Marilyn McKay, MLS
Library
UT Southwestern Medical Center Library

Hernert K. Hagler, PhD
Department of Pathology
UT Southwestern Medical Center Library

Case Studies Program in Pathology and the Role of the Library in the Networked Medical Curriculum

ABSTRACT

A networked solution for delivery of Pathology, "Case Studies in Pathology" is a replacement and supplement to the traditional 35mm slides used in teaching medical students. The Pathology Department faculty of UT Southwestern Medical Center has converted approximately 2000 35mm slides to Kodak photo CDs. The images are then used in SuperCard to annotate and present details of teaching cases to second year Pathology students. The system presently consists of 100 Macintosh Power Pc 6100s and a Workgroup Server 80 connecting computers in the labs and Library via the ethernet.

PAPER

The Library's non-print collection, including computer software, has been used by faculty to supplement curriculum courses. (Rankin 1993) The non-print collection consists of over 2000 videos, 6,000 slides (including 3,000 Ciba slides), 40 videodiscs and 193 single user computer software packages. In the last two years, growing interest among faculty has led to integrating Library purchased computer software into the medical curriculum. This software has been purchased off-the-shelf (Fundamentals of Embryology, MacOrbit, MacLung) - until now.

The Case Studies Program in Pathology was developed by UT Southwestern Department of Pathology faculty to enhance the teaching of pathology to sophomore medical students. Why develop Case Studies? What is Case Studies? How was Case Studies created? How does Case Studies work in a networked environment? How is the Library involved?

Why has the Case Studies Program been developed?

Some factors leading to the Case Studies Program development have been:

  1. The impact of computer technology in the delivery of information in learning and practice of medicine is influencing medical education. Both faculty and students use computers in their work and increasingly use computers for more than just word-processing. (Whiteside and others 1993) (Barzansky 1993)

  2. Faculty are looking for innovative ways to address low lecture attendance, which continues to be a troublesome problem. The way students seem to have addressed the knowledge explosion is to skip lectures, rely on scribe notes (which may or may not be accurate) and use other short-cuts to learn just enough to pass exams.

  3. Like other medical schools throughout the United States in recent years, UT Southwestern faculty, and in particular the Pathology faculty have been interested in revamping the curriculum to reflect a more problem-based approach to educating medical students. The Pathology faculty wanted to address this issue, as well as such issues as low lecture attendance and student reliance on the use of inaccurate scribe notes. (Cohen and Dacanay 1992)

  4. After evaluating off-the-shelf programs, the Pathology faculty decided that existing computer software was inadequate for what they wanted to do. Many computer software programs allow no repurposing due to copyright issues. The Library staff helped in evaluating this software by setting up computer work stations for faculty to preview materials. Such programs as National Library of Medicine's Basic Medical Pathology videodisc program, Keyboard Pathology and MedPics were previewed.
What Is the Case Studies Program?

The Case Studies Program in Pathology is a key component in the case based approach to the teaching of pathology at UT Southwestern. It has changed the way pathology is taught here. Lectures have been replaced with biweekly small group discussions. In lieu of lectures, students use independent study time to assimilate weekly topics.

Pathology is a 20 week course starting in August and ending in February. There are 3 exams. The Case Studies Program in Pathology is divided into 17 sections. Each section has 2 to 13 cases. Altogether there are 85 cases plus 14 general concept sections. Each section begins with a list of objectives, a scenario and a table of contents.

General pathology principles are taught in the first eight weeks and systemic pathology is taught during the last twelve weeks. In the General Pathology segment there are 4-5 lectures, and one hour demonstration sessions or one hour of case studies discussion per week. This section is generally similar to the traditional pathology course, with the addition of a selected number of case studies. In the Systemic Pathology segment there are two lectures a week - Monday Overview and Friday Review - which a student may or may not attend. The student, however, is expected to know the material by reading the textbook, viewing the Case Studies Program images as well as Lab kodachrome slides, and researching the section objectives. To do this, the student uses independent study time to prepare for the small group discussions. There are 16 students in each of the 12 small groups which meet biweekly in the student labs. There are four computers to a lab totaling 54 computers (12 LC IIIs and 42 6100/60 Macintoshes). Four LC IIIs are located in the Library. All computers are networked to a Macintosh Work Server 80 running Appleshare 4.0. At Ease software controls the interface the students use. They do not have access to the hard drive but can save to a 1.4 mg floppy disk.

To access the Case Studies Program Images, students use the At Ease program to select Pathology (Case Studies) from the networked medical curriculum server. The menu has the following setups:

Anatomy (Fundamentals of Human Embryology)
E-mail, Internet, Word
Histology (HyperCell)
Microbiology (Protein Structure)
Neurobiology (Digital Anatomist; World of Neurobiology)
Pathology (Case Studies)
Physiology (MacLung)
Other Curriculum (Ear, Molecular Cloning, HeartLab)

Students select the Pathology option, then find their name and enter a password assigned by the Pathology Department. When the Pathology folder appears the students click on the Case Studies Main Menu icon. The student then sees the entire Pathology curriculum laid out in 17 sections starting with Inflammation and ending with Hematopathology. Each section has cases which students must review. The number of cases varies, for example, Inflammation has five while Hematopathology has 13. Most sections include two to five cases. Some of the sections also include an introduction or other general subject information. All together there are 99 sections from which to choose. The graphs below indicate students' reactions.

