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Case Editor’s Handbook

OVERVIEW
STRUCTURE OF THE EDITORIAL BOARD
iInTIME LEARNING SYSTEM (ILS)
   Collaboration
   Curriculum
   Pedagogy
   Development/Authoring
   Academics
   Integration
   Maintenance
   Infrastructure
ANNUAL REVIEW
CASE EDITING DETAILS
   General Guidelines
   Style Guidelines
   Common Editing Topics
        General
        Pronouns
      Order of Vital Signs
      Units of Measurement
        Lab Values
      Writing Numbers
      Hyphenation
CASE STRUCTURE
   Introduction
   History
   Physical Exam
   Investigation (Labs and Studies)
    Question/Answer Cards
    Answer Comment
   Diagnostic Network
   Expert
   Conclusion
   References

OVERVIEW

The Institute for Innovative Technology in Medical Education (iInTIME), creator of MedU, was launched in 2006 by Dartmouth pediatricians Dr. Leslie Fall and Dr. Norm Berman as a proactive response to changing requirements in medical education.

The mission of The Institute for Innovative Technology in Medical Education is to advance medical education through the collaborative development, maintenance, distribution, and research of innovative and comprehensive computer-assisted instruction programs and other on-line educational modules that are consistent with iInTIME’s educational philosophy throughout the United States, Canada and beyond.

iInTIME is a 501(c)(3) non-profit organization headquartered in Lebanon, New Hampshire.

MedU is the place where medical education knows no boundaries – crossing core disciplines, time, and distance, empowering medical educators to collaborate and educate tomorrow’s physicians in today’s health care environment.

MedU offers the following courses:
CLIPP(Computer-assisted Learning in Pediatrics Program)
eCLIPPs (Extended CLIPP Scenarios)
SIMPLE (Simulated Internal Medicine Patient Learning Experience)
fmCASES (Family Medicine Computer-Assisted Simulations for Educating Students)
CORE (Case-based Online Radiology Education)
WISE_MD (a series of web-based modules for surgical education, jointly developed by the Department of Surgery and the Division of Educational Informatics at NYU)

MedU’s interactive virtual patient cases are designed to encompass the curriculum objectives of the Clerkship Directors in Internal Medicine (CDIM)-Society for General Internal Medicine (SGIM) Core Medicine Clerkship Curriculum Guide, Council on Medical Student Education in Pediatrics (COMSEP) Curricular Objectives, Society of Teachers of Family Medicine (STFM) Family Medicine Clerkship Curriculum, and the Alliance of Medical Student Educators in Radiology (AMSER) National Medical Student Curriculum in Radiology, respectively.

These virtual patient cases harness the power of medical knowledge and are designed to supplement traditional clerkship teaching and patient care activities for third-year medical students, but also are appropriate for many other learners.
To be most effective, computer based learning must be formally integrated into the clerkship curriculum. To assist clerkship directors throughout our subscribing area in using our products, we have developed a password-protected Instructor’s Area that includes essential supporting materials needed to fully integrate our products into your clerkship.

Our virtual patient cases have been widely accepted by medical educators, with use in more than 130 medical schools in the U.S. and Canada, and more than 500,000 virtual patient case sessions completed by students. iInTIME products are available by institutional or individual subscription.
As of the 2011-2012 Academic year, fmCASES has also been approved for CME credit by the American Academy of Family Physicians (AAFP).

STRUCTURE OF THE EDITORIAL BOARD

Each course offered by MedU is overseen by an Editorial Board. Two co-Editors-in-Chief head the CLIPP, SIMPLE, and fmCASES Editorial Boards while a single Editor-in-Chief leads the CORE Editorial Board. The Board consists of the Editors-in-Chief, as well as four to six Associate Editors, who each oversee the work on five to six cases, and a Case Editor responsible for the content in one assigned case.

iInTIME LEARNING SYSTEM (ILS)

The Institute for Innovative Technology In Medical Education (iInTIME) has developed a proven system for virtual patient case development, integration, and distribution – the iInTIME Learning System (ILS). Virtual patient cases developed, integrated, and distributed with the ILS model provide medical students and clerkship directors access to peer-reviewed learning materials providing a solid foundation in medical knowledge appropriate to the level of the third-year medical student. The ILS incorporates the unique method of virtual patient case development created by Drs. Norm Berman and Leslie Fall.

