Beyond multiple‐choice questions: using case‐based learning patient questions to assess clinical reasoning

Context and setting Case-based learning (CBL) occurs in Foundations of Clinical Practice (FCP I) during the first semester of medical school. Students work through 3 cases over the course of the semester. The purpose of CBL is to help students understand how underlying mechanisms relate to identifying and treating illness, to help them integrate information learned in other courses in a clinically meaningful way, and to help them learn the initial skills required for the practice of evidence-based medicine. Why the idea was necessary A new evaluation mechanism was necessary to reflect the goals of the course. What was done Three types of questions were implemented: matching terms with definitions; identifying pertinent positives and negatives, and an integrative essay question regarding the case. Evaluation of results and impact Student response to these types of questions has been generally favourable. As the purpose of CBL is not to master the content of the cases, it is important to have an appropriate evaluation mechanism that encourages students to synthesise the information they have learned. Groups covered somewhat different material (with an approximately 80% overlap), so the evaluation method needed to be flexible. Performance in CBL already constituted 25% of student grade, so the number of questions in the examination needed to be low in order that CBL was not over-represented. Firstly, students are given a list of terms that have been covered in the case and are asked to match them with definitions. Students know in advance that any terminology in the case is testable material. Secondly, students are given a list of physical findings, laboratory test results or imaging studies and asked whether each finding is a pertinent positive or pertinent negative for a defined problem or diagnosis. Thirdly, students write a long essay (approximately 1 handwritten page) in which they are asked to write as if they are talking to the patient. They are asked to tell the patient the results of the tests, to describe the underlying mechanisms related to those findings, to talk about the treatment plan, and to tell the patient what to expect over the next 5 years (all in terms the patient can understand). On the end-of-course evaluations, students are asked whether they believe essay questions are an appropriate method of assessment for FCP I. The mean has ranged from 3.8 to 4.0 on a 5-point scale (5 = strongly agree). The number of concerns about differential coverage of topics across groups has declined. Subjectivity in the selection of topics for the multiple-choice questions is no longer an issue. The matching questions and pertinent positive/negative questions are easy to grade and have shown good discrimination in relation to overall performance on the examination. Writing the essays shows students how the physical findings, laboratory results, treatment and prognosis all relate to the underlying mechanisms of the disease. They also get practice in how to explain things to patients in terms patients can understand. One drawback is that grading the long essays is time-consuming. An alternative may involve asking students to grade 2–3 of their colleagues' essays.