Case teaching method in clinical medicine, refers to the use of carefully selected cases, through the active guidance of teachers and the students ‘ learning, making system for students to understand theory of medical knowledge, clinical skills and logical thinking of a teaching tool. In the process of case teaching in clinical medicine, case selection and problem of design is the key, organization is key.
Case method is means education who spirit theory and actual organic combination of purposes, under teaching purpose, to case for basic teaching footage, will students introduced a specific of real situation in the, through teachers and students Zhijian, and life Zhijian of multi-directional interactive, actively participation, equal dialog and discussion, focus training students of clinical logical thinking, and reasoning judgment ability, to reached high-level cognitive learning target of teaching method [1]. It originated in United States, Harvard University, and is widely used in medicine, economics, management science, law practice, applying strong disciplines such as [2, 3]. With the traditional “teachers teach, students learn” teaching mode of one-way information transfer, case method not only advocating students ‘ “learning” (discussion), and more emphasis on teacher “guidance” (boot), is part of the study on the modes of learning, is an extension of students ‘ thinking, capacity training emphasized. Practice of clinical medicine is a subject of very strong, especially suitable for the application of case teaching method.
1 features and function of case teaching method
1.1 help stimulate students ‘ initiative
One notable feature of the case method, is to make students feel things and their own observations, analysis, reflection, so that their own sensible, law of development and changes of ownership of things. It both focus on theory teaching links, more note practice teaching links, to clinical case plot for clues, makes students consciously to entered asked disease, and examination, and set secondary check and treatment programme of work “site”, application past by learn knowledge, combination classroom theory teaching of enlightenment, active to will collection to of case information be analysis, and reasoning, and judgment, clear disease diagnosis of possibilities, prompted they diligent thinking, and at decision. Students passive lecture for positive thinking, the process of active participation in the process, each student’s subjective initiative effectively, fully mobilize the enthusiasm of the students ‘ learning. 1.2 in favour of improving student’s comprehensive quality
Clinical case teaching method by analysis of the actual case, students will ever learn Anatomy, pathological physiology, Symptomatology, diagnostic and other vertical and horizontal linkages related knowledge initiative, mastery, mutual penetration, flexible application. Consolidate knowledge and improving student’s comprehensive ability and capacity to address issues such as clinical diagnosis. Students through real-world case-discussions, experienced clinical analysis, process of thinking, reasoning and judgment, fully realized active participation, development, Exchange and cooperation, optimism, inquiry learning method brings the fun and help. Case method provides each student with a relative opportunities for personalized, multi-channel access to knowledge, in close connection with reality in the theory of learning to improve the comprehensive quality of students, laying a foundation for students lifelong development.
1.3 to promote the professional development of teachers
Clinical case, encourage teachers to widely collected a variety of complex and difficult cases in clinical practice, scientific arrangement and to collect the data, different case selection applies to teaching needs; pursuance continuous updates of medical theory and technique of diagnosis and treatment of development and change, make the necessary amendments, updates in a timely manner, so as to keep teachers teaching, scientific research level are constantly increasing. And teachers guide students analyze the clinical cases, the process of solving practical problems, is the process of teacher learning, could further improve the teachers ‘ own business quality.
2 case study organizations implement process
2.1 selection of typical clinical cases
Selection and preparation of clinical medical case is the basis and prerequisite for implementing case teaching, case level directly impacts on the quality of teaching is good or bad, so case choice should be based on the following principles:
Is a clear objective, the prominent theme. A good case, must show a clear set of objectives and a distinct topic, at least through discussions should enable students to deepen the understanding of some of the key points and difficulties in the course and to benefit from lessons learned theoretical knowledge for horizontal linkages, intertwining. Cases for deaths caused by acute cholecystitis, cholecystolithiasis extensive anterior myocardial infarction cases, it is stressed by the differential diagnosis of abdominal pain, in a process of discussion highlights in acute abdomen and abdominal disease identification of important, students from local to the overall expansion of clinical thinking, improve students ‘ ability to analyze and solve problems.