ILS Purpose: iInTIME’s ILS provides a system made up of seven critical components that ensure the quality, relevance, and accessibility of iInTIME’s or its collaborators’ learning materials throughout their development, maintenance, integration, and distribution.
Originally created for CLIPP the method has continuously been refined through ongoing feedback from medical students and clerkship directors nationally as well as through the development of SIMPLE and fmCASES virtual patient cases.

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Collaboration

iInTIME furthers its organizational mission through an ongoing collaborative process. At the root of the process are a nationally accepted curriculum and a collaborative relationship with the national organization responsible for that curriculum. The collaboration harnesses the expert knowledge of medical educators worldwide resulting in virtual patient cases designed as complete programs ready for integration into individualized clerkships. Enhancing integration is the ability of the virtual patient cases to expand to a full-circle program addressing curricular goals and objectives, teaching methods, and assessment thus honoring the needs of educators and students.
Throughout the development and ongoing maintenance of MedU Virtual Patient Cases, medical educators, professional standards boards, and iInTIME staff collaborate to build and refine effective cases that represent sound pedagogical features and accepted best practices within and across disciplines.
Methods to ensure high quality, accessible content:

Development teams and Editorial Boards are composed of and led by medical educators at institutions of varying sizes and locations nationally and internationally.
Membership and active engagement in relevant national boards and/or their curriculum committees is a pre-requisite for case authoring, editing, peer reviewer involvement, and editorial board membership.

Curriculum

MedU’s interactive virtual patient cases for each case series are designed to encompass the curriculum objectives of the respective national organization:

SIMPLE: Clerkship Directors in Internal Medicine (CDIM)-Society for General Internal Medicine (SGIM) Core Medicine Clerkship Curriculum Guide
CLIPP: Council on Medical Student Education in Pediatrics (COMSEP) Curricular Objectives
fmCASES: Society of Teachers of Family Medicine (STFM) Family Medicine Clerkship Curriculum
CORE: Alliance of Medical Student Educators in Radiology (AMSER) National Medical Student Curriculum in Radiology, respectively.

Cases are based on a nationally accepted curriculum and undergo an extensive case and course evaluation process annually utilizing the ILS Case Matrix, which addresses comprehensive coverage of national curriculum by a given set of cases.
Each set of cases is developed using the ILS Professional Practice Blueprint and individual Case Outlines that reflect nationally accepted best practices and curricular objectives for the related discipline.

Pedagogy

iInTIME seeks to deliver its high-quality medical education programs to students whenever and wherever they are learning. One of the ways we do this is through a consistent and thoughtful approach to teaching methodology. Our cases incorporate sound pedagogical features as follows:

MedU virtual patient cases are focused on teaching and incorporate effective use of interactivity and feedback
Linear case structure provides efficient case-based learning with an emphasis on core objectives
Expert comments provide additional in-depth information where applicable
Polling and peer-response questions allow for student-to-student comparison and learning support
Unique Diagnostic Network teaches clinical reasoning
Clipboard navigation tool builds itself as the student progresses through the case
Thorough explanation of correct and incorrect responses and a conscious decision not to share scored responses creates a safe learning environment where students can explore, make mistakes, and ultimately learn
Multimedia content brings the case alive for students and teaches them about valuable online resources

Development/Authoring

We ensure high quality, consistent pedagogical approach through a variety of quality assurance processes:

Original authors are trained in the ILS at national meetings and supported through the entire development process by peer mentors with the process administered by iInTIME
Ongoing maintenance of the ILS is under the purview of the iInTIME Medical Editor, in conjunction with the Associate Editors
All cases are peer reviewed by experts in the field
Cases go through extensive evaluation and editing during development, pilot testing, and finalization
The iInTIME Learning System utilizes CASUS software, which promotes the ILS Style and provides a uniform look and feel to MedU’s virtual cases across disciplines
Following development, each case is assigned a Case Editor, in some cases the original author of the case, who performs an annual review on the case under the guidance of iInTIME and the course Editorial Board

