case vignette vs case study

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Writing a Clinical Vignette (Case Report) Abstract

Case reports represent the oldest and most familiar form of medical communication. Far from a "second-class" publication, many original observations are first presented as case reports. Like scientific abstracts, the case report abstract is governed by rules that dictate its format and length. This article will outline the features of a well-written case report abstract and provide an example to emphasize the main features.

Scientific forums have specific rules regarding how the abstract should appear. For the ACP, the rules are available on the electronic abstracts portal. Organizers of scientific meetings set explicit limits on the length of abstracts.

The most difficult decision to make is whether your case report is worth submitting as an abstract. Of course, rarity of a condition almost always meets the criterion of worthiness, but few of us have the opportunity to describe something that is completely new. Another reason to report a case is the lesson that it teaches. With this in mind, consider presenting a case if it increases awareness of a condition, suggests the proper diagnostic strategy, or demonstrates a more cost-effective approach to management. Alternatively, a case can be presented because it represents an unusual presentation of a relatively common condition. Other twists include an unusual complication of a disease and its management. Again, it's important to think about the message or lesson that the case can deliver.

Before you begin writing the abstract, present a quick summary of your case to colleagues or mentors to determine if they agree that the case is worthy of presentation. It is important to contribute something unique, but not if it depends on some trivial variation from previously presented cases. For example, if it is known that a certain cancer widely metastasizes, it is not worthwhile to report each new site. Similarly, drug reactions often merit a case report, but not if it is simply a report of a drug in a class whose other members are known to cause the same reaction.

Once you have decided to submit a case report abstract, describe it in such a way as to make it interesting, yet conform to the accepted format. The following paragraphs provide suggestions on both style and format.

Title and Author Information: The title is a summary of the abstract itself and should convince the reader that the topic is important, relevant, and innovative. However, don't tell everything about the case in the title, otherwise the reader's interest might lag. Make the title short, descriptive, and interesting. Some organizations require a special format for the title, such as all uppercase letters. Be sure to check the instructions. Following the title, include the names of authors followed by their institutional affiliations. Deciding upon the authorship of a case report can be tricky. In the past, it was acceptable to include as authors those contributing to the management of the patient, but this is no longer true. Currently, it is expected that the authors contribute significantly to the intellectual content of the case report. It is assumed that the first author will present the work if the abstract is accepted. The first author may need to meet certain eligibility requirements in order to present the abstract, for example, be a member of the professional society sponsoring the research meeting. This information is always included with the abstract instructions.

Introduction: Most case report abstracts begin with a short introduction. This typically describes the context of the case and explains its relevance and importance. However, it is perfectly acceptable to begin directly with the description of the case.

Case Description: When reporting the case, follow the basic rules of medical communication; describe in sequence the history, physical examination, investigative studies, and the patient's progress and outcome. The trick is to be complete without obscuring the essence of the case with irrelevant details.

Discussion: The main purpose of the discussion is to review why decisions were made and extract the lesson from the case. Not uncommonly, reports from the literature, or their absence, are cited that either directly support or contradict the findings of the case. Be wary of boasting that your case is the "first" to describe a particular phenomenon, since even the most thorough searches often fail to reveal all instances of similar cases. Keep in mind that the best case report abstracts are those that make a small number of teaching points (even just one) in clear and succinct language.

When writing the abstract, avoid the use of medical jargon and excessive reliance on abbreviations. Limit abbreviations to no more than three, and favor commonly used abbreviations. Always spell out the abbreviations the first time they are mentioned unless they are commonly recognized (e.g., CBC).

It typically takes several days to write a good abstract, and the process should not be undertaken alone. Get help from a mentor who is not familiar with the case; such mentors can quickly point out areas that are unclear or demand more detail. Make revisions based upon the feedback. Finally, have others read your draft in order to check for technical errors, such as spelling and grammar mistakes. Reading the abstract out loud is another good way to catch awkward phrasing and word omissions. Finally, a Clinical Vignette Abstract Checklist  and an example of a clinical vignette abstract  are available to help you with the process of writing a successful abstract.