Second, objective truth, lively and typical. So-called real-world, typical that the case should be derived from clinical practice, and has a certain general, able to reflect more fully the proposed contents of theoretical system, and to inspire students ‘ thinking. In the actual activities of teachers from the phantasmagoria, complicated medical, to choose, by category and sort out a representative instance of clinical, students can play a role by analogy, reason by analogy. Select case must be lively and attractive, so as to arouse students ‘ interest, to in-depth discussion.
Third, moderate difficulty and amount of information. Teaching cases to have a certain degree of difficulty, not too simple. Complex should consciously choose some critically ill, easily lead to misdiagnosis cases stimulate students ‘ interest in learning, and active enthusiasm for study reasons, data access, in-depth analysis. In addition, to reflect the key issue in the case, teachers should provide clear information to facilitate cases of the use and implementation of case teaching. Hansen, who referred to the case when writing once said, “from the perspective of case author, I am willing to put the case into a description of real events, the information contained therein, to be enough to attract interest in thinking and debate, is rich and instructive. “[4]
2.2 design issues
Question design is key to the smooth implementation of case teaching. Issues of design, which is the common sense, of a single, such as which organs are included on the upper right abdomen? ; Can also be a logical, integrated, such as with symptoms, signs and auxiliary examination information inferring what is the most likely diagnosis? Or: why the patients follow the treatment of cholecystitis well? And so on. Generally, arrangements should be in the order as to the problem of curriculum theory as the guidance going forward, from the outside to the inside, and easy-to-digest. When you select the real cases, final diagnosis hidden to pay particular attention to the case, especially the pathological results of the autopsy must be hidden, thinking space left to the students is broad enough, and participation in class discussion space.
2.3 case layout and group discussion
Layout case study is designed to give students have full understanding and analysis on the case, so that students can better active participation in the teaching process. Due to limited classroom time, students take the time to understand the case is unlikely in the classroom, the arrangement of case should be completed before the lesson. When the layout via a local area network (such as a personal home page or other specific home page) published are also available through the issuance of paper materials. General layout of a week or so before the lecture as well.
A panel discussion before class, students develop self-confidence, and master the textbook is an extremely effective way. Establishment of the learning group is for students to change past “go it alone” roles in each other voluntarily formed on the basis of “learning communities”, it should not be too large, General 4-6, not more than 10 people. Panel discussion provided for each student in the form of a participation in the Exchange, opportunities to express their views and ideas, cultivate a spirit of teamwork, enhance case studies of the effect.
2.4 class analysis and summary
Analysis of classroom discussion-analysis methods should be adopted as far as possible, the students take, encouraging students to fully speak, teachers only as a facilitator, cleverly guiding discussions, timely introductory briefing or discussed. If the teacher to do your basics before the discussions (as a concept or content system) explanation, it should not be too long a time. If the teacher before the discussion is not for explaining basics, you can require students to speak basics of fusion in the discussions in the discussion. Student discussion, teachers should pay special attention to Flach point appeared in a discussion of the issues and thought, to promptly adjust teaching focus, make teaching more targeted. At the time of conclusion, students in teachers ‘ comments on the subject during the discussions (such as ideas and argumentation methods, problems, etc), attention should also be made according to the logic of teaching content of the main line a complete analysis and conclusions of, especially on cases involving key clinical manifestations of the value of the differential diagnosis should also be extended to explain, to improve case teaching practical effects.
2.5 after school jobs
May this discussion in the form of jobs require students to compose a written analysis reports, in 1500-3000 words. Mainly help students to digest this discussion, to consolidate the school you want to feel more deeply, future clinical medical personnel can also exercise type Foundation.
3 paying attention to some problems in the case teaching of clinical medicine
3.1 a good grasp of application timing
Case teaching requirements students must first acquire a certain amount of theoretical knowledge, only theoretical knowledge thorough understanding of the premise to fully carry out analysis and discussion of case, achieve teaching objectives. On teaching, Diagnostics, surgery, clinical medicine, etiology, mechanism of disease, symptoms, signs and laboratory examination construe of such basic knowledge is essential to the advantage only of case teaching method and traditional teaching complement can be on full display.