Academics

iInTIME seeks the highest academic integrity for our cases. Therefore, we actively seek to promote trust and advance the field of medical education by maintaining a focus on academics and professional development in all that we do, including:

Providing our collaborators with opportunities for professional development (e.g. case authoring, editing, peer review, serving on an editorial board, and partnering on medical education research initiatives)
Partnering with our collaborators to conduct medical education research using our virtual patient cases
Providing research grants in the use of technology in medical education

Integration

Students value learning methods that are well designed, uniform, interactive, realistic and engaging. Thoughtful integration of the cases into the standard curriculum allows educators to effectively address the Liaison Council for Medical Education (LCME) accreditation standards requiring all medical schools to provide and document a consistent education for all medical students regardless of training site or time of year.
To be most effective, computer based learning must be formally integrated into the clerkship curriculum. To assist subscribing clerkship directors in using our products, we have developed a password-protected Instructor’s Area which includes essential supporting materials needed to fully integrate our products into individual clerkships, including but not limited to:

Log data documenting case completion by students
Case summaries featuring case goals and objectives and key teaching points
Supplemental teaching material for some of the courses
Integration workshops at national meetings
Exam item bank and exam scoring for CLIPP and fmCASES. SIMPLE is slated for exam availability in 2012/2013

Maintenance

In addition to the extensive care taken to develop and deliver high quality cases, iInTIME diligently attends to the maintenance of cases to ensure best practices and up-to-date curricular content. iInTIME employs the following approach to making timely and thoughtful changes to existing cases:

iInTIME maintains nationally representative Editorial Boards made up of seasoned educators and practitioners
Continued collaboration and national meeting involvement encourages sharing of the most current trends and practices
A focus on research - our own as well as others' - allows us to select the most effective and efficient online pedagogies
Online delivery allows for timely and seamless implementation of necessary edits

Infrastructure

iInTIME provides the technical structure and support to facilitate all of the above activities through the development, oversight, and/or provision of:

Necessary technologies
Editing processes and procedures
User support
Agreements with national boards, editorial boards, case authors and case editors
Quality assurance processes and procedures
Financial sustainability

ANNUAL REVIEW

The annual review is designed specifically to systematically address key content updates and improvements on an annual basis, ensuring that each case in each discipline is up-to-date and of the highest quality.

The annual review targets three main areas:

The accuracy and relevance of case content
The impact of changes on the overall curriculum
The assurance that proposed changes are implemented across all associated resources and tools.

Additional reviews

Occasionally, a case will require additional revision, based on factors not addressed in the annual review. These revisions can arise from many sources, including student feedback, mid-year guideline changes, or a decision by the Editorial Board to alter a case, either in medical content or storyline.

CASE EDITING DETAILS

General Guidelines

The case should include all of the content that an average student would need to understand and complete the case.
In general, the case should include a total of 15-25 cards.
It should be clear where the people are physically located on each card. This can be further supported by the multimedia.
Multimedia should be available (but not overused) and captioned. For more details, see Multimedia section
Interactivity is not overused or used inappropriately. See section on Hyperlinks.
Cases should model and teach an evidence-based approach to patient care.
The case should model expected professional behavior and good general medical practice. Examples include:
- Review patient’s problem lists, reconcile medications, check for medication interactions.
- Wash hands.
- Talk to patients based on their level of understanding.
- Address relevant prevention.
- Incorporate and model empathy for the patient and family.
- Use appropriate name for patient. See below for additional details.

Style Guidelines

When deciding on a specific stylistic guideline regarding grammar, punctuation, or general publishing, please refer to the Chicago Manual of Style. For more specific medical terminology or reference formatting, please refer to the AMA Style Manual
All abbreviations should be spelled out initially (except the few listed on the acceptable abbreviations list). Avoid acronyms & the words “normal” & “benign”
Do not use drug trade name. The generic name should be used. (For very common drugs the trade name may be included in parentheses as an example: diphenhydramine (e.g. Benedryl ®))
All lab values should be labeled with units, both American and SI when possible

Timeliness Guideline

Avoid the use of dates or other references that have the potential to make a case outdated either in terms of accuracy or in a way that causes people to question the relevancy of the teaching to current day practice/issues.

