Dr Joel Fuller (Department of Health Sciences) aims to provide his Doctor of Physiotherapy students with rich and detailed case studies to prepare them for in-depth and often complex case and client interactions. In this post, Joel talks about the challenges of teaching and assessing clinical skills, and how he uses case-based learning to connect students with real-life scenarios to help them thrive as clinical practitioners. As told to Kylie Coaldrake and Karina Luzia.

From sports enthusiast to physiotherapist to academic to award winner. Read about Joel’s journey by clicking the arrow to the left. 

I grew up loving and enjoying sports and that eventually led me into physiotherapy as a profession.

I completed my physiotherapy training and worked clinically in Adelaide before embarking on my PhD (Physiotherapy/ Health Sciences) at the University of South Australia. My clinical and research interests have always been primarily in sports-related areas.

It was during my PhD that I first got some experience with higher education teaching. I tutored health science students, which I really enjoyed, and marked assessments, which was maybe a bit less enjoyable, but still an important part of my development. My PhD supervisors were teaching-research academics, and occasionally I would get some valuable unit-convening experience when they were on leave.

In 2016, I started at Macquarie University in the department of what was then Health Professions, now Health Sciences, teaching into exercise units as a tutor or assessor, and lately, into the first year of the Doctor of Physiotherapy postgraduate course, with some involvement in later stages.

As a physiotherapist, I’m fortunate because a significant part of our professional role involves educating clients, so, I already had skills in communicating with people from a variety of backgrounds and people who engage with things differently. I did feel that teaching was perhaps less of a challenge for me, compared to some colleagues who had come from backgrounds with less person-to-person interaction.

I was also lucky because my PhD supervisors were very active educators, and as a student, I could easily approach them on teaching matters. We had a good informal community of research students who were tutoring, some with a bit more teaching experience than me, and we would learn from each other and take pride in what we were doing.

I would definitely have benefitted from some more formal training to optimise my approach to teaching tutorials. When I joined Macquarie, I really enjoyed the FILT (Foundations in Learning and Teaching) program which was my first formal experience in learning how to be an educator.

Clinical practice experience has a lot of educational elements to it. A big game changer from my first-year tutoring was realising that I could be autonomous and have control of my own teaching style – that is something that you have that is a bit unique to you and you should be growing and reflecting on. Initially, I was just running through class activities and being quite robotic.

I learnt from others a year or two ahead of me and saw how they were delivering the same tutorial. I noticed how they added value to their tutorials just because of their own interest and passion. And I realised that I could bring my own personal flavour to the way I teach.

My current teaching roles now involve leading the first year and a half of the Doctor of Physiotherapy course (which we refer to as Stage 1). Since the pandemic, I’ve been teaching in a hybrid delivery format where I curate and moderate online content forums, design activities, and develop, deliver and facilitate multiple practical classes a week. We’ve also recently introduced thematic in-person seminars held at key times throughout semester where we bring students on campus in smaller groups.

TECHE: In 2021, Joel was the recipient of the Vice-Chancellor’s Early Career Award. Read more about Joel’s student-centered approach to teaching and how he articulated his career goals to put him on that trajectory.

Even the most motivated of students need support

Many of our Doctor of Physiotherapy students have a sports background (like me!) but are postgrad learners.

A very small number are making a career change after establishing themselves in other fields (and hats off to them!). We know from the educational literature that the undergrad-to-postgrad transition can be a challenge for students in any discipline, and physiotherapy is no different. In my role as Stage 1 lead, I aim to foster motivation, enthusiasm and interest and guide them through the growing pains of learning about a master’s level curriculum.

Being a professional clinical degree, there are very high professional standards that are a jump up from the undergrad experience. In working through these challenges, I do a lot of hand-holding and supporting before watching them progress to clinical placement like a proud parent.

In my leadership roles, I’ve also gained insight into the challenges students face in life outside the classroom. Managing the cost of living and the need to have employment with the demands of a full-time master’s level degree does challenge students – they are often very stretched, and they welcome all the breaks that come their way. Often when a student receives a result that they’re not happy with (and I say not happy in the sense that they’re not achieving the outcomes they would like) I meet with them to unpack what’s going on. It usually involves more than just academic challenges.

