1. Teaching Clinical Case Presentations as Codified Speech Events (presentation)
Recently (Oct. 2019), I delivered a presentation at the EALTHY Conference in Spain entitled ‘Teaching Clinical Case Presentations as Codified Speech Events‘. The slides used can be downloaded here: Teaching Clinical Case Presentations as Codified Speech Events. This presentation was based on my observations and interviews of clinical case presentations carried out over 2017-2019 in Thailand, Taiwan, Vietnam, Myanmar, and Indonesia. I have submitted a manuscript to a respected journal on the same topic and am currently waiting the outcome. I will link it when published.
2. How English clinical case presentations are performed in Thailand: A case report
(hints on usage and management for non-native English speaking EMP teachers)
My original research plan, based upon my existing Grant-in-aid for Scientific Research from the Japanese Ministry of Education was to determine what the synoptic structure is for English clinical case presentations when carried out by non-native English speakers in clinical settings. What are the extant purposes for performing these speech events? How are these events typically managed in clinical and/or educational contexts? What variations in their presentation form exist and what conditions are these variations based upon? How do practitioners teach or carry out these events in non-native English speaking environments? Knowledge or insights gained from this endeavor would not only serve my academic interests in the field of English for Specific Purposes (ESP) but also in terms of establishing accurate and helpful teaching materials and methods for those teaching medical English in any similar environment.
With the help of Thammasat University and my own University of Miyazaki, Japan, I was able to secure a research sabbatical position at Thammasat University’s Faculty of Medicine for five months in late 2018 to early 2019. During this time, Thammasat University’s Ethical Review Board (ERB) allowed me to observe English clinical teaching/learning sessions within the Faculty of Medicine. My goal was to observe a number of English clinical case presentations in a number of different clinical departments. These included, OBGYN, Surgery, Pediatrics, Family Medicine, Community Medicine, Anesthesiology, and Ophthalmology. I was also able to establish a similar observational role in the Faculty of Medicine at Chiang Mai University and was also given opportunities to carry out similar functions for a brief time at hospitals/universities in Vietnam and Myanmar.
In order to take comprehensive notes on a number of clinical speech move categories, I created an observational clinical case check sheet (available in the members only section) that was used to clarify and note pertinent clinical and linguistic data that was used during these observations. I observed and notated a total of 13 clinical case presentations during the course of my research sabbatical, including 8 at Thammasat University, 2 at Chiang Mai University, and 3 conducted outside Thailand. The items, linguistic moves, and modes of management noted and gathered during these observations were then reduced to a core synopsis of clinical case presentation categories (also available in the members only section).
Case Presentation as a part of clerkship rounds
Significant findings on the institutional management of clinical case presentations:
The clinical case presentations I observed did not fall into a single overall structure. Rather, the extant purpose of the presentation determined both the form and structure of the speech event. How so?
Some presentations I attended were peer-to-peer ‘interesting case’ presentations, meant largely to edify and inform clinical peers (particularly residents). Some were evaluative, with senior clinicians present who subsequently critiqued and further advised presenters regarding the presentation contents. Some were bedside teaching sessions held between a clinician and upper-grade medical students, the latter of whom were carrying out case presentations as a part of their rounds in clinical clerkship sessions. Finally, some were actual scheduled teaching classroom scenarios with medical students who had been assigned teacher-chosen case data to report upon in a standard class.
In some cases, these presentations were performed individually, in other cases as pairs, and in some cases as fully interactive sessions between a leader (preceptor) and a number of participants (preceptees). The speech functions too ranged from monologues, to elicited dialogues, to team evaluative responses, and group discussion.
These factors drastically affected both the content and structure of the case reports, which negatively impacted my intention to note and classify features and speech moves according to established pre-set categories.
Some case presenters provided multimodal presentation resources (PowerPoint, lab results, imaging samples, textbook data, online websites, medical documents) to augment their presentations while others, typically those carrying out the discussion type, referred primarily to printed data sheets (provided to participants in advance). In short, understanding of the role/function of clinical case presentations within the university hospital was multi-faceted.
Case presentations as teamwork classroom activity
The larger purpose as to why these functions were to be carried out in English also varied significantly. Some were due to the students’ choice of having entered a English-specialized seminar or program, whereas others were utilized largely as staff brush-up sessions. None of the presenter I observed, however, spoke of an immediate plan to study/practice abroad, present at an international conference, or engage in an upcoming collaborative task although this has been noted as a primary motivation in outside contexts.