Examples include:

Immunizations – reference age instead of birth date in the page itself (ages should not be substituted for dates in immunization records but added to body of the page)
Pictures of immunization records should NOT be used (fake authenticity doesn’t add anything and runs the risk of becoming outdated)
Not framing a case by a current event or a season, etc. that it is not relevant to the case itself (However, you may not be able to avoid this in some cases such as setting the scene for diagnosis of seasonal allergies)
Avoid referring to trends (such as references to PDA) or world events (recession, H1N1) that can date the case
Use generic fashions and make sure they are appropriate to the case presentation. They should not be specific to the region or season in which they are shot (not shorts for a child with the flu - even though this could be the case in FL, not appropriate for a student doing the case in NH)
Take care when discussing new guidelines that it is not discussed in a way that will become outdated in a couple of years. I.e. Rather than saying "Recently, a study showed...." Simply say, "Studies show..." because in a couple of years, those studies won't be recent anymore, and the case will seem outdated

Common Editing Topics

General

Stay away from negative connotation of patient statements/history.

"Chief concern" not “chief complaint.”
"Does not have" not “denies.”

Pronouns

> 18 use "man" or "woman"
< 18 use "male" or "female"

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Order of Vital Signs

Temperature, Heart Rate, Respiratory Rate, Blood Pressure, Weight, Height, Body Mass Index

Units of Measurement

Temperature: Celsius (Fahrenheit)
Weight: kg (lbs.)
Height: cm (in)
BMI kg/m2

Laboratory values: Conventional (hyperlink SI). NBME is the source for normal ranges.

Writing Numbers

Spell out single-digit whole numbers.

He consumes five beers daily.

Use numerals for numbers greater than nine.

He consumes 10 beers daily.

A few exceptions: type 2 diabetes; stage 1 hypertension, beta2-agonist, alpha1-adrenergic antagonist.

Above all be consistent within a category. If you choose numerals because one of the numbers is greater than nine, use numerals for all numbers in that category. If you choose to spell out numbers because one of the numbers is a single digit, spell out all numbers in that category. (Chicago Manual of Style)

When you talk about a numbered age range, you don't need an apostrophe.

Her father died in his 80s of colon cancer.

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Hyphenation

If you are confused about whether to spell as two words, hyphenate, or as a single word, the first place to look is in Webster's dictionary. Chicago Manual of Style also discusses treatment of compounds according to their grammatical function.

Adjective + participle is hyphenated BEFORE a NOUN, but not after a noun.

“A 46-year-old man with diabetes well controlled with metformin” would not be hyphenated b/c the noun diabetes is described as well controlled after it. However, “A 46-year-old man with well-controlled diabetes” it would be hyphenated because the descriptor is before the noun.

This is why descriptors of history are often hyphenated, and why you hyphenate when age is used as an adjective followed by a noun.

50-pack-year history
He has a four- to five-day history of fever. He has a several-week history of malaise.
He is a seven-year-old boy.
He is seven years old.

Note: the adjective "mid" is a separate word, though, as is the case with any adjective, it may be joined to another word with a hyphen when used as a unit modifier: in the mid Pacific but a mid-Pacific island. e.g.:

(Excerpted from American Heritage Talking Dictionary)

Mid back or midback for the noun and mid-back for the adjective, like mid-back pain.

Self words are always hyphenated.

Self-image, self-concept, self-discontinued, self-referred, self-examination.

Ethnicity: According to Chicago Manual of Style (8.42) p. 325, words indicating ethnicity don’t need hyphenation.

African American

Hyphenate phrases used as compound adjectives before a noun only.  

