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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity.

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Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact Allison Bodznick , Harvard Chan Case Library administrator, for access.

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Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

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To request teaching notes for cases that are available for free through this website, look for the "Teaching note available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

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Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country.

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department. The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center.

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods.

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Chai, J., Gordon, R. & Johnson, P. , 2013. Malala Yousafzai: A Young Female Activist , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case traces the story of Malala Yousafzai who has advocated passionately for girls’ right to education. In October 2012, a militant group with ties to the Taliban shot 14-year-old Yousafzai in the head as she was riding the school bus home after a day of classes. Yousafzai recovered and became the youngest recipient of the Nobel Peace Prize in 2014. This case explores the social factors that made such an attack possible and why there continue to be such barriers to educational opportunities for girls. "Malala Yousafzai: A Young Female Activist" is a part of a case series on violence against women that illustrate the critical role for leadership through an examination of how factors within a society influence women’s health. Students analyze the situations described by considering the circumstances that placed each protagonist in vulnerable positions. Participants examined the commonalities and differences of these situations in an effort to understand the circumstances that affect women’s well-being. Additionally, using the cases as a framework, students analyzed the connections between collective outrage, reactive action, and leadership.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

Weinberger, E. , 2015. Retweet Does Not Imply Endorsement: The Logic of Cyberbullying in Schools , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract School nurse Hazel O’Leary and her supportive principal, Jamal Morden-Jones, strive to effectively respond to weight-related cyberbullying at their middle school. While there is a district-wide bullying prevention and intervention program guide that supposedly has all the necessary guidance on the subject, the duo still find themselves scrambling to implement the plan in the school, highlighting the gap between policy and practice. As the case study ends, Hazel prepares to initiate her school’s first foray into the world of logic models for public health program planning. Teaching note available for faculty/instructors .

Weinberger, E. , 2015. Full of Surprises: Dietary Supplements and the Gym, or, a Tale of Corporate Social Responsibility , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Working out at the gym is a healthy endeavor, but many gyms endorse unhealthful practices. They may advertise or sell dietary supplements for weight loss or muscle building that not only fail to do what they promise, but contain potentially dangerous ingredients. Callie Guertin is a primary care physician in Hamilton, in the fictitious U.S. state of Columbia, and a daily gym-goer who is slowly awakening to the fact that her chosen new gym, MuscleTone, sells weight-loss supplements at its welcome desk. She wants them to stop; but what can she do on her own? With some guidance from a young activist, Stacie Lubin, and her sympathetic personal trainer, Rudi, Guertin learns skills of coalition building to pressure the MuscleTone chain to change its practices. Perhaps, using principles of corporate social responsibility, or CSR, MuscleTone can be made to realize that abandoning sales and advertising of supplements can produce a good result for everybody—healthier customers, of course, but also a new marketing campaign touting MuscleTone as the gym for “healthy living”? Guertin and her allies are working on MuscleTone to make just this case. Teaching note available for faculty/instructors .

Gordon, R. , 2014. Who Owns Your Story? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case uses a role play simulation to illustrate ethical implications when research practices violate cultural taboos and norms. In Who Owns Your Story? the Trilanyi - a fictional Native American tribe based on a real community that is not identified or located in the case – is adversely affected by a high prevalence of diabetes. They ask a university professor with whom they have a close relationship to study their tribe, and they agree to give samples of their blood – which they consider sacred – for the study. Tribe members signed a consent form to participate but it was unclear whether they realized that the consent covered the university potentially using their blood for other possible research topics beyond diabetes. Ultimately, the study does not discover that the tribe has a genetic predisposition to diabetes. Years later, however, tribe members learn that their samples had also been used to study topics they considered objectionable. The case is based on true events between the Havasupai tribe and the University of Arizona which ultimately led to a legal suit that was settled out of court. In the case, students are asked to develop and simulate role play negotiations toward an acceptable resolution for all the parties involved.

Focus on Diversity, Equity, and Inclusion

Yatsko, P. & Koh, H. , 2017. Dr. Jim O'Connell, Managing Crisis, and Advocating for Boston's Chronically Homeless Community , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract A deep sense of foreboding filled Dr. James O'Connell and his team at Boston Health Care for the Homeless (BHCHP) in October 2014. The Boston mayor's office had just condemned the 64-year-old bridge that provided the only passage to the island in Boston Harbor housing the city's largest homeless shelter. It did not have a long-term contingency shelter plan in place and the city's other shelters were full. With winter fast approaching, O'Connell, who had been serving Boston's homeless population for over a quarter century, feared some of the city's dispossessed would die on the streets from cold. BHCHP would be hard pressed to provide them the medical care they needed. To implement his solution-reopening the Boston Night Center-O'Connell had to overcome the disinterest of BHCHP's traditional allies in the homeless service provider community, who for a number of years had been channeling their energies away from sheltering toward permanent housing solutions. The Boston Night Center's reopening helped achieve an unprecedented feat for the City of Boston: Not a single homeless person died from the elements that winter, the harshest in the city's recorded history. O'Connell parlayed this achievement into city and state financial support for the Boston Night Center for the next several years. How did O'Connell work with stakeholders to accomplish his goal? What could he do to maintain financial support for the Boston Night Center and shelter programs in Boston more generally?

Al Kasir, A., Coles, E. & Siegrist, R. , 2019. Anchoring Health beyond Clinical Care: UMass Memorial Health Care’s Anchor Mission Project , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

Weinberger, E. , 2017. Coloring the Narrative: How to Use Storytelling to Create Social Change in Skin Tone Ideals , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Many millions of people around the world experience the pervasive, and often painful, societal messages of colorism, where lighter skin tones are asserted to be more attractive and to reflect greater affluence, power, education, and social status. Even in places where the destructive effects of colorism are fairly well understood, far less is known about the problem of skin-lightening (really, it’s “skin bleaching”) creams and lotions, and the health risks that consumers assume with these products. In this teaching case, the protagonists are two women who have recently immigrated to the United States from Nigeria and Thailand, both with a life-time of experience with these products like many of the women of their home countries. As the story unfolds, they struggle along with the rest of the characters to copy with the push and pull of community norms vs. commercial influences and the challenge of promoting community health in the face of many societal and corporate obstacles. How can the deeply ingrained messages of colorism be effectively confronted and transformed to advance social change without alienating the community members we may most want to reach? Teaching note and supplemental slides available for faculty/instructors .

