Volume 49 Issue 5, October 2022, pp. 575-583

Veterinarians are required to use clinical reasoning skills to successfully manage their patients with eye diseases. Case-based assignments can be an effective tool for teaching problem-solving skills. Very few models or online modules exist to deepen the instruction of veterinary ophthalmic clinical reasoning skills. The current study aims to assess the value of online case-based assignments given to students during the Ontario Veterinary College’s Phase 4 ophthalmology rotation over a 4-year period. Nine case-based assignments were developed as an online module and provided signalment, history, ophthalmic database, and clinical photography. For each case, students were required to describe the ocular lesions, provide a diagnosis, and develop a short-term and long-term treatment plan. A grading rubric was created, and student feedback was collected using an online survey. A frequency analysis was conducted to evaluate final grades across each case. This analysis was also completed for grades of each question across all cases. A total of 285 students were graded individually. Students’ grades were normally distributed across each assignment. Students performed better on lower-order cognitive skills (description of ocular lesions) but poorer on high-order cognitive skills (therapeutic plans). These results suggest that students tend to have difficulty with the analysis and interpretation of these cases. Student feedback reported case-based assignments were useful. Online case-based assignments may be a useful adjunctive teaching tool for students rotating through ophthalmology in their clinical year, and this tool could be considered for other specialized rotations.

Clinical reasoning skills are vital for veterinarians to successfully detect and assess patients’ ocular symptoms with subsequent formulation of a diagnosis and appropriate treatment plan. The development of these skills in veterinary students requires their exposure to clinical cases and active commitment to case management.1 The cognitive processes needed for case diagnosis and management are typically emphasized in the clinical ophthalmology rotations of the veterinary curriculum’s final year. These skills are less widely used or practiced in the curriculum’s first 3 years as the veterinary ophthalmology syllabus is mainly taught with didactic lectures. As a result, when entering final year, senior veterinary students often struggle to incorporate these skills while balancing educational and patient-related activities.2

One of the fundamental elements to effective clinical education is fostering an environment that permits individual problem solving.3 Although final-year rotations in veterinary teaching hospitals provide a rich environment for learning and reinforcing concepts, they are not without limitations.4 Time restraints due to busy clinic schedules and arrivals of unscheduled emergencies may restrict a student’s exposure and learning experiences to hospital cases.5 Ophthalmology rotations are often within a veterinary teaching hospital that is a secondary, if not tertiary, referral center. Referrals to a specialty service such as ophthalmology often attract more uncommon or complicated cases than those typically addressed in general practice. In addition, during a specialty rotation, not all illnesses will be seen and exposure to a variety of diseases within this specialty may be limited. As a result, the referral basis of the teaching hospital selects a sub-population of clients and patients within the general public, which can limit the type of cases presented to students.4 The inclusion of interns and residents in case management may also lead to suboptimal experiential learning for the veterinary student.5 Kochevar et al.5 has reported that not only do students compete with each other, but interns, residents, technicians, and veterinary technical student trainees can impede their learning opportunities.

As seen in medical teaching hospitals,6,7 online virtual patient modules have been created to increase case exposure in veterinary teaching hospitals.1,815 The main advantages of these modules include accessibility to clinical cases or procedures that cover curriculum requirements, convenience to address cases irrespective of time and place, welfare guidelines, and lack of live patient inconvenience and/or discomfort due to numerous student examinations.8,9 The use of virtual patients has been linked to better achievement of learning outcomes16 and the development of key cognitive clinical skills.6,17 However, these virtual patients are part of online programs that can be extremely expensive and time-consuming to create.1,6,10,15,18

Online case-based assignments provide an alternative to computerized virtual patients. Previous studies have shown that case-based learning can be used as an effective tool for teaching veterinary medicine.10,15,1821 The development of students’ clinical reasoning skills can be improved by case-based assignments, which are problem-solving exercises.10,15,1820 They have also been shown to improve clinical engagement, understanding, and application.20 The high clinical relevance of case-based assignments augments student-centered learning and boosts a deep approach to both discipline-specific problem solving and improvement of a particular knowledge base.21 The instructional philosophy underlying the use of case-based learning is to provide students with an opportunity to apply knowledge to solve a problem using critical skills and potentially change their behavior.22 The high clinical relevance of case-based assignments in connecting theory to practice provides a spectrum of opportunities for learners to navigate surface, strategic, and deeper learning approaches.23 This spectrum of potential learning approaches and improvements for students can be reflected by enhancements in knowledge, focused learning of new case contexts not previously considered, and engagement with more critical thought about the case, respectively.

