Over the past decade, physicians in every discipline have reexamined how to best deliver health care to women. However, bringing about real change will require a fundamental shift in medical education. Vast amounts of new scientific data, including information about sex- and gender-associated variations in health care, are emerging. To help students keep up with this information and become competent physicians, we must teach them lifelong learning skills and a critical ability to read the literature.1,2 Several authors have called for dramatically different approaches to medical education,3–5 and others have described a diverse collection of curricular experiments and processes addressing the need to incorporate the ever-growing amount of medical information that is emerging.6–8
In particular, there are two teaching tools, case-based learning and concept mapping, that support cross-disciplinary, multidisciplinary, and interdisciplinary learning; use a biopsychosocial model; and promote the integration of sex-and gender-based science into the medical curriculum.
Case-based learning is a subset of problem-based learning (PBL). PBL, introduced more than 20 years ago, provides a format and framework for approaching medical education. Medical students using PBL acquire relevant knowledge in an integrated fashion through the use of clinical cases and the development of problem-solving skills. This includes honing of diagnostic and clinical reasoning skills. The approach enables students to take an actual problem delivered through a clinical case scenario and use it as a template for relevant learning, appropriate for the student's educational development at the time.9 The format has been successfully applied in a variety of medical specialties10–12 as well as applied to the integration of women's health information in an existing problem-based curriculum.13
Concept mapping, first developed by Novak and Gowin,14 is another educational tool for learning across disciplinary boundaries and integrating relevant content. The technique allows students to organize and represent knowledge in an explicit interconnected network. Linkages between concepts are explored to make apparent connections that are not usually seen. Concept mapping also encourages the asking of questions about relationships between concepts that may not have been presented in traditional courses, standard texts, and teaching materials. It shifts the focus of learning away from rote acquisition of information to visualizing the underlying concepts that provide the cognitive framework of what the learner already knows, to facilitate the acquisition of new knowledge. Concept maps have been used to guide and evaluate students' learning in a number of educational environments,15,16 and for the development of cases.17
We first describe the process of case development at MCP Hahnemann University (MCPHU) by showing the development of a specific case, which is presented in the text. We then provide an example of a concept map addressing a different women's health topic. We discuss how both these tools might be used, in the future, to transform medical education by making it more integrated and interdisciplinary.
THE PROCESS OF CASE DEVELOPMENT AND REFINEMENT
Curriculum designers can develop their own cases or they can modify cases purchased from other institutions18,19 to suit their own needs and resources. We developed the following teaching case to illustrate how case-based learning can be applied to meet the important components of women's health learning. Table 1 lists examples of the key participants involved in the development of this case, in teaching about it, or in serving as resources to students as they utilize the case to expand their knowledge of women's health.
At MCPHU, a case is assigned to a faculty member whose discipline is the major focus of the case. This educator develops the initial learning objectives, and other objectives are inserted by members of other disciplines or specialties. Based on the goals listed of the case, learning objectives are developed that guide the development of the case.
Goals and Learning Objectives for This Case
- Students will have an understanding of the causes and treatment options for urinary incontinence.
- Students will recognize the complications caused by smoking and the difficulties patients encounter in trying to stop smoking.
- Students will be familiar with contraceptive options and their efficacies.
Urinary incontinence. At the end of this case, students should be able to:
- identify the anatomy of the bladder, ureters, and urethra and describe their relationships to other pelvic organs;
- describe the innervation of the bladder;
- describe the role of collagen in the pathogenesis of incontinence;
- list and describe the anatomic, physiologic, and pathologic causes of incontinence;
- describe the differences between frequency, urgency, dysuria, and urge and stress incontinence;
- know the prevalence of incontinence over a women's life cycle;
- identify the age-specific causes of urinary incontinence;
- explain the functions of the various members of the incontinence care team;
- take a sensitive history about incontinence;
- recognize how incontinence affects the ability to perform activities of daily living; and
- recommend treatment for incontinence.
Smoking cessation. At the end of this case, students should be able to:
- describe sex and gender differences in tobacco use and smoking cessation;
- describe the complications of tobacco use in women, particularly concerning cancer, cervical dysplasia, and health risk due to secondary smoke;
- recognize that women are at higher risk for toxicity of smoking, chronic obstructive pulmonary disease, and lung cancer, even when adjusted for amount of consumption; and
- explain some of the molecular mechanisms responsible for the greater susceptibility of women than men to tobacco complications.
Contraceptive options. At the end of this case, students should be able to:
- list contraceptive options available for men and women, and their mechanisms of action;
- recommend the most suitable options for this patient;
- know what mechanism of contraception is contraindicated for this patient; and
- know what preparations of emergency contraception exist, their effectiveness, and their availability to women.
The Development of This Case
After the primary faculty member assigned to the case has completed the first draft, the “rough” case is circulated among the faculty whose disciplines pertain to the case. Then a meeting is called to review and finalize it. A representative from each of the basic sciences and clinical disciplines being addressed in the case is always sought out, as well as an expert(s) for the psychosocial issues. The case-development group is responsible for providing facilitator notes for the small-group sessions that will be vehicles for case learning. These notes are particularly important for those needing assistance with their knowledge of women's health. The facilitator prompts and notes can also function as a study guide for students after the case is completed. A case that integrates women's health into its fabric thus emerges as an interdisciplinary product.
Using the goals and learning objectives listed earlier, the following case was developed using the process just described:
The Cases of Ms. Emily Johnson
Ms. Emily Johnson is a 38-year-old patient of yours who has come for her yearly well-check appointment. Ms. Johnson is married and has two children, ages 14 and 10. Both pregnancies were normal, with vaginal deliveries. She is an elementary school teacher in a suburban school district. Despite trying to quit smoking on several occasions, she has not been successful and still smokes about 15 cigarettes a day.
