show that three-quarters of learners across all cohorts recognized the importance of teamwork as a generic skill and agreed that the process helped engagement in teamwork.
There were, however, a number of references to difficulties with group work (see Table 4); students identified problems including domination by certain group members, lack of organizational skills, difficulties with conflict resolution, the unfairness of group assessment, and lack of workload equity. Some students perceived that having their groups chosen for caused an unequal distribution of work.
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| Topic | Relevant Student Comments |
|---|---|
| Dominance | In our case, the group was dominated by one or two people who would not allow discussion/comments by other people |
| Group organization | Really enjoyed ICAPs but a lot of people struggled with their groups. Maybe it would be possible to have something like an allocated group leader each week to be in charge of one case and direct the group. |
| I found it hard for the whole group to work around a computer—too many cooks spoil the broth. | |
| It sort of promoted teamwork however people still tended to split up anyway and wasn't good if you had a bad group. | |
| Conflict resolution | As far as the groups went you either love your group at the end or are willing to commit a federal offence to never see them again. Even placing certain personalities together who are friends is dangerous. |
| Our team dynamics was interesting and it was often a challenge to overcome fundamental problems of personality clashes. | |
| It did help to improve our teamwork skills but has created a lot of tension (and fights) between individuals in our year. | |
| Workload equity | There was a problem with teamwork in our group in that some members would not show up or would do little preparation therefore contributing very little to the report. |
| For some groups, much of the work was placed on a few people. Group work for our group was reasonably well-distributed, most of the time but controls for at least attendance need to be put in place. | |
| As with all group work it seems to always be unequal distribution of work amongst the members of the group. | |
| Theoretically group work always sounds like a good idea, but is much more difficult in its practical application. For example, attendance at sessions by group members wasn't really monitored adequately and participation was very variable and not really assessed. However, I did enjoy the sessions and if everyone pulled their weight it would be very beneficial learning experience. | |
| Random allocation of group members was a very good idea, but there needs to be developed a way to have individual members input integrated into the marks for ICAPs, maybe evaluation by other group members. Maybe stricter marking of rolls at ICAP sessions would help less motivated group members to put in more effort. | |
| Group formation | Teamwork was emphasised but it did create a lot of tension in the year. It would be appropriate to place each person with at least someone they would prefer to be with. |
| Working in groups chosen for us was bad as there was quite a difference in the level of work different members put in. If we weren't being assessed this wouldn't be so much of a problem, but it's a little unfair to give us as individuals a mark based on the performance of a group we didn't even get to choose. | |
| Group assessment | Not all group members contributed or even showed up and any complaints about this were ignored. It's not fair for those that didn't contribute to receive the same mark as those that did the work. |
| How can you assess the group evenly when no one has seen whether all members contributed? I was luckily in a fairly hardworking group but still feel that we mopped up two group members lack of involvement—yet they may get the same mark. | |
| Group assessment allowed certain members of the group to participate minimally yet still get a mark reflecting the overall effort of the group. |
With the initial allocation of groups by the unit-of-study coordinator, we received feedback suggesting that students would prefer choice in the group formation process. Following this feedback, the allocation of students was modified in subsequent years by allowing students to choose their own groups. While this change was somewhat successful, allowing students to choose their own groups did not always yield positive results. One particularly interesting comment reflects this:
Personally I had some trouble with members of my group so my impression of group learning was not overly pleasant (my own fault for choosing these people to work with).
Some process issues received variable responses, with respondents equivocal on mode and fairness of assessment. Judging by the students’ comments, such feedback is mostly driven by angst about group marks.
Students were less enthusiastic about peer feedback, with only 37% agreement overall that providing feedback enhanced their learning and 28% agreement that receiving feedback enhanced their learning.
The success of this innovation has been recognized by our peers to some extent, with three colleagues, one clinical and two para-clinical, adopting similar online case-based programs from the ICAP model on the basis of ongoing discussions regarding the effectiveness of ICAP in providing contextual relevance and delivering desired learning outcomes. These initiatives are in veterinary microbiology (Case-Based Applied Veterinary Microbiology On Line, or CAVMOL) and ruminant production (Teaching Innovation Livestock Health and Production, or TILHAP). As a result, the students are familiar and comfortable with the format.