This case describes and explores the development of the first medical transitions clinic in Louisiana by a group of community members, health professionals, and students at Tulane Medical School in 2015. The context surrounding health in metro New Orleans, the social and structural determinants of health, and mass incarceration and correctional health care are described in detail. The case elucidates why and how the Formerly Incarcerated Transitions (FIT) clinic was established, including the operationalization of the clinic and the challenges to providing healthcare to this population. The case describes the central role of medical students as case managers at the FIT clinic, and how community organizations were engaged in care provision and the development of the model. The case concludes with a discussion of the importance of advocacy amongst health care professionals.

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Quelch, J.A. & Rodriguez, M.L. , 2015. Mérieux NutriSciences: Marketing Food Safety Testing , Harvard Business Publishing. Available from Harvard Business Publishing

Teaching note available for faculty/instructors .

Gender-based analysis in public health is a systematic examination of the differences and similarities in the lives of women and men, as shaped by systems of gender relations, and the causes and consequences of these differences and similarities with respect to population health, policies and laws, programs and services, research priorities, and public discourse. As the Harvard School of Public Health Interdisciplinary Concentration on Women, Gender, and Health (WGH) states:

"Addressing issues of women, gender, and health requires the study of the health of women and girls—and men and boys—throughout the lifecourse, with gender, gender inequality, and biology understood as important and interacting determinants of well-being and disease.

"Also included are the study of gender and gender inequality in relation to individuals’ treatment by and participation in health and medical care systems, the physical, economic, and social conditions in which they live, and their ability to promote the health of their families, their communities, and themselves.

"Inherent in this definition is recognition of diversity and inequality among women—and men—in relation to race/ethnicity, nationality, class, sexuality, gender identity and age, and that protection of human rights is fundamental to health."

The WGH 207 teaching example assignment provides students with the opportunity to create brief teaching examples to expose students in non-WGH courses to gender-based analysis. Students work in pairs to create teaching examples based on the substantive material presented by guest speakers throughout the term (e.g., reproductive technologies). Teaching examples focus on cultivating a key technical skill within public health (e.g., Directed Acylic Graphs) through the exploration of a central issue in gender-based analysis (e.g., challenging simplistic conflations of gender and sex). Beyond building the pedagogical skills of WGH 207 students, the assignment has yielded—and continues to yield—teaching examples that can introduce the concept of gender-based analysis into core courses across all departments at HSPH.

This assignment was originally developed by course instructors Jerel P. Calzo, PhD, and Sabra L. Katz-Wise, PhD.

To cite an individual teaching example, please reference the author(s) and year of publication on the first page of the document.

Teaching examples available for download:

Measuring and Analyzing Gender:

Sex and Gender Analysis within a Demonstration of Effect Measure Modification versus Confounding and supplemental materials
Gender-Based Analysis and Directed Acyclic Graphs
Unbiased Sampling Methods for Sexual and Gender Minorities and supplemental materials
Gender-Based Analysis for Variable Selection in Logistic Model Building and supplemental materials
Gender-Based Analysis in Sample Size and Power for Binomial Proportions
Gender Analysis, Effect Modification, & Environmental/Occupational Exposures
Exploring Model Specification Options for Adolescent Gender Expression and supplemental materials

Intimate Partner Violence:

Sex and Gender Analysis of Intimate Partner Violence
Intimate Partner Violence Mock Trial
Gender Analysis of Intimate Partner Violence in “High Risk” Behavior Epidemiology

Gender, Policy, and the Law:

Gender-Based Analysis and Op-Ed Writing: The Example of Sexual Minority Reproductive Health , supplemental materials , and supplemental slides
Using Gender-Based Analysis in a Policy Brief on Paid Family and Medical Leave
Public Health Law Teaching Example: Forced Sterilization Law & Policy
Gender Analysis of COVID-19 Response
Sex/Gender, COVID-19, and DAGs: A 60-Minute Teaching Module for Introductory Epidemiology Lab

Asante Teaching Hospital: Activity-Based Costing

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Asante teaching hospital: activity-based costing description.

In August 2015, an intern at Asante Teaching Hospital, a prestigious not-for-profit hospital in Johannesburg, South Africa, wanted to organize the cost data she had gathered from staff interviews into clear recommendations for the hospital's chief executive officer. Asante Teaching Hospital's maternity ward competitors had begun offering bundled pricing for natural births, and the intern wondered if Asante Teaching Hospital should do the same. In order to calculate the costs of the service, she planned to employ both activity-based and time-driven activity-based costing techniques. With this information, she could present the results of her analysis and recommendations for a pricing strategy. Melissa Jean is affiliated with Brescia University College. Courtney Young is affiliated with Brescia University College.

Case Description Asante Teaching Hospital: Activity-Based Costing

Strategic managment tools used in case study analysis of asante teaching hospital: activity-based costing, step 1. problem identification in asante teaching hospital: activity-based costing case study, step 2. external environment analysis - pestel / pest / step analysis of asante teaching hospital: activity-based costing case study, step 3. industry specific / porter five forces analysis of asante teaching hospital: activity-based costing case study, step 4. evaluating alternatives / swot analysis of asante teaching hospital: activity-based costing case study, step 5. porter value chain analysis / vrio / vrin analysis asante teaching hospital: activity-based costing case study, step 6. recommendations asante teaching hospital: activity-based costing case study, step 7. basis of recommendations for asante teaching hospital: activity-based costing case study, quality & on time delivery.

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Case Analysis of Asante Teaching Hospital: Activity-Based Costing

Asante Teaching Hospital: Activity-Based Costing is a Harvard Business (HBR) Case Study on Finance & Accounting , Texas Business School provides HBR case study assignment help for just $9. Texas Business School(TBS) case study solution is based on HBR Case Study Method framework, TBS expertise & global insights. Asante Teaching Hospital: Activity-Based Costing is designed and drafted in a manner to allow the HBR case study reader to analyze a real-world problem by putting reader into the position of the decision maker. Asante Teaching Hospital: Activity-Based Costing case study will help professionals, MBA, EMBA, and leaders to develop a broad and clear understanding of casecategory challenges. Asante Teaching Hospital: Activity-Based Costing will also provide insight into areas such as – wordlist , strategy, leadership, sales and marketing, and negotiations.

