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The Use of Innovative Teaching Me

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					    The Use of Innovative
Teaching Methods to Prepare
 Students for USMLE Step 2



         Lucia I. Soltis, MS-IV
                  and
        Aaron M. McGuffin, MD
            Introduction
How do professors help students
understand and remember medical
information?
  – Mnemonics
  – Buzz words
  – Models, as described by McMenamin
    (2005)
  – Films, as described by Masters (2005)
  – Artwork, as described by Inskeep & Lisko
    (2001)
              Introduction
• Masters (2005) used movies in place of
  clinical experience in a psychiatric mental
  health nursing course
  – Students involved in the course “reported that
    they liked watching the films better than staying
    at the hospital”
  – Students “thought they learned from them”
• Inskeep & Lisko (2001) took nursing students
  to an art gallery
  – Students were told to “assign a nursing
    diagnosis to each picture” chosen by the
    instructors
  – Students reported that it was a “creative way to
    make them develop and refine their ability to
    formulate nursing diagnoses”
               Introduction
• I have been drawing
  pictures to help
  remember medical
  concepts since the first
  year of medical school

• My classmates would
  occasionally ask to look
  at my sketch book to
  see what I had done
             Hypothesis

Using illustrations to present medically
related material will help students learn
  and remember the material better as
    compared to those who learn the
material without the use of illustrations.
                        Topics

•   Psoriasis                  • Gout
•   Infectious Mononucleosis   • HIV
•   Tuberculosis               • Burns
•   Squamous Cell Carcinoma    • Temporal Arteritis
•   Portal Hypertension        • Acute Pancreatitis
•   Systemic Lupus             • Lyme Disease
    Erythematosus              • Chronic Obstructive
•   Rheumatoid Arthritis         Pulmonary Disease
•   Crohn’s Disease            • Direct Inguinal Hernia
•   Ulcerative Colitis         • Glucocorticoid Excess
•   Varicella Zoster           • Ankylosing Spondylitis
Psoriasis
     • Silver scale on an
       erythematous base
     • Nail pitting
     • Separation of the nail
       bed
     • Mild anemia
     • Psoriatic arthritis at
       the DIP joints
     • May be worse in winter
     • May be associated with
       depression
Mononucleosis
         • EBV is excreted in
           saliva
         • Fatigue
         • Avoid contact
           sports
         • Get a rash when
           given penicillin type
           drugs
         • Hairy leukoplakia
           (balloon cells on
           histology)
         • Burkitt’s lymphoma
Tuberculosis
      • Acid-fast bacilli
        with a waxy coat
      • Slow growing (long
        course of therapy)
      • Alcoholism is a risk
        factor
      • Hemoptysis
      • Diagnose with an
        early morning
        sputum sample on
        3 consecutive days
Squamous Cell Carcinoma
             • Risk factors include:
                – Sun exposure
                – Arsenic exposure
             • Cutaneous horn,
               actinic keratosis
               lesions are precursors
             • Lichen sclerosis may
               develop into SCC
             • Keratoacanthoma is a
               variety of SCC
Portal Hypertension
          • Caused most commonly
            by alcoholic cirrhosis in
            N. America
          • Caused by
            schistosomiasis
            elsewhere
          • Signs of portal
            hypertension
             – Spider angioma
             – Caput medusae
             – Jaundice
          • AST:ALT ratio 2:1
Systemic Lupus Erythematosus
                • Occurs more often
                  in women
                • Malar rash
                • Photosensitivity
                • Decreased C3 & C4
                • Pericarditis
                  – Pain from
                    pericarditis is
                    relieved by leaning
                    forward
Rheumatoid Arthritis
          • Affects women more
            often
          • Pain & stiffness for
            at least 1 hour in
            the morning
          • Swan-neck
            deformities
          • Associated with
            HLA-DR4
          • Treat with NSAIDS
Crohn’s Disease
         • Occurs more often
           in women
         • Cobblestoning of
           the mucosa
         • Creeping
           mesenteric fat
         • Fistulizing perianal
           disease (“watering
           can anus”)
Ulcerative Colitis
           • Crypt abscesses in
             colon
           • Loss of haustra in
             the colon
           • Bloody diarrhea
           • More commonly
             seen in Jewish
             population
           • Smoking helps
Varicella Zoster
          • Vesicular rash on an
            erythematous base
          • Red/pink rash
          • Rash appears in crops,
            diagnosis based on
            three different lesions
            seen at same time
          • Spreads from the trunk
            to the periphery
          • Contagious for 24
            hours before the rash
            appears until all
            lesions are crusted
            over
Gout
  • Yellow, needle-shaped
    crystals
  • Occurs more often in
    men
  • Most often involves the
    big toe (podagra)
  • Worse at night
  • Alcohol makes it worse
  • “Rat bite” lesions in
    advanced gout
  • Treat acutely with
    colchicine (destroys
    microtubules) or
    NSAIDs
HIV
 • Low CD 4+ count
 • Opportunistic
   infections include:
      –   Tuberculosis
      –   Cryptococcus
      –   Histoplasmosis
      –   Varicella Zoster
      –   Pneumocystis carinii
          pneumonia
 • Diagnose with
   ELISA and Western
   blot
Burns
    • Rule of 9s
        – Whole arm = 9%
        – Whole leg = 18%
    • Give Lactated Ringers
    • May get Pseudomonas
      aeruginosa from fresh
      flowers, vegetables
    • P. aeruginosa has a
      fruity odor
    • Treat P. aeruginosa
      infection with acetic
      acid
Temporal Arteritis
         • Occurs more often in
           women, especially of
           Northern European
           descent
         • Causes a headache
         • May cause blindness
         • Fragmentation of the
           internal elastic lamina
         • Polymyalgia
           rheumatica
         • May be confused with
           Varicella Zoster
Acute Pancreatitis
            • Caused by gallstones
            • Caused by alcohol
            • Caused by scorpion
              bites
            • Caused by trauma
            • Caused by burns
            • Caused by viruses
              such as Coxsackie B
              virus (Devil’s Grippe)
              and Varicella zoster
            • Patient may be
              dehydrated.
Lyme Disease
        • Borrelia is a
          spirochete
        • Causes a bull’s eye
          rash
        • Rash has a median
          width of 15cm
        • May cause
          myocarditis
        • Found in Northeast
          and Pacific coast
        • History of camping
        • Use ELISA &
          Western blot to
          detect disease
COPD
  • “Pink puffers”
    (emphysema)
  • “Blue bloaters”
    (chronic bronchitis)
  • Barrel chest
  • Smoking is a risk
    factor
  • Muffled breath
    sounds
  • Skinny heart on
    CXR
Direct Inguinal Hernia
             • Occur in Hesselbach’s
               triangle
             • Hesselbach’s triangle:
                – Inferior epigastric
                  vessels
                – Rectus abdominus
                – Inguinal ligament
             • Hernia has a wide neck
             • Occurs over the age of
               50
             • Smoking is a risk
               factor
Glucocorticoid Excess
(Cushing’s Syndrome)

