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Presenting case studies on a microcomputer.

Increased availability of microcomputers and ready-to-use educational software have spurred development of computer-assisted instruction (CAI) in clinical labs.

CAI for medical technology students and the lab staff may range from simple question-and-anwer lessons to case studies involving decision making at several junctures. With the appropriate educational material, CAI enhances learning activities. Otherwise, it becomes just a gimmick--a simple substitute for more conventional forms of presenting information.

Case studies are good teaching tools and ideal candidates for CAI. They give students a chance to synthesize patient information, laboratory data, and knowledge of disease states. When a strudy encompasses several disciplines, it can help the student understand their interrelationships.

In a key contribution to the exercise, the computer requires the student to work through the case from beginning to end--reading a case on paper on one's own may not achieve the same result. In addition, by reviewing the student's computer-entered choices, the instructor may uncover areas that need further discussion.

We chose a complex thyroid toxicosis case study as a prototype, both to check out available software and to learn how to construct other studies for use in our medical technology program. The case was adapted with permission from "Disease States and Conditions in Man Correlated with Chemistry Procedures," a prepackaged education program of the American Society for Medical Technology.

Figure I diagrams the entire study with all the possible branches a student can pursue. The lesson begins with a paragraph describing the case (Figure II). The student proceeds to a multiple choice "first question" that leads to one of four sources for more information: physical findings, bacteriologic culture, patient history, or tentative clinical interpretation. Each source of information routes the student to another section on physical findings (B), laboratory data (C), or additional clinical information (D and D-1). These are shown in Figure I, along with subsequent sections that eventually lead the student to a choice of disease states (G).

Along the way, correct answers offer additional information and lead directly to the selection of diagnoses, while wrong answers lead to loops that offer "hints" (Figure III). The loop's return the student to the previous section--and another opportunity to select the correct response and continue the case.

We tried two different commercial software packages capable of handling entries that have multiple branches, such as case studies. One is Scholar/Teach 3, or S/T 3, from Boeing Computer Services, Seattle. The other is the IBM Personal Computer Instructional System from IBM, White Plains, N.Y. Both were written for mainframe computers and later adapted to personal microcomputers. This gives them upload (remote storage memory) and download (disk) capabilities.

S/T 3 turned out to be easier to use. The software comes in three parts: lesson generation, lesson presentation, and file utilities. Instructional material is entered in a source file using any of the common text editor programs. The lesson generation program converts the source file to a presentation file, which is used with the lesson presentation program to administer the lesson to the student. The file utilities program handles record keeping the grading functions. S/T 3 requires an IBM PC with 128K, of main storage, at least one floppy-disk drive, an 80-character display, and an IBM Disk Operating System.

Writing lessons with S/T 3 is as simple as typing, once the branches and loops have been constructed. Figure IV lists the program's key words, one of which must appear in the first two spaces of every line to define the material. They allow the author to structure the material in the sequence needed for the lesson.

Figure IV shows the first frame of this case study in S/T 3 as the author, not the student, would see it. FN (frame name) identifies each screen of material, FF (first frame) directs the computer where to start the lesson. TT (text) is placed alongside any written information--most new information in any lesson is presented in the TT format.

Other key words generate questions and answers: QQ for each line of the body of the question and the possible responses in a multiple-choice format, CA for the correct answer, NA for a neutral answer, and IA for an incorrect answer. After any of these key words, the students can receive an author comment, AC. Correct and neutral answers are followed by a branch key word, BR, in the construction, which elicits a new frame name from the author directing the computer to the next frame. When the student selects an incorrect answer, RP repeats a portion of the same frame, ED signifies the end of a frame.

S/T 3 doesn't require that frames be entered sequentially. Branch commands send the student through the lesson in the order that fits the responses. Once the author creates all the frames for the case, the lesson generation program prepares it for the student, who uses the lesson presentation program with the data disk to view the lesson.

We are pleased with the operation S/T 3. But for the sake of comparison, let's look at the IBM system's capabilities.

The IBM software also has three parts: the author guide, which leads the author through the entry of instructional materials; the student guide, which presents tha materials to the student; and the administrative guide, which lets the instructor control, monitor, and report on student progress. These components can be purchased separately.

The program requires an IBM personal computer with 128K of main storage, two double-sided disk drives, an 80-character display, and an IBM Personal Computer Disk Operating System.

There are two levels of instruction in the author guide. LEvel I is for the author who is a computer novice. It produces text followed by a series of questions, such as a simple study consisting of a case history and a short quiz. Multiple pathways to a correct answer are not possible in level I.

Level II broadens the author's abilities. A case study can begin with the history and branch out to multiple pathways, all of which lead to the correct diagnosis. Along the way, blocks of patient information and laboratory data appear, as do more questions. The student guide program directs the student along the paths, provoking decisions at numerous points.

The author constructs the level II case with a menu of options. Choices are: Create a five-character label or heading for each section of information (for the computer to locate the section), enter text, enter true-false question, enter matching/ranking question, enter multiple-choice/fill-in-blank question, create quiz structure, or exit from the program.

After creating a label, the author can enter as many as 22 lines of text pertinent to the case. There is a one-time opportunity to edit this material. After editing, the author branches the case to another screen.

Then the author can choose one of the several question formats. Once a question is entered, the author provides the correct response and selects various feedback options. Computer responses to incorrect answers can give the student additional information that prompts a correct answer. Finally, the author can create a review quiz by selecting a question format.

When the case study is entered in this manner, the program generates a presentation format using the author guide. The study is then ready to be used by the student in conjunction with the student guide.

It took us about three hours to enter our thyroid toxicosis case with either program. Scholar/Teach 3 takes less time to learn, however, and a computer novice can readily understand its design. After we have set up a few cases with S/T 3, we should be able to enter others much more quickly.

With the IBM PC Personal Computer Instructional System, the author has only one chance to edit material entered on a screen--a major drawback. You also need a separate editing program to make corrections and modifications. Further complicating this system, branch commands and machine language appear within the text during the editing and hinder the author's work. Creating labels for each section of material is time-consuming, too.

S/T 3, on the other hand, employs a word processing program to enter material. The editing function makes entry easier because corrections and modifications can be performed at any time. Furthermore, S/T 3 is not menu-driven, so the author has more control over the arrangement of material. Given all these factors, we found S/T 3 easier to use. Incidentally, the two programs, including the IBM system's administrative guide, cost about the same.

CAI will become an integral part of primary and continuing education for technologists as microcomputers become familiar tools in the laboratory. When put in a CAI format, case studies encourage thinking. They direct the student or the practicing laboratory scientist to synthesize and interpret patient information and laboratory data.

We're hoping that our efforts will make a difference in how much and how well our students learn.
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Author:Beam, Kenni B.; Bishop, Michael L.
Publication:Medical Laboratory Observer
Date:May 1, 1984
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