By: Rachel W. Thompson, MD | Pediatric Clerkship Director | Boston University School of Medicine

Like many others, Boston University moved to a shortened virtual-only clerkship (packed with the full knowledge of our regular in-person 6-week clerkship, of course) in March of 2020. We were able to leverage Aquifer cases as a framework for preceptor discussion sessions and learning activities. The plan outlined below was for our 2-week virtual pediatrics clerkship, but I think the framework could apply to a variety of clerkships or courses transitioning to virtual group discussions.

Scheduling Small Group Precepting Sessions

We designed the two week-curriculum to mirror the different services and clinical experiences students would typically rotate through, moving progressively from nursery to well-child care, and then to varying depths and acuity of patient illness.  Small groups of three to four students met in physician-precepted online discussion sessions six times over the two weeks with the cases aligning with the clinical domain they were learning about. Each session was structured as a deep dive into one Aquifer case. While the students in the groups were consistent from one session to the next, the preceptors typically did 2-3 sessions each.  This allowed us to match the expertise of our preceptors to the cases and groups, allowing preceptors to choose the case they cover.

Oral Presentations & Discussion

For each session, every student comes prepared to give an oral presentation on the assigned case. Depending on the case, either one student will give the presentation, or the preceptor may divide presentations into sections (history/physical exam, differential diagnosis, discharge instructions, etc). 

At each stage, there is a planned pause for discussion, prompted by the preceptor’s copy of the Aquifer Case Analysis Tool (ie. what were the pertinent elements of the history, what was overlooked, how would you support the differential diagnosis, etc).

Sharing Expertise & Deeper Learning

The magic happens when the preceptor shares their pearls about the management of the case, adding personal experiences, expertise, and deeper learning beyond the standard case content. For example, building on the framework of the Aquifer syncope case, one of our preceptors who is a cardiologist brought multiple ECGs (shared on Zoom) and had each of the students tell her first what one might look for on an ECG as a source of syncope, and then helped them learn to read a pediatric ECG. 

Another attending (who runs our general academic pediatrics division) sent each student a pertinent article in advance, asking them to augment their clinical reasoning on the case and walking them through an analysis of the data. I think for many of us, this was the best part and felt the most similar to how we really teach in the clinical setting.

Writing Notes & Follow-up

Lastly, each student has to submit to the preceptor a “note” for the medical record based on the final presentation of the patient which appropriately summarizes the history of present illness across all visits. This worked very well with the students who were experienced with note writing.  However, for more novice students, I found that the Case Analysis Tool form is a great method to orient students to thinking through the case data.  I plan to use this with the Block 1 students in the virtual clerkship this summer, and then move to requiring a note once students know how to break down the case.

If there were good questions raised that went unanswered, we sometimes assigned that as “homework” and had students teach the group in our next meeting. For example, I knew one of the students was interested in radiology, so when we were discussing pertinent findings of increased ICP on CT for a patient, I asked him to return and present on that the following meeting–and he did an exceptional job, preparing a few slides and talking us through the findings.

Lessons Learned

I have used the Aquifer cases for years in our clerkship, typically as a means of self-directed learning and to facilitate uniformity in exposure to a variety of different patients.  From this experience with the students, I learned just how much there is to unpack from each case, and how much more students can learn when there is the ability to discuss subtle but pertinent elements of the history and physical that are woven into the cases.  It was exciting to see them energized about learning more, asking questions as they would about a real patient, and then pursuing self-directed learning and providing peer teaching.  With all of those factors, it was possible to do a true (albeit limited) assessment of clinical skills in the virtual setting.

For those considering implementing a model like this, here are some strategic lessons learned: 

• It’s best for the faculty member to set up their own zoom sessions and coordinate scheduling with their group.  We had a shared google calendar so that everyone could see all the sessions to better coordinate. 
• The faculty time commitment was approximately 2-3 hours per session: 1 hour in person, with time on either end to coordinate the timing, become familiar with the cases in advance, and edit notes.  
• I feel we benefited from a small group size as that essentially required active participation from each student, but it’s possible for a group of 5-6 to work as well.  
• I provided each faculty member with the Aquifer case summaries and learning objectives to help them choose cases.
• I used the Case Analysis Tool (CAT) the first time and had students write notes in the second implementation due to student feedback that this was more useful at that stage of their training (end of the clinical year)—however they proposed using the CAT with novice learners. 
• For students who have not yet seen pediatric patients, supplementing the Aquifer case with videos of children was seen to be helpful. For example, showing students videos of children with different degrees of respiratory distress was recommended by one of our preceptors.

Rachel W. Thompson, MD
Pediatric Clerkship Director
Boston University School of Medicine
Rachel.Thompson@bmc.org