Overview: Background

The past two decades have witnessed major changes in pediatric training, with a greater emphasis being placed on the biopsychosocial issues facing children, adolescents, and their families. A number of professional groups have published health supervision guidelines, including Bright Futures Guidelines for Health Supervision, Guidelines for Adolescent Preventive Services (GAPS), Putting Prevention into Practice, and the U.S. Taskforce Clinical Preventive Services. 1-4Bright Futures, published initially in 1994 and revised in 2000, provided health care providers with extensive guidelines, strategies for screening, and broader concepts of anticipatory guidance to enhance the delivery of services to children, adolescents, and their families. 1 Bright Futures has been in the forefront of promoting a concept of child health that emphasizes health promotion by building on the strengths of families and communities. Bright Futures materials have included office questionnaires, pocket guides, and manuals on oral health, nutrition, and mental health. However, a continuing challenge has been to transform these guidelines into practical training experiences that will promote knowledge and skills among primary care providers. This case-based curriculum was based on the premise that child health clinicians best learn knowledge and skills about communication with families, anticipatory guidance and health promotion by struggling with complex cases, and that formal teaching should therefore be built around clinical narratives that rapidly engage individuals in active learning.

With grant support from the Maternal Child Health Bureau (MCHB) and the Genentech Foundation for Growth and Development, we established the Bright Futures Resource Center for Curricula (BFRCC) at Children’s Hospital in Boston in 1996. This project completed a needs assessment of 220 pediatric residency programs, published the results, 5, 6 and developed new case-based teaching materials in response to the unmet content needs. The needs assessment revealed, not surprisingly, that programs desired more learner-centered materials, including both standardized written cases and computer-based materials.

Over the next four years, we developed 29 written case-based teaching modules based on the needs revealed in the 1997 BFRCC survey of pediatric residency programs. The written cases were authored by residents, fellows, junior and senior faculty, pilot-tested in a number of training programs, evaluated, and revised in an iterative process that has included input from psychology, psychiatry, social work, nutrition, nursing, law, and medical education. What has been clear from the evaluation and pilot-testing is that residents and faculty desire to “problem solve” as they master content and develop new skills. Through the written case vignettes, learners can individualize their own learning goals and objectives. The content and new skills learned have been directly transferable to patient care. The cases were therefore written and revised to engage the learner immediately in a problem at hand, to stimulate assessments of families and systems of care, to help them learn to work with colleagues in case management, and to facilitate discussion of community and family resources and prevention strategies. To deliver effective preventive care, clinicians need to feel comfortable about asking sensitive screening questions. They must also feel empowered by having the knowledge and skills needed to deal with positive answers to these screening questions. Each case was crafted with these particular needs in mind.

More than 830 copies of these case modules have been distributed to more than 170 training programs in the U.S. since 1996, and the directors have taught a number of national workshops to enhance faculty development in case-based teaching. 7-10 The original MCHB project goal of 16 cases was significantly exceeded, in part through additional funding from the Genentech Foundation for Growth and Development. These case modules are now available for direct download via the internet (including one interactive case) at http://www.pedicases.org/, and a grant from MCHB has provided the opportunity to publish this three volume Casebook series.

To date, pre- and post-testing of several cases has revealed that knowledge and problem-recognition skills were enhanced as a result of interactive case discussions. 11-13 Qualitative data have demonstrated that this case-based curriculum has been critical to helping residents become competent in health supervision and the management of psychosocial and developmental problems in children and adolescents. We are fortunate that the Bright Futures curriculum development project could be built on the expertise of the Office of Educational Development at Harvard Medical School (HMS), which developed the original New Pathway approach to problem-based learning. 14-16 According to this approach, the writing of successful teaching must include (1) providing the case with the “vitality of the living stories of patients with disease, injury, and illness that unfold in medical practice;” (2) coupling the narrative with science that keeps the students engaged in learning; and (3) highlighting the issues in the case to meet educational objectives. 14 Adults often learn when faced with a practical challenge to overcome. After all, “necessity is the mother of invention.”

