Case presentations are complex skills requiring thoughtful instructional design, yet they are often neglected within formal medical school curricula. The authors provide a model curriculum, based on theory, to systematically introduce longitudinal instruction of case presentations. Early introduction of simplified presentation tasks to novice learners prepares students to encounter more challenging learning tasks in the clinical environment where case presentations often significantly impact the impression a student makes on the healthcare team [15], and the quality and safety of patient care [16].
Application of the 4‑C/ID model to case presentation curriculum development has the potential to address several educational obstacles. The first is compartmentalization, which occurs when curriculum designers intentionally separate into distinct units the composite knowledge, skills and attitudes necessary for performance of an integrated and complex skill [17]. In our curriculum, knowledge, skills and attitudes are incorporated into each learning task by simultaneously varying the context, case complexity, clinical reasoning, and the audience. The second obstacle is fragmentation, which occurs when a complex skill is broken down into all its subcomponents with the expectation that learners will be able to re-assemble those parts at a later point in the performance of the real task [7]. This is addressed in our curriculum by ensuring that even in the earliest task class, learners are confronted with the whole task, but in a manner attending to cognitive load. The third obstacle is the transfer paradox, wherein students cannot translate component skills of a complex task into actual practice. Our curriculum addresses this obstacle by ensuring that learners are always engaged in the whole task of delivering a case presentation while moving closer and closer to the highly varied and relatively unpredictable clinical environment.
Some might argue that 4‑C/ID has some features of compartmentalization, fragmentation and the risk of transfer paradox: Supportive and just-in-time information may be introduced in the form of brief lectures, readings or exercises distinct from learning tasks. The backbone of the curriculum, however, centres on learning tasks. This is distinctly different from lecture-based curricula where learners are left to assemble information from disparate sessions into a whole skill. Part-task practice may also seem to isolate components of the whole skill. The use of part-task practice, however, was minimized in our curriculum. When we did utilize it, we always introduced it in the context of the whole task first to provide appropriate context.
To date, the 4‑C/ID model has not been widely implemented in medical education, despite articles that highlight the benefits of whole task learning [6, 8, 17, 18]. Based on our experience, we hypothesize that this lack of adaptation may be multi-factorial: 1) The 4‑C/ID model as currently presented in the literature may be difficult for busy clinician educators to comprehend and apply. The model appears complex when presented in diagrams [6, 7], and may be better understood when concrete examples within medical education are provided. In the words of a member of the development team, ‘When you read about it, you don’t get it. When you sit down with an example applicable to the field you work in and work through it, you get it.’ Ultimately, the fundamental concepts are straightforward: Create curricula comprised of whole learning tasks, sequenced simple-to-complex and scaffold the experience using supportive information, just-in-time information and part-task practice. If more emphasis were placed on these core and simple to understand principles, perhaps the model would be adapted more broadly. 2) Use of the 4‑C/ID model to teach case presentations challenges educators to depart from traditional teaching of constituent parts towards a whole task approach to foster complex skill development. For implementation to be successful, faculty must understand why whole task approaches are more beneficial to learning. This requires faculty development.
In this paper, we attempt to make the 4‑C/ID model more broadly accessible to medical educators: We present an entire case presentation curriculum outline, with a significant level of detail supported by multiple concrete examples. Such specifics may assist educators considering using the model, not only to implement a case presentation curriculum, but also to design curricula for other complex tasks. We outline a few important steps early in the design process that have not been robustly described elsewhere: The first step involves a collaborative brainstorming session in which instructional designers gather key stakeholders together to identify all aspects of a skill that make it ‘complex.’ The second step involves organizing this brainstorm into a manageable set of themes. Once themes are identified, task class descriptions are developed that address each theme in a developmental manner (online Supplementary Tab. 1–4). This is a replicable process that can be applied to instructional design for other complex skills.