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| Topic | Discipline | Teaching Staff Peer Comment |
|---|---|---|
| Integration | Ruminant health and production | What I have noticed most is as of last year there now appears to be a much smoother transition from ICAPS etc to the TILHAPs. They just get on with them and do a pretty good job, despite the widely expanded expectations of the outcomes … . ie problem management and resolution. |
| Animal disease Veterinary microbiology | We use the knowledge they have gained in pathology to approach cases in veterinary microbiology and especially in Animal Disease where a broader approach to the clinical problem is required and the pathological processes give them a framework in which to make a differential diagnosis and then diagnostic approach. … [We] used to use the DAMNIT system in animal disease but struggled—as soon as we aligned with pathology, I think 3 years ago, building a differential diagnosis has been easier to accomplish in a large and small group teaching environments. | |
| Pathology support to other disciplines | Equine medicine | With respect to an understanding of the host-pathogen-environment relationship, I think they do OK. Most of the diseases that we deal with commonly in the horse would be classified as inflammatory or degenerative [and] I would say that the students have a reasonable grasp of these basic pathologic processes as they apply to the horse (I cannot comment on the other processes). |
| Animal disease | The students have an excellent grasp of the HPE relationship … The students have an excellent grasp of the 5 pathological processes. | |
| Ruminant health and production | I can confirm that they appear to have a better understanding of the importance of host-pathogen-environment interactions in the diagnostic process … quite impressive really. | |
| I can report that in necropsy classes and field trips to Arthursleigh in particular (i.e. where we see a range of pathological materials) the categories of the 5 basic pathological processes (inflammation, degeneration, vascular disturbances, disorders of growth and pigmentations and deposits) is often discussed in relation to interpreting signs and lesions. However I do have to prompt it! | ||
| Radiology | By comparison, the 2006 year 4 … ask deep questions and clearly have a deeper understanding of our subject (diagnostic imaging) that encourages us to believe that we have succeeded in teaching them the principles that we believe are important graduate attributes. Was it our successful teaching environment … your ICAPs, or did we just get lucky and have a particularly enquiring year? … I don't know … ask me again this time next year. | |
| The bright students appear to integrate information well, and if we can get them to talk they express an understanding of pathophysiology in all of its guises. The strugglers only want to know what's in the test, and target their learning to clear the assessment barrier. Some individuals don't appear to have learned anything in any subject area in their 5 years with us, from basic anatomy through to morbid pathology. … I’m sure ICAPs provide information in a stimulating way … something that we are all trying to achieve in our specific subject areas. Having seen some of the ICAPs, I find them interesting and relevant. Can I see a measurable impact … No, sorry. |
Both clinical and para-clinical colleagues have offered both positive and negative feedback. Generally they reported that students had a good grasp of the host-pathogen-environment (HPE) interaction and the pathological processes; however, some of our peers were not sure that this was attributable to ICAPs. Other colleagues indicated that many students in the later clinical years required significant reiteration to reinforce the worth of veterinary pathology in the diagnostic process. Some responses were more negative and failed to recognize any impact on students in their units of study. Interestingly, this failure was reported in the same cohort of students in which other colleagues noted significant success in other units of study.
Students’ acceptance of and involvement in a paper-based cased-based approach in veterinary clinical pathology in year 4, in operation since 1990, appeared to be facilitated by their prior exposure to ICAP in year 3 from 2002 on (PJC). This facilitation was expressed in decreased time spent working through cases, enhanced understanding of the importance of pathological processes in disease diagnosis, and a greater awareness of the role of histopathological examination and other laboratory procedures as diagnostic tools. Moreover, all authors had the opportunity to assess a limited number of students undertaking an elective rotation in veterinary diagnostic pathology in year 5 on their level of understanding of ICAP by allowing them to develop additional ICAPs online. While these students were obviously highly focused on diagnostic pathology, they did display an aptitude for the process of development of online ICAPs that reflected a high level of understanding.