Case Study Solutions Background Work

Asante Teaching Hospital: Activity-Based Costing case study solution is focused on solving the strategic and operational challenges the protagonist of the case is facing. The challenges involve – evaluation of strategic options, key role of Finance & Accounting, leadership qualities of the protagonist, and dynamics of the external environment. The challenge in front of the protagonist, of Asante Teaching Hospital: Activity-Based Costing, is to not only build a competitive position of the organization but also to sustain it over a period of time.

Strategic Management Tools Used in Case Study Solution

The Asante Teaching Hospital: Activity-Based Costing case study solution requires the MBA, EMBA, executive, professional to have a deep understanding of various strategic management tools such as SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis.

Texas Business School Approach to Finance & Accounting Solutions

In the Texas Business School, Asante Teaching Hospital: Activity-Based Costing case study solution – following strategic tools are used - SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis. We have additionally used the concept of supply chain management and leadership framework to build a comprehensive case study solution for the case – Asante Teaching Hospital: Activity-Based Costing

Step 1 – Problem Identification of Asante Teaching Hospital: Activity-Based Costing - Harvard Business School Case Study

The first step to solve HBR Asante Teaching Hospital: Activity-Based Costing case study solution is to identify the problem present in the case. The problem statement of the case is provided in the beginning of the case where the protagonist is contemplating various options in the face of numerous challenges that Asante Brescia is facing right now. Even though the problem statement is essentially – “Finance & Accounting” challenge but it has impacted by others factors such as communication in the organization, uncertainty in the external environment, leadership in Asante Brescia, style of leadership and organization structure, marketing and sales, organizational behavior, strategy, internal politics, stakeholders priorities and more.

Step 2 – External Environment Analysis

Texas Business School approach of case study analysis – Conclusion, Reasons, Evidences - provides a framework to analyze every HBR case study. It requires conducting robust external environmental analysis to decipher evidences for the reasons presented in the Asante Teaching Hospital: Activity-Based Costing. The external environment analysis of Asante Teaching Hospital: Activity-Based Costing will ensure that we are keeping a tab on the macro-environment factors that are directly and indirectly impacting the business of the firm.

What is PESTEL Analysis? Briefly Explained

PESTEL stands for political, economic, social, technological, environmental and legal factors that impact the external environment of firm in Asante Teaching Hospital: Activity-Based Costing case study. PESTEL analysis of " Asante Teaching Hospital: Activity-Based Costing" can help us understand why the organization is performing badly, what are the factors in the external environment that are impacting the performance of the organization, and how the organization can either manage or mitigate the impact of these external factors.

How to do PESTEL / PEST / STEP Analysis? What are the components of PESTEL Analysis?

As mentioned above PESTEL Analysis has six elements – political, economic, social, technological, environmental, and legal. All the six elements are explained in context with Asante Teaching Hospital: Activity-Based Costing macro-environment and how it impacts the businesses of the firm.

How to do PESTEL Analysis for Asante Teaching Hospital: Activity-Based Costing

To do comprehensive PESTEL analysis of case study – Asante Teaching Hospital: Activity-Based Costing , we have researched numerous components under the six factors of PESTEL analysis.

Political Factors that Impact Asante Teaching Hospital: Activity-Based Costing

Political factors impact seven key decision making areas – economic environment, socio-cultural environment, rate of innovation & investment in research & development, environmental laws, legal requirements, and acceptance of new technologies.

Government policies have significant impact on the business environment of any country. The firm in “ Asante Teaching Hospital: Activity-Based Costing ” needs to navigate these policy decisions to create either an edge for itself or reduce the negative impact of the policy as far as possible.

Data safety laws – The countries in which Asante Brescia is operating, firms are required to store customer data within the premises of the country. Asante Brescia needs to restructure its IT policies to accommodate these changes. In the EU countries, firms are required to make special provision for privacy issues and other laws.

Competition Regulations – Numerous countries have strong competition laws both regarding the monopoly conditions and day to day fair business practices. Asante Teaching Hospital: Activity-Based Costing has numerous instances where the competition regulations aspects can be scrutinized.

Import restrictions on products – Before entering the new market, Asante Brescia in case study Asante Teaching Hospital: Activity-Based Costing" should look into the import restrictions that may be present in the prospective market.

Export restrictions on products – Apart from direct product export restrictions in field of technology and agriculture, a number of countries also have capital controls. Asante Brescia in case study “ Asante Teaching Hospital: Activity-Based Costing ” should look into these export restrictions policies.

Foreign Direct Investment Policies – Government policies favors local companies over international policies, Asante Brescia in case study “ Asante Teaching Hospital: Activity-Based Costing ” should understand in minute details regarding the Foreign Direct Investment policies of the prospective market.

Corporate Taxes – The rate of taxes is often used by governments to lure foreign direct investments or increase domestic investment in a certain sector. Corporate taxation can be divided into two categories – taxes on profits and taxes on operations. Taxes on profits number is important for companies that already have a sustainable business model, while taxes on operations is far more significant for companies that are looking to set up new plants or operations.

Tariffs – Chekout how much tariffs the firm needs to pay in the “ Asante Teaching Hospital: Activity-Based Costing ” case study. The level of tariffs will determine the viability of the business model that the firm is contemplating. If the tariffs are high then it will be extremely difficult to compete with the local competitors. But if the tariffs are between 5-10% then Asante Brescia can compete against other competitors.

Research and Development Subsidies and Policies – Governments often provide tax breaks and other incentives for companies to innovate in various sectors of priority. Managers at Asante Teaching Hospital: Activity-Based Costing case study have to assess whether their business can benefit from such government assistance and subsidies.

Consumer protection – Different countries have different consumer protection laws. Managers need to clarify not only the consumer protection laws in advance but also legal implications if the firm fails to meet any of them.

Political System and Its Implications – Different political systems have different approach to free market and entrepreneurship. Managers need to assess these factors even before entering the market.

Freedom of Press is critical for fair trade and transparency. Countries where freedom of press is not prevalent there are high chances of both political and commercial corruption.

Corruption level – Asante Brescia needs to assess the level of corruptions both at the official level and at the market level, even before entering a new market. To tackle the menace of corruption – a firm should have a clear SOP that provides managers at each level what to do when they encounter instances of either systematic corruption or bureaucrats looking to take bribes from the firm.

Independence of judiciary – It is critical for fair business practices. If a country doesn’t have independent judiciary then there is no point entry into such a country for business.

