Differential Diagnosis In Primary Care Collins Pdf995

Differential diagnosis in primary care collins pdf995

Differential diagnosis is a crucial skill for primary care physicians. General practice plays an increasing important role in undergraduate medical education. Via general practice, students may be presented with an overview of the whole spectrum of differential diagnosis in regard to common symptoms encountered in primary care.


This project evaluated the impact of a blended learning program using the inverted classroom approach on student satisfaction and development of skills and knowledge. An elective seminar in differential diagnosis in primary care, which utilized an inverted classroom design, was offered to students. Evaluation followed a mixed methods design: participants completed a pre- and post-test, a questionnaire, and a focus group discussion.

Interviews were transcribed verbatim and answers were grouped according to different themes. Test results were analysed using the Wilcoxon matched-pairs signed-ranks test. Especially the inverted classroom approach was appreciated by all students, as it allowed for more time during the seminar to concentrate on interactive and practice based learning. Further research is necessary in order to explore the potentials of this approach, especially the impact on development of clinical skills.

The online version of this article doi One of the essential skills of the clinician is the ability to make an accurate diagnosis. Especially in the field of primary care the process of making a differential diagnosis is a challenging and sometimes daunting task.

Diseases often present at an early stage and sometimes in an atypical form, therefore primary care physicians use a broad range of diagnostic strategies [ 1 ].

Medical students are usually taught differential diagnosis in the high prevalence setting of a university hospital. In addition, differential diagnosis of disease symptoms with a broad underlying aetiology e.

Differential Diagnosis

However, many students will later work as physicians in the low prevalence context of primary care, where they will have to deal with the diagnostic uncertainty that is connected with seeing patients with a broad range of symptoms [ 2 ]. Nowadays, e-learning is an integral part of medical education, and has been shown to be most effective when combined with face-to-face teaching, facilitating the so-called blended learning approach [ 4 - 6 ].

Differential diagnosis in primary care collins pdf995

Students increasingly use mobile devices like smartphones for learning purposes, and appreciate being able to utilise multimedia materials like video clips [ 7 ] or podcasts [ 8 ] for the preparation or revision of course content. Undergraduate medical students highly value the use of e-learning, especially when integrated into a blended approach [ 9 ].

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While blended learning approaches are well established in the postgraduate education of primary care providers [ 10 , 11 ], there are fewer examples in the field of undergraduate medical education in primary care [ 12 ]. This concept is already widely used in other disciplines, for example in the social sciences.

While students still preferred live lectures to video lectures, they valued the interactive class time higher than in-person lectures [ 14 ]. Inverted classroom education has just started to be incorporated into medical education [ 16 ], and there are so far only few published examples [ 17 - 20 ], however none of these in the field of primary care.

In contrast, we consider especially the field of primary care learning as highly suitable for an inverted classroom approach. Primary care includes a broad range of complaints and diseases that can be well taught via e-learning. Class time can then be effectively used to teach the complex process of medical decision making in patients with a broad range of symptoms, the typical setting of primary care, and to explore ways how to deal with the connected uncertainty.

We redesigned a seminar on differential diagnosis in primary care for undergraduate students, using an inverted classroom approach. In this study we wished to address the following questions:. Will students appreciate this approach for studying differential diagnosis in primary care? What will the gain in skills and knowledge of students learning with the inverted classroom approach be?

All participants of this elective seminar were in their fourth or fifth year of undergraduate medical studies.

Differential diagnosis in primary care collins pdf995

The different modules consist of interdisciplinary clinical pictures derived from the everyday routine of primary care. A special focus was put on the diagnostic accuracy of symptoms and signs in regard to the different underlying disease aetiologies of a given clinical picture.

The whole seminar takes place at an interactive skills lab attached to the Marburg University Hospital and utilizes trained simulation patients and different models.

Differential Diagnosis and Treatment in Primary Care

Further details of seminar content and underlying didactic considerations have been published elsewhere [ 21 ]. One year ago, we redesigned the whole seminar, using the inverted classroom approach [ 22 , 23 ]. At the faculty of medicine, our seminar is currently the only taught medical course using the inverted classroom design.

To our knowledge, this method is so far also not used by other primary care departments in Germany and in general not yet widely established in medical education at German Universities. Each seminar session is structured as follows:. Preparation: Several video and audio lectures giving introductory information and key knowledge content are available on the web-based learning platform.

Face-to-face teaching, which takes place in the interactive skills lab: several didactic approaches, such as simulation patients, training models, interactive small group work, and quiz exercises are used. Follow-up: Additional video and audio lectures present more detailed information in regard to the single leading symptom and its underlying etiologies.

Differential diagnosis in primary care collins pdf995

Supplementary facultative reading material e. We used a mixed methods design in order to investigate our study questions. Student satisfaction research question 1 was measured using information from different sources.

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The first source was a standardized questionnaire that is used by the University of Marburg to evaluate seminars. In addition, after the 8th out of 14 course sessions, an evaluation consisting of a focus group discussion and a short questionnaire that was handed out after the focus group were conducted.

