A Teaching case system with a multiple viewpoint mechanism for medical education

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(1)A Teaching case system with a multiple viewpoint mechanism for medical education Lih-Shyang Chen ,Yuh-Ming Cheng, Sheng-Feng Weng Department of Electrical Engineering, National Cheng Kung University E-mail:chens@mail.ncku.edu.tw Ai-Wen Kao Department of Internal Medicine National Cheng Kung University hospital E-mail: kaoaiwen@mail.ncku.edu.tw viewpoints and knowledge of the patient care Abstract In medical education, the basic science. problems. We implement a prototype system. curricula are coordinated in the teaching schedule. called “HINTS” that is based on a computerized. or text books, usually in organ system units.. PBL system and provides many clinical teaching. Their integration occurs in the schedule or books,. cases with a more integrated view in the context. not in the minds of the students. Knowledge from. of the clinical cases that the students will face in. each basic science discipline is presented in. the future medical practice. The system has been. terms of organ functionalities not in the context. installed in the medical center of the National. of patient’s problems and laboratory data. Each. Cheng Kung University for the trials. The. domain expert in each department teaches the. comments from students are in the results.. clinical knowledge and experiences from his own. Keywords: medical education, e-learning,. perspectives using his own teaching cases that. integrated teaching case. were prepared in isolation by each individual. As. 1. Introduction. a result, the students may experience many. In medical education[12], the basic science. different teaching cases from many different. curricula are coordinated in the teaching schedule. clinical disciplines. All the teaching cases are. or text books, usually in organ system units.. isolated. any. Their integration occurs in the schedule or books,. association with each other. As a result, it is. not in the minds of the students. Knowledge from. difficult for the students to relate the association. each basic science dis cipline is presented in. with each other and fully understand the overall. terms of organ functionalities not in the context. picture of the integrated view of the clinical. of patient’s problems and laboratory data.. knowledge within different disciplines in clinical. Furthermore, as far as clinical practice is. practice. In this paper, we study how a PBL. concerned, students in medical schools learn the. teaching case should be presented to the users in. clinical knowledge by going through each. such a way that is most integrated, effective, and. clinical department in a medical center for the. efficient for the users to learn about the overall. clinical practice training during their internship.. instances. and. do. not. have. 1.

(2) Each domain expert in each department teaches. We also analyze how medical teaching cases. the clinical knowledge and experiences from his. should be presented to the learners in a more. own perspectives using his own teaching cases. integrated fashion so that the learners can get the. that were prepared in isolation by each individual.. overall pictures of the teaching cases. The. As a result, the students may experience many. concepts of a teaching case template and. different teaching cases from many different. different operation modes of a teaching case used. clinical disciplines. All the teaching cases are. by our prototype system as part of the. isolated. implementation mechanisms are also briefly. instances. and. do. not. have. any. association with each other. As a result, it si. described [1].. difficult for the students to relate the association. workflow of the system from both an author’s. with each other and fully understand the overall. and a user’s perspectives and implementation of. picture of the integrated view of the clinical. the system from an engineering perspective. In. knowledge within different disciplines in clinical. the section 4, we present the results of the users’. practice.. and the authors’ experiences and experiments. In this paper, we study how a PBL[6][10]. In section 3, we discuss the. with our prototype system. Section 5 draws the. teaching case should be presented to the users in. conclusions of our system and experiments.. such a way that is most integrated, effective, and. 2. background. efficient for the users to learn about the overall. (a) Case templates. viewpoints and knowledge of the patient care. In order to explain how our prototype. problems. We implement a prototype system. system is implemented, we first introduce the. called “HINTS”[1] (Health Information Network. PBL teaching case template concept we use in. Teaching- case System) that is based on a. our system. Our PBL teaching case system is. computerized PBL system and provides many. essentially a multimedia CAI (Computer Aided. clinical teaching cases with a more integrated. Instruction) system[1]. Generally speaking, a. view in the context of the clinical cases that the. CAI system is composed of three major models:. students. medical. a knowledge model, a student model, and a tutor. practice[3][12][14][15]. The basic idea is to use. model [7][8]. We further describe the details of. the same clinical case as the subject matter and. these models here.. will. face. in. the. future. have the experts in different clinical disciplines. (a) Knowledge model.. to edit the teaching material for the subject so. This is a database which contains the. that the users can learn more integrated. knowledge of specific topics which an expert in. knowledge from different perspectives in the. that particular domain would reasonably be. context of the same clinical case. In the section 2,. expected to possess.. we discuss the background and problems about. (b)Student model.. the current most prevailing method used by most. This. model. provides. a. mechanism. for. medical centers (ex. Medical Center of the. assessing the state of the student's current. National Cheng Kung University), commercially. knowledge of the information held within the. available PBL computerized systems, or many. knowledge base.. web sites on the Internet[2][4][5][11][13][15].. (c)Tutor model. 2.

