Abstract
Problem-based learning (PBL) is now a common method of teaching and learning in medical schools around the world. 1 . The fundamental premise of PBL is that a problem, from a case or clinical scenario, is used as the basis for small group discussion and independent, self-directed learning. The material, usually presented as a written case or video trigger, serves as a stimulus for learning.
PBL should ideally require an understanding of the relevance of both basic scientific knowledge and clinical principles. The case is pivotal to the PBL process. The case must trigger students to an exploration of the objectives identified by faculty as important, should be interesting and of relevance to medical practice, should stimulate discussion, and should be sufficiently open to allow different avenues of thought to be pursued. 1 Wood lists a number of possible materials on which to base a PBL case, 1 but a narrative account written by a real patient is not among them. Most commonly, PBL cases are written by academic or clinical faculty members using one patient's case notes, or by construction of a composite, ‘typical’ patient, drawn from the writer clinical experiences and knowledge.
Although the literature on PBL in medical education is considerable, there are very few papers describing the use of PBL specifically as it relates to psychiatry. 2 ,7
Despite the fact that actual, rather than standardized, patients and clinicians are used for teaching, the use of real patients and real people involved in the care of patients is a concept rarely mentioned in the medical education literature. 8 Because patients are now viewed as collaborators and partners in their health care, this seems unusual. Emphasised within all medical curricula is listening to patients, not just in the literal sense, but through an understanding of patients's personal stories. Real patients present complexities that can be controlled in contrived paper cases but in clinical medicine-and perhaps particularly in psychiatry — an ability to accept ambiguity and deal with complex problems is an essential skill and, we would argue, one that should be broached from early in medical training.
There is a growing literature to support the notion that expressive writing about traumatic experiences is beneficial to both psychological and physical health. Improvements in physical and psychological health have been associated with writing for as little as 15 min over 3 days, and this finding has been replicated across age, gender, culture, social class and personality type. 9 The benefits of writing about traumatic events have been demonstrated for patients suffering physical maladies such as asthma and rheumatoid arthritis. 10 Similarly, the efficacy of writing for psychological illnesses such as depression has been shown empirically, 11 and even psychologically healthy subjects have reported positive effects from writing about emotional experiences in their lives. 12
The aim of the present paper was to describe a problem-based case written for first-year undergraduate medical students at the University of Adelaide, with a focus on psychological and psychiatric concepts, written in collaboration with a patient. Although a therapeutic benefit for the patient was not a direct aim of the exercise, we postulated that the process of writing about one's psychiatric illness may be a positive experience, and that partnership with us may be empowering.
METHOD
The second author identified an inpatient under his care whom he thought would be willing to tell her story. He believed that it was unlikely the process would cause her distress or harm. To maintain anonymity the patient asked to be referred to as ‘Ms Grace Ashton's. Both authors met with her and spoke with her over the course of 90 min about the process of PBL, and the reasons why they felt her story was important. It was stressed that the authors wanted Grace to be a collaborator in this process, and that her role was a significant one. Grace was then given a consent form and advised to talk over the proposition with her family if she wished. It was explained that consent, if given, was continuing, meaning that unless Grace contacted us to request otherwise, the material could be used repeatedly for teaching purposes. Grace did discuss her participation with her son, a process that we encouraged given that it was possible that some material may have pertained to family members.
Two weeks later, after giving informed consent and while still an inpatient, Grace provided us with an 8 page, handwritten account of her medical history. Several days later a further 2 pages of manuscript were sent.
We both edited her account, and made it suitable for a PBL format. We were careful to de-identify the material to maintain anonymity. Our edited version was then given to Grace for her final approval. Grace asked that she be provided with a typewritten account of her transcript. She was given this, and a final version of the PBL case that was to be distributed to students, with Grace included in the authorship.
The overall aim of the case was to introduce students to the integrative and interactive workings of the human nervous system, with an emphasis on the biopsychosocial model.
The material that we took from Grace's narrative was strategically chosen to help students consider the following learning objectives.
A basic conceptual understanding of the human nervous system, and how it interacts with the environment to receive, process, reformulate and respond to information (stimuli). An understanding of the importance of psychosocial stressors on the individual, and the need for management of those stressors. An ability to describe the development of global cognitive impairment, including the feeling of being confused and mentally impaired. An appreciation of the importance of listening to what the patient is trying to tell you. Consideration of the illness and impairment from the perspective of the patient. An appreciation of diagnostic and management decisions and the impact of these upon the individual.
Students met in small groups, facilitated by ‘non-expert’ tutors, and were presented with Grace's own words over three sessions. It was made explicit to students that Grace was a real person and that this was her voice.