Eight notable (internal) features of clinical case presentations I observed:
- When the case was presented as part of a bedside learning session (preceptor-preceptee) much greater focus was placed upon the interpretation of lab results/imaging and, in particular, future management of the patient. On the other hand, when presented as a peer-to-peer informative session, a much greater emphasis was placed upon history taking, particularly the chief complaint and associated symptoms (and to some degree, systems review). If and when questions were elicited from participants, this was performed primarily during the initial history taking.
- Specific departmental features and contents also affected the structure and sequencing of the presentation on several occasions. For example, social and family histories were rarely discussed at length, with the exception of one case in Community Medicine. In OBGYN/pediatrics, day-to-day or recent developments and active monitoring of the fetus/mother/baby are central to the presentation. In Surgery, the physical examination, developed as a ‘baseline status’ of the patient, was discussed comprehensively. The interpretation of images (whether by the presenter or elicited from participants) was emphasized in all departments, with the exceptions of Family and Community Medicine. In the anesthesiology presentation a large section was devoted to listing and explaining interventions, a feature not noted in any other department.
- The use of formulaic academic phrases (associated with/marked by/decreased distance with a narrowing of X/consolidation of data among numerous others) and acronyms/abbreviations was also notable. Among such noted acronyms were NPO (nothing by mouth), PTA (prior to arrival), GA (gestational age), NS (not significant), PR (peripheral), and CBC (complete blood count).
- On occasion, students displayed superior communicative English to the instructor, however the instructor was often able to amend the learner’s speech by adding the appropriate professional register. For example,
S: …stuff will come out.
T: …agents will be discharged.
Further, although instructors committed numerous technical errors in their English speech (‘…if it is infect or not infect’ ‘…anything vomiting’ ‘How to assess about X?’ )these did not impede the discussion nor the teaching content of the session.
- Features widely used in these case presentations that I had not noted often previously included sections focusing upon the development of ‘problem lists’ , ‘post-admission developments’, ‘pertinent findings’, and/or the generating of lists of ‘operative approaches’, ‘operative findings’ and ‘post-operative findings’. These can and should be added to the core synopsis of the case presentation speech event (as can be seen in the members only section document).
- Often instructors and/or presenters seemed uncertain as to whether to generate a list of initial or provisional diagnoses or to proceed quickly to the differential diagnosis. However, if the emphasis of the case was assumed to be upon management and follow-up, the latter approach was generally preferred. The marking of temporal expressions (especially the accurate use of the perfect or past perfect tenses) also lead to confusion regarding the nature of the data on some occasions. English instructors can and should emphasize these areas of concern.
- Negative data (i.e., ‘There was no sign of X’) figured prominently in both past medical history (PMH) and physical examination (PE)/lab report sections, as well as, to a lesser degree, with imaging. The ruling out or exclusion of certain possible diagnoses was carried out most noticeable in the interactive teaching-based sessions. Contraindications were also raised when formulating initial or provisional diagnoses (IDx/PDx), which had not been factored into my original classifications.
- Clinicians were not always confident with the quality of their own English but, more importantly, were often uncertain how to manage or balance the language and clinical content when it was conducted as a standard class or bedside teaching lesson. In practice, English often became combined with the speakers’ native language in such interactive sessions requiring a great degree of linguistic code switching by participants. This, however, is not necessarily a negative feature in a non-native English setting, particularly within the field of medicine in which specialist terms are often more readily and more easily presented in English. However, this too rarely impeded the conveying of data.
2. Case Reports as EMP Lessons: Tips on Class Management
Using actual clinical cases as materials for upper-grade EMP classes involves an almost perfect combination of challenging clinical content and demanding, yet stimulating, English cognition. At my own university we have focused upon clinical case reports as the centerpiece of our 4th and 5th year EMP programs for some time now. Over the years, we have gradually learned how to manage such lessons. Below are some tips and considerations so that you may carry this out successfully yourself.
A. Clinician-led or student-led?
In-house English-proficient experts can be drafted into the EMP classroom to manage individual sessions (getting members from a variety of clinical departments is essential here). The other option is to have students test their own clinical and English skills by serving as leaders. Each type will involve slightly different means and methods of classroom management.
