Learning Transfer in Online Case Studies for Orthopaedic Surgeons

Heather Hodge

EDAE 668 Cognitive Theory and Learning Transfer

Dr. Jeffrey Foley

Colorado State University

Case based learning is used in many different disciplines, from medicine to law to

accounting to education, and depending on how they are developed, encourage learning transfer

by using constructivist theory principals. The constructivist orientation states that “meaning is

made by the individual and is dependent of the individual’s previous and current knowledge

structure” (Merriam, Caffarella, & Baumgartner, 2007, p. 291). Cases are often used in

medicine, especially in surgical specialties, as a teaching format. In orthopaedic surgery,

learning through cases currently takes several forms. Most forms are interwoven within didactic

presentations, journal articles, webinars and other online learning. However, none include most

of the characteristics that make an effective case presentation, including that it tells a story that is

relevant to the learner, that it states the problem without resolving it and that it produces conflict

and drives decision making.

While physicians are typically a good audience for didactic lectures because of their level

of intelligence, lectures do not allow learners to directly apply the information they learn and

construct knowledge. One solution may be to provide a variety of cases to help facilitate

learning. Developed properly, medical case based learning mirrors clinical experience (often

through real cases) by engaging, stimulating and informing the learners and requiring them to

construct knowledge based on their experiences, a clear example of the constructivist orientation.

Background

In mid-2014, AOSSM conducted an extensive member needs survey. This online survey

was sent to 2,884 members with 732 AOSSM members completing it over a three week period,

representing a response rate of 25.4%. In short, the results showed that members were pleased

with AOSSM educational offerings. That said, when asked, “Below are educational activities

that could potentially contribute to your professional development. Please rate the importance of

each to you,” the number two answer was “On-line learning (e.g., case studies, surgical videos,

webcasts).” The number one answer was that they wanted more faculty/participant interaction,

which has been addressed in as many live activities as possible and which will be a consideration

in an online learning environment.

In late 2014, after the results of the member survey were compiled and reviewed by the

AOSSM Board and Education Committee, the AOSSM Enduring Education Committee was

tasked with looking at the survey results and addressing the online education situation. At about

this same time, AOSSM purchased a learning management system (LMS). This would allow

online education to be delivered easily and in a more user-friendly manner to learners and it

would also allow for a discussion mechanism for faculty or another subject matter expert to

interact with the learners.

Upon initial review, the committee decided that their main priority would be to develop a

series of case based modules. The content initially would be based only on the surgical

treatment options in an already existing orthopaedic sports medicine curriculum. There are

several non-operative treatment options that orthopaedic surgeons manage but the majority of

their work is surgical and therefore the surgical treatment options would be covered first.

The target audience would be orthopaedic surgeons broken down into three groups:

1. Young orthopaedic surgeons with 0-5 years as an attending.

2. Intermediate orthopaedic surgeons with 6-10 years as an attending.

3. Experienced orthopaedic surgeons with over 10 years as an attending.

The content would be broken down into topic areas in orthopaedic surgery and is

identical to the way content is broken down in the AOSSM curriculum:

1. General Sports Medicine Topics

2. Shoulder

3. Elbow

4. Wrist and Hand

5. Hip, Pelvis, Thigh

6. Knee

7. Tibia, Fibula, Ankle and Foot

8. Spine

There are three other areas included in the curriculum: general sports medicine topics (not

orthopaedic related), sports medicine research, and ethics which may be added at a later date.

Again, the committee wanted to focus on clinical topics related to surgical treatment options at

the start of this project.

Description of Proposed Learning Activity

While this project is still in the early phases, there are several things the committee is

working on. One way is that they are going to focus on a single topic area at a time. Based on

the American Association of Orthopaedic Surgeons’ Orthopaedic Practice in the U.S. in 2014,

the most commonly performed procedure is arthroscopy of the knee. Therefore, the committee

decided to first develop cases in the topic area of knee. They have completed an outline with

topics for the knee section and are in the process of identifying subject matter experts to submit

the cases. Below is the list of knee cases:

Ligament Person Responsible

ACL D. Johnson

PCL Moorman

MCL B. Cole

Posterolateral F. Fu

ACL/medial R. Benner

ACL/lateral

PC/lateral Busconi

Dislocated Knee

Arthritis/Instability

Cartilage/Articular Person Responsible

Traumatic (acute/chronic) Cole

Degenerative Fu

Inflammatory

Meniscal Person Responsible

Meniscectomy

Meniscal Repair Busconi

Meniscal Replacement

Tendon Person Responsible

Partial Tear

Complete Tear Cole

Acute Inflammatory

Chronic Inflammatory

Muscle Person Responsible

Traumatic (intra/extra articular)