We concentrated on the learning experience of the course participants, with a special focus on how the inverted classroom approach is perceived. For the quantitative evaluation of gain in skills and knowledge research question 2 we designed a questionnaire consisting of extended matching items 13 items , and key-feature tests 20 items.


Both examination formats can measure the process of clinical reasoning, and help to assess clinical decision making skills [ 24 , 25 ]. Together, both question formats covered all major seminar content.

Questions were pre-tested on another group of students with comparable pre-existing knowledge. After the pre-test we replaced two key feature cases that were too easy and one extended matching question that was too difficult and in addition modified one key feature question that was misleading.

During the seminar, students were asked to complete the pre-test at the beginning of the first session, and the post-test after the last session before starting to learn for the OSCE that was conducted one week later. Tests were completed by students using an unique identifier that allowed the anonymous matching of pre- and post-tests at an individual student level.

Additional file 1 shows example questions of the questionnaire. For the 4 variables of the standardized questionnaire for student satisfaction means and standard deviations were calculated and plotted.

Differential diagnosis in primary care collins pdf995

Results average in percentage of maximal test score that could be gained of the pre- and post-test were compared for statistically significant differences using the Wilcoxon matched-pairs signed-ranks test.

Error probability with a p-value less than 0. The focus group discussion was taped and transcribed verbatim. For data analysis we utilised a deductive approach based on the questions of the focus group guideline and of the short written questionnaire. Analysis was performed by SB and results discussed among all authors.


Responses from the focus groups and the free text answers from the evaluation questionnaires were grouped under different themes. The entire here presented data are part of the routine evaluation of courses at our faculty.

Ethical approval was therefore not required. Altogether, 17 students applied and were all enrolled in the seminar. One student did not participate in the pre-test. All 17 students took part in the focus group and the final evaluation.

The inverted classroom concept of the seminar reached the highest possible marks. Interaction with students and the relevance of the course contents were rated accordingly. The quantity of material offered, and the complexity of course content were rated as completely adequate.

Red bars reflect mean values and horizontal bars reflect standard deviations. Answers from the focus group discussion and the evaluation questionnaires can be grouped under the following themes:. All students appreciated the symptom-oriented approach, which was seen to reflect the reality of daily practice. This is what usually lacks in other seminars or lectures … it is difficult to remember all the differential diagnoses, because you have to screen all diseases that you know in order to see whether these contain the symptom… here in this seminar it is the other way around.

Differential Diagnosis in Primary Care

Most students mentioned that the seminar helped to understand the importance of epidemiological knowledge for the diagnostic process and the integration of this knowledge into the process of clinical decision making.

The blended learning design of the seminar using an inverted classroom approach was appreciated by all students, as it gave more time during the seminar to concentrate on interactive and practice based learning. The immediate application with the help of simulation patients is very practical. Some students criticized the fact that key information of the preparation videos was repeated during the face-to-face sessions.

What is Differential diagnosis?, Explain Differential diagnosis, Define Differential diagnosis

Several students mentioned the positive impact of teamwork during the seminar — a key competence that was also considered as important for later professional life. I think that this is also important for being a doctor later, to learn this capacity for teamwork.

For some students the seminar was also a trigger for meta-learning, as they reflected their own learning experience. Then I am most creative and it the knowledge remains in the long-term memory.

Differential diagnosis in primary care collins pdf995

Upper part: Overall results of the written pre- and post-test including confidence intervals. Percentages of the total number of possible points are presented indicating absolute gain in skills and knowledge.

Lower part: Results of the written pre- black color and post-test grey color stratified by test format. Gain in skills and knowledge of each individual course participant.

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We aimed to give a first account of the effects of a blended learning program in primary care with this study. To our best knowledge the above presented seminar is the first to teach differential diagnosis in primary care for undergraduate students using an inverted classroom approach. Our evaluation showed both a high satisfaction rate and a significant gain in skills and knowledge.

The high approval of our blended learning approach is consistent with the available literature. Our finding of high student satisfaction with this approach especially, is supported by the — presently sparse- literature in the field of medical education. While we could not identify evaluations of other primary care programs that use the inverted classroom model, there have been programs in teaching palliative care skills [ 19 ], cardiovascular, respiratory and renal physiology [ 20 ], renal pharmacotherapy [ 17 ] and perfusion skills [ 18 ].

All of the above mentioned programs used the inverted classroom approach and were positively evaluated, which supports our own findings. An additional finding in our focus group discussion was that the new learning experience during the seminar also triggered part of the participants to critically reflect on their own learning. He encourages a deep approach to learning which includes the promotion of guided self-questioning, using other students as a resource or to derive own heuristics to suit a given task [ 30 ].

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All these mentioned elements can be found in our course and it is interesting to note that an innovative and unusual teaching approach can trigger this kind of critical self-reflection, which we consider an important prerequisite for later professional life. While a broad acceptance of participating students is surely a precondition for establishing a successful blended learning program [ 31 ], there should also be a positive impact on clinical skills.