              •   Moon facies
              •   Hump back
              •   Fatigue
              •   Depression
              •   Purple striae
Ankylosing Spondylitis
               • Symptoms are
                 worse in the
                 morning
               • Fused vertebrae
                 (bamboo spine)
               • May result in 3rd
                 degree heart
                 block
               • Associated with
                 HLA-B27
Screen capture from Slideshow




                              2
         Board Review Session 1
                            Pre-test/ Post-test
Student Number__________________
1.Which joints are affected most often by psoriatic arthritis?       11. Which drug used in treating gout destroys microtubules?
___________________________________________________                  ___________________________________________________
2.Patients with infectious mononucleosis will develop a rash if      12. What tests are used to diagnose HIV?
given what antibiotic?                                               ___________________________________________________
________________________________________                             13. Which bacterial organism is most closely associated with
3.What is the gold standard method used to diagnose                  burns? _________________________________
tuberculosis?                                                        14. What infectious process can temporal arteritis be
___________________________________________________                  confused with?
4.Which heavy metal is a risk factor for squamous cell               ___________________________________________________
carcinoma?                                                           15. Name two viruses known to cause acute pancreatitis?
___________________________________________________                  ___________________________________________________
5.List 3 signs of portal hypertension:                               16. What is the classic description of the rash in Lyme
___________________________________________________                  disease?
6.In what position do patients suffering from pericarditis take to   ___________________________________________________
decrease the associated pain?                                        17. In COPD, how does the heart appear on chest x-ray?
___________________________________________________                  ___________________________________________________
7.Rheumatoid arthritis is associated with which HLA type?            18. Why do direct inguinal hernias not tend to incarcerate?
_________                                                            ___________________________________________________
8.What is the classic description of the colon when seen on a        19. What physical exam finding on the back is a symptom of
barium study in Crohn’s disease?                                     glucocorticoid excess?
_______________________________________                              ___________________________________________
9.Crypt abscesses are most commonly seen in which                    20. What conduction deficit can be seen in ankylosing
inflammatory bowel disease?                                          spondylitis?
__________________________________________________                   ___________________________________________________
10. The rash of varicella zoster spreads from the
_____________________ to the ________________________
                     Pictures group
             (Board Review Session 1)
  Student Number      Pre-test Score   Post-test Score   Change in Score
     901058860             15                15                0
     901171699              8                20                12
     901245117             14                19                5
     901246220             12                22                10
     901248420             15                20                5
     901257201             14                23                9
     901268587             13                22                9
     901348333             18                17                -1
     901348684             14                17                3
     901349104             14                22                8
      Average             13.70            19.70              6.00
Standard Deviation                                            4.35
                 No Pictures Group
             (Board Review Session 2)

  Student Number     Pre-test Score   Post-test Score   Change in Score
     280721621            12                12                0
     901192218            12                16                4
     901242963            14                18                4
     901251642            12                18                6
     901252479            10                15                5
     901254368            18                18                0
     901277494            14                21                7
     901316852            15                17                2
     901330436            10                11                1
      Average            13.00            16.22              3.22
Standard Deviation                                           2.59
Comparison
                               Change in Score
                           Pictures       No Pictures


of Change in
                              0                0
                             12                4


    Score
                              5                4
                             10                6
                              5                5
                              9                0
                              9                7
                              -1               2
                              3                1
                              8
      Average               6.00              3.22
      Standard Deviation    4.35              2.59


      p value                         0.114
       Student Response
• One student from the Pictures group
  remarked after the post-test that she
  could see the picture for a particular
  question in her mind, but could not
  remember the teaching points
• Students during Board Review
  Session 2 asked repeatedly to see the
  pictures and complained some when
  told that they were not allowed to see
  them
            Conclusion
• There appeared to be a trend where
  the Pictures group had a larger
  change in score than did the No
  Pictures group, but the results are not
  statistically significant
• Repeating the experiment with a
  larger group of students may yield a
  more statistically significant result
          Thank you


                             Any
Many thanks to Dr. Darshana Shah
                          Questions?
and Dr. Yulia Dementieva for helping
         with the statistics.

				
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