B. If led by a clinician… just one detailed case may be sufficient to fill an entire class. If led by students, having 4 or 5 students per session act as leaders, each to a small ‘audience’ of fellow students who rotate a few times during the lesson, may be more effective – relieving the pressure of having just one or two students manage an entire class and keeping all students active and engaged. Each week, a different set of students serve as case presenters/audience.
C. Groupings
Groupings are always essential. If it’s a clinician-led class, students need time to discuss and analyze contents and to formulate an adequate English response when asked to answer questions or to complete tasks. They can more comfortably carry this out in small groups (3-4 members each). If student-led, the entire class will be made up of the constant rotation of these various small groups among the student presenters.
D. Case Data
It helps students to prepare both cognitively and linguistically if they are given some details of the case in advance. Basic patient data (sex, age, chief complaint etc.) should be provided at least a few days prior. If the session is student-led, students should submit outlines of their cases to their EMP teachers in advance of the class to make sure that both the English and the clinical contents are in reasonable order.
E. Making sessions interactive
This is really the key to a successful session. Every clinical case is a mystery story that is solved in a process that gradually reveals itself. Allowing time and creating activities that allow students to process the data step-by-step and actively ask, check, and confirm information with the presenter is far more engaging than just the presentation of a bunch of data. For example, after the HPI (history of present illness) is presented, leaders can ask students to a) summarize the data for significance and accuracy, b) decided what systems or physical examinations should be prioritized, c) clarify or confirm any vague or missing details, and d) make a list of very preliminary diagnoses. If there are groups of 4 students, each member can respond on one task back to the presenter in English, after discussion with his/her peers so that the group has a representative response.
Similar interactive stages can be repeated as the clinical data unfolds step-by-step (e.g., pre/post investigations, pre/post family/medical/social history). ‘What would you ask/check/want to find out next?’ questions are also helpful and engaging at this point.
F. Summarization and Consolidation
One of the keys of a successful clinical case lesson is to reveal data gradually, in sections, much like a mystery novel. At the end of each section, presenters should summarize (or have students summarize) the case to that point. In this way, potential misunderstandings or omissions can be cleared up.
One tool that can be used readily for such a purpose is the humble whiteboard. Presenters can write down data when elicited from students for all to see (if it is done only vocally, a lot of pertinent data orb commentary may not be grasped by those unable to hear the speaker).
Once each section of data is summarized, it should naturally lead to questions – What does the data thus far suggest? What would your next investigation or line of inquiry be? These can also be discussed by groups of students with a representative providing a final response to the entire class.
G. How much English vs. local language?
Naturally, classes that involve foreign instructors as case presenters will be conducted only in English. In cases with local presenters or student-led sessions, I’ve seen a variety of combinations. Some use English only when highlighting the key academic phrases or terminology, while some force every interaction to be carried out in English. I lean towards the latter if the class is, fundamentally, considered to be an English class. However, allowing a mother-tongue Q&A sessions after the case has been fully presented with the leader can aid in furthering clinical understanding and can help clarify points that may not have been well understood.
H. Case contents and materials
Of course the clinical level of the case should match the knowledge level of the students, but with a few twists and subtleties added to give it some spice and make it less predictable.
Handouts can be helpful but please, not all at the beginning! Once again, the session should be unfolding section-by-section as a narrative. I prefer giving out summary handouts at the completion of the session.
Many, if not most, presenters use PowerPoint. This is fine but one should remember to use a lot of animation to keep students guessing – reveal gradually!
I. Potential problems
a. Case is too easy or obvious and students can smell the correct diagnosis well before the final step.
b. Session ends with differential diagnosis. Go further – What is the prognosis? How will it be managed? What are priorities for follow-up? What are the treatment options?
c. Presenter gives too much information. Make students ask questions or elicit it from them.
d. The chief complaint and basic data is given too quickly, not allowing students to fully grasp it. Time should be allowed for any participants to consolidate the information.
J. What is the English teacher’s role?
The first is to suggest to the clinician (or students) leading the session how to manage and time the sections. We always meet with our clinicians in advance, get their clinical data, and then offer suggestions as to how best make the class interactive and fruitful. Many clinicians are not teachers and will tend to lecture if not given guidance about classroom and content management. The English teacher can actively aid in physical and temporal real-time class management.
English teachers can also monitor the groups as they interact and respond, noting problematic expressions and phrases – perhaps to be introduced in a follow-up class. The non-native English speaking clinician may encounter a few English problems too, but it’s good policy not to correct them, embarrass them or undermine their authority. Most minor errors do not impact the greater flow of clinical data anyway.