(3) This model mimics a human tutor, and is. appropriate set of titled sections, e.g. history,. responsible for managing the overall learning. diagnosis, etc. Each section can be further. environment.. partitioned. into. several. sub-sections.. Each. For the purpose of this paper, we further. teaching case within the system di entifies the. explain the knowledge model in our system.. case template which it uses. In other words, the. Ideally, the knowledge model within a CAI. knowledge model is structured in both a. system should represent the knowledge which is. macroscopic fashion, i.e., the case templates, and. to be taught in an abstract fashion in order that it. a microscopic fashion, i.e., all the teaching cases.. is capable of dealing with different learning. With the concept of the teaching case template in. situations. system the. our system, the authors have to set up a teaching. knowledge model contains data relating to the. case template or select an existing one in an. many different clinical cases which are to be. internal template database before they can enter. taught. Due to the volume and variety of the. the contents of a teaching case.. cases involved, it is difficult to draw simple. (b) Document-view. inferences. intelligently.. or. In. knowledge-based. Each department in a hospital has its own. conclusions out of the teaching cases. For these. clinical data representation semantics for its. reasons, it is virtually impossible to use abstract. teaching cases and can edit its own templates for. principles or rules to represent all the domain. the teaching cases suitable for the teaching. knowledge. model.. material of the department. For instance, for the. However, since many teaching cases in the. radiology department, the system has to present. system will share similar scenarios, it is possible. the MRI, CT, or X-ray images[9], the basic. to use a number of "case templates" [1] to form. patient information, such as age and sex, and the. an abstract model of the domain knowledge. In. patient’s chief complaints to the user. The sound. other words, the templates outline the main. of the patient’s heart beats may not be important. contents of the teaching cases, and serve as the. from the radiologist point of view. However, for. directories of each case. Consider a template for. the internal medicine department, other than the. a typical medical teaching case. It might well. user the patient’s basic information and the. include the following sections: (1) basic personal. patient’s chief complaints, the user may want to. information such as age and gender. (2) brief case. hear the heart beats. On the other hand, if a case. history (3) reported complaints (4) physical. has a CT examination, the physician may want. examinations (5) findings (6) diagnosis (7). simply just to read the report done by the. relevant associated cases (8) discussions, (9). radiologist or some key images critical to his. comments, and (10) learning points. A single. diagnoses while the users in the department of. case template may be used by many teaching. radiology may want to see the detailed analysis. cases if they are all of the same type. All sections. of the CT images. In other words, for the same. of the template can be presented via hypermedia. case, each department has its own emphases and. techniques. The authors of the system are given. case templates, each of which is a specific. the ability to create a case template database in. meta-data to present a specific semantics of a. which each template has a defined name and an. teaching case for the teaching purpose.. within. specific. our. the. knowledge. 3.