The format of this three volume series is to provide information to teachers about the many facets of the project. As Directors, we are providing the background and history of the development of this project. Dr. Elizabeth Armstrong, one of the creators of the New Pathway at Harvard Medical School and a consultant on the project, discusses the advantages of case based learning and the implementation of these cases into medical student curricula. Dr. Knight provides an overview of actual case module structure, Dr. Blaschke provides a guide on facilitating case discussions, a number of authors provide their practical perspective on implementation with a variety of medical and nursing specialties and levels of learners, and Dr. Goodman talks about the evaluative phases of this project and incorporating lessons learned. Part of this project has also been the promotion of the “resident as a teacher,” so well described by our Fellow and resident writers (Drs. Wilson and Brooks).

The Casebooks are divided into three sections: (1) A Guide to the Case Teaching Method; and Growth in Children and Adolescents, (2) Bright Futures Case Studies for Primary Care Clinicians: Child Development and Behavior, and (3) Bright Futures Case Studies for Primary Care Clinicians: Adolescent Health. They are all designed to enable the Bright Futures Guidelines to be translated into clinical practice to improve the health of children and adolescents.

S. Jean Emans, M.D. and John R. Knight, M.D.
Project Directors

References:

1. Green M. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health; 1994.
2. American Medical Association. Guidelines for Adolescent Preventive Services (GAPS). Chicago: Department of Adolescent Health, AMA; 1993.
3. U.S. Department of Health and Human Services. Clinician’s Handbook of Preventive Services: Putting Prevention into Practice; Washington, D.C.: DHHS; 1994, 2nd edition 1998.
4. US Preventive Services Task force. Guide to Clinical Preventive Services, Second edition. Baltimore: Williams and Wilkins; 1996.
5. Emans SJ, Bravender T, Knight J, Frazer C, Luoni M, Berkowitz C, Armstrong E, Goodman E. Adolescent medicine training in pediatric residency programs: Are we doing a good job? Pediatrics 1998; 102:588-595.
6. Frazer C, Emans SJ, Goodman E, Luoni M, Knight J. Teaching pediatric residents about development, behavior, and psychosocial problems: Meeting the new challenge. Archives of Pediatric and Adolescent Medicine 1999;153:1190-1194.
7. Emans SJ, Bravender T. Teaching adolescent medicine to residents using written cases (Educational Workshop). Society for Adolescent Medicine; Los Angeles; 1999.
8. Knight J, Blaschke G, Frazer C. Keep ’em awake in conference: Preparing residents to teach each other (Educational Workshop). Ambulatory Pediatric Association; New Orleans; 1998.
9. Knight J, Levy S, Blaschke G. Keep ’em awake: Using cases to teach Bright Futures (Educational Workshop). Ambulatory Pediatric Association; San Francisco; 1999.
10. Vandeven A, Wilson C, Knight J. Substance abusing families: Helping the parent while protecting the child (Educational Workshop). Ambulatory Pediatric Association; Boston; 2000.
11. Knight J, Frazer C, Goodman E, Blaschke G, Bravender T, Luoni M, Hall M, Emans SJ. Case-based teaching by pediatric residents (abstract). Ambulatory Pediatric Association; San Francisco; 1999.
12. Knight J, Sherritt L, Frazer C, Palacios J, Hall M, Emans S. Teaching pediatric residents about growth using standardized cases (abstract). Pediatric Research 2000; 47:92A.
13. Knight JR, Frazer CH, Goodman E, Blaschke GS, Bravender TD, Emans SJ. Development of a Bright
Futures curriculum for pediatric residents. Ambulatory Pediatrics (In Press).
14. Glick T, Armstrong E. Crafting cases for problem-based learning: Experience in a neuroscience course. Medical Education 1996; 30:24-30.
15. Armstrong E. A hybrid model of problem-based learning. In: Boud D, Feleui G, editors. The Challenge of Problem Based Learning. London: Kogan Page Publishers, 1991. p. 137-149.
16. Wetzel M. Problem-based learning: An update on problem-based learning at Harvard Medical School. Annals of Community-Oriented Education 1994; 7:237-247.