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• March 01, 2024 | VOL. 181, NO. 3 CURRENT ISSUE pp.171-254
• February 01, 2024 | VOL. 181, NO. 2 pp.83-170
• January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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DSM-5 Clinical Cases

• Rachel A. Davis , M.D.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

• Cited by None

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• March 01, 2024 | VOL. 75, NO. 3 CURRENT ISSUE pp.203-304
• February 01, 2024 | VOL. 75, NO. 2 pp.107-201
• January 01, 2024 | VOL. 75, NO. 1 pp.1-71

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Best Practices: Using Case Vignettes to Train Clinicians and Utilization Reviewers to Make Level-of-Care Decisions

• Peter B. Rosenquist , M.D. ,
• Christopher C. Colenda , M.D., M.P.H. ,
• Judy Briggs , R.N. ,
• Stephen I. Kramer , M.D. , and
• Michael Lancaster , M.D.

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Note from the column editor: Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function.This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Medical necessity has emerged as the de facto standard for decisions about payment for behavioral health services, despite criticisms leveled from theoretical ( 1 , 2 ) and practical ( 3 ) perspectives. Moreover, it has been difficult to define best practices within the current framework of medical necessity, largely because of the many sources of variation in decisions about appropriate levels of care.

In practice, when clinicians and clinical case managers—that is, utilization reviewers—communicate information about a patient, usually by telephone, they use a narrative case presentation. Discussion is focused on assessment of necessity criteria, such as symptom severity, dangerousness, social support, and resource availability, that would support a higher level of care, such as inpatient hospitalization. Unfortunately, the dialogue may break down without resolution of differences, and with considerable residual ill will between parties ( 4 ).

In this column we report on our use of case vignettes as a training device to help clinicians and clinical case managers make consistent decisions about appropriate levels of care and to develop best practices.

Development and use of case vignettes

Partly because of their research and teaching missions, academic centers have been slow to react to changes in health care financing and have a reputation of inefficiency and overuse of intensive levels of care ( 5 ). In 1995 Wake Forest University established a health maintenance organization with about 50,000 enrollees. In the first year of operation, the university contracted with an outside, for-profit managed behavioral health organization to provide behavioral health utilization review and case management. Eventually the department was able to establish its own internal managed behavioral health care organization ( 6 ).

Initially, however, the department struggled to meet the demands of managed care, working with the outside organization. To promote greater uniformity in decision making, we designed four case vignettes and used them in joint training with our clinicians and the clinical case managers from the outside organization.

Case vignettes have been used previously to compare decision-making strategies of different groups ( 7 ). Because use of vignettes limits variation in how people perceive a case by providing all persons with the same information, vignettes offer training advantages over real-life patients. Case vignettes are ideal when the primary objective is to identify conflicts in judgment ( 8 ).

Each vignette developed by the department is a typical narrative case presentation and includes details about the patient's history and mental status. Each patient has a different diagnosis—delirium, comorbid depression and substance abuse, chronic depression, and schizophrenia. In two vignettes, the patient presents as an outpatient. In another, the setting is an emergency room. In the fourth case, the patient has been referred for a consultation to an inpatient general medical setting. The vignettes do not convey any expectations about case disposition or information about insurance status.

Thirty-one persons participated in the training—seven attending physicians, 16 house officers (psychiatric residents), and eight clinical case managers. After reading each vignette, respondents were prompted to choose the most appropriate treatment setting—inpatient care, partial hospitalization, or outpatient care. They provided up to five of their own reasons for each decision. In a translational process paralleling the interaction between clinician and reviewer, the reasons were examined to determine whether they referred to either of two common medical-necessity criteria: the patient's level of dangerousness and the patient's support system. These reasons were tallied separately and compared by group using Fisher's exact tests.

Results are summarized in Table 1 . All the respondents recommended that the patient with delirium receive inpatient care. Similarly, for the patient with comorbid depression and substance abuse, 94 percent recommended inpatient care, and only 6 percent recommended partial hospitalization.

For the patient with schizophrenia who was experiencing negative symptoms, 52 percent of respondents recommended outpatient services, 36 percent recommended partial hospitalization, and 13 percent recommended inpatient care. For the patient with chronic depression, 39 percent recommended outpatient services, 26 percent recommended partial hospitalization, and 36 percent recommended inpatient care.

No significant differences were found between attending physicians and clinical case managers on any of the four level-of-care decisions. Only house officers selected inpatient treatment for the patient with schizophrenia. Compared with attending physicians and case managers, house officers selected higher levels of care for this patient; however, the difference was not significant.

