Methods and Materials
Our academic teaching hospital has been holding monthly clinical-radiology-pathology orbital case rounds for the last 6 years, and putting these online for dissemination and wider access. Typically these include orbital, oculofacial and neuroophthalmic cases, which involve various invasive and non-invasive imaging modalities and often require histopathological confirmation for diagnosis to direct further management if indicated. Occasionally, there are cases contributed by other ophthalmic specialties, and from non-ophthalmic specialties like neurosurgery, otorhinolaryngology, and paediatric and adult oncology when there is orbital presentation of disease.
About a year ago, we started to come to a realization that just reviewing a presentation online, or attending a multidisciplinary case conference as a passive observer does not optimally promote learning. A decision was made in July 2009 to attempt to more optimally utilize the specialty specific learning potential of this material for different users in ophthalmology, radiology and pathology.
We made a decision to create an interactive online teaching resource based on selected cases presented at our multidisciplinary rounds with separate pathways for ophthalmic, radiology and pathology learners using the same basic case material (Figure 1). We realized that we had to replicate the question and answer format used in the clinical rounds to stimulate thinking in our residents. In addition, it was felt that a method to capture and record the residents free text responses, and a method of routing this information selectively to the specialty specific training supervisor or their nominee for feedback was important.
Four to five cases are discussed monthly during our multidisciplinary rounds. These cases are selected based on their teaching potential, and have been fully worked up to a final diagnosis. Most of these cases also have significant radiology and pathology available for clinical correlation. Selection for presentation is by the senior clinician in charge of the individual patients. The pathologist and radiologist are given advanced notice of the patients to be discussed at the next round.
All patients have provided written informed consent for the appropriate use of clinical photographs as well as radiology and pathology for teaching purposes. A resident who participated in the management of the patient writes up a clinical summary with relevant clinical tests and selected clinical photographs. This summary is revised by the senior clinician in charge of the patient. The clinical material is then assembled together with the relevant radiology and pathology by the radiologist coordinator of these teaching sessions. A concerted effort by the clinical team, radiologist and pathologist is made to maintain patient confidentiality and anonymity by removal of the name and identifying numbers on the radiology and pathology images, and by cropping the clinical photographs to reduce distinguishing facial features (usually only one or both eyes is visible without the rest of the facial features). Each case presentation is assembled as a PowerPoint presentation.
Selection of one or two patients for our multiple pathway website is made prospectively at the end of each monthly multidisciplinary round. The radiologist coordinator meets with the clinician in charge of the case and a clinical summary with specific ophthalmology specific questions including questions on radiological investigations is generated together with selected key clinical photographs, and imaging studies. Separate PowerPoint files one with questions, and one with questions and answers is prepared. This forms the basis of the clinical pathway.
The same clinical summary and clinical photographs are provided for the radiology pathway, however the clinical questions and answers are given (Figure 2). As the focus on radiology training is interpretation of the imaging studies, the focus of the radiology pathway is presentation of the radiology images, followed by radiology specific questions (Figure 3). Separate PowerPoint files one with questions, and one with the questions and answers is prepared forming the basis of the radiology pathway.
Preparation of the pathology pathway involves presenting the clinical scenario, clinical photographs and radiology images as well as questions and answers of clinical and radiology pathway, followed by the pathology images, with one PowerPoint file with pathology specific questions, and a second with the questions and answers.
The six files (2 clinical, 2 radiology, 2 pathology – one with questions the other with questions and answers), together with a full multidisciplinary case presentation is given to our web designer, who then codes the material for each webpage using Hypertext Markup Language (HTML) and JavaScript. The final product is a webpage allowing residents to select a specialty specific pathway for each case, and specialty specific questions. Residents are given the opportunity to enter their answers in a free text box, which is then emailed directly to the relevant postgraduate training supervisor or their nominee when the residents submit their answers. As soon as they submit their answers, they receive a webpage with a specialty specific model answer, including a link to download the whole original multidisciplinary case presentation [4] (Figure 4 to 6).
Results
To date 12 cases have been completed with plans for 12 more over the next 6 months. Use by ophthalmology has been in a formal scheduled quiz setting followed by face-to-face feedback. Use by radiology has been through biweekly emails encouraging residents to work through one case followed by intermittent feedback sessions after several cases. Use by pathology has been on a voluntary basis with the material used as supplemental learning material.
Feedback from our residents has been positive with online access found to be convenient, with specialty specific questions followed by model answers a useful way to practice specialty specific problem solving. Residents also appreciate the opportunity to look at material from the perspectives of other specialties.