Government attitude towards trade unions – Different political systems and government have different attitude towards trade unions and collective bargaining. The firm needs to assess – its comfort dealing with the unions and regulations regarding unions in a given market or industry. If both are on the same page then it makes sense to enter, otherwise it doesn’t.

Economic Factors that Impact Asante Teaching Hospital: Activity-Based Costing

Social factors that impact asante teaching hospital: activity-based costing, technological factors that impact asante teaching hospital: activity-based costing, environmental factors that impact asante teaching hospital: activity-based costing, legal factors that impact asante teaching hospital: activity-based costing, step 3 – industry specific analysis, what is porter five forces analysis, step 4 – swot analysis / internal environment analysis, step 5 – porter value chain / vrio / vrin analysis, step 6 – evaluating alternatives & recommendations, step 7 – basis for recommendations, references :: asante teaching hospital: activity-based costing case study solution.

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The role of place on healthcare quality improvement: A qualitative case study of a teaching hospital

Affiliation.

1 Queen's Management School, Queen's University Belfast, Riddel Hall, 185 Stranmillis Road, Belfast, BT9 5EE, Northern Ireland, UK. Electronic address: [email protected].
PMID: 29524869
DOI: 10.1016/j.socscimed.2018.03.003

This article examines how the built environment impacts, and is impacted by, healthcare staff day to day practice, care outcomes and the design of new quality and patient safety (Q&PS) projects. It also explores how perceptions of the built environment affect inter-professional dynamics. In doing so, it contributes to the overlooked interplay between the physical, social, and symbolic dimensions associated with a hospital's place. The study draws on 46 in-depth semi-structured interviews conducted at a large teaching hospital in Portugal formed by two buildings. Interview transcripts were analysed inductively using thematic analysis. The major contribution of this study is to advance the understanding of the interactions among the different dimensions of place on Q&PS improvement. For example, findings indicate that some of the characteristics of the physical infrastructure of the hospital have a negative impact on the quality of care provided and/or significantly limit the initiatives that can be implemented to improve it, including refurbishment works. However, decisions on refurbishment works were also influenced by the characteristics of the patient population, hospital budget, etc. Likewise, clinicians' emotional reactions to the limitations of the buildings depended on their expectations of the buildings and the symbolic projections they attributed to them. Nevertheless, differences between clinicians' expectations regarding the physical infrastructure and its actual features influenced clinicians' views on Q&PS initiatives designed by non-clinicians.

Keywords: Case study; Healthcare quality management; Hospital; Patient safety; Place.

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Published: 05 June 2024

Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study

Jacob Kumakech 1 ,
Ian Guyton Munabi 2 ,
Aloysius Gonzaga Mubuuke 3 &
Sarah Kiguli 4

BMC Medical Education volume 24 , Article number: 621 ( 2024 ) Cite this article

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Introduction

The long case is used to assess medical students’ proficiency in performing clinical tasks. As a formative assessment, the purpose is to offer feedback on performance, aiming to enhance and expedite clinical learning. The long case stands out as one of the primary formative assessment methods for clinical clerkship in low-resource settings but has received little attention in the literature.

To explore the experiences of medical students and faculty regarding the use of the Long Case Study as a formative assessment method at a tertiary care teaching hospital in a low-resource setting.

Methodology

A qualitative study design was used. The study was conducted at Makerere University, a low-resource setting. The study participants were third- and fifth-year medical students as well as lecturers. Purposive sampling was utilized to recruit participants. Data collection comprised six Focus Group Discussions with students and five Key Informant Interviews with lecturers. The qualitative data were analyzed by inductive thematic analysis.

Three themes emerged from the study: ward placement, case presentation, and case assessment and feedback. The findings revealed that students conduct their long cases at patients’ bedside within specific wards/units assigned for the entire clerkship. Effective supervision, feedback, and marks were highlighted as crucial practices that positively impact the learning process. However, challenges such as insufficient orientation to the long case, the super-specialization of the hospital wards, pressure to hunt for marks, and inadequate feedback practices were identified.

The long case offers students exposure to real patients in a clinical setting. However, in tertiary care teaching hospitals, it’s crucial to ensure proper design and implementation of this practice to enable students’ exposure to a variety of cases. Adequate and effective supervision and feedback create valuable opportunities for each learner to present cases and receive corrections.

Peer Review reports

The long case serves as an authentic assessment method for evaluating medical students’ competence in clinical tasks [ 1 ]. This form of assessment requires students to independently spend time with patients taking their medical history, conducting physical examinations, and formulating diagnosis and management plans. Subsequently, students present their findings to senior clinicians for discussion and questioning [ 2 , 3 ]. While developed countries increasingly adopt simulation-based assessments for formative evaluation, logistical challenges hinder the widespread use of such methods in developing countries [ 4 ]. Consequently, the low-resource countries heavily rely on real patient encounters for formative assessment. The long case is one such method predominantly used as a primary formative assessment method during clinical clerkship and offers a great opportunity for feedback [ 5 ]. The assessment grounds students’ learning into practice by providing them with rich opportunities to interact with patients and have the feel of medical practice. The long case thus bridges the gap between theory and practice, immersing students in the real tasks of a physician [ 1 ]. The complexity of clinical scenarios and the anxiety associated with patient encounters may not be well replicated in simulation-based assessments because diseases often have atypical presentations not found in textbooks. Assessment methods should thus utilize authentic learning experiences to provide learners with applications of learning that they would expect to encounter in real life [ 6 ]. This requires medical education and the curriculum to focus attention on assessment because it plays a significant role in driving learning [ 7 ]. The long case thus remains crucial in medical education as one of the best ways of preparing for practice. It exposes the student repeatedly to taking medical history, examining patients, making clinical judgments, deciding treatment plans, and collaborating with senior clinicians.

The long case, however, has faced significant criticism in the medical education literature due to perceived psychometric deficiencies [ 8 , 9 , 10 ]. Consequently, many universities have begun to adopt assessment methods that yield more reliable and easily defensible results [ 2 ] due to concerns over the low reliability, generalizability, and validity of the long case, coupled with rising litigations and student appeals [ 11 , 12 ]. Despite these shortcomings, the long case remains an educationally valuable assessment tool that provides diagnostic feedback essential for the learning process during clinical clerkship [ 13 ]. Teachers can utilize long-case results to pinpoint neglected areas or teaching deficiencies and align with course outcomes.