As compared with human medicine, limited online learning resources or modules are focused on veterinary medicine and especially veterinary ophthalmology. Although several undergraduate human ophthalmic education resources are available,7,24 there exist very few modules to increase or reinforce students’ veterinary ophthalmology knowledge.25 Senior students participating in the ophthalmology rotation at the University of Guelph’s Ontario Veterinary College were assigned online case-based assignments designed to promote problem-solving skills and augment experiential learning of ophthalmic knowledge of common ocular diseases. The current study aimed to assess the teaching and learning value of these cases over a 6-year period, from 2011 through 2016. To do so, we examined the following research questions:

  • Research Question 1 (RQ1): Based on the distribution of student performance on the case-based assignments, do the cases appear to promote problem-solving skills in the ophthalmology rotation?

  • Research Question 2 (RQ2): By examining the correlation between grades on the case-based assignments and the overall grade for the ophthalmology rotation, are the cases a valid measure of students’ skills in the ophthalmology rotation?

  • Research Question 3 (RQ3): How do students evaluate the effectiveness of these cases?

This study was part of a larger study of the development and proficiency of veterinary competencies approved by the Research Ethics Board at the University of Guelph #17-05-023.

Case Development

Nine cases were available to students through the institutional online course learning management system (Courselink) during the Phase 4 (senior year) 2-week ophthalmology rotation from 2011 through 2016. Although not mandatory for the completion of the rotation, these cases were highly recommended to be done while on rotation. The first case was identified as a practice case, followed by eight other cases. The information provided with these cases included signalment, history, clinical ophthalmic data (neuro-ophthalmic exam findings, Schirmer’s tear test results, fluorescein stain uptake, and tonometry measurements), and one to four images of the affected eye(s). An introductory page with hints or guidelines on how to best complete the cases was also included (i.e., how to navigate the photographs; how best to describe, diagnose, and formulate a plan of action). Using a problem-oriented approach, the students were asked to respond in short-answer format to identical questions for all cases. The questions originated from the primary author’s (CLP) private practice experience: what to do you see? (Question 1: describe ocular lesions); what do you think? (Question 2: what is your diagnosis?); and what do we do about it? (Questions 3 and 4: what are your short- and long-term plans of action?).

During the rotation, students completed the cases in their own time. They had access to the cases from offsite locations and could refer to online material, lecture notes, and textbooks. Students were strongly encouraged to complete the cases individually rather than in groups. The subjects of the clinical cases were as follows: entropion (practice case), keratoconjunctivitis sicca (case 1), recurrent or indolent ulcer (case 2), glaucoma (case 3), proptosis (case 4), cataracts (case 5), complex or complicated ulcer (case 6), uveitis (case 7), and feline herpes (case 8). Following submission of answers to all four questions, students could immediately review the cases and have access to expert answers generated by the primary author (CLP). For students to receive an authentic formative learning opportunity, they were graded on their performance on the cases; however, these marks did not contribute to the students’ final grade in the course.

Grading Rubric

A rubric was developed to assess students’ performance on description, diagnosis, and therapeutic planning. One author (CS) marked the cases, and the primary author (CLP) reviewed all answers. For all cases, each question was scored out of 1: correct (1 point), incomplete (.5 point), and incorrect or not attempted (0 points) (Table 1). Other factors, including the number and quality of written observations, were also considered when calculating students’ final scores for each case. Each case was graded out of 4, and non-attempted cases were given a grade of 0.