Inflammatory

Tumor Provencher

Infection

Neuropathic

Bone Person Responsible

Fracture

Stress Fracture Busconi

Metabolic Disease

Infectious Disease

Tumors

Nerve Person Responsible

Rupture

Entrapment

Inflammatory

Tumor

Vessel Person Responsible

Partial Rupture (intimal tear)

Complete

Inflammatory

Tumors

Patellafemoral Person Responsible

PF Instability Bollier

Authors for many cases still need to be identified. Each person invited to submit a case will be

sent instructions (see attachment A). Each submission must include pre- and post-test questions

and each case must include references.

Once each case is submitted, it will be peer reviewed by at least one subject matter

expert. A form has been created to ensure all requirements are met (see attachment B). This

process is managed by staff.

Learning Transfer

The plan of the committee includes scaffolding the cases so that participants will start out

working on cases that are typically seen by younger surgeons and work up to more complex

cases seen by more experienced surgeons. Their hope is that by having them work on a variety

of cases building on top of one another will encourage far transfer by having them apply what

they’ve learned in the simpler cases to the more complex cases.

The committee struggled a bit with how to determine where a surgeon enters the

curriculum and ultimately decided to base it on years of experience as previously mentioned. A

young neurosurgeon with five or less years of experience will start with the simplest cases. Each

category will have a minimum of three cases per level of experience. Each case will be entered

in the LMS by level of experience. A learner will enter the category and will have to complete

all the cases in that category in order before being able to move up to the next level. Each case

will include a five question pre- and post-test. Participants must receive a score of 4/5 on each

post-test to move to the next case. All of this will be managed by the LMS. In addition, each

category will include a discussion board that will be moderated by a subject matter expert and/or

the author(s) of the cases.

Conclusion

This is an extensive project that is still in its infancy and will likely take a couple of years

to fully implement. The goal given to the committee is to have the first topic area of knee

available summer 2016. There are several challenges that the committee is facing including

finding subject matter experts that are not already over committed working on other projects. In

addition, there is a significant amount of work to review each case and then to format them so

that there is a uniform look for each case. A template has been created but not yet approved (see

attachment C for the first couple of slides from one case).

This project may also serve as a pilot for other medical specialty societies who are faced

with the challenge of how to determine if their member physicians are staying current on

standards-of-care in their specialty and improving their practice, which is a topic of debate by

medical boards. Performance improvement is a component of maintenance of certification

(MOC) that many are struggling with how to show. If this curriculum is completed with the

learners showing that there is an improvement in their pre- and post-test scores, this may be able

to help them fulfill their performance improvement requirement of MOC. In short, there are

further implications for this project.

Attachment A: Online Case Instructions for Submissions

ONLINE CASE STUDY SUBMISSION INSTRUCTIONS

Not all cases will be alike in terms of length and content. That said, in an effort to ensure as

much continuity as possible amongst cases and to present a uniform look to learners, below is the

suggested minimum requirements for submitting a case. Cases can be submitted as a PowerPoint

presentation on plain white background. You do not have to submit the following in this order

but please be sure to include the following:

1. Pre/Post Test Questions

Please submit 5 questions that will be used for a pre and posttest. The same

questions will be used for both in an effort to measure a change in competence

and determine if learning transfer occurred as a result of participating in the

activity.

These questions should be different than the ones included within the case if

applicable.

2. Title Slide

Title that is descriptive of the case without giving away pertinent details.

Author(s) name and degrees; disclosures

3. Course Objectives

Please submit 2-3 learning objectives.

Learning objectives should reflect what the participant should know or be able to

do at the end of the case.

The best way to communicate learning objectives effectively is to use specific

action verbs and to introduce them with this statement: “Upon completion of this

educational activity, participants will be able to . . . “

Use good action verbs like explain, describe, discuss, assess, determine,

analyze, differentiate.

Avoid using include understand, know, and learn.

4. Meet the Surgeon

Please submit a photo and brief CV.

5. Patient History & Physical/Other Background

What brought the patient to you?

6. Important Case Details with Test/Lab/Imaging Results

If there are any available test/lab/imaging results that will help with the case,

please include.

7. Questions

Please provide question text with answer choices and indicate the correct answer.

Provide feedback on the question and the correct answer.

You must also include references.

NOTE: It is not necessary to include all the questions at the same time.