1. Which of the two teaching formats do you think is (would be) optimal for learning Pathology: (check one): (see legend p.8)

The current case history-based format of the Pathology course ( 1 ) The lecture format used by some other courses ( 2 )

% Respondents

2. Usefulness of case studies in learning mechanisms of disease ( 1-5 )

% Respondents

5. Usefulness of computer images/text in preparation of cases ( 1-5 )

%Respondents

How was the Case Studies Program Created?

Using the computer to enhance teaching is a 21st century technology already well established. Many educators recognize this, but are not prepared for the changes necessary to implement that technology.

To make the Case Studies Program a reality required just such a recognition. Due to a unique combination of courage, communication, cooperation, luck and hard work among a diverse group of campus educators, the Case Studies Program was created. Changes in communication occurred among Pathology faculty, who had to communicate with each other in order to exchange curriculum content information; network administrators had to reconfigure networks to electronically deliver the Case Studies Program; library staff had to coordinate one-on-one instructional information with faculty; and finally, curriculum and Library administrators had to reevaluate budgets to allow for new hardware and software expenditures.

It was the leadership of the Pathology Chairman and his commitment to computer technology's future role in medical education which was crucial in launching the development of the Case Studies Program.

He committed all of the Pathology faculty to the concept of changing from a lecture-based to a case-based format. The Dean of the Medical School helped by providing critical monies for building the infrastructure. Funding was used to purchase equipment, including 70 Mac 6100s and a Macintosh Work Server 80 to deliver the curriculum over a network. A faculty member of the Department of Pathology provided the computer and software expertise to take the case based concept and make it into a network-friendly and usable program.

Because of the Pathology Chairmen's commitment to the Case Studies Program concept, all of the Pathology faculty were involved in writing the individual cases. This also meant that the faculty were expected to learn to use computer hardware and software. There are about 81 Pathology faculty scattered over a number of buildings and institutions: Veteran's Affairs Medical Center, Parkland Memorial Hospital, Children's Medical Center, Zale Lipshy University Hospital, and UT Southwestern Medical Center main campus and north campus. Developmental files for the Case Studies Program were located on another Macintosh Work Server 80 for curriculum development. Starting in June of 1994, an interested and dedicated faculty member coordinated the digitization of 3000 faculty slides, which were mastered to Kodak Photo CDs. The slides were cataloged using Aldus Fetch. With the help of the Pathology Department's photographer/illustrator, the faculty member enhanced the slides in Photoshop and imported them into Persuasion files which were then put on the Curriculum Development Server. Each of the Pathology faculty had available a networked Macintosh which was used to access the Persuasion files to add text and drawings for overlays to illustrate a topic. The files were saved onto the Curriculum Development Server. The faculty member imported the files into Supercard and created the enhancements, including the overlays. Because development time was critical, MacroMind Director was rejected early in the development in favor of SuperCard.

On the Friday before each section was used by the students, the faculty expert of the week met with the other small group instructors to go over the highlights of the cases. Concepts which needed to be conveyed to the students in their small group discussions were demonstrated to the small group instructors by that week's faculty expert. On the next Monday, the faculty expert gave an overview lecture and on Friday a review lecture covering that week's Case Studies.

The Library played a role by providing a Macintosh computer lab, located on UT Southwestern Medical Center's north campus where the small group instructors met. The lab has 8 networked 6100 Macintoshes. Using an LCD panel and overhead projector, which the Library had recently purchased for classroom teaching, the faculty expert connected to the Curriculum Server on the main campus, where a presentation was illustrated by bringing up that week's cases on the projection screen. At the same time, faculty at the computers could see the same case, as well as the projected image.

How does the Case Studies Program work in a networked environment?

As mentioned above, the Case Studies Program is accessible using the eight computers on north campus as well as the 54 computers located in the student laboratories. All computers were connected to the server simultaneously. The SuperCard based Case Studies program worked very well over the network. The same cases with images were displayed with little time lag even when all 62 machines, whether in the Library, labs or north campus, were using the program at the same time. One of the reasons for selecting Supercard was its ease of use and reliability over a network. There have been virtually no problems using the program in a networked environment.

How is the Library Involved?

Members of the Education Consultation Services Group in the Library have worked closely with the Pathology faculty to provide curriculum computer expertise and support. Library staff have participated in liaison support among the various faculty. Library facilities have been used to provide workspace and equipment. Staff have supported the Case Studies Program by answering students' questions when they are using the curriculum Macintoshes located in the Educational Technology Lab in the Library. From its collection budget, the Library has also purchased site licenses either wholly or as a partner with the Department of Pathology.