These are up-to-date expense figures 
The expense figures are up to date

More examples:

     Short-acting beta2-agonist
     This is a well-developed, well-nourished, 58-year-old man. He was 58 years old, well developed and well nourished.  
      He is on a 10-day course of steroids.  
     He took over-the-counter medication.
     He was on patient-controlled analgesia.  
      He had blood-tinged sputum. His sputum was blood tinged.  
     She has community-acquired pneumonia. Her pneumonia was community acquired.  
      Diet was low cholesterol and low salt. She was on a low-cholesterol, low-salt, low-fat diet.  
     He was high risk. He was in the high-risk category.  
     He had Hemoccult-positive stool. Stool was Hemoccult positive.
      He was HIV positive.  He had an HIV-positive history.  
      She had diet-controlled diabetes. Diabetes was diet controlled.  
     He is up-to-date on his immunizations.  
     Low-dose corticosteroids

CASE STRUCTURE

Anatomy of a case

MedU VPCs share a common basic structure. For an explanation of the case structure, please read below. For a visual example of case structure, download this PDF.

Introduction

What is “expected” of the student in the clinical encounter is outlined for them at the outset.

The opening card(s) describe the scenario for the student in as much detail as necessary, including the patient’s age, name, gender, and chief concern, an image of the setting.

Clipboard:

Make sure clipboard with summary of the case thus far is present. If not, create one.

List the key findings from history, physical exam, lab tests, and studies.

This is NOT a patient write-up, but simply a reminder of key info such as a student might write to himself.

Clipboard comments should be formatted in short hand and can include abbreviations (especially if previously defined/identified in case).

The clipboard should be consistent with an office note. There should be NO TEACHING on the clipboard; it is not a relevant summary of case teaching like the end of Case Summary. Instead it is the relevant chart data for that patient.

Always include actual vital signs

History

A picture of the patient is provided at the time that the student “meets” them within the case. The student obtains historical information in a manner that is interactive yet efficient, avoiding excessive use of hyperlinks (not more than 4 or 5 links).

The history should model appropriate interviewing technique.

The student is required to actively discover or uncover important findings. The rest of the dialog should be summarized and delivered within the text of the case. The case history includes all that is needed to make an accurate diagnosis.

Physical Exam

The physical exam includes a variety of images of the patient in a clinical setting.
Multimedia is used to demonstrate key positive or negative findings, which the student should be required to discover or uncover.

Whenever multimedia is used, there must be a written description of the finding as well. If the student is being asked to interpret the finding, the description may be in the follow-up screen.

Teaching specific PE skills and techniques should be incorporated when possible, including the direct modeling of an exam procedure through either description or the multimedia itself.

Teaching the interpretation of PE findings should be incorporated when possible.

Investigation (Labs and Studies)

The student is given the option of ordering blood work, radiologic investigations, or other studies when appropriate. Students are encouraged to think about the potential costs and risks associated with the studies they order.
Whenever multimedia is used there must be a written description of the finding as well. If the student is being asked to interpret the finding, the description may be in the follow-up screen.

Students are asked to interpret images (e.g., x-ray, ECGs) only if doing so is one of the learning objectives of the case.

All lab values should be labeled with units, both American and SI when possible.

Question/Answer Cards

Question and answers are used to teach core teaching objectives and not just to add interactivity to a case.
Questions should be poised in the context of this clinical scenario.
Questions test students’ understanding and clinical reasoning, not quiz them on factoids.
Only one question/answer per card.
Questions include a set of options with reasonable distracters, not blatantly incorrect options.
The student should be asked a question for every 3-4 cards of information.
“Guess what I’m thinking” or “GWIT” questions are avoided.
Questions should be answerable by a third-year student. If not, the information is better directly taught through preceptor-student dialog.
There are several types of questions:
- Multiple choice (use capital letters for the choices, bold the correct answers)
Multiple choice question options should be given in alphabetical order
- Free-text with a non-evaluated answer
- Polling question (adaptation of Multiple Choice...student is able to see what percent of other students answered each option) – useful when a certain issue is vague, extremely subtle, or uncertain.

Answer Comment

The Answer Comment includes an explanation of why each correct answer is correct and why all of the incorrect answers are incorrect. The reasoning behind the answer is explained and includes a reference to literature, if appropriate.

For a multiple-choice question, multiple choice answer options should be in alphabetical order.