However, there is a paucity of research into the long case as a formative assessment tool. A few studies conducted in developed countries highlighted its role in promoting a holistic approach to patient care, fostering students’ clinical skills, and a driving force for students to spend time with patients [ 2 , 13 ], . There is a notable absence of literature on the use of long case as a formative assessment method in low-resource countries, and no published work is available at Makerere University where it has been used for decades. This underscores the importance of conducting research in this area to provide insight into the effectiveness, challenges, and potentials for improvement. Therefore, this study aimed to investigate the experiences of medical students and faculty regarding the utilization of the long case as a formative assessment method within the context of a tertiary care teaching hospital in a low-resource setting.

Study design

This was an exploratory qualitative study.

Study setting

The research was conducted at Makerere University within the Department of Internal Medicine. The Bachelor of Medicine and Bachelor of Surgery (MBChB) degree at Makerere University is a five-year program with the first two years for pre-clinical (biomedical Sciences) course and the last three years dedicated to clinical clerkship. Medical students do Internal Medicine clerkships in third- and fifth-year at the two tertiary teaching hospitals namely; Mulago and Kiruddu National Referral Hospitals. The students are introduced to the long case in third-year as Junior Clerks and later in the fifth-year as Senior Clerks. During clerkship, students are assigned to various medical wards, where they interact with patients, take medical history from them, perform physical examinations, and develop diagnosis and management plans. Subsequently, students present their long cases to lecturers or postgraduate students, often in the presence of their peers, followed by feedback and comprehensive case discussions. Students are afforded ample time to prepare and present their cases during ward rounds, at their discretion. The students are formatively assessed and a mark is awarded on a scale of one to ten in the student’s logbook. Each student is required to make a minimum of ten long cases over the seven weeks of clerkship.

Study participants

The study participants were third- and fifth-year medical students who had completed junior and senior clerkship respectively, as well as lecturers who possessed at least five years of experience with the long case. The participants were selected through purposive sampling. The sample size for the study was determined by data saturation.

Data collection

Data were collected through Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). A total of 36 medical students participated in FGDs, reflecting on their experiences with the long case. Five faculty members participated in individual KIIs. The students were mobilized by their class representative and a brief recruitment presentation was made at the study site while the lecturers were approached via email and telephone invitation.

Six FGDs were conducted, three for junior clerks and three for senior clerks. Each FGD comprised of 5–7 participants with balanced male and female gender representation. Data saturation was achieved by the fifth FGD, at which point no additional new information emerged. A research assistant proficient in qualitative research methods moderated the FGDs. The discussions lasted between 55 min and 1 h 10 min and were audio recorded. The Principal Investigator attended all the FGDs to document interactions and record his perspectives and non-verbal cues of participants.

Semi-structured KIIs were used to collect data from Internal Medicine faculty. Five KIIs were conducted, and data saturation was achieved by the fourth interview, at which point no new theme emerged. The Principal Investigator conducted the KIIs via Zoom. Each interview lasted between 25 and 50 min and all were audio recorded. A research assistant proficient in qualitative methods attended all the Zoom meetings. The data collected were securely stored on a hard drive and Google Drive with password protection to prevent unauthorized access.

Data analysis

Data analysis was done through inductive thematic analysis method. Following each FGD or KII session, the data collection team listened to the recordings to familiarize themselves with the data and develop general ideas regarding the participants’ perspectives. The data were transcribed verbatim by the researchers to generate text data. Two separate transcripts were generated by the Principal Investigator and a research assistant. The transcripts were then compared and manually reviewed by the research team to compare the accuracy with the audio recordings. After transcript harmonization, data cleaning was done for both FGDs and KIIs transcripts.

The transcribed data from both FGDs and KIIs underwent inductive thematic analysis as aggregated data. This involved initial line-by-line coding, followed by focused coding where the relationships between initial codes were explored and similar codes were grouped. Throughout the analysis, the principle of constant comparison was applied, where emerging codes were compared for similarities and differences.

Study results

Socio-demographics.

A total of 36 medical students participated in the FGDs, comprising 18 junior clerks and 19 senior clerks. The participants were aged between 21 and 25 years except two participants who were aged above 25 (30 and 36 years old). Among the third-year students, there were 10 male and 9 female participants while the fifth-year student comprised of 8 male and 10 female participants.

Five lecturers participated in the Key Informant Interviews, three of whom were females and two male participants. They were aged between 40 and 50 years, and all had over 10 years of experience with the long case. The faculty members included one consultant physician, one associate professor, two senior lecturers, and one lecturer.

Themes that emerged

Three themes emerged from the study: ward placement, case presentations, and case assessment and feedback.

Themes	Codes
Theme 1; ward placement	Allocation to specific ward, specialization of the wards, orientation on the ward, and exposure to other ward
Theme 2; case presentation	Variation in the mode of presentation, limited observation of skills, and unreliable presence of lecturers.
Theme 3; case assessment and feedback	Marks awarded for the long case, case write-up, marks as motivators, pressure to hunt for mark Feedback is given to the student, feedback to the lecturer, limitations of the feedback practice

Themes

Codes

Theme 1; ward placement

Allocation to specific ward, specialization of the wards, orientation on the ward, and exposure to other ward

Theme 2; case presentation

Variation in the mode of presentation, limited observation of skills, and unreliable presence of lecturers.

Theme 3; case assessment and feedback

Marks awarded for the long case, case write-up, marks as motivators, pressure to hunt for mark

Feedback is given to the student, feedback to the lecturer, limitations of the feedback practice

Theme 1: Ward placement

The study findings disclosed that medical students are assigned to specific wards for the duration of their clerkship. The specialization of medical wards was found to significantly restrict students’ exposure to limited disease conditions found only in their allocated ward.

With the super-specialization of the units, there is some bias on what they do learn; if a particular group is rotating on the cardiology unit, they will obviously have a bias to learn the history and physical exam related to cardiovascular disease (KII 1).

The students, particularly junior clerks, expressed dissatisfaction with the lack of proper and standardized orientation to the long case on the wards. This deficiency led to wastage of time and a feeling of being unwelcome in the clerkship.

Some orient you when you reach the ward but others you reach and you are supposed to pick up on your own. I expect orientation, then taking data from us, what they expect us to do, and what we expect from them, taking us through the clerkship sessions (FGD 4 Participant 1).