Although the physiotherapy course has a clear trajectory, traditionally with roles in hospitals or private practice, students can land in many different places. A small number, after spending time clinically, choose to come back to uni and explore research pathways. A few might pursue a medical training degree.

Some students have gone the full loop and returned to join our teaching team. The course has now been running long enough to have that full loop experience. We have really good employment rates.

A case study in case-based learning – connecting students with real stories

I’m definitely not the only one using case-based approaches – it’s very widely used in health education! My own reflection is that people naturally connect with stories, and case-based learning taps into that. I’m mostly focused on optimising how students learn in this area.

Case-based learning means I can provide opportunities for students to see how, for example, an injury impacts a person and drive home the experience of that injury.

Information about injuries is much more memorable when you’ve had a chance to see what it might look like for someone. Sometimes you’re unlucky enough to have a particular injury yourself and you get that intimate experience! So I want to make sure the content that my students engage with, is giving them an understanding they won’t forget.

One limitation of cases is that, by nature they are narrow– and we have a lot of breadth to cover in this degree. But they do create a very memorable interaction with a health condition that ‘sticks’ with students. The more we can enrich those cases, the more memorable they will be and the more relatable they will be when students eventually go out on their clinical placement.

The aim is that the cases provide students with greater pattern recognition capabilities. We want them to be sound clinical reasoners, able to navigate uncertainty, and solve clinical problems. But we also want them to have a bank of clinical patterns they recognise from their learning, so that when they see it in a placement or clinic situation, they can recall and use it. We want students to have both the ability to reason and work through every clinical decision they’re making, but also have patterns they recognise and can use to check their reasoning and make sure they’re on the right track.

I think case-based learning can do all that, and it helps students thrive on placement, which is a real success indicator for me.

We get immediate feedback about how the students are going on their placements because our clinical education team do an amazing job of visiting students at their placement sites, getting feedback from the educators, and finding out what’s working, what’s not working, and any common pain points or challenges.

I’m always anxious to find out how they’re going and what things need to be done better to prepare the next cohort for that transition. The cases are just one thing that we can constantly tweak and adjust to try to align with the constantly changing clinical environment.

Building up a repertoire of cases

I build up a repertoire of cases often by drawing on past clinical experiences, refashioning them for various scenarios. For example, if someone has a knee problem, it could present as many different scenarios in terms of diagnosis and the way it impacts them. You can often use one stimulus for a case story and spin it a few different ways to get extra value out of it. Others who have run these units before me have also already curated cases that I’ve been able to use and expand on. So, there’s a team element to it.

Here’s an example of a case study where one stimulus has been used to generate several activities: a group work task and a role-play in pairs.

Click on the image on the right to view the full case study and activities.

Over time, I’ve tried to enrich the personal and social element of cases. Earlier cases tended to be very biomedical: the profile would be just like what you would read in a medical textbook for someone with an injury, but there wouldn’t be anything about the social context, family environment, or goals of the patient, which are more crucial in many ways. Adding those aspects into the cases has created more opportunity for unpacking person-centered care. Without that, it’s very hard for students to apply and recognise how critical patient education is. It’s one of the better-evidenced modalities, but it’s hard to train and practice it unless you consider rich case examples that go beyond a textbook script of clinical findings. You need to educate the person rather than the pathology and the education needs to address their context, where they’re coming from and what their goals are.

In this case study, the context and goals of the patient are incorporated for students to consider as part of their assessment and treatment plan.

Click on the image on the right to view the full case study and activities.

I’m excited about the potential and increased accessibility of artificial intelligence (AI). I’ve been working through some AI algorithms to scale up the variety and quantity of cases that I can work with to create additional opportunities for students, by growing the number and variety of asynchronous case opportunities. I’m hoping it will be fruitful.

If we can get the AI communication dialogue right, my hope is that I can skill students up so they can create their own cases and start to grow their clinical language and expectations for a case. Even though AI can create a case, there will often be elements of it that don’t make sense – i.e., it would never go that way in real life. And if the students can start to have those experiences with AI, evaluate the parts that AI got wrong, recognise those things that don’t make sense, and then tidy them up, they’re learning and growing and improving their clinical understanding. That’s AI prompt engineering for health!

