Practicing from an Evidence Based Perspective On-Line
Little is known about healthcare clinicians' experiences while participating in online programs and few studies have focused on specific approaches to facilitate online learning and measure clinical outcomes. Within this online context, there is a need to help support students to acquire the diagnostic skills and approaches that are based on evidence as opposed to merely experience. This project describes one method to do this using online student-generation of cases to spark a connection between professional practice and course content.
Instructional Strategy
The instructional strategy behind the project involved the use of modeling of the CDM process to assist students with connecting CDM with their clinical practice experience. Based upon other similar projects in the field of medical instruction, it was expected that the use of a student-generated database of clinical cases would be the best method to achieve the modeling strategy.
Within the CDM project, the input forms served the function of providing the structure for the student, forcing them to view their cases through the CDM lens. In that way they were made aware of the structure and logic of CDM, while simultaneously contributing to the variety of cases in the database .The variety of cases, and their direct connection to the clinical practice context of the students, was another key to the strategy's success.
Development of the Database
The initial work on the Medically Complex Patient Database (MCPD) involved creating several sample cases from the instructor's practice. The cases ranged in topic from oncology to cardiac to vascular disorders. Documentation was included, though with all identifying information removed in compliance with patient confidentiality regulations. The database was developed using Cold Fusion, a product that allows entry of data from a Web-based form into a Microsoft Access database file. Cold Fusion also allows searching and other functions via the Web, allowing students to edit as well as peruse the database for cases.
Three input forms allowed for the full range of the CDM approach to be modeled. The case form insured students would see all the separate components of their practice and how they fit within the CDM framework; the interventions underscored the logic of applying the CDM for a case; and the references supported the importance of using evidence to support diagnosis. With the database and Web interface in place, the final step was to use it for an actual PT course.
Implementation and Utility of the MCPD
The MCPD was introduced as part of a course for a group of students seeking to earn their doctorate via an online transitional program designed for practitioners who already possessed their Masters in Physical Therapy. With the intent to include "real world" clinical practice, a case-based approach to learning CDM was employed, including a review of the existing instructor cases in the MCPD. Students reviewed several cases in order to model the template in the MCPD and guide the discussions regarding CDM.
At the end of the course, students were asked to reflect on their understanding of the CDM approach, as well as their reactions to the course itself. Largely the responses showed that student believed they had learned a good deal about CDM that they had not known prior to the course. Some made specific comments related to the use of the MCPD:
"Keeping up to date with article reviews and journal clubs is a great way to keep on top of all the various topics out there. I love the idea of contributing appropriate articles to a CAT database at work. I wish we had something like that were I work."
"The use of the MCPD was interesting in that I was able to read many patient caes done by different therapists about a variety of diagnoses."
The tie between the cases and practice was not lost on the students, as one wrote:
"My work setting has formal inservice structure where I intend to disseminate this knowledge immediately and throughout my career to other clinicians through the use of CATs, utilization of evidenced based examination tools, functional outcome measures, and interventions. I also intend to present my case study to the office staff."
However, in reflecting upon its use, one graduate assistant who was also a student in the course notes:
"I see that not many therapists from my class…offered references to support a case or offered new interventions for another's case. I think I did not fully grasp the full intent of how I might have best used the tool at the time it was available to me."
As for the online learning experience, students' responses raised issues inherent to online learning that must be addressed to optimize student-centered learning. These issues relate to: clarity of communication; difficulties in negotiating team work and in building relationships; technical demands; learning style preferences, and time commitment. Students provided recommendations for strategies to address these issues such as how to communicate clearly, facilitate teamwork, and optimize time management. Seasoned PT clinicians consistently have these skills on a daily basis in the healthcare system, so this is a natural extension to online clinical development.
In the final analysis, the MCPD appears to have served as an instrument to support greater clarity of evidence based practice and determination of specific tools to enhance CDM. This CDM course provides a current understanding of the cognitive processes involved in diagnostic reasoning in PT. It also fosters the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving and decision making. The ability for students to work in small groups throughout the course, provides candid comments about various cases, while the larger group discussion impacts an overarching appreciation in the lack of evidence in CDM and how errors can occur. This may lead to more prudent CDM in future care of patients in PT.