Students’ exposure to cases in other wards poses significant challenges; the study found that as some lecturers facilitate visits to different wards for scheduled teaching sessions, others don’t, resulting in missed learning opportunities. Additionally, some lecturers leave the burden on students’ personal initiative to explore cases in other wards.

We actually encourage them to go through the different specialties because when you are faced with a patient, you will not have to choose which one to see and not to see (KII 4).

Imagine landing on a stroke patient when you have been in the infectious disease ward or getting a patient with renal condition when you have been in the endocrinology ward can create problems (FGD 6 Participant 3).

Theme 2 Case presentation

Medical students present their long case to lecturers and postgraduate students. However, participants revealed variations among lecturers regarding their preferences on how they want students to present their cases. While some prefer to listen to the entire history and examination, others prefer only a summary, and some prefer starting from the diagnosis.

The practice varies depending on the lecturer, as everyone does it their own way. There are some, who listen to your history, examination, and diagnosis, and then they go into basic discussion of the case; others want only a summary. Some lecturers come and tell you to start straight away from your diagnosis, and then they start treating you backward (FGD 6 Participant 3).

The students reported limited observation of their skills due a little emphasis placed by examiners on physical examination techniques, as well as not providing the students with the opportunity to propose treatment plans.

When we are doing these physical examinations on the ward no one is seeing you. You present your physical examination findings, but no one saw how you did it. You may think you are doing the right thing during the ward rotations, but actually your skills are bad (FGD 4 Participant 6).

They don’t give us time to propose management plans. The only time they ask for how you manage a patient is during the summative long case, yet during the ward rotation, they were not giving us the freedom to give our opinion on how we would manage the patient.(FGD 2Participant 6).

Supervision was reportedly dependent on the ward to which the student was allocated. Additionally, the participants believe that the large student-to-lecturer ratio negatively affects the opportunity to present.

My experience was different in years three and five. In year three, we had a specialist every day on the ward, but in year five, we would have a specialist every other day, sometimes even once a week. When I compare year five with year three, I think I was even a better doctor in year three than right now (FGD 1 Participant 1).

Clinical training is like nurturing somebody to behave or conduct themselves in a certain way. Therefore, if the numbers are large, the impacts per person decrease, and the quality decreases (KII 5).

Theme C: Case assessment and feedback

The study found that a student’s long case is assessed both during the case presentation on the ward and through the case write-up, with marks awarded accordingly.

They present to the supervisor and then also write it up, so at a later time you also mark the sheet where they have written up the cases; so they are assessed at presentation and write up (KII 2).

The mark awarded was reportedly a significant motivator for students to visit wards and clerk patients, but students also believe that the pressure to hunt for marks tends to override the goal of the formative assessment.

Your goal there is to learn, but most of us go with the goal of getting signatures; signature-based learning. The learning, you realize probably comes on later if you have the individual morale to go and learn (FGD 1 participant 1).

Feedback is an integral part of any formative assessment. While students receive feedback from lecturers, the participants were concerned about the absence of a formal channel for soliciting feedback from students.

Of course, teachers provide feedback to students because it is a normal part of teaching. However, it is not a common routine to solicit feedback about how teaching has gone. So maybe that is something that needs to be improved so that we know if we have been effective teachers (KII 3).

Whereas the feedback intrigues students to read more to compensate for their knowledge gap, they decried several encounters with demeaning, intimidating, insulting, demotivating, and embarrassing feedback from assessors.

Since we are given a specific target of case presentation we are supposed to make in my training , if I make the ten, I wouldn’t want to present again. Why would I receive other negative comments for nothing? They truly have a personality effect on the student, and students feel low self-esteem (FGD 1, Participant 4).

This study aimed to investigate the experiences of medical students and faculty regarding the use of the long case as a formative assessment method at a tertiary care teaching hospital in a low-resource setting. This qualitative research provides valuable insights into the current practices surrounding the long case as a formative assessment method in such a setting.

The study highlighted the patient bedside as the primary learning environment for medical students. Bedside teaching plays a crucial role in fostering the development of skills such as history-taking and physical examination, as well as modeling professional behaviors and directly observing learners [ 14 , 15 ]. However, the specialization of wards in tertiary hospitals means that students may not be exposed to certain conditions found in other wards. This lack of exposure can lead to issues of case specificity, which has been reported in various literature as a cause of low reliability and generalizability of the long case [ 16 , 17 ]. Participants in the study expressed feeling like pseudo-specialists based on their ward allocations. This is partly attributed to missing scheduled teachings and poor management of opportunities to clerk and present patients on other wards. Addressing these challenges is essential for enhancing the effectiveness of the long case as a formative assessment method in medical education.

Proper orientation at the beginning of a clerkship is crucial for clarifying the structure and organization, defining students’ roles, and providing insights into clinical supervisors’ perspectives [ 18 ]. However, the study revealed that orientation into the long case was unsatisfactory, resulting in time wastage and potentially hindering learning. Effective orientation requires dedicated time and should involve defining expectations and goals, as well as guiding students through the steps of history-taking and physical examination during the initial weeks of the rotation. Contrary to this ideal approach, the medical students reported being taken through systemic examinations when the clerkship was nearing its end, highlighting a significant gap in the orientation process. Proper orientation is very important since previous studies have also documented the positive impact of orientation on student performance [ 19 ]. Therefore, addressing the shortcomings in orientation practices identified in this study is essential for optimizing learning outcomes and ensuring that students are adequately prepared to engage in the long case.

There was reportedly a significant variation in the way students present their long cases, with some lecturers preferring only a case summary, while others expect a complete presentation or begin with a diagnosis. While this diversity in learning styles may expose students to both familiar and unfamiliar approaches, providing a balance of comfort and tension [ 20 ], it’s essential for students to first be exposed to familiar methods before transitioning to less familiar ones to expand their ability to use diverse learning styles. The variation observed in this context may be attributed to time constraints, as lecturers may aim to accommodate the large number of students within the available time. Additionally, a lack of standardized practices could also contribute to this variation. Therefore, there is a pressing need for standardized long-case practices to ensure a consistent experience for students and to meet the desired goals of the assessment. Standardizing the long case practice would not only provide a uniform experience for students but also enhance the reliability, validity, and perception of fairness of the assessment [ 9 , 21 ]. It would ensure that all students are evaluated using the same criteria, reducing potential biases and disparities in grading. Additionally, standardized practices facilitate better alignment with learning objectives and promote more effective feedback mechanisms [ 22 ].

