Category Archives: case-based learning

Teaching when you don’t know the answers

Fortunately it is often effective to use the perplexing case as a teaching tool and sometimes it is possible to have the patient as a partner in the teaching and learning process. It also gives the opportunity to treat the learner as a colleague.

This approach can be used for either medical students or registrars. Supervisors often call in registrars to see a “classic” rash and this is great in increasing clinical exposure.  Sometimes we are tempted to leap in with answers rather than leading the learner to work out the solution to a diagnostic or management dilemma.   However, if there isn’t yet an “answer”, there can be an even more valuable learning exercise.

In the past I have asked those finishing a gastro term for suggestions on abnormal LFTs or a student with a previous life as a physio for advice on musculoskeletal problems, but this is still seeking answers. The patient I have in mind is where we are still puzzled and are trying to work out how to proceed.  This brings in the opportunity to make clinical reasoning skills a bit more overt.  This calls to mind when I had  a patient with an itchy annular lesion that wasn’t quite “classic”(barely visible scale)  and was getting worse.  The registrar and I discussed the top-of-the-list differential diagnoses and the most useful investigation to do as the next step.  It raised the issue of tinea incognito (which skin scraping confirmed).

Sometimes you see a patient’s name on your session list with a medical student booked in also. You have gone a certain distance in the diagnostic process but all is not clear.  I might speak with the patient beforehand and ask them to be part of the learning process.  I guess this is more than just signing the consent form before they enter the room.  You might admit to the student that you still don’t have an answer so your “interrogation” of their history and examination is not an attempt to catch them out (or demonstrate your superior expertise).  When the patient has a skin problem, you might structure it by leaving the student to take a “dermatology history and examination” and return to ask them to present their findings (with the patient to comment as need be).  You can add anything they might have missed in the history (and discuss why it’s important) and also chat about how to describe things in “dermatological language”.   You might share your own diagnostic process so far (and this can be informative for the patient). You may lead the student to the next diagnostic step that you perhaps already have in mind.  With the patient gone you can put the learner on the spot a bit more with asking them to commit to (say) three differential diagnoses and  ask them to identify some questions that remain – for self-directed learning.  You can share online resources for instance if relevant (useful sites might be    or )or share brief stories of other cases if relevant.

I thought I would use this approach a couple of weeks ago but then the patient went off on holidays so I had to adapt. The patient had already given me permission to take a photo and use it to discuss with colleagues or for teaching. In fact she was happy for this to happen since we didn’t have a diagnosis as yet. It was on a nicely unidentifiable part of the body. The evening before the session I put the picture into a power point and structured the slides historically with the questions that arose as the case unfolded.  I put questions at appropriate points and printed out the half dozen slides. I  had also sent a question around my colleagues at the practice asking their opinion and one of them said it reminded her of an article she had just read in AFP on skin biopsies which I printed off and gave to the student to read later

The session had my usual collection of older complicated patients with multiple problems, some with diabetes, a couple of teenagers, a person with an unexpected result to explain etc. We took five minutes between patients and I suggested we pretend the patient was there and we worked through the printed case thus far.  We reasoned through it and I asked for suggestions.

This particular student was very knowledgeable and the diagnosis (revealed at biopsy later) was on their list of differentials. At the end of the session as they left they said “Oh, and thanks for the teaching session with the dermatology case. It was great.”  And I thought I was teaching the whole afternoon!  Amazing what a bit of structure does.

and the presenting problem is……

Textbooks in various specialties often tend to group problems pathologically or by some other logical system. Thus a dermatology text may have a contents page with chapter headings on infections and infestations, bullous diseases or vascular disorders and so forth.  Internal medicine will divide itself into systems and musculoskeletal and orthopaedic problems may be organised according to anatomy or causes such as trauma, inflammation, degeneration etc.  This is useful as it helps systematise and broaden our knowledge and directs our thinking to causes and management for particular diagnoses.  Sometimes curricula are framed in this sort of way.

However, general practice patients don’t always present with a specific diagnosis at the ready and management cannot always be restricted accordingly. This is why trainees often prefer to learn with case-based discussion and why Murtagh’s General Practice has been so useful with many of its chapters based on commonly presenting symptoms. Similarly in Problem-Based Learning even the learning of basic physiology and anatomy is stimulated by the problem presented by the patient.  It is helpful for learning to be based in the real world but the educator’s challenge is to then ensure that the learner is also made aware of the broader context of the curriculum in its entirety.

The last post was about teaching in the musculoskeletal medicine area. The presenting problem may be a sore shoulder – but turn out to be cardiac pain or polymyalgia rheumatica rather than adhesive capsulitis or rotator cuff injury. The presenting problem may be a sore foot but turn out to be a plantar wart or tinea rather than a Morton’s neuroma or gout, thus drawing in the broad area of dermatology.  And all these possibilities are relevant to the trainee GP.  With cases it is possible to explore other important factors in general practice and to emphasise the importance of patient-centredness, the biopsychosocial perspective and whole person care.  

Perhaps a pain has become more significant because of other things happening in the patient’s life and functional deficits may become more crucial if the patient is also a carer or becomes unable to do their job.  There may be a cure for a particular problem within a limited time frame – or the condition may be chronic, requiring ongoing care and support where the doctor patient relationship is crucial and this should be articulated. It may even be possible to include concepts such as coping with uncertainty.  The presenting problem can be a window onto much more.

At the end of a successful educational session (in its broadest definition) the outcome could be expected to include increased confidence, increased skills (competencies), and their implementation in practice – but also an increased understanding of the uniqueness of the general practice context and its possibilities and limitations.

Don’t let learning be limited to a dot point in a curriculum document!  There are broader horizons.