Teaching to the middle

In teaching first year, there’s this constant tension between trying to make complex things simple, but not too simple and not shielding too much from complexity. I really enjoy those moments where we get to take some of the guard rails off. It’s not that the usual cases are on train tracks, but the more you can bring the complexity to light and talk through it helps students have that “Aha” moment.

The ability to operate effectively under a little bit of uncertainty is critical.

Sometimes, despite our best efforts, some students may not have sufficient awareness of complexity and everything they might need to be mindful of – perhaps it’s because they needed more time – but you can see that it’s going to be a problem for them moving forward.

If we do get a poor student outcome, it often comes back to an inability to handle complexity to the extent that’s required of a health practitioner. I think the cases at times have needed to ramp up complexity, not so much that students lose confidence, and that’s the tension there, but just enough that they don’t become inappropriately overconfident – they should be constantly checking their reasoning and being mindful of what else could be going on.

We really need to know where the students are at to know when the right point is to introduce that added complexity. And you’re trying to teach to the middle – you know there are some that probably could have handled that earlier and some who it might push too far. We try to have mechanisms around these key moments to stretch those high achieving students earlier than the average. But then we also need to have catchment mechanisms to know when to pull a struggling student aside and help them not fall behind and not get thrown too far by a really complex case activity in class.

The challenge of teaching clinical skills

Teaching clinical skills is a challenge. Many of the case-based scenarios we use involve peer-to-peer simulation where students work in pairs where one is role-playing a patient. I’ll take those who are playing the role of patients and talk them through how they need to play that part – that their partner is going to try to “solve” and make sense of what’s going on. Sometimes, the ‘patients’ are far too forthcoming with the right information. I remind them that a real patient is going to make them work for that more!

We have a community clinical placement program where the students work in pairs with a volunteer from the community who has a health condition. They interact with them over a semester to understand their story and that experience makes them realise that it does take a bit more to get the information and that the patient may not describe their condition in a clinical way. Ultimately, they get lots of that sort of experience when they go out on placement.

In-class activities focus on skill development, preparing students for in-depth case interactions.

The tutors help them develop skills to unpack uncertainty, and to recognise that no real patient is going to be textbook-scripted and there will be natural variations.

We teach them to look for patterns in patient outcomes and to develop ways of constantly checking reasoning and whether they are on the right track. We teach skills and strategies for unpacking whether a deviation is due to patient variation that shouldn’t sway them down a different assessment management pathway or whether it is something they need to dig into.

We discuss that it’s often the case that the more times you feel like you’re getting pulled in a different direction, the more likely you might actually be heading in the wrong direction, and you need to follow a different path.

So, it’s very complex. It’s part of the art of what we do – teaching pattern recognition and reasoning to be able to constantly verify that they are seeing the right patterns and that they aren’t misconstruing something.

Teaching students risk awareness is also critical. We are constantly trying to make sure students have a safe working limit in place so they can identify emergency situations that can’t be missed.

I think by nature they just want to help people, and so sometimes they don’t consider the option that they’re not the right person to help this patient and they urgently need a different kind of intervention. We call these red flags and it’s important for students to recognise when they’re seeing them and understand what they need to do in that situation, even if they feel the risk is low.

The cases that have been most critical are often more complex than standard ones. You have to pick the right time to introduce these though and it’s not in Week 1. We wait until they have seen some cases and understand how they work. Cases that are far from black and white can drive a lot of interesting in-class discussion, especially where there’s uncertainty and the students are coming up with notably different outcomes when we’re talking through what everyone’s found and why.

This happens all the time in clinic situations – there might not necessarily be a Right and Wrong- we’re always fractionally certain of our diagnosis, and fractionally uncertain. We explore how to navigate such situations – how to operate when you are on the fence about it and how to ensure that your patient management is not going to be inappropriate if you are wrong.

The challenges – and creativity – behind assessing clinical skills

Challenge number 1 – The sheer number of skills that must be covered

One challenge is the enormous breadth of technical skills to be covered and the inability to assess every one of them.