Related to the above, students reported limited observation of skills and little emphasis placed on them to learn physical examination techniques. This finding resonates with the research conducted by Abdalla and Shorbagi in 2018, where many students reported a lack of observation during history-taking and physical examination [ 23 ]. The importance of observation is underscored by the fact that students often avoid conducting physical examinations, as highlighted in Pavlakis & Laurent’s study among postgraduate trainees in 2001 [ 24 ]. This study sheds more light on the critical role of observation in forcing medical students to master clinical assessment and practical skills. The study also uncovered that students are rarely given the opportunity to propose management plans during case presentations, which hampers their confidence and learning of clinical decision-making. These findings likely stem from the large student-to-lecturer ratio and little attention given to these aspects of the long case during the planning of the assessment method. The result is students not receiving the necessary guidance and support to develop their clinical and decision-making skills. Therefore, addressing these issues by putting more emphasis on observation of student-patient interaction, management plan, and having a smaller student group is vital to ensure that medical students receive comprehensive training and are adequately prepared for their future roles as physicians.

The study found that the marks awarded for the long case serve as the primary motivator for students. This finding aligns with previous research indicating that the knowledge that each long case is part of assessment drives students to perform their duties diligently [ 2 , 25 ]. It underscores the crucial role that assessment plays in driving learning processes. However, the pressures to obtain marks and signatures reportedly hinder students’ engagement in learning. This could be attributed to instances where some lecturers relax on supervision or are absent, leaving students to struggle to find someone to assess them. Inadequate supervision by attending physicians has been identified in prior studies as one of the causes of insufficient clinical experience [ 26 ], something that need to be dealt with diligently. While the marks awarded are a motivating factor, it is essential to understand other underlying motivations of medical students to engage in the long case and their impact on the learning process.

Feedback is crucial for the long case to fulfill its role as an assessment for learning. The study participants reported that feedback is provided promptly as students present their cases. This immediate feedback is essential for identifying errors and learning appropriate skills to enhance subsequent performance. However, the feedback process appears to be unilateral, with students receiving feedback from lecturers but lacking a structured mechanism for providing feedback themselves. One reason for the lack of student feedback may be a perceived intimidating approach from lecturers which discourages students from offering their input. It is thus important to establish a conducive environment where students feel comfortable providing feedback without fear of negative repercussions. The study underscores the significance of feedback from students in improving the learning process. This aligns with the findings of Hattie and Timperley (2007), who emphasized that feedback received from learners contributes significantly to improvements in student learning [ 27 ]. Therefore, it is essential to implement strategies to encourage and facilitate bidirectional feedback between students and lecturers in the context of the long case assessment. This could involve creating formal channels for students to provide feedback anonymously or in a structured format, fostering open communication, and addressing any perceived barriers to feedback exchange [ 28 ]. By promoting a culture of feedback reciprocity, educators can enhance the effectiveness of the long case as an assessment tool.

Conclusions

In conclusion, the long case remains a cornerstone of formative assessment during clerkship in many medical schools, particularly in low-resource countries. However, its effectiveness is challenged by limitations such as case specificity in tertiary care hospitals, which can affect the assessment’s reliability and generalizability. The practice of awarding marks in formative assessment serves as a strong motivator for students but also creates tension, especially when there is inadequate contact with lecturers. This can lead to a focus on hunting for marks at the expense of genuine learning. Thus adequate supervision and feedback practices are vital for ensuring the success of the long case as an assessment for learning.

Furthermore, there is a need to foster standardized long case practice to ensure that scheduled learning activities are completed and that all students clerk and present patients with different conditions from various wards. This will promote accountability among both lecturers and students and ensure a consistent and uniform experience with the long case as an assessment for learning, regardless of the ward a student is assigned.

Data availability

The data supporting the study results of this article can be accessed from the Makerere University repository, titled “Perceptions of Medical Students and Lecturers of the Long Case Practices as Formative Assessment in Internal Medicine Clerkship at Makerere University,” available on DSpace. The identifier is http://hdl.handle.net/10570/13032 . Additionally, the raw data are securely stored with the researchers in Google Drive.

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Kumakech, J., Munabi, I.G., Mubuuke, A.G. et al. Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study. BMC Med Educ 24 , 621 (2024). https://doi.org/10.1186/s12909-024-05589-7

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Poor communication by health care professionals may lead to life-threatening complications: examples from two case reports

Abhishek tiwary.

1 Department of Internal Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal

Ajwani Rimal

Buddhi paudyal, keshav raj sigdel, buddha basnyat.

2 Oxford University Clinical Research Unit, Patan hospital, Lalitpur, Nepal

Associated Data

All data underlying the results are available as part of the article and no additional source data are required.

Peer Review Summary

Review date	Reviewer name(s)	Version reviewed	Review status
	Jill Allison		Approved
	Sharad Onta		Approved

We report two cases which highlight the fact how poor communication leads to dangerously poor health outcome. We present the case of a 50-year-old woman recently diagnosed with rheumatoid arthritis from Southern Nepal presented to Patan hospital with multiple episodes of vomiting and oral ulcers following the intake of methotrexate every day for 11 days, who was managed in the intensive care unit. Similarly, we present a 40-year-old man with ileo-caecal tuberculosis who was prescribed with anti-tubercular therapy (ATT) and prednisolone, who failed to take ATT due to poor communication and presented to Patan Hospital with features of disseminated tuberculosis following intake of 2 weeks of prednisolone alone. These were events that could have been easily prevented with proper communication skills. Improvement of communication between doctors and patients is paramount so that life-threatening events like these could be avoided.

Introduction

Communication refers to exchanging information with the help of different mediums, such as speaking, writing or body language 1 . It is of great importance in the field of medicine. Effective physician-patient communication is vital as it is related with favourable health outcomes such as increased patients satisfaction, compliance and overall health status 2 . A study in 2008 by Bartlett G et al. concluded that communication problems with patients lead to increased preventable adverse effects which were mostly drug-related 3 . It has been estimated that 27% of medical malpractice is the result of the communication failures. Better communication can reduce medical errors and patient injury 4 . Poor communication can result in various negative outcomes, such as decreased adherence to treatment, patients dissatisfaction and inefficient use of resources 5 . The cases discussed here highlight the importance of proper communication, how such unfortunate events could have been prevented with good communication skills. The traditional medical education curriculum in South Asia usually focuses more on technical expertise than teaching communication skills. This fact has hindered the capacity of technically expert health professionals to effectively communicate with their patients regarding the disease and treatment approach 6 , 7 . Thus, a concerted effort needs to be made to improve the communication skills of health professionals in South Asia.

