Creating Effective Application Exercises: Basic Sciences

1
Creating Effective Application Exercises Basic
Sciences

• John Pelley, PhD (Texas Tech) and Dan Mayer, MD
  (Albany)
• Fifth Annual Team-Based LearningCollaborative
  Conference
• March 2-4, 2006 Lubbock, Texas

2
Three Part Agenda

• General procedure Getting organized helpful
  content in handout (15 min)
• Group Exercises Evaluating question
  construction (40 min)
• Evaluation of presentation (5 min)
• Break and Posters 3pm to 330pm

3
Memorization vs. HOTS

• Memorization
• Recall
• Higher Order Thinking Skills (examples in
  handout Writing Learning Objectives, pg 8)
• Analysis (organization, indexing, grouping)
• Comparison (similarities, differences)
• Inference (deduction, cause-and-effect)
• Evaluation (predict, prescribe)
• HOTS used in clinical problem solving

4
Fundamentals For TBL Exercises

• Review from TBL101
• Problem oriented learning requires a specific
  decision.
• A decision requires a rationalea guess is not a
  rationale!
• Types of rationales (prompted by lead-in)
• Similarities, differences
• groupings/categories
• cause-and-effect relationships

5
Designing A TBL Exercise

• Start at the end the application exercise
• Prevents irrelevant RAT questions
• HOTS questions are essential
• One case vs. several cases time factor
• Step 1 (in handout, page 1)
• Too few is better than too many
• Three application question sets per hour
• 2-3 hour time blocks total
• 50 of time in application exercise

6
Sample Case Application Question

• See also handout (page 2)
• Question on next slide
• Required concepts are underlined
• All concepts in the question should be useful in
  reaching the correct answer.
• All answer choices are rational alternatives
  (NBME Item Writers Guide)

7

• A 74 year old female has come to your office
  suffering from hyperventilation, malaise,
  dizziness, and muscle pains. She was diagnosed
  with Type 2 diabetes at the age of 50 and has
  managed her disease successfully with diet,
  exercise, and hypoglycemic agents. She was
  initially put on a hypoglycemic agent called an
  oral sulfonylurea (chlorpropamide), but recently
  was switched to metformin which is better
  tolerated in the elderly. Her blood pH is 7.2 and
  her serum lactate is 10X normal levels. Her
  creatinine clearance and serum creatinine
  concentrations indicate diminished renal
  function.

8
Long Answer Choices

• This patient has a blood pH of 7.2 because
• ketones from excess fat mobilization are making
  her blood acidic.
• increased glycolysis and reduced TCA cycle
  activity leading to excess lactate formation.
• hypoxia resulting from inhibition of electron
  transport is creating excess carbon dioxide.
• increased blood sugar increasing glycolysis and
  lactate production in red blood cells.

9
Or, Short Answer Choices

• Metformin action in the production of lactic
  acidosis is most analogous to which of the
  following?
• Fluoride
• Pentachlorophenol
• Cyclic AMP
• Oligomycin

10
Barriers

• You dont know everything about the clinical
  aspectsor,
• You dont know how to integrate other disciplines
  (see handout page 7, Resources for Application
  Level Questions also TBL Collaborative).
• Hard to find people that can help.
• Time consuming to look things upcan you trust
  the internet?

11
Group Exercise 1

• Evaluating the quality of lead-ins (5-7 minutes
  group, 10 minutes discussion).
• Greatest opportunity for dialogue and problem
  solving?
• Look for integrative knowledge vs. memorized
  knowledge

12
Group Exercise 2

• Evaluating the quality of the answers. (5-7
  minutes group, 10 minutes discussion)
• Lead in Which of the following is the best way
  to correct her elevated pulse rate?
• Greatest problem solving challenge?
• Emphasis on HOTS rather than memorization

13
Core Knowledge RATs and Learning Objectives

• Steps 2 and 3 in handout (page 1)
• RATs can have HOTSor not.
• RATs should be relevant derived from
• application exercise answer choices
• patient data in case vignette
• RATs are not comprehensivebut objectives are!
• Objectives should be relevant derived from RAT.

14
Two part application exercisePathophysiology and
EBM

• Part 1 calculation problem
• A study is done to look for the best diagnostic
  test to detect pancreatitis. The study is done
  on 2400 patients, of whom 950 have pancreatitis
  as determined by a Gold Standard test. The tests
  are lipase, amylase and trypsinogen. The numbers
  of positive tests for each group are listed
  below.
• Test Disease present Disease absent
• (n 950)
• Trypsinogen 941 1204
• Lipase 817 1436
• Amylase (Beckman) 903 1291
• Calculate the sensitivity, specificity, and
  likelihood ratios for each of these tests.

15
Part 2

• Your patient comes into the ED with abdominal
  pain, which is consistent with pancreatitis, but
  also with other diseases of the abdomen.
  Pancreatitis is a disease characterized by sudden
  onset of severe abdominal pain. These episodes
  must be treated properly in order to prevent
  complications. You desire to make a rapid and
  accurate diagnosis that will distinguish acute
  pancreatitis from other illnesses. Which test is
  the best choice in this setting?
• Test Cost Turn around time
• Trypsinogen 150.00 24 hours
• Lipase 30.00 1 hour
• Amylase (Beckman) 20.00 0.5 hours
• Treat the patient without doing any tests.

16
Summary

• TBL exercises are most effective if designed with
  the application exercise first.
• Higher order thinking skills are always
  accompanied by a rationale.
• NBME templates and question resources are
  time-savers can be adapted.