Compared with attending physicians and case managers, house officers were significantly less likely to take into account the patient's support system as a factor in decision making in two cases—the patient with schizophrenia (Fisher's exact test, p=.09) and the patient with chronic depression (p=.09). Attending physicians were less likely than house officers and case managers to take into account the patient's level of dangerousness in their decision about the patient with chronic depression (Fisher's exact test, p=.06).

Our study failed to demonstrate significant differences between groups of clinicians and utilization reviewers in level-of-care decisions for any of four common psychiatric presentations. Similarly, we identified very few differences between groups in their use of particular criteria as a rationale for their decisions.

Both the clinicians and the utilization reviewers in our setting have expressed surprise at these findings, because they run counter to the expectation that level-of-care decisions and decision rules used by each group would be quite different. In a study of implementation of a managed care plan during the course of which use of inpatient services markedly declined, it was shown that over time clinical case managers rated fewer patients as severely disturbed while ratings by clinicians remained unchanged ( 8 ).

Use of the vignettes has effectively demystified the process of utilization review for clinicians in our department. Two vignettes engendered strong agreement by all respondents. The others revealed more variation in decisions about the most appropriate level of care, both across all respondents and within respondent groups. This finding raises the question of how we can increase the level of agreement for more equivocal cases. Level-of-care decisions must be reliable—that is, care managers must make similar decisions in similar cases across time. Without some degree of reliability, a meaningful best practice is unlikely to emerge.

First, we must develop meaningful and reliable criteria. Some progress has been made. In one study, when clinicians were presented with a broad and unstructured list of variables, they were unable to achieve an acceptable level of agreement about indicators for hospitalization ( 9 ). On the other hand, expert panels using modified Delphi techniques have achieved high levels of agreement in decisions about levels of care for both hypothetical and actual cases, and in the process they have identified and developed anchored ratings for a number of key variables ( 10 , 11 ).

Second, level-of-care decision criteria must not remain the sole province of health services researchers and clinical case managers. Instead, they should be widely disseminated to the network of providers. At our facility, the outside managed behavioral health care organization shared its criteria with clinicians from the outset. When the department took over care management, this practice was continued. Also, medical-necessity criteria have been incorporated into the admission forms, admitting orders, and computerized treatment planning documentation of the inpatient and partial hospital unit ( 12 ).

Experience and training would seem to be likely sources of variation in decision making in clinical and managed care settings. Although our study was limited by its small sample size, the results suggest that house officers may differ from more experienced psychiatrists and clinical case managers in their decisions and approach. By ensuring that the house officers encounter the decision criteria in the course of their daily work and by providing them with training material on managed care principles, we hope to create a working model of best practices against which they can compare their decisions. Senior residents may also participate in an elective rotation in managed care during which they can review cases and make interpretations of medical necessity.

Criterion-based admission policies and procedures clearly narrow the range of variables used in level-of-care decisions. However, we will continue to encounter equivocal cases. One approach to improving the reliability of decisions would be to conduct field tests to systematically identify sources of variation in decision making. Once we know the sources, we may more clearly define what constitutes best practice. In a study using videotaped interviews conducted in an emergency room, agreement between raters was low for recommended disposition, psychopathology, impulse control problems, ability to care for self, and danger to self ( 13 ). A somewhat higher level of agreement was reached for psychosis and substance abuse.

Clinical case managers and medical directors continue to oversee care management in our system through traditional review processes. Every three months appeals are presented for discussion and comment before a quality improvement committee composed of a rotating group of network clinicians. Level-of-care criteria are reviewed and amended annually. This body recently voted to begin using the Criteria for Short-Term Treatment of Acute Psychiatric Illness, jointly published by the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association ( 15 ).

As practice guidelines become more detailed, and more reflective of best practices, we anticipate an eventual eclipse of more generic level-of-care criteria. For example, the use of the Clinical Institute Withdrawal Assessment protocol ( 16 ) in our facility has supplanted the need for concurrent review of necessity and intensity of service for alcohol detoxification because such a review is part of the protocol. The measure of our success will be how well we work collectively to meet the needs of patients as we develop our mental maps, whether they are vignettes, criteria, practice guidelines, or protocols.