You should intersperse lab/test/imaging results or teaching points in

between the questions. Just be sure to send your PowerPoint in the order

you want the final presentation.

8. Case Management and Patient Outcome

Please include as much detail as possible on patient outcomes post treatment.

What procedure was used and how did the patient do (recovery).

9. Teaching points/resources

NOTE: These can all be included on the last page or interspersed throughout the

presentation. Be sure to send your Word document in the order you want the final

presentation.

SUBMITTING MATERIALS

Provide content in PowerPoint.

The case will also be reviewed by two to three additional surgeons.

QUESTIONS?

If you have any questions or need further assistance, please do not hesitate to contact Heather

Hodge via email at hhodge@aossm.org or via phone at 847.655.8636.

Abbreviations, Nomenclature, Symbols and References should conform to those found in the

AMA Manual of Style: A Guide for Authors and Editors, 10th Edition, 2007, published by Oxford

University Press, Inc., 198 Madison Avenue, New York, NY 10016. The use of standard

international units is encouraged.

GUIDELINES FOR ALL AOSSM EDUCATIONAL ACTIVITIES

Quality of Content Guidelines

The quality of the activity is subject to the review of scientific peers who will evaluate the

activity on the basis of the following criteria:

1. The activity must recognize and meet the needs of orthopaedic surgeons and their patients.

2. Content material must be the highest quality, timely, and scientifically valid.

3. The content must not duplicate that of another existing activity offered by the AOSSM or any

other organization (including for-profit companies). If the topic is similar to that of an

existing activity, the content for this activity must be materially different and provide value

beyond that of the original activity.

CME Guidelines

Disclosure Information In advance of the cases going live, all individuals engaged in course planning, content

development, or presentation (i.e., course directors, planning committee members, moderators,

speakers, etc.) must complete and submit a financial disclosure form for review and approval

well in advance of the course. A review process is in place to manage and resolve any possible

conflicts of interest. If you have updated your disclosure for the year, you will need to reconfirm

this information is still accurate. This information is included in the official Faculty Invitation

that goes out once faculty are selected.

Fair Balance Presentations should be free of commercial bias for or against any product. Statements about

products should be objective and based on evidence drawn from generally accepted scientific

methods in the medical community. To facilitate fair balance, speakers should:

Disregard any attempts by commercial supporters to influence the content of their

presentation (to include selection of topics, speakers, and/or learning objectives).

Use generic, rather than trade names of products.

When using data from published studies, reference the source and highlight the study

design and its limitations. When using data from unpublished studies, confirm that the

study methodology is sound, and be prepared to produce the study if requested to do so

by the CME provider.

Discussion of Off-Label CME courses provide an educational forum in which off-label uses may be discussed. However,

speakers discussing off-label uses should indicate that the product is not labeled for the use under

discussion or that the product is still investigation.

HIPPA

Patient identity must be kept confidential. If you use photographs in your activity, faces and

other identifying features must be covered.

Additional Information More information on accreditation requirements can be found in The Accreditation Requirements

of the Accreditation Council for Continuing Medical Education (ACCME) document. To view or

download the complete text, click here.

Attachment B: Content Review Form

Content Review Form

Title of Activity:

Specialty:

Original/Expected Release Date: Termination Date:

Link to Activity:

Author/Faculty:

Learning Objectives:

Upon completion of this presentation, participants will be able to:

1.

2.

3.

Do you feel that the learning objectives as listed above were met? Yes No

Does the content submitted include pre- and post-test questions? Yes No

Does the content submitted include adequate and current references? Yes No

Did you perceive any commercial bias during this activity? Yes No

If yes, please explain what was perceived as promotional and not educational (Please be as

specific as possible):

How long was the review process?

Please provide additional comments for the faculty/author(s) if applicable:

Do you approve this activity? Yes No

Any other comments:

Signature of Reviewer: Date:

Print Name:

*After completing your review, please return this form to Heather Hodge at

hhodge@aossm.org.

Attachment C: Case Template (Not Approved)

Running Head: LEARNING TRANSFER FINAL PROJECT

References

American Academy of Orthopaedic Surgeons. (2014). Orthopaedic practice in the U.S. 2014.

Rosemont, IL: AAOS Department of Research and Scientific Affairs.

American Orthopaedic Society for Sports Medicine. (2014). 2014 AOSSM Member Survey.

Rosemont, IL: AOSSM Research Department.

Merriam, S.B., Caffarella, R.S., Baumgartner, L.M. (2007). Learning in Adulthood (3rd Ed.). San

Francisco, CA: Jossey-Bass.