(4) In general, there are many different. which sections in the case template will be. department views (perspectives) to look at a. included in a given department view of a. teaching case. Within these different department. teaching case so that when the user browses the. views for the same teaching case, some parts of. case latter, the system can respond accordingly.. the case are shared among some department. 3. Methods and Implementation. views while some other parts may be used by. (a) the workflow from an author’s perspective. only one department alone.. For a given patient case, we ask several. From a more abstract point of view, the situation. domain experts to edit the teaching case material. is well fitted into the “document-view” design. from their own perspectives. This involves. pattern in which a document in an interactive. (1) the generation of a case template that can. system. may. have. many. different. views. accommodate. depending on what the user wants to be able to. perspectives.. the. needs. of. all. the. visualize the data in hand. For instance, a. Each domain expert should define his own. document may contain a set of data that. case template first. All the templates of all the. represents the statistics of the number of users. perspectives will be put together to form the. visiting a certain website at different time. The. overall template of the teaching case. This is. view of the document may be a table of a lot of. because some sections are shared by many. numeric numbers or a bar chart or a pie chart for. different templates of different department views. easy understanding of the data. The users can. and the system needs to keep only one copy of. interactively select different views of the same. each section for the consistency control instead. data. The Document-view architectural pattern. of making several copies of the same data and. divides an interactive application system into two. complicating the maintenance work. Therefore,. components.. at this step, we set up an overall teaching case. The. document. component. contains the core functionality and data of the. template.. object of interest while the view component. (2) Set up a “discipline-view-rule” database that. displays the data of the object of interest to the. specifies which sections belong to which views. user and handle user interaction. There can be. so that the system can present the teaching case. multiple views of the same document. If the user. material to the users properly. Each department. changes the data of the document, all the views. view has its own case template which is a subset. dependent on this document should reflect the. of the overall case template. All the case. changes.. templates are recorded in a database called the. In. our. implementation,. a. rule-based. department-view-rule database.. mechanism is used to support the document-view. For instance, the sections for the internal. concept of the teaching case system. When the. medicine case(fig. 2(a)) are the Basic information,. author enters the case template into the system. Chief complaint, Present illness, Past history,. using the template authoring tool, the sections. Family history, Physical examination, Laboratory. that will be used by at least one department view. test, Tentative diagnosis and Final diagnosis. will be entered into the case template. The author. section while the sections for Radiology (fig.. can make use of a rule database for specifying. 2(b))are Radiological images, Basic information, 4.

(5) Present illness, Laboratory test, Differential. on the website. The overall architecture of the. diagnosis . Note that they share the Basic. system is shown in figure 1. In order to ease the. information, Present illness, Laboratory test. (3). management of all the multimedia documents of. All the domain experts hold a meeting to discuss. the teaching cases in the system, all the. how the case should be presented to the users. (4). documents are also stored in a teaching case. All the domain experts use the authoring tools to. database.. edit the teaching case material using the teaching. database. case template. (5) All the domain experts review the teaching case in a meeting to discuss various. userprofile process. userprofile database. issues as to how to present the case to the users login and select a teaching case. in an integrated fashion. (6) Iterate through steps 4 and 5 until the results are satisfied.. casetemplate database. system administrator. view-rule process. The. presentation database. details are described below. (b) the workflow from a user’s perspective. browse. For a explanatory reason, some engineering. present the teaching case to the user. mechanism, which works behind the scenes,. decision of a presentation format. authoring tools. teachingcase database. author author author. end-user view. is also included here. In our prototype system, there are two databases: (a) a user profile database that includes. Figure 1: system architecture. each user’s name, major such as internal. When a user uses the web browser and. medicine, sophistication level, such as an intern,. logins into the system, the system will retrieve,. a specialist, or a student in a medical school, and. from the user profile database, his user major and. so on. (b) a presentation database (briefly. user level which is used as the default user level.. described before) that has several fields: (1) user. The user can change his level if he wants and the. level, (2) department name (or user major from. system will record it and use it as the user level. the user perspective, such as internal medicine),. for further processing.. (3) case template ID, (4) section names in the. teaching case for the interactive browsing, based. case template (5) the operation mode, such as. on his user level, user major, and the case. interactive mode or plain mo de (6) switch flag. template ID (which is saved within the case), the. that records how each section in a teaching case. system will retrieve the case template and the. should be presented based on the user level and. section names for the particular department view. user major. As we will see later, the items 1 to 5. stored in the presentation database. At this point,. will be used as the indexes to retrieve the switch. the system is ready to present the teaching case. flag that specifies how a particular section in a. to the user with the particular department view.. teaching case should be presented. These two. On the right-hand side of the browser window as. databases have to be populated using some tools. shown in figure 2, the system will show all the. by the system administrator (for the user profile. section names in the case template each of which. database) and the authors (for the presentation. is represented as a push button for this particular. database) before the teaching cases are published. department view. When a section is activated, the 5. When he activates a.

