El estudio de casos como método problémico en ciencias médicas: una experiencia necesaria

María Elena Artiles Monteagudo; Carlos Javier Artiles Rivero; Frank Ernesto Rodríguez

The case study as a problem-solving method in medical sciences: a necessary experience

COMUNICACIÓN

The case study as a problem-solving method in medical sciences: a necessary experience

El estudio de casos como método problémico en ciencias médicas: una experiencia necesaria

María Elena Artiles Monteagudo¹, Carlos Javier Artiles Rivero², Frank Ernesto Rodríguez Gómez³

¹ MD. Specialist in Ophthalmology and Comprehensive General Medicine. Associate professor and researcher. "Arnaldo Milián Castro" Surgical-Clinical University hospital. Santa Clara. Villa Clara. Cuba. E-mail: mariaam@hamc.vcl.sld.cu
² MD. Specialist in Comprehensive General Medicine. Resident of Neurosurgery. "Arnaldo Milián Castro" Surgical-Clinical University hospital. Santa Clara. Villa Clara. Cuba. E-mail: mariaam@hamc.vcl.sld.cu
³ 5th. Year Medicine student. Villa Clara University of Medical Sciences. Cuba. E-mail: mariaam@hamc.vcl.sld.cu

ABSTRACT

The case study method is considered favorable to apprehend a complex situation; it is based on its interpretation which is obtained through the description and the analysis of each part, it is assumed as a group and within a context. Among its advantages it is mentioned that it favors the learning through findings, it encourages the student to ask questions, to formulate their own answers and to deduce principles through practical examples or experiences; in spite of being used in varied fields of knowledge, in the medical education it is applied little through the case reports. The authors communicate the educational experience of its usage and they suggest that its effectiveness is valued in the process of health professionals formation.

MeSH: Case studies, education, medical.

RESUMEN

El método de casos o estudio de casos se considera propicio para aprehender una situación compleja; se basa en su interpretación la cual se obtiene a través de la descripción y el análisis de cada una de sus partes, asumidas como un conjunto y dentro de su contexto. Entre sus ventajas se menciona que favorece el aprendizaje por descubrimiento, anima al alumno a hacer preguntas, formular sus propias respuestas y a deducir principios a partir de ejemplos prácticos o experiencias; a pesar de ser empleado en variados campos del conocimiento, en la educación médica se aplica poco a través de los informes o reportes de caso. La autora comunica las experiencias docentes de su uso y sugiere que se valore su efectividad en el proceso de formación de los profesionales de la salud.

DeCS: Estudios de casos, educación médica.

The case study has a long history in teaching; it has always been used as a form of example or practical problem. Its essence consists on looking for a solution to a concrete case.

With the course of time this method has been applied in varied contexts and it has become a very effective strategy so that the students acquire diverse knowledge and develop different abilities, thanks to the leading role that it has in solving cases¹.

The case study method, as a problem-solving teaching method, starts by the description of a concrete situation with pedagogic purposes. The case is presented to a group of students who individually and collectively analyze it and make proper decisions. The situation can be presented by means of a printed, filmed, or in computer or audiovisual materials. Generally, the outlined difficulties don't have a sole solution, so that it favors the understanding of divergent problems and the adoption of different solutions by means of reflections and consensus².

This type of teaching-learning requires of the student's active participation "to discover" the principles or concepts that they should study; it foments curiosity and the development of skills for a lifetime, besides that the student becomes an active part of the process.

The employment of the case study method in teaching is justified thanks to the idea that the students learn better, because they accept more responsibility in the development of the discussion and they come closer to the reality of their future profession; it is an active method of study that demands the student's constant participation, fundamentally its success depends upon the competence of the professors while using it.

In the bibliographical reviews, either printed or digital, the authors of this communication perceived little use of the application of this method through the case reports. The authors assume the definition of case report given by Romaní Romaní³: "The case report is a biomedical publication that makes a detailed report of symptoms, signs, results of diagnostic procedures, treatment, complications of the treatment, and an individual patient's follow up, through a brief logical and rational description."

The above mentioned author states some of the characteristics that let a case report be publishable, among them:

Condition or new illness.
Strange, uncommon condition or little communicated.
Unusual presentation of not very common or not communicated disease.
Unexpected association between signs or uncommon symptoms.
Impact of the disease in the evolution of another.
Impact of the treatment of a condition in another.
Unexpected complications of procedures or treatments, etc.

Although it is mentioned the educational value of the case report, it doesn't make reference to the didactic value as a problem-solving teaching method, in which the student faces theoretical elements revealed by the professor, which are assimilated as educational problems whose solution is made by means of cognitive tasks and questions that contain problem-solving elements, through which they acquire a new knowledge. The pedagogic base of the problem-solving method is based on the necessity of enlarging the cognitive capacities of the students. To achieve a developing teaching presupposes not only a solid assimilation of knowledge, but also the acquisition of a comprehensive personality of the student; it constitutes a principle of the Marxist pedagogy⁴.