We have in-class hurdle assessments that are flexible in the sense that they are not held every week. So, we’re doing assessments in a formal manner in class where students need to demonstrate skills in front of us to a functioning standard. We call it skills mastery and the students must show competency in a minimum number of a set list of skills within each semester within each unit.

This has been a good strategy to make sure students engage with the idea that they need to know these skills now and can’t just put them all off to the end. It’s a relatively low stakes hurdle as if they don’t get it on the day, we give them another opportunity down the track. That helps de-threaten the clinical assessment mystery that they feel in first year because they would not have had one on one clinical performance assessment situations before where they must do things in front of us. So, I think it both de-threatens and allows good coverage of a broad depth of skills.

The skills we select to assess don’t cover every skill, but they are representative of key skills for that unit and stage of learning. We are confident that showing competency in those skills is a good marker of competency in broader and relatable skills. It is always a challenge balancing time spent on assessment versus teaching in class.

Challenge number 2 – Assessing work readiness

A common challenge in all courses is preparing students for the workplace. There’s a tension between trying to support and nurture your students and also having them work ready. I’m so acutely pulled between those two directions because when students commence, I’m doing everything I can to help them integrate into the course and succeed and progress. But once they finish and move to a clinical environment, such as a busy hospital or clinic, they become one of many and they’re not the number one priority – the patient is.

While our teaching team responds promptly to help students unpack every uncertainty, we recognise that they can’t have that expectation of their clinical educator or in the workplace where the patient is the priority. Therefore, they have to learn to wait and be productive despite having an unanswered question.

At times I wonder if we’ve done a good enough job of preparing them for that transition because we’ve been so keen to make them the priority while they are students, which is kind of giving them the opposite experience of workplaces where the patient is the priority.

Work readiness and autonomy are quite challenging to assess. Many of our clinical education staff are also involved in teaching tutorials and running assessments and we have open conversations about what they think is a good balance. This helps keep me grounded on the appropriate way to pitch assessments, to ensure that someone excelling in our assessments is also someone who is work ready and will excel in a clinical placement environment.

I constantly tweak and adjust how assessments are pitched, but it’s never going to be perfect. I enjoy the process of trying to ensure tasks are the best indicators of how a student is going to transition to a clinical work environment and interestingly I’ve found that the best way to do that is by making the task more open. This puts the student in an open clinical scenario and allows you to see how they reason their way through. You could put two students through a task, and they could take very different approaches and get very good results – or they could take different approaches and get poor results. What I’ve learned is that it’s not a bad thing to have openness in an assessment. I’m still trying to get it right. I don’t know if I ever will. But that’s a challenge for us.

Challenge number 3 – Assessing key skills in class time

Another challenge is physically getting around the classroom to see all the students performing their skills assessments. The approach will fluctuate depending on class numbers. There are typically 20-plus students in our standard classes, and they’ll work in pairs to demonstrate a skill or competency. Often several different mastery skill items will be relatable to that same case scenario. For example, a case scenario with a suspected traumatic knee injury will involve one student role-playing a clinician and the other student the patient. The task for the student clinician is to work through all the targeted testing that they’ve been taught. I emphasise to them that this a mastery skills assessment task and they are not to help each other – it’s not skill development, it’s skill performance. I’ll make my way around the classroom and even though I might not see all the clinical tests done by all the students, I’ll see at least one done by all students and make my assessment based on that. I’ve found the roaming approach works well, and it provides opportunities to give targeted feedback that can help to improve their skills performance in non-hurdle assessments, which have a marked component, later in semester.

With this roaming approach it’s quite evident when a particular student is floundering and has not spent the time required to master the skill. While you’re floating around and scrutinising everyone, it’s easy to recognise the small number who just don’t know what to do. Whereas during group work, you might not be tuned in to someone who’s just blowing through. With roaming, you can have a conversation on the spot with them “I’m sensing that you’re not across this skill and not ready for mastery assessment at this stage,” and they’re usually pretty upfront about it. They might say “No, I haven’t really had a chance to practice that properly” and so I would give them a bit of advice and direction about the skill and say use this time to practice and we’ll find time for you to re-do this specific skill down the track. It certainly demands more of your tutor time, but I think it is valuable and important.