(6) system, as a web service application system responding to the web browser’s request, will retrieve the section from the teaching case database, reference the corresponding switch flag, and present the particular section accordingly to the user. As a result, the teaching case will be presented to the user as planed. At the end of browsing a teaching case, a performance summary can be shown to the user to indicate how well he is doing for the given. (b) the screen view of the radiology. case as shown in figure 3. The summary includes. Figure 2. system screen layout. the correct answer, the user’s answer, the time the user has spent on this case, all the laboratory examinations the user has ordered and the total cost the laboratory examinations, and so on. When the user browses the case up to this point, a learning point section can be activated. The learning point includes the points to be learned in this case, a hyperlink to the plain view of the current case, and a hyperlink to the plain view or interactive view of the other disciplines for the same case. The user can select which mode and. Figure 3. case summary. which department view he wants to view the case. (c) the implementation of the system from an. so that he can understand how other people from. engineering perspective. other disciplines view the same case and have. 2.. through understanding of the case.. Some of the engineering mechanisms have been described in the previous paragraph and will not be repeated here. Each switch flag is corresponding to a section as to how the particular section should be presented at run time.. 4. Results The system has been installed in the medical center of the National Cheng Kung University for the trials. The students ranging from the grades 5th to 7th to try out the (a) the screen view of the internal medicine. system. and. have. the. following. comments after using various teaching 1. 6. cases in the system: As we expected that all the students felt that.

(7) the teaching cases with multiple views are. this fact does not concern us. This is because. much more interesting and give them more. that the teaching cases for training the. integrated view of the cases than the isolated. students in medical schools are relatively. teaching cases. 2.. easy and frequently seem in the medical. All the students believe that the system can. practice as opposed to the teaching cases for. significantly improve the skills for real. the specialists where the rare clinical cases. clinical cases. 3.. are more suitable for the teaching case. Based on our experience, although the. subject matters. There is no particular notion. system provides user friendly authoring tools. of “interesting” cases from research point of. for the teaching material entry, the actual. view. Therefore, for the training of medical. teaching material collection and their entry. school students, it is still important to give. into the system had better be done by some teaching assistants who are more skillful to. students an integrated viewpoint. In this. work with the computers and do the time. situation, we still need to integrate all the. consuming work. The real authors are. possible department views and give students. physicians who have heavy clinical and. opportunities to see various views from. research workload and are mainly in charge. different perspectives.. of managing the contents of the teaching. 4.. 5.. This. research. work. also. provides. an. case and ensure the correctness of the. opportunity for the experts (authors) in. teaching case and learning points of the. various medical disciplines to get together. teaching case.. and discuss how the teaching material should. Since the same patient case is used as the. be presented to the students. The authors. subject matter, as stated before, theoretically. also get an opportunity to learn more about. each view from a different perspective. how other experts view the same case and to. should be more interesting than the view of. further sharpen their medical knowledge in. the same case described alone. It turns out. general.. that the results are somehow different from. 5. Conclusions. what we expected originally. We have found. In this paper, we propose the concept of. that in some cases a teaching case that is. integration of various department views of. interesting enough to a specialist from one. computerized PBL teaching cases. In order to. department viewpoint may not be interesting. experiment the concept, an interactive PBL. from. teaching case system is implemented using the. another. department. viewpoint.. Therefore, for the training of specialists, it. document-view. technique. that. allows. one. may not be appropriate to integrate all the. document with many different views. Based on. related departments’ views in one teaching. our experiments, the users indeed feel strongly. case. Instead, we can integrate only certain. about the way the cases are presented to them.. departments’ views that are interesting. The system appears to be more interesting to the. enough from those departments’ viewpoints.. users and also gives the students much more. However, for the medical students’ training,. strong feeling about how medical knowledge are integrated in the real clinical setting they are 7.