Next, an experience is described on how the case study method was used through a case report.

The teacher presents the case report:

Blindness produced by non ophthalmological cause. About the patient.

A 74 year old white female Patient visited the Ophthalmological office complaining of vision loss in both eyes. In the doctor-patient interview, the patient referred about the loss of vision in both eyes since six months ago in a slow and progressive way, past medical history and family history were unremarkable. The Ophthalmological exam showed: visual acuity RE PL, could count fingers to cm, nm/AE. Bio-microscopy of the anterior segment showed posterior sub capsular opacity in both eyes, no other alterations were found. Tonometry showed RE 12 mm Hg, LE 15 mm Hg at 9:00 o'clock(Normal). Isochoric pupils, pupil reflections were present, pupil afferent disorder was not defected, no limitation in the ocular movements, preserved convergence, no diplopia. Fundoscopy showed normal corneal and cutaneous sensibility with midriasis on medications , Tropicamide 1% (eye drops) atrophic paleness was found in both optic disks, thin blood vessel, no hemorrhage, no exudates. Normal peripheral retina. It could not be carried out the computerized exam with the Humphrey's perimeter due to the vision loss of the patient, who could not be able to locate the fixation point, as well as a non useful result in the exploration of the vision of colors^5-8.

The teacher formulated the following questions to generate the reflection and the problem-solving discussion that characterizes the case study method:

Does the serious decrease in visual acuity (VA) match with the opacity grade of the crystalline lens and the founding of the bilateral optic atrophy?
Is the senile cataract that the patient presents the responsible for these symptoms?
Do you consider reasonable to suspect that the referred blindness has taken place for some non ophthalmological cause related to the eyes?
As future specialist in Ophthalmology, what specialist would you refer the patient to continue the searching for the cause of her blindness? Which are the possible diagnoses that support your decision? Air your views.

This report classifies as case-problem or case-decision. It is the most frequent type; it is the description of a problem-solving situation of the reality on which it is necessary to make a decision. In the described experience, the professor reminds the students to respect the ethical, scientific and humanist elements of their profession.

While using the case study as a teaching method, the professor kept in mind its componentes⁹:

The subject: it provides the previous knowledge of the concepts, methods, tools and abilities whose validity and updating will be subjected on approval in the discussion of the case.

The case report: it serves as a base of the discussion. It constitutes the study object on which the professor and the student act to achieve learning, it's the leading process to knowledge and valuation of its essence, which implies its transformation and the addition of an added value to each component: the object and the subject. In the object it is the transformation of health; and in the subject, the appropriation of the characteristics of the object at a phenomenological level and different degrees of esenciality¹⁰.

The professor: with the particular experience in its profession and acting as a facilitator of learning, where they should develop a dynamic role providing the methodological tools for the discussion, ordering the procedure, guiding the analyses to avoid confusions, motivating the participation and stimulating the position of novel thesis. They have the responsibility to guide the individual contributions, to maintain the rhythm of the discussion in such a way that allows the appropriate use of time and the understanding of the participants, maintains the discussion inside an ideal atmosphere and the interest of the participants, they should provide authority, management and wisdom to offer a warm, ethical, dynamic atmosphere and with a marked scientific character.

The student: who directly participates in learning construction through the case study, they develop communication abilities and the mastery of the methods of the profession. They give opinions and reflections about the presented situation, making the process to be active. When using the case study method it is pretended that the student study the situation, define the problems, reach to their own conclusions on the actions that it would be necessary to undertake and contrast ideas, they defend them and they reprocess them with new contributions.

The case study can make a great contribution to the development of the abilities in the students due to its links with the reality of this profession and it allows them to adopt an appropriate solution. In this sense, the cases present the following characteristics:

Make possible the application of theoretical and technical concepts proven in real life.
They help them develop problem-solving and decision-taking abilities.
They demand an active participation which favors communication abilities.
They can refute critical, risky or uncertain situations as strengths of collaborative learning.
They contribute to give a practical and pragmatic approach to diverse and varied situations.
They make the student responsible for their own learning, and they motivate them to keep informed and active in their profession.

According to the above-mentioned aspects, the case study method through the case report can be highly scientific and formative, but it requires a great discipline and an enormous preparation on the part of the professor in all sense.

Because of it valuable contribution, the authors inquire:

Why to present the case report as a novel aspect in a general way and not to present it as a problem-solving method for the teaching-learning process in the medical education? How profitable this experience can be in the formation of health professionals?

BIBLIOGRAPHIC REFERENCES

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Submitted: April, 20 2015.
Accepted: September, 8 2015.