Table

Table 1: Rubric for case-based assignments

Table 1: Rubric for case-based assignments

Question Correct Incomplete Incorrect Not attempted

1. Descriptions

3 or more key ocular lesions described

1 point

2 or fewer appropriate ocular lesions described

0.5 point

Listing no or inaccurate ocular lesions

0 points

0 points
2. Diagnoses

Appropriate and complete diagnosis

1 point

Partial diagnosis, such as listing only a portion of the diagnosis or an appropriate underlying cause

0.5 point

No or inaccurate diagnosis

0 points

0 points
3. Short-term plan

Listing core medications or procedures needed for successful therapy

1 point

Appropriate therapies but missing key medications or procedures

0.5 point

Inaccurate treatments listed

0 points

0 points
4. Long-term plan

Listing core medications or procedures needed for successful therapy

1 point

Appropriate therapies but missing key medications or procedures

0.5 point

Inaccurate treatments listed

0 points

0 points
Note: Allotted points for each category are bolded.
Survey Development

In 2016, online surveys were distributed to students who completed the ophthalmology rotation between 2011 and 2016. The surveys assessed the perceived learning value of the assignments. The following four questions were rated on a 5-point scale from not useful (1) to extremely useful (5):

  • How useful were the cases in helping you practice describing common ophthalmic conditions?

  • How useful were the cases in helping you practice diagnosis common ophthalmic conditions?

  • How useful were the cases in helping you practice defining a treatment plan?

  • How useful were the cases in helping you understand key ophthalmic concepts?

Additional questions included the following:

  • How clear were the Courselink instructions explaining how to complete the cases? (measured on a 5-point scale from not clear [1] to extremely clear [5])

  • Did you complete the cases individually or as a group? (Response options: completed all cases individually, completed most cases individually, completed all cases in a group, completed most cases in a group, and I don’t remember)

  • Please explain what made the cases useful or not useful for you. (Open-ended response)

Statistical and Qualitative Analysis

To address RQ1, frequency analyses were conducted to examine the distribution of final grades across each case and grades for each question across all cases. By having the analysis of each case and each question, results may enlighten us on the students’ performance on case progression across time and on low- and high-order cognitive skills, respectively.

To address RQ2, we examined the correlation between students’ overall ophthalmology rotation grade and case assignment grade.

To address RQ3, analyses of the descriptive statistics were conducted for the quantitative survey responses. A thematic analysis26 was conducted on the written responses to the survey question “Please explain what made the cases useful or not useful for you.” For the thematic analysis, one of the authors (JR) read all written responses several times to become familiarized with the data. Next, the same author coded all responses according to whether they identified an aspect of the case that was useful or not useful (or both). Next, an inductive coding scheme was developed based on patterns of responses identified in the data. All responses were coded through an iterative process of moving between the codes and the written responses to refine the coding scheme. Next, broader themes were identified within the coded data. Themes were named to describe salient features of the useful and not useful aspects of the cases (variety of ophthalmic conditions covered; working through cases from start to finish; discussing cases and receiving feedback; and identifying gaps in knowledge).

A total of 285 students were graded over a 6-year period (2011–2016). At one time point, one author graded all cases (CS) and grading was reviewed and validated by a veterinary ophthalmologist (CLP). Both authors were masked to the students’ identity during grading.

Student Performance Data

Student performance on each question was examined across the eight cases (excluding the practice case). Table 2 displays the average score for each four questions; this score was averaged across all eight cases.

Table

Table 2: Average student performance by question (averaged across eight clinical cases)

Table 2: Average student performance by question (averaged across eight clinical cases)

Question no. Skill assessed by question Average score/1 (SD)
1 Description of ocular lesion(s) .89 (.10)
2 Diagnosis of ocular disease .88 (.14)
3 Development of short-term plan of action .52 (.19)
4 Development of long-term plan of action .38 (.16)

Across the eight cases, students performed best on question 1, in which they described the ocular lesions, and worst on question 4, in which they developed a long-term plan of action. An examination of the performance distribution of scores on each question indicated that student performance on question 1 was negatively skewed, with approximately 50% of students receiving a grade of .90 or above on the question. Figure 1 displays the distribution of student performance for each question. The frequency analysis suggests that students performed best on question 1, which tested description, a lower-order cognitive skill. Student performance was lower on questions testing higher-order skills (especially question 4—long-term planning). This finding suggests that the cases challenged higher-level learning skills but did not necessarily promote problem-solving skills; the cases did allow students to successfully employ lower-order skills such as identification and description (RQ1).