Correct answers are explained first alphabetically with bold headers in a paragraph style (not simply A, B, C).
Incorrect answers are explained next alphabetically without bold headers.
Answers should be most likely & most life-threatening – not esoteric.
Exception: The answer comment for the pre-network DDx MCQ only explains why the wrong answers are wrong, while the correct answers are elaborated on in the next card in the network.

Diagnostic Network

Teaching clinical reasoning is a major focus of MedU VPCs. The diagnostic network sequence typically falls at the end of the history and/or physical examination. Each case has one or two networks, depending on complexity and difficulty of the differential and the length of the case (e.g. networks add significantly to the time on case).

Each network is made up of 'pre-network cards' that break down the clinical reasoning thought process as follows:

Identifying key findings of the case at this point in time.

This step is represented by a key findings list where the student is simply asked to list the key findings in the case at this point in time (generally reserved for a second network in a case) OR This can be in the form of a Summary Statement where students are asked to generate a summary of the key findings that includes:

Patient epidemiology info
Temporal pattern of sx
Key findings

Develop a list of diagnoses that the students would consider based on these key findings (DDx or Differential).

This is a multiple-choice question that includes viable distractors. It's important that the author/editor uses the answer comment to explain why distractors are wrong. Correct answers are not addressed until the student completes the network in the following card. Typically, we try to limit the number of correct answers to 4 to 6 viable diagnoses (any less really does not warrant teaching through a network and any more is too much for the third year student).

Network card:

The student scores the viable diagnoses to consider against the key findings in the case at this point in time. The network is scored on a three-point scale (-, blank, +) as to the strength/nature of the association between the key finding and the possible diagnosis. The author/editor should include mouse-over comments in the form of 'info bubbles' at the connection points in the network grid (these explain why specific network connection findings differentiate the DDx) as well as more generalized post-network answer comments that summarize what the most viable diagnoses to consider is/are at this point in time. Important Notes:
Second network often doesn’t require a new differential, but should include a re-statement of new key findings since the previous network. Key findings on the network apply to this patient specifically, not to the general teaching concept. Key findings from the network are included in the summary statement.

Expert

Expert comments are used to provide valuable background or additional information.
Core curricular teaching is not contained in the Expert. Information in the Expert is not essential to the case, and is generally beyond the scope of the curriculum.
Suggest & create Expert comments if not enough present, including pertinent references, links, and multimedia.
Signpost the expert in the general text. In rare situations, it is not possible to do this & the expert is referred to in the answer comment.
The expert should not just be an external hyperlink. At the very least, there should be a paragraph summarizing the hyperlink before it is referenced.

Conclusion

The case concludes with a clear resolution of the clinical scenario for the patient, including appropriate follow-up, planning of care, and provisions of educational materials.
Ensure concluding case cards effectively represent the relationships developed during the case between patient, doctor, and student.
The standard sequence for the last few cards are: learning objectives, references, key teaching points, questions for further consideration. Make sure each component addresses and corresponds with major curricular objectives.

References

References should be included in each card and gathered in a summary collection at the end of the case.

References should be formatted in AMA style.

References are sources used for the content of the case, and therefore must be properly cited.

In contrast, resources are additional sources of information - not directly cited - pertinent to the case. (E.g., useful websites or articles which students should know of).
Below are the guidelines for citing references and resources.

References:

Must use AMA guidelines
All articles and periodicals must be cited
All external websites used for content must be cited
All PDF’s must be cited
References must be cited both at the bottom of the card on which they are referred to, as well as in a list on the references card
CARD FORMAT: Located at the bottom of the card, title “References” in bold, small text; citation info in normal, x-small text
REFERENCES PAGE FORMAT: Title “References” in bold, small text; all citation info on page in normal, small text

Resources:

Resources only need to appear in a list on the references card
All resources must be listed in a separate list labeled “Resources” at the bottom of the references page
All websites linked for more information must be listed (Including AMA, CDC, AAP pages, etc.)
All articles and other periodicals listed for additional information must be listed
RESOURCES PAGE FORMAT: Title “Resources” in bold, small text; all citation info in normal, small text

Each citation must include the title of the source and list the correct web address.