English teachers can also help students formulate responses more succinctly or professionally, helping them to sound more like academics and professionals.
I hope that readers will use some of these hints to make their own case presentation classes, whether student or clinician-led, so that they are more fruitful – both as tools for deploying practical, clinical English but also in developing the learners’ clinical knowledge.
3. The Case for Case Presentations
Case Presentations (often referred to as ‘Case Reports’ and ‘Grand Rounds’) are core medical speech events that are practiced in most medical institutions. In their most formal manifestation, case presentations are performed by healthcare professionals to an audience of their peers. The purpose is to inform their colleagues of clinical cases, medical events, clinical practices and techniques through reporting in a set, formalized manner. Often, an hour or so is set aside in the mornings so that departmental peers can present (this is often done by rotation). Besides informing peers of pertinent recent cases, they also often serve as teaching/evaluation sessions, where senior colleagues will quiz or evaluate the performance of their juniors or trainees.
Often, in countries where English does not have official status and most medical staff are considered to be non-native speakers of English, these case presentations are performed in English. One reason for this is to help improve the English proficiency of the staff, both presenter and audience. Another factor is the reality that medical terms, shorthand, and speech events are often managed to some degree in English in actual clinical situations, hence English becomes well-suited to being the language of case presentations.
Other versions of case presentation exist. Truncated, but formally similar, case presentations appear as parts of conference presentations, generally as an illustrative case study. Much of the language and structures used will echo the more formalized departmental case presentations mentioned above.
An even more abbreviated version of case presentation occurs in real-time scenarios in the healthcare workplace in which doctors and other allied health professionals are required to share relevant patient information quickly and accurately. This often involves utilizing a medical shorthand that is almost impenetrable to the outsider but nonetheless follows the same general structure of the formalized departmental presentations.
Helping trainees or medical students to master case presentations in English should thus be considered a pedagogical priority for EMP teachers. Not only does the learner acquire a valuable workplace English skill but the very practice of assembling and conducting case presentations in English helps to organize and consolidate the medical content itself – the speaker has to consciously organize, prioritize, add, rule out, emphasize, and connect details in a type of medical narrative. In fact, I would argue that that this practice can have positive cognitive washback on the learner’s mother tongue.
In 2017, I visited four Asian universities and both interviewed staff, trainees, and students about the practice and purpose of giving case presentations, and attended several actual clinical case presentation speech events. The four universities (affiliated with nearby hospitals) were:
Brawijaya University, Malang, Indonesia
National Cheng Kung University Hospital, Tainan, Taiwan
Prince of Songkla University (Songklanagarind Hospital), Hat Yai, Thailand
Thammasat University Hospital, Bangkok, Thailand
Here is a brief report covering what I learned about English case presentations as practiced in the above Asian healthcare locales as a result of the research trip.
Please do not copy this or material from the links without reference or authorization.
4. Case Presentation Material Samples
On this page I will be gradually submitting my own case presentation materials, both Word files and PowerPoint slides, including descriptions as to how these are managed within varying East Asian locales. Members who would like to add their own insights or materials should write to me at michael@med.miyazaki-u.ac.jp or through the contact page on this website.
Let me start below with an item that I use for an introduction to clinical case presentation English for 2nd year students. The parenthetical areas allow for specific case input to be completed by students. One thing to remember is that the order of a case presentation content is flexible (depending upon pertinence) and some ‘moves’ could even be omitted if considered non-pertinent.
How a Case Presentation Works in English
The following link is to a series of slides I composed outlining how an English clinical case presentation typically works. I have used this both as a classroom tool and as a conference presentation. If you use it, and you may, please acknowledge my authorship.
Medical Case Presentations in English
Below are some links to some very helpful and interesting articles, resource websites, and discussions on ‘grand rounds‘:
The central resource for articles regarding clinical case presentations is the Grand Rounds Journal: http://www.grandroundsjournal.com/
All full website resource on Grand Rounds hosted by Duke University can be found at: https://guides.mclibrary.duke.edu/educators/grandrounds
From the Journal of Graduate Medical Education: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886451/
From the British Medical Journal: https://www.bmj.com/content/333/7582/1298
From the New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJM199905133401918
From the Medical Journal of Australia: https://www.mja.com.au/journal/2005/183/11/hospital-grand-rounds-australia