In each session, students read an extract from Grace's narrative and then explored the meaning, the psychological, social and biological implications of her illness, the importance of the doctor-patient relationship, and any other issues that they felt needed to be considered in order to grasp an understanding of the case. Excerpts from Grace's narrative were strategically selected to generate discussion around issues pertinent to the learning objectives of the case.
Session 1 included four quotes, given two at a time, for students to consider. The quotes were selected to prompt consideration of the nervous system, including the brain, and the effects of stress on this system, and the effects of mental illness on an individual, particularly the consequences of a diagnosis of epilepsy.
Session 2 consisted of three quotes that aimed to generate thoughts and questions about cognitions, the way in which they are tested and how cognitive functioning may be affected by medication. In the final session, students were guided to consider, over three quotes, what the consequences might be if the health-care practitioner does not listen to the patient. Near the end of the session, students were given a summation of a psychiatrist's understanding of the problem as compared with Grace's interpretation, to contrast the explanatory models of illness of both parties. In conjunction with the problem-based tutorials, students also received a series of lectures to clarify material they were exploring in their self-directed learning. The lectures, for which notes were available online, focused on an introduction to the nervous system, higher function testing, the Mental State Examination, the neurobiology of epilepsy, the physiology of anticonvulsants and antidepressants, how to measure quality of life and ethics in psychiatry.
The narrative content of the tutorial sessions (which was provided to students both in paper form and over the University website, accessible only to medical students) was as follows.
Session 1A
I am a 59-year-old woman and I find myself with a nervous system that is exhausted. This is no surprise to me. My life has been inwardly very stressful.
I have been unable to access my higher mental faculties. My brain, in the past, was never able to do that which was asked of it.
Session 1B
At the age of 12 I was diagnosed with epilepsy. I was in a lonely place. It was traumatic and frightening on an inner level. I remember an event that had occurred one year earlier. I saw a girl at school have a fit. The people around her laughed and said, “Don't worry about her, she's insane, they'll be coming to take her away soon.”
Looking back, I see this event as the trigger which made me look into myself and which caused me to confront the issues of mental illness, trauma, imperfection and prejudice. At first I locked myself up and blocked it out as best I could. When I was 30 I decided to confront that which I feared.
Session 2
I was on medication to control my epilepsy. I had no idea how powerful primidone was. When I went off it recently I was delighted to find I had a brain. I noticed things in greater detail. I saw my shortcomings. I saw the life that might have been.
The apathy set in about three months after going off the primidone. I was devastated. Apathy was new to me. There were so many things I couldn't do during this period. I couldn't remember what I had for breakfast. I couldn't read a bus timetable. I found it hard to use ATMs. I stood in my kitchen at home, in front of the microwave. I was unable to think through how it worked, which buttons to push, even though I had used it before every day.
My physician ordered a SPECT scan, and whilst I was told it was not conclusive for dementia, I was told the test should be repeated in a year. I was told I would need a good psychiatrist.
Session 3A
The next step was the new psychiatrist. He was young, supposedly up-to-date and good with drugs. This was not my experience. At first tests were done to rule out dementia. The diagnosis was depression caused by chemical imbalance and depression caused by lifestyle. I was told I needed to get out more. I was told I needed to join groups. I was told if I didn't do this I would never get better.
For the past 25 years I had seen my health problems as quite simple — a nervous system stressed by good or bad stress and needing not to be overloaded. I long ago learned that my mood improved with rest. But the need to rest was seen by the psychiatrist as a symptom of depression.
[At around the same time that her primidone was ceased, Grace's new psychiatrist changed her anti-depressant from trimipramine to sertraline.]
I experienced suicidal feelings as I made the change in medication. But I was more mentally alert. I reported the suicidal feelings but there was virtually no response. I was made to feel my feelings were irrelevant. I reported debilitating sleeping problems. Sleep was erratic and I was very groggy until 11 am. It was very hard to keep trying. I reported significant weight loss. I was totally unable to function. I had a buzzing in my head and I had to lie down all the time.
Session 3B
[Through a chain of events, Grace was eventually hospitalized and admitted to a psychiatric ward. The following is an account of the consultant's interpretation of what was wrong with Grace.]
The medical explanation of Grace's illness
Grace is a 59-year-old woman who was diagnosed with epilepsy at the age of 12. She was treated with an anti-epileptic drug called primidone for the next 35 years. Primidone is a powerful anticonvulsant that stabilizes neuronal membranes and can have the effect of dulling the brain and provoking depression. After having been seizure-free for many years, the primidone was ceased. Despite the fact that she was then able to see things with greater clarity, the downside was she became overwhelmed by environmental stimuli. She was not used to perceiving the world with this degree of detail. As a homeostatic self-protective mechanism, she withdrew from the environment, as she realized that her brain needed a rest. This withdrawal was unusual for her and interpreted by her as apathy, and diagnosed by doctors of different specialties, first as dementia and secondly as depression. In order to treat her depression, the psychiatrist changed her antidepressants. This combination of ceasing the anticonvulsant and changing the antidepressant had the unfortunate result of worsening her epilepsy, and further compromising her cognitive functioning. Ceasing the antidepressant and recommencing the treatment of her epilepsy with a more modern, less toxic anticonvulsant has restored some of the balance and helped her to be less withdrawn.