Dr. Rosenquist is assistant professor and Dr. Kramer is associate professor in the department of psychiatry and behavioral medicine at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Ms. Briggs is chief executive officer of Carolina Behavioral Health Alliance in Winston-Salem. Dr. Colenda is professor in the department of psychiatry at Michigan State University in East Lansing. Dr. Lancaster is regional medical director of Value Options in Raleigh, North Carolina. Send correspondence to Dr. Rosenquist at the Department of Psychiatry and Behavioral Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1087 (e-mail, [email protected] ). William M. Glazer, M.D., is editor of this column.

Table 1. Level-of-care decisions made by seven attending physicians, 16 house officers, and eight case managers about patients described in four case vignettes

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12. Glazer WM, Gray GV: Psychometric properties of a decision-support tool for the era of managed care. Journal of Mental Health Administration 23:226-233, 1996 Crossref , Medline ,  Google Scholar

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Creating case scenarios or vignettes using factorial study design methods

Affiliation.

• 1 Department of Family Relations & Applied Nutrition, University of Guelph, Canada. [email protected]
• PMID: 19694857
• DOI: 10.1111/j.1365-2648.2009.05055.x

Aim: This paper is a report of a study conducted to develop clinical case vignettes using an adaptation of an incomplete factorial study design methodology.

Background: In health care, vignettes or cases scenarios are core to problem-based learning, common in practice guideline development processes, and increasingly being used in patient or care-giver studies of chronic or life-threatening illnesses. A large number of behavioural, psycho-social and clinical factors can be relevant in such decision problems. Unbiased methods for choosing what factors to include are needed, when it is not possible to include all relevant combinations of factors in the vignettes.

Method: The factors to be considered, number of levels or categories for each factor, and desired number of scenarios were decided in advance. An algorithm was used first to create the full factorial data set, and then a random subset of combinations was generated, according to predefined criteria, based on maximizing determinants. The subset of combinations was incorporated into written vignettes. The study was conducted in 2004-2005.

Findings: Application of the method yielded diverse and balanced scenarios that covered the full range of factors to be considered for a project to elicit health providers' processes in diet counselling for dyslipidemia.

Conclusion: The approach is flexible, decreases possible researcher bias in the creation of vignettes, and can improve statistical power in survey research. This novel application of study design methodology merits consideration when vignettes are being developed to elicit opinions or decisions in studies of complex health issues.

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• Research Support, Non-U.S. Gov't
• Decision Making
• Medical Records*
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• Pilot Projects
• Problem-Based Learning / methods*
• Research Design*

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Clinical vignette-based interactive discussion sessions: feedback from residents

Rano mal piryani.

1 Health Professions Training Committee, Universal College of Medical Sciences, Bhairahawa, Nepal

Suneel Piryani

2 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

Introduction

A clinical vignette is a useful tool for teaching both clinical and basic sciences courses. The clinical vignette-based interactive discussion sessions were conducted for residents in the internal medicine department of Universal College of Medical Sciences( Bhairahawa, Nepal) with aim to link the residents to clinical practice setting. The objective of this study was to assess the feedback of participant.

The sessions were done five days a week between January 16 and February 26, 2019. Each session was between 45 and 60 minutes. The clinical vignettes related to internal medicine were downloaded using Google. Each vignette was divided into sections, related questions with responses were developed and the discussion was updated referring to the latest articles on subject. Eleven residents participated in the session. At the end of last session feedback was taken on a validated semi-structured questionnaire. The data was analyzed using SPSS version 21.

Residents rated the clinical vignette-based interactive discussion sessions on the scale 1 = poor to 10= excellent; usefulness (9.45±1.04), content (9.27±0.90), relevance of session (9.18±1.08), facilitation (9.27±1.10), and overall (9.36±0.81). Participants rated the structure of vignettes discussed (3.73±0.47), the questions related to vignettes discussed (3.82±0.40), and discussion related to vignettes done (3.64±0.50) on a Likert scale 1–4 (4= extremely important, 3= moderately important, 2= slightly important, 1= not important). The two-way interaction, the approach toward differential diagnosis, diagnosis and management, choosing appropriate investigation, clinical relevancy of vignettes, boosts understanding, enhances thinking power and thinking outside the box, improving clinical approach and academic learning were among the strengths of sessions shared by residents. All residents proposed to continue these sessions and develop vignettes of our patients. The majority of the residents recommended conducting session on alternate days.