Figure 1: Distribution of students’ average grades on questions 1–4 across all cases (n = 285)

We also examined student performance across the eight cases. Table 3 displays the average scores for each of the eight graded cases, displayed from highest to lowest average score. Average scores ranged from 2.44/4 (61%) to 3.29/4 (82%). This distribution of performance across the cases revealed that no increase in scores as the students progressed from the first to the last case. These results suggest that the students’ diagnostic and treatment planning skills did not improve substantially with practice across the eight cases. However, although we assumed the students completed the cases in order and reviewed the feedback provided at each case’s completion, this assumption could not be verified. Knowledge gained from the feedback should have enabled students to progress with evaluation skills. Furthermore, since each case addressed a different ocular issue, each case had its own degree of difficulty, making it difficult to determine whether improvements in students’ problem-solving skills were being masked by case difficulty.

Table

Table 3: Average student performance for eight clinical cases

Table 3: Average student performance for eight clinical cases

Clinical case no. No. of students who completed cases Average final score/4 (SD)
1 282 3.29 (0.66)
3 273 3.24 (0.75)
6 246 3.19 (0.68)
5 249 3.02 (0.70)
8 224 2.93 (0.84)
4 269 2.91 (0.68)
7 238 2.47 (1.00)
2 276 2.44 (1.11)

To address RQ2, we examined the correlation between scores on the case assignments and overall scores in the rotation. Scores on the assignment were significantly associated with final rotation grades (r = .15, p = .015, n = 282). Although the assignments were graded, they did not contribute to students’ final grade in the rotation, so these variables are not confounded. The significant positive correlation between the case-based assignment grade and the final grade in the ophthalmology rotation suggests that the case-based assignments are valid measures of student performance.

Survey Results: Student Perceptions of the Case-Based Assignments

Of 285 students, 63 (22%) students that completed the ophthalmology rotation between 2011 to 2016 responded to the survey. Most survey respondents (79%) rated the case instructions as very clear or extremely clear (see Figure 2). Overall, 76% of respondents indicated that they completed all or most of the case assignments individually (see Figure 3).

Figure 2: Distribution of survey respondents’ ratings of clarity of case instructions (n = 63)

Figure 3: Distribution of responses to question about how students completed the case assignments (n = 63)

To address RQ3, we examined student responses to the four survey items measuring the usefulness of the cases. A composite variable consisting of the four items measuring the usefulness of the cases was computed (α = .89). On average, respondents rated the cases as very useful (M = 3.99, SD = .72). Respondents rated clinical cases as most useful for describing common ophthalmic conditions and least useful for diagnosing common ophthalmic conditions. Figure 4 displays the distribution of survey respondents’ ratings of the usefulness of cases for helping to practice ophthalmic skills.

Figure 4: Distribution of survey respondents’ ratings of usefulness of cases for helping to practice ophthalmic skills

Responses to Open-Ended Survey Question

Of survey respondents who answered the open-ended question, “Please explain what made the cases useful or not useful to you,” 84% described the cases as useful. Table 4 displays a summary of the themes describing the useful and not useful aspects of the cases, with quotations to illustrate each theme.