The development of the ICAP model into an online format was generally well accepted by students, but perhaps one of the most important features of this project has been the impact of this development on staff. Although the evolution in format initially amounted to more work for staff as a result of the need to convert material into digital form, the ability to re-use cases in subsequent years has resulted in less work. This advantage has been detailed in other publications describing Web-based technology in PBL, with the finding that Web-based technology made it easier to maintain course materials, alleviated administrative burdens associated with small-group teaching, and allowed for updating of cases to meet emerging student concerns.21
The evolution of the ICAP model, although primarily driven by student and peer perception feedback and by our own reflections, has also been dependent on curriculum design, with an emphasis on vertical and horizontal integration. Clearly, ICAP has assisted this process, both by influencing the design of other online cased-based models within the curriculum and by encouraging continual dialog among para-clinical and clinical academics. However, evaluating the success of ICAP in achieving its goals of developing problem-solving capacity in a group situation and an understanding of the role of veterinary pathology in the diagnostic process is somewhat more difficult. Student and peer perception feedback has suggested varying degrees of success and emphasized the importance of reinforcing principles and approaches—despite the fact that all three authors teach across three years of both para-clinical and clinical units of study and, therefore, have ample opportunity to reinforce principles and approaches.
Student feedback identified two key issues: group-member interaction and peer assessment. It was clear from individual students’ comments (Table 4) that group dynamics often left much to be desired and that there was concern about unequal distribution of work within the groups. The issue of selection of group members was addressed in ICAP Version 3 when students were allowed to select their own groups (with varying degrees of success). However, the issue of group dynamics and the consequent unequal distribution of workload is one that the authors felt needed to be addressed in a generic way earlier in the curriculum. This conclusion was reinforced through student feedback for similar group-work activities in other units of study. Consequently, one of the authors (PJC) contributed to the establishment of a session on understanding teamwork for first-year veterinary students in a Professional Practice unit of study, which focuses on developing self-awareness, interpersonal skills, and leadership (a further example of vertical integration). This student-focused session takes students through reasons why teamwork succeeds or fails and offers them some insight into how they and others best work in a group via a simulated teamwork activity. These generic aspects are then reinforced in all group activities throughout the curriculum. Since the session was introduced only in 2006, its impact on student perceptions of ICAP sessions cannot be assessed until 2008.
It is well accepted that the success of group work is heavily dependent on members’ agreeing on common goals and, through self-awareness, developing trust and respect.22 Other factors necessary for success are usually subsidiary to these, but some, such as technical expertise, cooperation, and shared workload, may be equally important, depending on the teamwork exercise.22 The authors suspect that the difficulties in group work for ICAP sessions emanated from a lack of trust and respect rather than from disagreement on the goals of the project. This view was based on student comments that other group members were often “holding them back” or “didn't have the expertise required.”
There is evidence that some students did not perceive the value of engaging in group activities. One student commented,
The main problem I believe was the grouping together of individuals to work together who may not necessarily chose to work together in real life. From that point of view I found the entire ICAP unconducive to learning. Any benefit gained from each exercise was based on my own individual research and collaborating with people from other groups.
For these students to accept the usefulness of group work, there must be an attitudinal paradigm shift, which can come about only through self-awareness and reinforcement of the importance of interpersonal skills. This conclusion is consistent with other studies of collaborative learning, in which student survey responses suggest that the students do not necessarily appreciate the benefits gained from the pedagogical approach of working in teams and that emphasizing how students gain from such assignments and identifying the skills developed would be advantageous.23 The global veterinary profession expects all graduates to have attributes based on leadership, communication, and interpersonal skills.18, 24 Teamwork, therefore, must remain an important component of the veterinary curriculum.
Our reflections and feedback from both students and peers have clearly shown that ICAP is contributing to discipline-specific learning, vertical and horizontal integration, alignment of learning outcomes and assessment, and the enhancement of veterinary and generic graduate attributes for undergraduates. We have successfully integrated the approach into the curriculum, and it is reinforced in veterinary clinical pathology in year 4 of the curriculum for all students and in an elective diagnostic pathology rotation for a small number of students. However, the real key to success for ICAP will be its translation and application by graduates to problem solving in real-life situations in veterinary practice. Consequently, it will be imperative for us to obtain feedback from recent graduates to assess whether there is long-term implanting of the importance of veterinary pathology in the diagnostic process. We can then effectively evaluate the necessity for further refinement of ICAP to align our veterinary pathology curriculum with graduates’ skill requirements.
ACKNOWLEDGMENTS
We thank Dr. Mano Chetty, Mr. Federico Costa, and Mr. Gerard Marcus of the Educational Innovations Unit, Faculty of Veterinary Science, University of Sydney; and Dr. Jacqueline Norris Associate Professor Peter Windsor, Professor Graeme Allen, and Dr. Anthony Mogg, teaching staff in the Faculty of Veterinary Science, University of Sydney.
a Blackboard, Inc., Washington, DC 20036 USA <http://www.webct.com>.
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