Upon review of her interval history, she indicates that she had been using a mini-pad because of urine dribbling. Further inquiry indicates that she has stress and urge incontinence and that it has been increasing in the past year. She says that she is quite embarrassed and is afraid that she will not have the time to go to the bathroom while teaching and will have an “accident.” In discussion, she tells you that she keeps an extra set of clothing in her classroom. Upon questioning, she informs you that she has had no episode of fecal incontinence.
After you finish the exam, Ms. Johnson asks you about possible choices of birth control. She would like to consider what options are available to her and her husband because, as she tells you, “Using my diaphram is so messy, and I don't want to get pregnant.” You order the following laboratory studies, including blood glucose, due to Ms. Johnson's family history of type II diabetes.
You arrange another appointment to address Ms. Johnson's desire to switch her birth control method.
After you review the laboratory results, you contact Ms. Johnson. You assure her that all the tests were normal. You have a discussion with her about the need to stop smoking and arrange for her to be oriented about smoking cessation through your office's health education programs. You refer Ms. Johnson to a urologist specializing in pelvic floor disorders to further evaluate her urinary incontinence.
The Use and Refinement of the Case
In “working” this case, students in the problem-based program at MCPHU develop one or several concept maps, drawing connections to each of the various topics elicited by the case. The concept maps allow for students to fully explore their understanding of the issues in the case and the relationships of the new issues to any previously learned concepts, and provide a framework from which students develop their own learning issues.
Resource sessions are scheduled to take place after the students have worked through the case, have developed concept maps, and have done some reading. These sessions provide an opportunity for the students to have their learning issues addressed, and allow the involved faculty experts to convey additional women's health teaching. Last, the resource session can provide a forum for students and faculty to discuss ethical and human rights issues that may not have yet made their way into standard texts or lectures.
It is insufficient to just create and implement a women's health case. The learning environment needs to be friendly to examining sex and gender differences and to becoming free of gender bias.20 Well-developed cases will fail if students and faculty experience a hostile or intimidating environment where sex and gender issues are scorned, ridiculed, or passed over.
Cases are reviewed yearly by the appropriate group or committee to ensure the inclusion of accurate and timely information. Faculty and student feedback is also elicited in revising cases. The case is reviewed to assure appropriate diversity in patient demographics. Comparisons are made with other cases in the course or block for balance in age, sex, race, ethnicity, marital status, and occupations to reflect what a physician would see in actual practice.
THE POTENTIAL USE OF A CONCEPT MAP
Example of a Concept Map in Women's Health
Most of the literature addressing concept mapping focuses on evaluation and analysis.2,15,16 Edmondson,17 in describing case development efforts at Cornell University College of Veterinary Medicine, illustrated the use of concept mapping in case design. The technique of concept mapping is being proposed as a novel way to conceptualize women's health education by the American College of Women's Health Physicians.2 Figure 1 is a concept map on women and alcohol use, developed by Eileen Hoffman, MD. The concept map defines our current knowledge of women and alcohol use. Reading the map from a hierarchial perspective, top to bottom, allows for identification of numerous possible cross-links, from very general to specific areas for learning and researching topics associated with women and alcohol. The map also serves as a useful tool for selecting and developing learning objectives concerning the problem. Course directors and case writers can select the goals, disciplinary themes, interdisciplinary concepts, and specific clinical manifestations that are important to the specific overall goals of their school's curriculum plan.
Goals and Learning Objectives Identified by This Concept Map
- Students will have an understanding of gender and sexbased differences pertaining to alcoholism.
- Students will recognize the relationship between utilization of alcohol and any physiologic effects.
- Students will appreciate the interactions between alcohol and pharmacologic substances.
Students should be able to:
- obtain a complete risk history;
- recognize the signs and symptoms of alcohol abuse in women and men;
- explain sex and gender differences of alcohol abuse in women and men;
- discern the difference in the metabolism of alcohol between men and women;
- define depression and anxiety in women and men and the differences between the sexes in their manifestations of depression and anxiety;
- administer and interpret the CAGE;
- describe differences in sequelae of alcoholism between women and men, including the pathology of cirrhosis of the liver;
- recommend effective treatment options for alcohol abuse for women and men.
In this illustration, the concept map serves as a blueprint for developing curricular goals and learning objectives. From the objectives selected, a case such as the one illustrated previously for urinary incontinence can be constructed. At another school the concept map might identify a scenario suitable for case-based integrated learning about the epidemiology of smoking, depression in women, and the pharmacology of drug and alcohol interaction. Yet another integrated scenario might include the physiologic effects of alcohol, injuries sustained from a motor vehicle accident, cultural issues surrounding alcoholism, and risk-taking behavior among adolescents. The use of concept maps as such a blueprint can identify a broad range of relevant potential collaborations between various departments and disciplines involved in women's health medical education.
THE VALUE OF THESE TOOLS
Case-based learning and concept mapping facilitate the introduction of women's health objectives into the medical curriculum. They foster learning experiences that
- encourage patient-centered approaches to problem-solving;
- address sex- and gender-based differences in disease as well as in pathophysiology and pharmacology;
- integrate psychosocial issues, such as family dynamics, environmental stressors, access to health care, effective gender-based communication between patient and provider, and cultural variation, along with biomedical ones; and
- encourage a multidisciplinary approach to patient care.
We are encouraged to see that these tools are being recognized for their potential in women's health education, and urge that medical schools that have not already done so make the effort necessary to integrate case-based learning and concept mapping into their women's health curricula.
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A New and Wider View—Women's Health as a Catalyst for Reform of Medical Education