This method of learning allowing the residents to follow and construct clinical outcome in a logical and systematic sequence that may be applicable in real-life clinical practice settings. This method enhances the thinking power of residents and their problem-solving capacity.

Carolyn Jeffries and Dale W Maeder define vignettes as incomplete short stories that are written to reflect, in a less complex way, real-life situations in order to encourage discussions and potential solutions to problems where multiple solutions are possible. 1

A clinical vignette is an abridged report of a patient summarizing any relevant history, physical examination findings, investigations data and treatment. 2 This is one of the formats used for teaching problem-solving skills, assessing judgment and decision-making processes, including clinical judgments made by healthcare professionals, as well as assessing professionalism. 3 – 5 The clinical vignette is one of the very useful tools for teaching clinical, as well as basic science subjects, as it provides comprehensive stages where possible etiology, individual patients’ characteristics, symptoms and signs, family history, important investigations and relevant information are revealed and explained. 2

Clinical vignettes are patient-related cases and scenarios that have educational value for a wider audience. To link the residents to clinical practice settings and situations, the clinical vignette-based interactive discussion sessions were conducted for the residents in the internal medicine department of Universal College of Medical Sciences (UCMS; Bhairahawa, Nepal). The objective of this study was to take feedback from the participant residents and assess it.

Methodology

To link the residents to clinical practice settings and situations, the clinical vignette-based interactive discussion sessions were conducted for the residents in the internal medicine department of UCMS for post-graduation (MD). These sessions were done for six weeks, five days a week from January 16 to February 26, 2019. Each session was between 45 and 60 minutes, starting at 9.00 am. The sessions were conducted by the principal author.

The vignettes related to internal medicine were downloaded from various sources using Google by the principal author. Each vignette was divided into sections such as history, physical examination, investigations, treatment; related questions and responses were developed and the discussion was updated referring to the latest article on the subject. An example of a clinical vignette is given in Figure 1 . There are concerns that the learner would usually take a superficial view of vignette activity and work, deduce and interpret vignettes at lower order of thinking or intellectual levels, i.e., remembering and understanding based on the revised Blooms’ Taxonomy of Learning. 6 , 7

Example of a clinical vignette.

The principal author intended to stimulate the residents at a higher-level of thinking, i.e., applying, analyzing and evaluating ( Figure 2 ).

Revised Blooms’ Taxonomy of Learning.

At the end of last session, feedback of the residents was taken on validated semi-structured questionnaire. 8 The questionnaire contained four closed ended and three open ended questions. The closed ended questions were: 1) rate the interactive session on the scale 1 = poor to 10 = excellent, for usefulness, content, relevance of session and content, facilitation and overall; 2) rate the structure of clinical vignette discussed on a Likert scale 1–4; 3) rate the questions related to clinical vignettes discussed on a Likert scale 1–4; and 4) rate the discussion related to clinical vignettes done on a Likert scale 1 = not important, 2 = slightly important, 3 = moderately important, 4 = extremely important. The questionnaire is annexed.

Eleven residents participated in these sessions; nine were from internal medicine (three each of first, second, and third year), one each from the emergency department and dermatology, who were posted in the department for their rotational training. Informed consent was taken from the participant residents and Institutional Review Committee of UCMS approved the study vide Letter No: UCMS/IRC/053/19, dated March 20, 2019.

The data collected was checked for completeness, accuracy and consistency. The data was entered into IBMS SPSS version 21 for analysis. The descriptive statistics was calculated for the mean and standard deviation.

The residents rated the interactive clinical vignette-based discussion sessions on a scale of 1 = poor to 10 = excellent; the rating was notable ( Table 1 ).

Rating of residents on the clinical vignette-based discussion sessions

The residents rated the structure of clinical vignettes discussed in all sessions, the questions related to clinical vignettes discussed and discussion related to clinical vignette done on a Likert scale 1 = not important to 4 = extremely important, the rating was remarkable ( Table 2 ).

Rating of residents on the clinical vignette structure, questions and discussion

Notes: 4= extremely important, 3= moderately important, 2= slightly important, 1= not important.