3.2 adequate preparation
The saying goes, don’t fight no preparation for battle, case teaching as well. Adequacy of preparation before class is the important guarantee for the smooth implementation of case teaching. First of all, teachers must master the whole case material, clearly involves the teaching of basic theories of; followed by forecasting potential ideas and perspectives of students, and determine their own intervention timing of discussions, create an elaborate case discussion guide plan; three is gathering case-related symptoms, signs, and auxiliary images such as checks, image data, making the multimedia courseware. Using text, graphics, images, sound and other multimedia teaching method of combination of elements, or visit the clinic so that it seems to better attract the attention of students.
3.3 control of teaching rhythm
Emphasis on teaching time, control of the content and form. Because of the limited classroom time in hours and, in the implementation of case teaching in the process, not only with teachers teaching schedule as a whole is in order, also requires teachers of the overall ability to master. Class analysis, case discussion of teachers to seriously listen to the students to speak, raised key issues in a timely manner, prompted students to do a more in-depth consideration, or adjust the direction of thinking; timely summarized the recommendations or opinions of students, help students to clear thinking, built on a solid theoretical basis point. Also when there is silence or too intense in classroom discussions, timely intervention, creating a relaxed and harmonious atmosphere; according to the priorities assigned to discuss the problem of time, using a variety of different ways of effective control of the process of classroom discussion, discussion of seeking to achieve the desired effect.
4 Summary
Case teaching method is the outcome of the quality education reforms [4], to make it in clinical medicine teaching in universities full play to the role, need combined with the current situation on health reform, appropriate adjustments to training objectives and training program in clinical medicine, and create a system, a wealth of case teaching resource library. At the same time, teachers in such areas as education and teaching methods and teaching means also to make the appropriate changes. Only in this way, to develop basic skills and the ability to work in a down-to-earth manner of practical, innovative clinical medical personnel.
