STEPS IN CONDUCTING AN ASSISTED TUTORIAL DISCUSSION 

SESSION 1

STEP 1	Present the case scenario     Allow time for students to think and consolidate their thoughts. Their silence might mean they are  thinking.            Initiate discussion by asking the Trigger question:             "How would you like to approach this case?"    Allow students to think loud. Do not interrupt while they are talking.     Simply keep the discussion going by asking…..             What do you think about the suggestion of (Name of student)?              Do you agree with ( Name of student )?             What are your thoughts about this issue , ( Name of student) ?             Does everybody agree with the approach we shall take?
STEP 2	Trigger the discussion on the pathophysiology Encourage them to list LEARNING ISSUES Encourage the students to use the blackboard to illustrate their point. This helps consolidate their thoughts.
STEP 3	Trigger the discussion back to the patient. Ask for the Differential Diagnosis. Encourage the listing of the differential diagnosis based on the mechanism rather than on the disease entities.             e.g. Mechanism of Edema
STEP 4	Based on the listed differential- trigger the students to ask for additional            information from the history or PE that will help rule in or rule out their differential diagnosis
STEP 5	Based from the information gathered, trigger the student to validate their hypotheses. Help them focus on the important cues-by asking them to come up with the list of important cues in the history and PE
STEP 6	Challenge the students to make the diagnosis Encourage them to make more LEARNING ISSUES by challenging some other issues not in their list? E.g. Why is there no ascites here? Ask the student to synthesize the whole discussion in a few words.
STEP 7	Close the session. Ask students to critic themselves. Comment on how they could have done better.    Appreciate students who have done well. Point out politely the weakness of some.(E.g. some who are quiet) Assign the learning issues by requesting for volunteers who will look into the matter more in-depth.  Volunteers are better than topics being assigned to students. Agree on the schedule for the  next meeting. Advise students to come back  with prepared audiovisuals (sketches or diagrams) and  to provide their  classmates a  copy. Their sharing should not be more than 2 minutes. It has to be brief,  concise and direct to the point. They are to provide the source of their reading material  as well.

SAMPLE CASE

CLINICAL PRESENTATION

An elderly man presenting with edema of the lower extremities and back with prominent superficial veins of the lower limbs, abdominal wall and thoracic wall. 

HOW TO OPEN THE DISCUSSION

How would you like to approach discussing this case? Are there any other alternative approach that you have in mind?  Why do you prefer to approach this case this way?

HOW TO TRIGGER DISCUSSION ON PATHOPHYSIOLOGY OF EDEMA?

What is Edema? What causes Edema? What are the forces that causes fluid shifting from the intravascular to interstitial ?  Why don't we list them in the board while we rationalize the mechanisms for each of the causes?

HOW TO TRIGGER DISCUSSION ON DIAGNOSIS?

Based on the causes of edema, what would your differential diagnosis be? What other information in the history or PE do you wish to know? Why did you want to know that information? How will that help in the diagnosis of this case? Why was there edema of the LE and superficial vein engorgement of the Abdomen and chest wall but no ascites?

HOW TO TRIGGER CONSOLIDATION OF THE DISCUSSION

Let us synthesize the case: What were the important critical points of this case. List them down in the board. Out of these issues, what cues would you consider strongly to help you make the diagnosis? Based on the added information from the History and PE, how would you validate your differential diagnosis?

HOW TO TRIGGER DISCUSSION ON THE ANATOMICAL BASIS

How was the venous blood from the lower half of the body able to by pass the obstruction in the  inferior vena cava?      Would you expect that deep veins as well as superficial veins be involved? What are the superficial veins involved? Which are the deep veins involved? Review the tributaries of the inferior vena cava and the anastomotic connections that would allow the necessary collateral circulation in this case.    What specific characteristic of the development of this condition prevented a more serious or perhaps disastrous crisis to the patient?  Would the occlusion be more serious at the level of the Lumbar Vertebrae 1 or higher? What additional problems would you expect to observe if the obstruction were at the level of LV-1 ?