Grace's thoughts about her illness, after having been treated
I am glad I survived as I have discovered there was a real, not imaginary reason for my fatigue over the years. I finally got it explained to me as the collapse of the nervous system. I had suspected for some time that it was the nervous system wearing out. At least we know what we are dealing with now and I am on the proper medication.
I have been fortunate to have had good, clever, dependable people supporting me. It must have been very perplexing for them, but they hung in there. Without this support, I probably would not have survived.
In a way my life has just begun. I have begun to break through the fear of having fits (avoiding anything ‘clever’), the fear of failure (inability to do things), fear of rejection (pleasing others), fear of humiliation (keeping quiet) and the fear of insanity. It is a lonely place but it is also a shelter. I can now incorporate the concept of mental illness as a part of life. I see that my life is exactly that — my life. It is now up to me to grow through the experience. I have no unrealistic expectations about the future as I know the road will not be easy — the body is weak. But I am empowered. My life now makes sense to me and I can see how others might benefit from my experiences. I'd have been lost in the system, filed under depression, if I hadn't listened to the inner voice. But who was listening to me? Who is taking notice of the long and short-term effects of the powerful drugs being used to supposedly improve one's quality of life?
DISCUSSION
The aim of the present paper was to describe the use of a psychiatric patient's narrative as the basis for a PBL case. The narrative with which we were provided was rich. Our task of editing the case was challenging because the patient provided us with numerous avenues for possible exploration. Guided by our case objectives, we were able to meaningfully extract relevant excerpts that allowed us to give justice to the narrative even though we were able to present only a fraction of it.
No formal evaluation was taken to ascertain the impact of this case upon students, or their perceptions of it. This was a missed opportunity. However, the impact of the opportunity for Grace to tell her story and be heard was evident. Grace has a long and substantial psychiatric history. Writing her story resulted in providing her with coherence, which provided her with greater meaning and helped her to understand and manage the emotions related to her illness.
13
Also, the task gave her a sense of personal achievement and empowered her, as she became an equal collaborator in the teaching process. She wrote:
I am pleased to have the opportunity to tell my story. I thank you for giving me the opportunity to speak and to write. It has been a truly cathartic experience. My life now makes sense to me and I can see how others might benefit from my experiences. There must be a lot of people like me out there. Perhaps my story might help them.
Not all patients will wish to write about their experiences, 14 and not all psychiatric patients will be suitable candidates for either using narrative as therapy or as the basis of a PBL case. Clinicians will need to make their own decisions about individual patients and the suitability of this approach, and informed consent will be an important aspect in decisions about whether a patient's story should be used as a teaching tool outside the ward environment. Utilizing patients from a hospital setting requires careful selection in terms of the seriousness of their illness, consent and confidentiality. 8 In addition, it is important that the treating doctor's relationship with the patient is not compromised in any way; again, the clinician's judgement will be paramount in this regard.
There is a tendency for psychiatry to be viewed unfavourably as a specialty among medical students. Singh et al. 5 and Baxter et al. 6 found that medical students's attitudes towards psychiatry became more positive following undergraduate psychiatric training in the short term but not in the longer term, and that these attitudes decayed over a 1 year period. In both studies, the impact of a 6 week problem-based attachment was evaluated. Perhaps ongoing exposure to psychiatry in an integrated problem-based curriculum would facilitate long-term attitudinal change, but to our knowledge this is yet to be investigated. Similarly, the use of real patients in teaching may promote interest in psychiatry, but this is yet to be empirically demonstrated.
Machado and Goncalves see narrative as ‘a way of understanding human experience and as a clinical tool's, and posit narrative as a common ground for academics and clinicians to understand and promote change. 15 We assert that, in addition, narrative can be used as a teaching tool, and that medical educators can also take advantage of this. Narratives have an authenticity and credibility that an academic text-book cannot impart. 16 Read in conjunction with academic material as part of the PBL process, they are under-utilized yet powerful teaching and learning tools.
Footnotes
Acknowledgements
We are indebted to Grace Ashton for her willingness to share her story and engage in the teaching process with us. We also thank the University of Adelaide Medical Education Unit for the opportunity to contribute to their PBL programme.