Advice (aka useful things I’ve come to realise)

1. Knowing your stakeholders is key

I think it’s important to find out the ultimate stakeholder groups for where your students are headed. And get feedback from those groups on how case studies or assessments could be expanded, improved or made more powerful and whether they are fit for purpose. I’m fortunate in that I can just go around the corner to our clinical education team and get great feedback about this. It’s satisfying to know that students graduating from the course are at the required standard and meet the performance benchmarks that the stakeholder groups receiving them are actually wanting to see.

Assessments and marking can become pain points and sometimes cause us grief – but if you can find a way to get that stakeholder feedback and think about your assessments in an active and adaptable way, this will help to bring them to life and add some satisfaction and excitement to the process.

2. It’s important to empower your tutors

I really feel it’s important to empower your tutors. We don’t do enough of it. By that, I mean to help them come into their own as educators. For example, you can encourage them to provide feedback on class plans and learning resources, action their feedback, and discuss the impact of the changes with them. The more you follow through with actioning tutor suggestions the more their confidence as educators will grow and the whole unit will benefit from that. Many great learning resources and improved class activities in my units have come directly from suggestions and efforts by tutors. They provide a lot of deep insight into what works best for students and curriculum areas that need improvement.

3. Active feedback is more satisfying for both students and markers

I like to look for ways to, within reason, create dialogue in feedback with students. A continuous adaptive assessment approach is one way to do that – the assessment is broken up into stages and there is a motivating opportunity for students to dialogue with you on the feedback provided because it directly carries over to the next half of that assessment.

For example, early submission of assignments is an opportunity to provide feedback that the student can then incorporate into the final submission of that assignment. Sometimes the feedback that we give can be a workload grind and a notable pain point in semester. But if you’re able to make it more active and give an opportunity for it to have a translational impact on the next submission, you’re likely to make your marking job easier in the next round. From my experience the added work has been less than you would think. And it is more satisfying.

I set a high bar on that dialogue. One key learning for me is that students need to come with you in their feedback dialogue and ask really specific and thoughtful queries. I set clear expectations in the way the dialogue opportunity is pitched so that it’s a transparent process. For some students the response will be ‘yes, I’ll participate in this dialogue and here’s my thoughts and hopefully this is helpful’. In other cases, I might say ‘you need to come back to me with a more thoughtful request for clarification because I expect more of you and I think you can accomplish more and it will ultimately get you a better answer if you think about this a bit before we have a discussion.’

When we pour our heart and soul into this feedback, we’re thinking, are they even going to read it, use it, whatever – that’s a huge thing. I think seeing dialogue flow from feedback and hopefully the student growth that comes out of it in the next submission or the next assignment or just in their response would help make that a more satisfying and beneficial experience.

This teaching strategy where we think about ways to create sensible, practical dialogue around assessment feedback can help build that element of work readiness we want to promote in our students. I don’t have the exact answers of how to do that. I’m sure it will look different for everyone, but I’d be excited to see what strategies people have already in place or what they come up with because if we can get more of that right, we’ll find the process of preparing and giving student feedback more satisfying.

It’s a difficult concept to apply and workload appropriately, but if we can make feedback processes a more satisfying experience then I think the workload frustrations associated with assessment feedback would be somewhat reduced.

And a final word from Joel:

I find that taking time to stop and think about why you believe something or why you do things the way you do is always useful. It helps you become clearer in your current thinking and also identify when you need to shift your current approaches. I see this happen in my role as an educator when I reflect on my teaching and also in my students when they engage in reflective opportunities during and after their assessments.

Triathlete image: Source – TrainingPeaks
All other images supplied by Joel Fuller

Posted by L&T Development

The Learning and Teaching Staff Development team works with staff across the University to ensure they are supported to facilitate quality learning for students. This includes offering professional development, contributing to curriculum and assessment design, recognising and rewarding good practice, supporting peer review of teaching, and leading scholarly reflection. Email professional.learning@mq.edu.au with questions or requests.

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