Table

Table 4: Themes describing what made the cases useful and not useful with quotations from participants

Table 4: Themes describing what made the cases useful and not useful with quotations from participants

Theme Useful? Participant quotation
Variety of ophthalmic conditions covered Useful “Not every common ophtho condition can be seen in 2 weeks. These cases re-emphasized those that we would be most likely to see and have to treat on our own.”
Working through cases from start to finish Useful “Being able to interpret test results and come up with our own diagnosis and treatment plans were very useful in terms of self-directed learning. It helps us think like doctors instead of being spoon fed answers.”
Discussing cases and receiving feedback Useful “It was helpful to work through the cases on my own and then to compare my answers to the answers given.”
Identifying gaps in knowledge Useful “It made me see the whole approach to a problem and all the things to consider that I often forgot.”
Two-dimensional photographs are difficult to interpret Not useful “By nature of being an image on the screen rather than a live patient, I frequently found it difficult to determine exactly what was going on—reflections in the eye from the environment looked like lesions (or lesions looked like reflections); telling depth of lesions to determine what structures were involved was also challenging.”
Too many cases to work through Not useful “Due to the case load and time invested in this rotation I found it difficult to spend MEANINGFUL time on these cases.”

Four main themes emerged describing what made the cases useful. The first theme, variety of ophthalmic conditions covered, focuses on the range of pathologies or conditions depicted in small animal cases. Respondents wrote that they appreciated working through cases on eight different conditions because the cases expanded their exposure to different aspects of ophthalmology.

The next theme, working through cases from start to finish, describes the value of working with a realistic case from observations to diagnosis to treatment plan. Several respondents described the process of working through the cases as good preparation for clinical practice. Some students indicated that practicing the process of working through full cases improved their confidence in their abilities.

The third theme, discussing cases and receiving feedback, focuses on the value of discussing the cases with other students and receiving feedback on their responses. Respondents indicated that they found it useful to see the correct case response after they submitted their completed cases, and this feedback could be seen immediately following completion of the case. The fourth, related, theme was identifying gaps in knowledge. Several students indicated that by working through the cases, and receiving feedback from the instructor and other students, they were able to identify gaps in their knowledge where they needed to learn more.

Only two themes emerged describing aspects of the cases that respondents described as not useful. Most respondents who described the cases as not useful focused on the two-dimensional photographs. Some respondents indicated that the photographs were not high enough quality to allow them to interpret the lesions. One respondent suggested that a short video of the eye could be a useful addition to the cases.

The final theme describing aspects of the cases that were not useful was too many cases to work through. Approximately 7% of respondents to the open-ended question indicated that they would have liked fewer cases or more time to complete the cases. They stated that other work during the ophthalmology rotation made it difficult for them to find time to complete all eight cases to the best of their ability.

The main goal of this study was to explore how case-based assignments completed throughout an ophthalmology rotation could reinforce previously taught ophthalmic knowledge and promote problem-solving skills. The value of the online cases was in working in a complementary manner with other aspects of the curriculum where knowledge elements were introduced. The use of case-based learning in an online context meets the learner where they are in their learning. McLean22 as well as Thistlethwaite et al.23 describe case-based learning as an opportunity for learners to make use of different cognitive skill sets. Thus, the learner has the opportunity to work to advance their learning in a manner that is centered on their cognitive entry point of making meaning of the case. By asking high-order cognitive questions, we hope that the use of deep learning enables long-term retention for students.17,19 With our research questions, we aimed to not only evaluate the effectiveness of case-based assignments on the promotion of problem-solving skills in ophthalmology but also determine whether these assignments are a valid measure of students’ skills during rotation. Although our findings did not conclusively demonstrate that the case-based assignments rigorously promote problem-solving skills, they provided a valid measure of students’ skills and served as effective learning tools. This study’s development was largely motivated by the perceived ineffectiveness of in-person verbal-only rounds. Verbal in-person rounds has been witnessed by the first author to cause minimal long-term retention of knowledge from senior students on clinical rotations; students, having participated in verbal in-person rounds on a specific topic would have difficulty recollecting the information discussed when presented with a patient with a similar condition later in the rotation. We believe that this lack of information retention can largely be ascribed to a student participant’s marginal attachment or accountability to the discussion of a virtual case. If a student is held accountable for their decisions in an educational environment, their self-directed learning skills and memory retention may improve.