References:
[1] Harling KF; Akridge J. Using the case methodof teaching. Agribusiness 1998;14(1):1-14
[2] Harold W.Webb; Grandon Gill; Gary Poe.Teaching with Case Method Oline: Pure Versus HybridApproaches. Decision Sciences Journal of InnovativeEducation. 2005;3 (2): 223-250
[3] William F. Crittenden.A social learning theoryof cross-functional case education. Journal ofBusiness Research.2005;58 (7):960-966
[4] Sun gun industry. Case teaching [m]. Tianjin: Tianjin education press, 2004:1-53
案例教学和临床医学教学
临床医学案例教学法，是指运用精心选择的案例，通过教师积极引导和学生自主学习，使学生系统理解临床医学理论知识、掌握临床基本技能和逻辑思维方法的一种教学手段。在临床医学案例教学过程中，案例的选择与问题的设计是关键，组织实施是重点。
案例教学法是指教育者本着理论与实际有机结合的宗旨，根据教学目的，以案例为基本教学素材，将学生引入一个特定的真实情境中，通过师生之间、生生之间的多向互动，积极参与，平等对话和研讨，重点培养学生的临床逻辑思维、推理判断能力，以达到高层次认知学习目标的教学方法[1]。它起源于美国哈佛大学，并被广泛应用于医学、经济学、管理学、法学等实践性、应用性较强的学科[2、3]。与传统的“教师教、学生学”，单向式信息传递的教学模式不同，案例教学法不仅仅倡导学生“学”（研讨），更强调教师“导”（引导），是属于研究性的学习模式，注重的是学生思路的扩展、能力的培养。临床医学是实践性非常强的一门学科，尤其适合案例教学法的推广运用。
1 案例教学法的功能与作用
1.1 有利于激发学生的主观能动性
案例教学法的显著特点之一，就是让学生自己感受事物、自己观察、分析、思考，从而使他们自己明白事理，自己掌握事物发展变化的规律。它既注重理论教学环节，更注意实践教学环节，以临床病例情节为线索，使学生自觉地进入问病、查体、设定辅助检查和治疗方案的工作“现场”，运用以往所学知识，结合课堂理论教学的启示，主动地将收集到的病例资料加以分析、推理、判断，明确疾病诊断的可能性，促使他们勤于思考、善于决策。变学生被动听课的过程为积极思考、主动参与的过程，有效地发挥每个学生的主观能动性，充分调动学生学习的积极性。1.2 有利于提高学生的综合素质
临床案例教学法通过剖析实际病例，引导学生将以往所学解剖学、病理生理学、症状学、诊断学等纵向、相关知识主动进行横向联系，融会贯通、相互渗透、灵活运用。既巩固已学知识；又提高学生的综合运用能力和解决临床诊断等际问题的能力。学生们通过真实病例的讨论，亲身感受了临床分析、思考、推理和判断的全过程，充分体会到主动参与、探究发展、交流合作、乐观向上的学习方法带来的乐趣与帮助。案例教学法为每个学生提供了一个相对个性化的、多渠道的获取知识的机会，在紧密结合实际的理论学习中提高了学生的综合素质，为学生的终身发展奠定了基础。
1.3 有利于促进教师的专业发展
采用临床案例教学法，能促使教师深入到临床实际工作中广泛收集各种复杂疑难病例，并对搜集的资料进行科学整理，选编出适用于教学需要的不同案例；同时依据医学理论的不断更新和诊疗技术的发展与变化，及时进行必要的修正、更新，从而使教师的教学、科研水平得到不断地提高。而教师指导学生剖析临床病例、解决实际问题的过程，是教师再学习的过程，也会使教师自身的业务素质得到进一步提高。
2 案例教学法的组织实施过程
2.1 选编典型临床案例
精选和编写临床医疗案例是实施案例教学法的基础和前提，案例质量的高低直接影响着教学效果的好坏，所以案例的选择，应依据以下原则：
一是明确目标，突出主题。一个好的案例，必然表现一个明确的目标和鲜明的主题，至少应该能使学生通过讨论加深对课程中的某些重点和难点的理解，并能利用课程中所学理论知识进行横向联系，融会贯通。如一例误诊为胆囊炎、胆囊结石而导致死亡的急性广泛前壁心肌梗死案例，它所强调的是腹痛的鉴别诊断，在分析讨论的过程中凸现急腹症与腹外疾病鉴别的重要，使学生的临床思维由局部向整体扩展，提高学生分析问题和解决问题的能力。
二是客观真实，生动典型。所谓真实、典型即该案例应当是来源于临床实际，且具有一定的综合性，能够较为全面地反映拟学内容的理论体系，并有利于启发学生的思维。教师应从千变万化、错综复杂的医疗实际活动中，分门别类地选择和整理出具有代表性的临床实例，对学生能起到举一反三、触类旁通的作用。同时选择的案例必须生动活泼、引人入胜，这样才能引起学生的兴趣，以便展开深入的讨论。
三是难易适中，信息适量。教学案例要具有一定的难度，不可过于简单。应有意识地选择一些复杂危重、容易造成误诊的病例，激发学生学习兴趣，以及主动探究原因、查阅资料、深入分析的热情。此外，对于案例中所要反映的关键问题，教师要提供条理清晰的相关信息以便于案例的使用和案例教学的开展。汉森等人在谈到案例编写时曾说过：“从案例作者的角度看，我愿意把案例说成是对真实事件的描述，其中所包含的信息，要能够足以引起大家思考和争论的兴趣，并且富含启发性。”[4]