Finally (anecdotally), although students were provided with computers in the student labs, many students preferred to use the Library's four networked LC IIIs because the Library is "quiet."

Results

For Students?

  1. Although more and more students who enter medical school are computer literate, computer literacy is very uneven among students. Although more and more students are using computers earlier and earlier in the educational process, there are still many students who are either computer phobic or computer illiterate. For this group of medical students, using the computer is a unique experience. What kind of an impact did using the computer have on these students' acceptance of the program? Students indicated they liked using computer technology to understand a highly visual subject like Pathology despite their lack of computer skills and the unique experience of studying using the computer. In a pilot survey with 88% response, 143 students liked this year's case-based format, compared to 33 students who would have preferred a lecture based format.

  2. Student study habits had to change from reliance on lectures and scribe notes to self-reliance. Students had to become more independent learners. The students rated using computer images and text in preparation for discussion as very useful. (Garrud and others 1993) Most students used and learned the subject matter from the computer based Case Studies.

    6. Usefulness of computer images/text in the study of topics not included in case studies (e.g., General Concepts folders) ( 1-5 )

    % Respondents

  3. Reflected in the pilot survey was the continuing unpopularity of lectures. Students rated the Overview and the Review lectures as "average" with 34% of respondents skipping that question.

    15. How useful were Monday overview lectures? (1 - 5 )

    % Respondents

  4. Students' reliance on the assigned textbooks was significant. Students rated both the Robbins Pathologic Basis of Disease, by Ramzi S. Cotran, Vinay Kumar, and Stanley L. Robbins, 5th ed, 1994 and the Handbook of Clinical Pathology as very useful.

    8. Usefulness Pathologic Basis of Disease textbook (1 - 5)

    % Respondents
For Faculty?
  1. Like students, faculty computer literacy varied widely. Library staff helped with some faculty education by doing a graphic handout on how to access the network and providing one-on-one coaching for some of the faculty on accessing the network.

  2. Faculty teaching habits changed from a lecture role to a facilitator role in small group discussion. This was an adjustment for some. In the pilot survey Comments section, some students said too much information was "crammed" into the overview and review lectures.

  3. Normal faculty work loads were increased significantly during this critical first year when the whole course was under revision. (Report 1993)
For Library?
  1. The Library became more active in initiating faculty partnerships with departments who do not normally interact with each other but do work with the Library. (Cohen and Dacanay 1992) (Evans et al 1994)

  2. Sharing materials costs with the Pathology Department allowed the Library to purchase site licenses for the Curriculum network in order to teach students.

  3. Adjusting to the concept of digital library materials located on a network was a unique experience for Library staff. How are such materials cataloged? What should the Library catalog record show when the material is located on a network so that a client knows to go to the networked computer rather than the traditional Library shelf to use the material?
Conclusion
  1. From UT Southwestern Library's experience, libraries can play a central role in the educational activities of the medical curriculum by facilitating inter- and intra-departmental communications and developing partnerships with faculty to share budgets, materials, resources and staff.

  2. Students can use the computer to learn a subject and like the experience.

  3. It would appear both students and faculty need more computer literacy training.

  4. By making strong commitments to and rewarding faculty for innovation in education, universities can do more to encourage faculty in innovative educational activities.
References

Barzansky, Barbara et al. "A view of medical practice in 2020 and its implications for medical school admission." Academic Medicine 68 (n1 1993): 31-34.

Cohen, Peter A. and Lakshmi S. Dacanay. "Computer-based instruction and health professions education: A meta-analysis of outcomes." Evaluation & the Health Professions 15 (3 1992): 259-281.

Evans, Leonard and et al. "Incorporating Computer-Based Learning in a Medical School Environment." Journal of Biocommunication (JBC) 21 (n1 1994): 10-17.

Garrud, Paul, I. R. Chapman, S. A. Gordon, and M. Herbert. "Non-verbal communication: Evaluation of a computer-assisted learning package." Medical Education 27 (6 1993): 474-478.

Rankin, Jocelyn A, PhD. "Preparing Medical Libraries for Use by Students in PBL Curricula." Academic Medicine 68 (n3 Mar 1993): 205-06.

Report, ACME-TRI. "Educating Medical Students. Assessing change in medical education - the road to implementation." Academic Medicine 68 (n6 1993): S1-S46.

Whiteside, Mary F., James W. Tysinger, and John C. Peirce. "Residents' knowledge about and attitudes toward use of computers." Teaching & Learning in Medicine 5 (3 1993): 138-142.

LEGEND
PATHOLOGY COURSE CRITIQUE 1994-1995

Please use the following rating system (unless otherwise indicated):

1 = excellent/extremely useful
2 = very good/very useful
3 = average/somewhat useful
4 = fair/marginally useful
5 = poor/not useful at all

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