For our study, we hoped to deliver our online cases in a way that would maximize student and instructor benefit and minimize time and financial constraints. Using our online learning management system, our cases were quick to set up and distribute. This distribution method also allowed for flexibility, as different cases could be rotated in and out for students. As well, an online delivery format fosters an environment where students work at their own pace on their personal timeline. As seen with other case-based models, no detrimental effects on patients transpire if incorrect or incomplete answers occur, and the use of virtual patients is superior to none.8,9,15

Case-based learning also presents a teaching method wherein a student takes responsibility and accountability for their work through the submission of a written answer. The purposes of developing and implementing these cases was to supplement the current case load on rotations and to improve experiential learning with more general cases.10 Case-based learning also decreases learning experience competition with house officers.5 One recommendation reported in Kocheva and Peycke’s study was to provide alternative activities during slow times in a rotation and that these activities are not linked to limited resources.5 As well, the completion of the cases can serve as a valuable resource for fostering self-directed learning and investigative habits.3

Like other case-based and problem-based teaching methods, our case-based assignments promoted self-directed and possibly cooperative learning skills.27,28 In our study, 16% of survey respondents discussed some or most cases with their peers. Our case-based assignments also helped students practice acquiring information via the case history and images provided, emphasized basic sciences such as anatomy and physiology, and ultimately improved students’ clinical performance.28 Veterinary students appear to be “competitive, externally directed and individual learners”29(p.302); these traits lend themselves well to case-based clinical education, as seen in our study.

Byron et al.11 and Sawras et al.15 have developed effective learning tools for case distribution and feedback: Case Manager and Articulate Storyline 2@, respectively. However, the absence of short-answer questions and deficiencies in explanations of wrong answers can impair self-directed learning.11 The inclusion of only multiple-choice questions may lead to poor development of problem-solving skills, as the student is aware that the answer is present within the choices provided.15 To mimic private practice reality, our cases were delivered with no multiple-choice questions and no assistance, as seen in other case-based models.11,15 In our study, students had to generate their own decision or plan of action without any suggestions provided. Although our case-based model provided feedback, it differed from other models11,15 as it was only available following case completion and was not given as expert advice during a case. Krockenberger et al. state that “tasks that require comprehension, critical thinking, and problem-solving skills will encourage the use of deep cognitive learning approaches.”21(p.397) Open-ended questions and delayed feedback (until after answer submission) foster an environment where students must fully assess and understand a scenario; this understanding leads to the application of critical thinking and self-directed learning.

An advantage of case-based education for ophthalmology is the inclusion of pictures that can be readily interpreted by students at their own pace. Research has shown that the addition of pictures that represent the same information as text has a positive effect on learning outcomes.3032 One study demonstrates the benefits for immediate and delayed knowledge retention through the use of good quality images.33 Clinical photography has the advantage of exposing students to real cases and thus increase the relevancy of the learning experience. In our study, all photographs were from patients previously seen by the primary author. Although in some case scenarios, more than one photograph was available for examination, not all angles could be presented; this can lead to a diminished understanding of the lesions and, consequently, an incorrect diagnosis and therapeutic plan. Online case-based delivery also allows students to repeat cases as desired in order to enhance knowledge retention through repetition. As students are continually exposed to a wide breadth of cases, enhanced by the presentation of gross and diagnostic images, they will be better prepared when faced with real patients. As a result, the use of case-based education presents a viable avenue for a virtual patient to be created for students, largely with the help of imaging.

We propose that our format of online cases also helped manage the discrepancy seen in student performance during the transition from didactic teaching to experiential learning on the clinical floor. The transition to the senior year of veterinary school can be challenging for most students as accountability and responsibility has yet to be tested. Our case-based assignment model enforced these attributes with short-answer questions and the need to submit prior to getting the sample answers. Although recall bias may have occurred with the student survey questionnaire, our survey results also confirm that reinforcement of knowledge and identification of gaps did occur. Student self-reflection builds decision-making skills. In addition, the ability to practice applying knowledge previously taught in class was a positive factor of our case model.