Strengths of the interactive clinical vignette-based discussion sessions

The strengths of the interactive clinical vignette-based discussion sessions shared by the residents were two-way interaction, making differential diagnosis, approaches toward diagnosis, differential diagnosis, and management, choosing appropriate or accurate investigation, awareness of different scenarios encountered in daily life, discussion among peers, strengthening knowledge and understanding, clinical relevancy and its application in day to day life, gives clues toward exam questions, vignettes based on common diseases prevalent in our society, brain-storming exercise, enhances thinking power and thinking outside the box, enhances problem-solving capacity, as well as understanding better how to improve clinical approach and academic learning.

Areas for improvement

The majority of the residents recommended that these sessions were conducted on alternate days. Some suggested having a clinical examination session (bedside) the next day, with more interaction and discussion, explanation of differential diagnosis in detail, and more sessions on specific management and protocols of common diseases.

Additional comments

All residents proposed to continue these sessions and also to develop vignettes of patients admitted to our ward, to discuss patients on the ward and treatment specific to them.

The clinical vignette-based interactive discussion sessions were conducted for the residents in the internal medicine department of UCMS (Bhairahawa, Nepal) to link and connect the residents to clinical practice settings and situations and to incite and excite them at a higher-level of thinking as per the revised Blooms’ Taxonomy of Learning. 6 , 7

The magnificence of the vignette activity is that when the residents learn, they must be able to transfer this knowledge to other situations and in doing so, incorporate and integrate their knowledge and skills well enough to make predictions and likelihoods about new situations and utilize their knowledge and skills for solving the problem. 1

Most of the studies on case vignettes mention the use of hypothetical case studies (patient scenario) designed to achieve a specific learning objective. 9 But we selected real cases from recent studies published in last five years and the discussion was focused on the differential diagnosis, investigation and comprehensive management.

Feedback from the learners helps to assess innovative teaching–learning methods, and feedback serves as guide for improvement when conducting the same sessions or training in the future. With this aim, feedback of the residents was taken on the clinical vignette-based interactive discussion sessions and assessed.

The participant resident rated the clinical vignette-based interactive discussion sessions on a scale of 1 = poor to 10 = excellent, for usefulness (9.45±1.04), content (9.27±0.90), relevance of session and content (9.18±1.08), facilitation (9.27±1.10) and overall (9.36±0.81); the rating is notable.

The residents rated the structure of clinical vignettes discussed in all sessions (3.73±0.47), the questions related to clinical vignettes discussed (3.82±0.40) and discussion related to clinical vignette done (3.64±0.50) on a Likert scale 1–4; the rating was remarkable.

The two-way interaction; approaches toward differential diagnosis, diagnosis and management, choosing appropriate investigation, clinical relevancy of vignette and its application in day to day life, strengthening knowledge and understanding, discussion among peers, vignettes based on common diseases in our society, brain-storming exercises, enhanceing thinking power and thinking outside the box, as well as how to improve clinical approach and academic learning, were among the strengths of sessions shared by the residents. All residents proposed to continue these sessions and also to develop vignettes of patients admitted to the ward, to discuss patients on the ward and treatment specific to them. The majority of the residents recommended conducting these sessions on alternate days. Some suggested having clinical examination sessions (bedside) the next day, with more interaction and discussion, explanation of differential diagnosis in detail, and more sessions on the specific management and protocols of common diseases.

Kathiresan J, Patro BK (2013) stated that the vignette-based discussion method enables the residents to apply their clinical reasoning skills in real-life contexts and this method motivates them towards self-directed learning and sharing of knowledge. Furthermore, the case vignettes are a promising complement to the existing methods of teaching. 10

The clinical vignette-based interactive discussion sessions transform the approach of residents toward patients and their problem-solving and decision-making skills, thereby improving quality of care.

The limitations of the study were the small sample size, conducted in one department of one institution, so the findings cannot be generalized. The study assessed only reaction and perception of the participant residents.

Residents feedback about clinical vignette-based interactive discussion sessions reveals that this method of learning allows them to follow and construct clinical outcomes in a logical, rationale, reasonable, analytical and well-organized sequence, that may be applicable in real-life clinical practice settings and situations. This method enhances their thinking power, thinking outside the box and their problem-solving capacity.

Acknowledgment

We highly appreciate for the residents who participated in training as well as in study.

The authors report no conflicts of interest in this work.