(8) going to face in the future. The research work. York: Dodd, Mead, 1871.. also benefits the authors of the teaching case in. [8] W. J. Clancey "Knowledge-based tutoring:. terms of teaching activities as well as research on. the. medicine.. Cambridge, Massachusetts, 1987.. This. paper. is. to. present. our. GUIDON. program,". The. MIT. Press,. preliminary experiments about the concept of an. [9] Bernie Huang, "PACS: Basic Principles and. integrated teaching case system and the long. Applications," Published by John Wiley and. impact of the system for the medical education as. Sons, 1999.. a whole still remains to be seen.. [10] Laila Oubenaissa, Max Giardina “Designing. Reference:. a Framework for the Implementation of Situated. [1] Yuh-Ming Cheng, Lih-Shyang Chen, Chyi. Online, Collaborative, Problem-based Activity:. Her. Chen, “A Multimedia. Operating within a Local and Multi-Cultural. Teaching Case Learning System for Medical. Learning Context” International Journal on. Education”,. 2003--World. E-Learning (IJEL) Vol. 1, Issue: 3, 2002 Page :. Multimedia,. 41-46. Lin, Jyh-Hong. Conference. ED -MEDIA on. Educational. Hypermedia & Telecommunications to be held in. [11]E D Lemaire and G Greene “Continuing. Honolulu, Hawaii, USA, June 23-28, 2003.. education. [2] Michael H. Malloy, “Enhanced Web-Based. internet-base modules”, Journal of Telemedicine. Otitis Study Case vs Simple Paper-Case: Impact. and Telecare, 2002; 8: page:19-24.. on. Structured. [12]J.A Joines, R. R. Barton, “Medical education. Clinical Exam (OSCE) Performance “, Med. as a model for simulation education” proceedings. Educ Online [serial online] 2002;7:1. Available. of the 2000 winter simulation conference, page:. from URL http://www.med-ed-online.org. 1624-1629. [3] A.C. Norris and J.M. Brittain “Education,. [13] Robert Sikorski, Richard Peters, “JAMA. Training and the development of healthcare. NetSight: A Guide to Interactive Medicine”,. informatics” Health Informatics Journal (2000) 6,. JAMA, September 16, 1998 Vol 280, No.11 page:. page:189-195.. 1013-1014. [4] Dx R Clinician web-based problem-based. [14] L.L. Alpay, K.S. Littleton, “Context for. learning software, Dx R Development Group, Inc.. collaboration in healthcare education”, Health. http://www.dxrgroup.com. Informatics Journal, Vol 7, 2001, pages: 121-126. [5] Yu-Chuan Li, Wen-Shan Jian, “Curriculum. [15] Kimball, A.M.; Shih, L.; Brown, J.; Harris,. for. T.G.; Pautler, N.; Jamieson, R.W.; Bolles, J.;. Medical. building. Student. medical. Objec-tive. resources. on. the. in. physical. rehabilitation. Internet— experience in Taiwan”, International. Horwitch,. Journal of Medical Informatics 54 (1999), page:. outreach:. 137–143. International. [6] G.R. Norman and H.G. Schmidt, "The. Informatics,January, 2003, vol 69, issue 1, pages:. psychological basis of problem-based learning: a. 57-62. review of the evidence", Academic Medicine, vol. 67, no. 9, pp53-61, 1992. [7] E. Freidson, "Profession of Medicine", New 8. “International. using. the. APEC Journal. distance-learning. EINet of. experience”, Medical.

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