Virtual patient simulation has been used in medical, dental, and nursing schools to provide better learning outcomes.16 The same benefits would also be seen in veterinary students. This learning modality provides the student access to numerous and diverse case scenarios and, as such, enhances reasoning skills.17 The use of computer-based education projects, such as our repurposed ophthalmology clinical case material presented as case-based assignments, increases student exposure to a broader case load that may not have been otherwise available.34 Based on our findings, case-based online learning presents a viable methodology for teaching problem-solving skills during a veterinary ophthalmology rotation; we also submit that our online case module has the ability to mimic aspects of real-life veterinary practice. To our knowledge, no veterinary ophthalmology-based commercially available virtual program currently exists. One key advantage of our case-based model is that instructors, using archived photographs and patient information, can easily construct it.

Although our results demonstrate the effectiveness of case-based assignments, our model does have limitations. The patients presented to the students mimic aspects of real-life veterinary practice and limit risks to live patients; however, they cannot simulate the full effort and attention to detail that live patients require. This factor can potentially impact the effort students apply to their training.9 Furthermore, although virtual patients have their benefits, one study reported that critical thinking skills may or may not be affected by the use of virtual patients.35 Arguably, the main limitation of our case-based assignments was the time it took for grading, as our system was not automated and every answer needed to be verified. This important limitation, however, was counteracted by the students’ access to expert answers; thus, self-assessment occurred in a timely manner, making grading an irrelevant factor. Furthermore, our cases offered a stimulated authentic formative assessment as the independent online access allowed time for the students to reflect on their answers once receiving the sample answers. At this time, our cases did not include a discussion of the (virtual) client’s budget as seen in Case Manager by Byron et al.11 This element is a crucial factor in veterinary practice, which is often not emphasized enough on the clinic floor. Finally, our case-based assignments were single-encounter case simulations,36 which better mimic veterinary practice than do multiple-encounter simulations.1

Moving forward with our case-based assignments, we would refine the questions as they may have affected responses. Following diagnosis, we would ask for a diagnostic and therapeutic/treatment plan instead of a short- and long-term plan. The inclusion of a diagnostic plan can be applied to several case scenarios and include a timeline of events. Students’ answers to these questions can include a timeline. Additionally, including a financial aspect to cases to simulate a more real-life decision-making process will add further relevance to the system.2,11 Future studies to develop a virtual patient simulation in veterinary medicine that evolves with case decisions may be warranted.17 However, it has been reported that learners may be less empathic toward virtual patients than live patients, which could impact the development of communication and emotional skills.37,38 Last, we believe the inclusion of a control group, members of which would not utilize case-based assignments, along with a pre- and post-test of all students on rotation would bolster evidence of the validity of our study; with this scenario, we would expect higher knowledge (higher post-test scores) in students that completed the case-based assignments than those in the control group. A pre- and post-test can further demonstrate the significance of case-based studies in the training of veterinary students.

In our study, the use of student surveys helped justify and give weight to the use of case-based assignments. It has been shown that programs that educators rate most likely to be highly effective are actually the least effective when tested on students, and vice versa.39,40 Based on the feedback we received from our survey, students described our case-based system as being useful for its immediate feedback, its ability to present a range of ophthalmology cases, its ability to reinforce knowledge learned in lecture, and its ability to pose application scenarios where students must critically think and justify their actions. However, although feedback on the system was largely favorable, we did discover some study limitations. The main survey criticism was the students’ inability to always describe the relevant lesions and this consequently impacted diagnosis and therapeutic plans. Unfortunately, the use of two-dimensional photographs has this inherent limitation, which cannot be corrected without using live patients. Within our student feedback survey, we were only able to measure perceived learning. In future studies, the inclusion of a pre- and post-test for knowledge evaluation may allow for a more dynamic survey where students can better critically assess the system.

The use of case-based assignments has shown its advantages in teaching veterinary students the breadth of knowledge needed for private practice. Additionally, our teaching tool promotes self-directed learning, an important aspect in veterinary medicine, which will foster acquisition and retention of problem-based learning.41 Our model of ophthalmic case-based assignments may be used with any other specialty given as a clinical rotation. With the refinements listed above, clinical case-based assignments can become a useful tool in veterinary medical education.

We would like to thank the students who participated in the survey section of this study.

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