Feedback from our teaching staff has also been positive as the online submission of answers provides a system for documenting learning activity by the residents. Formal feedback and face-to-face teaching can also be based on the questions attempted by the residents.
Discussion
Current educational thinking in constructivism argues that learning should be an active process where new knowledge is constructed based on integration with prior knowledge in a contextualized clinical application setting [5]. This can be stimulated by a question and answer active format during resident participation in a clinical case conference, but is more difficult to stimulate in the non-active participants in a multidisciplinary meeting. There are methods for stimulating active learning online, but often these are focused on the needs of one set of learners [6].
Online teaching resources have great potential to be reused for different learning purposes [7]. Our multidisciplinary team feels that this project leverages on the potential of reusability of digital learning material prepared for our regular multidisciplinary rounds. The key difference between this initiative and any other online learning repository is the attempt to identify different specialty users from the outset and repurpose the teaching material for these users. We have attempted to do this prospectively soon after multidisciplinary meetings as we feel that this captures some of the case specific discussions and specialty specific learning points that emerge from the multidisciplinary round.
There was some concern initially that we were just repeating material covered in the multidisciplinary meetings, and that residents would remember cases presented at these meetings. This has not turned out to be the case as time constraints prevent all the possible relevant specialty specific questions and answers to be covered in any one meeting. Quiz cases are also placed online sometime after each monthly round, and residents often are unable to then remember the specific details of each case unless they were the managing clinicians. Lastly, online access allows revision of the key points of each case, even if some of these were covered in a particular multidisciplinary round.
From a logistical and project management point of view, planning reusability from the outset and developing material in a regular prospective manner is helpful in maintaining the production schedule of the material of one case every 2 weeks. We have further refined the production process with pathology submitting the relevant questions and answers for each case by email to the radiology coordinator, and the radiology coordinator meeting the relevant ophthalmologist face to face to write up the clinical and radiology questions and answers on a regular basis.
As can be seen, each specialty has chosen to use the material in a different manner, with ophthalmology having formal quiz and feedback sessions, radiology using an email reminder every 2 weeks per case and intermittent feedback sessions, and pathology using a voluntary online access model with the cases as supplementary material. The advantage of this multidisciplinary web resource is that it can be used for supplementary learning or as part of a scheduled postgraduate curriculum.
We have found that the quiz format stimulates active learning due to the question and answer format, compared with passive review of a case presentation online. In addition, there is immediate direct feedback with active interaction as well as collateral discussion and learning that is otherwise not possible. Some residents have also used this material for revision practice before specialty exams.
For the purpose of the initial phase of this project, we have chosen to keep the questions and answers relatively brief. Our residents have reported that they are stimulated to download and review the full case presentation, as well as review the other specialty pathways for further insights into each case. We are planning to develop further questions and discussion points for more advanced trainees in the future and offer these as additional learning pathways.
Factors promoting success in this project are the commitment of the ophthalmology, radiology and pathology teaching staff to meet regularly and create digital case teaching material as well as questions and answers for the material. Our experience working together as a regular team to prepare and archive multidisciplinary case material online over the last 6 years has facilitated this project. Having a specific project coordinator, one clinician responsible for assembling the clinical, radiology and pathology elements of each case, as well as a departmental web designer has been most helpful in ensuring success of this project.
Some difficulties we have encountered include making sure residents assemble case write-ups on time, and keep the radiologist and pathologists informed of the cases for discussion. Ensuring regular participation in writing up the questions and answers can also be challenging, however, a two weekly production cycle has facilitated collaboration between ophthalmology, radiology and pathology.
To recap, some advantages of this online quiz approach is the availability of material at the residents/fellows’ time and convenience, the possibility for scheduling feedback at the supervisors’ time and convenience, the ability to view the material from different specialty perspectives, global accessibility, immediate feedback on attempted questions promoting self learning, confidentiality regarding various residents’ performance and the possibility of monitoring progression in learning.
Disadvantages of a pure online approach include a lack of face-to-face interaction, the ad-hoc use of material if this is not integrated into a postgraduate curricular training structure, the potential risk of violation of patient confidentiality, piracy of ophthalmic, radiology and pathology material, and the potential risk of conflicts of “ownership” of material between various departments, institution vs. individual physician and even the involved patient.
We hope that sharing our experience in this project stimulates other groups to organize the case material at multidisciplinary rounds for different specialty users. We have found that this specialty specific use of case material using an online quiz format with both model answers and later scheduled feedback maximizes the teaching potential of the case material presented at our regular clinical radiology pathology rounds.