2.2 精心设计问题
问题设计是案例教学顺利实施的关键。问题之设计，可以是常识性、单一性的，如：右上腹部包含哪些器官？等；也可以是逻辑性、综合性的，如：结合已有的症状、体征和辅助检查资料推断最可能的诊断是什么？或者是：该例患者按照胆囊炎治疗为什么效果不好？等等。通常情况下，问题的安排顺序应该以课程推进的理论体系为导向，由表及里、由浅入深。选择真实案例时，要特别注意将案例最后诊断结果隐去，尤其是尸体解剖的病理结果一定要隐去，留给学生足够广阔的思维空间，以及参与课堂讨论的空间。
2.3 案例布置与分组讨论
布置案例的目的就是让学生对案例有充分了解和分析，使学生能更好地主动参与教学过程。由于课堂教学时间有限，让学生在课堂上花时间了解案例不太可能，故案例布置应在课前完成。布置时可以通过局域网（如个人主页或其他特定主页） 公布，也可通过印发纸质资料等。一般应在讲课前一周左右布置为好。
开展课前的小组讨论，对于学生建立自信和掌握教材是一种极其有效的方法。学习小组的建立是要求学生改变以往“单干户”的角色，在彼此自觉自愿的基础上形成“学习共同体”，其规模不宜太大，一般4－6 人，不超过10人。小组讨论的形式为每个学生提供了参与交流，发表自己见解和主张的机会，培养了团队合作的精神，增强了案例学习的效果。
2.4 课堂分析与总结归纳
课堂分析应尽量采用讨论式分析方法，即由学生唱主角，鼓励学生充分发言，教师仅作为主持人，巧妙引导讨论，适时进行引导性讲解或归纳总结。如果教师在讨论进行之前要作基础知识（如概念或内容体系） 讲解，则时间不宜过长。如果教师在讨论进行之前未作基础知识讲解，则可要求学生在讨论时将基础知识融合在讨论发言中。在学生讨论时，教师应特别注意讨论中显现的问题以及思想闪光点，以便及时调整课堂教学重点，使教学更有针对性。在归纳总结时，教师除点评学生的讨论过程（如观点、论证方法、存在的问题等） 外，还应注意根据教学内容的逻辑主线提出完整的分析过程和结论，特别是对病例中涉及鉴别诊断的关键临床表现的价值也应作引申讲解，以提高案例教学的实际效果。
2.5 课后作业
可就本次讨论以作业形式要求学生撰写书面分析报告，字数在1500－3000 为宜。主要是帮助学生消化本次讨论内容，更深入地巩固所学所想所感，也可以锻炼未来临床医学人才的文字功底。
3 临床医学案例教学中应注意的几个问题
3.1 把握好运用时机
案例教学法要求学生必须首先掌握一定的理论知识，只有在对理论知识透彻理解的前提下，才能充分开展案例的分析和讨论，达到教学目的。对诊断学、内科学等临床医学的教学，疾病的发病原因、机理、症状、体征和实验室检查等基本知识的串讲是必不可少的，案例教学法的优势只有在与传统教学法的相互补充中才能得以充分展示。
3.2 做好充分的前期准备
俗话说，不打无准备之仗，案例教学也是如此。课前准备是否充分是案例教学能否顺利实施的重要保证。首先教师必须精通整个病例材料，明确教学要涉及的基本理论观点；其次是预测学生可能提出的思路与观点，并确定自己介入讨论的时机，制订周密的病例讨论引导计划；三是收集与病例有关的症状、体征、辅助检查等影像、图片资料，制作多媒体课件。运用文字、图表、图像、声音等多种元素结合的多媒体教学手段，使其仿佛亲临诊疗现场，更好地吸引学生的注意力。
3.3 掌控好教学节奏
着重强调教学时间、内容与形式的掌控。由于学时数和课堂时间的限制，在案例教学实施过程中，不仅要求教师对整个教学进度安排井然有序，还要求教师具有全盘驾驭的能力。课堂分析时，教师要认真听取学生对病例分析的讨论发言，及时提出关键问题，促使学生对问题做更深入的思考，或调整思考问题的方向；适时归纳学生的建议或见解，帮助学生理清思路，把观点建立在扎实的理论基础之上。还要在课堂讨论出现冷场或过于激烈时，适时介入，营造一种轻松和谐的氛围；要根据问题的轻重缓急来分配讨论时间，运用多种不同的方式有效控制课堂讨论的进程，争取达到预期的讨论效果。
4 小结
案例教学法是素质教育改革的成果[4]，要想让它在高校临床医学教学中充分发挥作用，有必要结合当前医改形势，对临床医学人才培养目标和培养方案进行适当调整，并创建系统、丰富的案例教学资源库。同时，教师在教育观念、教学方法、教学手段等方面也要作相应的转变。只有这样，才能培养出基本功扎实、工作能力强的应用型、创新型临床医学人才。
参考文献：
[1]Harling KF; Akridge J. Using the case methodof teaching. Agribusiness 1998;14(1):1-14
[2]Harold W.Webb; Grandon Gill; Gary Poe.Teaching with Case Method Oline: Pure Versus HybridApproaches. Decision Sciences Journal of InnovativeEducation. 2005;3(2):223-250
[3]William F. Crittenden.A social learning theoryof cross-functional case education. Journal ofBusiness Research.2005;58 (7):960-966
[4]孙军业. 案例教学[M]. 天津:天津教育出版社，2004:1-53
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