Case reports

A 50-year-old woman diagnosed with rheumatoid arthritis (RA) 3 weeks previously presented to Emergency Department of Patan Hospital in June of 2018 with complaints of multiple episodes of vomiting and oral ulcers for 5 days. She had a history of multiple joint pain for a year, for which she sought medical attention in New Delhi, India as her son used to work there. She visited New Delhi with her neighbour, and there was diagnosed with RA. As per the standard treatment of RA, her treating rheumatologist prescribed her 15 mg methotrexate once weekly and 5 mg folic acid twice weekly without emphasizing that methotrexate is to be taken weekly and not daily. The pharmacist also failed to stress the weekly dose schedule. Unfortunately, she consumed methotrexate 15 mg daily for 11 days. At 11th day, she presented with those above complaints to the National Medical College and Teaching Hospital near her home in Birgunj, in the southern plains of Nepal. There she was managed conservatively with folic acid and fluids for 2 days, then referred to our centre for further management. She had ongoing vomiting and her examination of the oral cavity revealed multiple erythematous and ulcerative lesions. Her total white blood cell count (WBC) was 2400/µl (normal range, 4000–11000/µl), with an absolute neutrophil count (ANC) of 1200/µl (normal range, 1500–8000/µl), haemoglobin of 9 g/dl (12–15 g/dl) and platelets of 84000/µl (150,000–450,000/µl). She was immediately admitted to the intensive care unit (ICU) for methotrexate toxicity (myelosuppression and mucositis). Her methotrexate was stopped and she was managed with leucovorin (15 mg once daily), GM-CSF (300 µg once daily) and nasogastric feeding as she was unable to eat anything because of the oral ulcers.

After 3 days in the ICU, she was transferred to the ward, where treatment with leucovorin and GM-CSF was continued at the same dose. She was discharged after a total of 11 days of hospital stay when her blood counts came back to within the normal range (WBC, 12300/µl; ANC, 6888/µl). Her haemoglobin increased to 13 g/dl and her platelet reached 340,000/µl. Her oral lesions subsided, and she was able to feed orally. She was started back on the correct dosage of methotrexate (15 mg once weekly) and counselled about the disease, medications (dosage and adverse effects) and was advised to follow up in rheumatology clinic. She has been followed-up every 3 months since then, is in remission and is taking medications properly.

A 40-year-old man from hills of Nepal presented to the emergency department of Patan Hospital in August 2018 with complaints of weakness in the right half of the body, deviation of the left side of the face and slurring of speech for 4 days. At 3 weeks prior to this, he had visited another tertiary level hospital in Kathmandu for pain in the lower abdomen and fever, where he was diagnosed as having ileo-cecal tuberculosis based on colonoscopy and biopsy with positive Ziehl-Neelson staining. He was then prescribed with antitubercular therapy (ATT) that included 3 tablets of Fixed dose combination consisting of isoniazid 75 mg, rifampicin 150 mg, pyrazinamide 400 mg and ethambutol 275 mg once daily and prednisolone 40 mg once daily. He was advised to take ATT from a health centre near his residence, whereas prednisolone was dispensed from the hospital pharmacy. Unfortunately, he just took prednisolone, but no ATT. As a result, he ended up in emergency with the aforementioned complaints. On evaluation, his chest x-ray showed features of pulmonary tuberculosis. Cerebral spinal Fluid (CSF) analysis was done which showed red blood cells (RBC) 200/µl (normal value, 0/µl), WBC 64/µl (normal range, 0–5/ µl), neutrophil 24%, lymphocytes 64%, protein 294 mg/dl (normal range, 15–45 mg/dl) and sugar 49 mg/dl (normal range, 50–80 mg/dl). Cerebrospinal fluid GeneXpert testing was positive for Mycobacterium tuberculosis . He was then diagnosed as disseminated tuberculosis with meningeal involvement and was admitted to Patan Hospital with ATT (3 tablets of fixed-dose combination consisting of Isoniazid 75mg, Rifampicin 150 mg, Pyrazinamide 400 mg and Ethambutol 275mg once daily) and dexamethasone (6 mg three times a day) for 3 days. He was then discharged with ATT (same dose as above) and prednisolone (40 mg once daily) after proper counselling about the nature of the disease and site of availability of anti-tubercular drugs. He came in for follow-up after 2 weeks with improvement in the symptoms and has been taking all medications properly.

In the discussed cases, the treating physicians had used the standard treatment protocol to best serve their patients. They used their medical knowledge in an appropriate manner to treat the disease condition, but proper communication with clear-cut emphasis on how and when to take the therapy, which is of utmost importance in achieving an overall positive health impact, was lacking. Had the doctors properly counselled and educated the patients regarding the disease, treatment options and the correct way of taking medications, these mishaps could have been prevented. Another major part of the communication involves the judgment of the doctor in figuring out how much the patient understood. As our patients were not literate, they could have explained about the disease and especially the weekly dosing of methotrexate and the availability and importance of ATT very clearly to the patient family. In South Asian countries like Nepal, the patient seldom is alone and therefore making things clear to the patient’s family is obviously a very important option that needs to be utilized to improve communication against the background of rampant illiteracy. In Nepal, only 48.6% of the population is literate; hence this fact needs to be kept in mind when explaining about diseases and prescribing drugs, especially regarding medicines that have dangerous side-effects 8 .

In Nepal, 25.2% population fall below the poverty line and 3.2% population are unemployed 9 . The young working generation have to leave their house for better employment opportunities, meaning they aren’t able to take care of their parents. In one of our cases, the son had to work in India for better employment opportunities and the patient came with her neighbour with whom the treating physician did not spend any time. It is possible that if the son had been there, he may well have been more concerned and asked more questions to the doctor. However, it is the responsibility of the health care professional to try to make sure the patient and their family have understood the matter clearly. There was also no caution mentioned by the pharmacy where the patient bought the medicine explaining the weekly (and not daily) dosing schedule of methotrexate. Hence there was failure of clear communication at various levels that led to this mishap.

Problems in doctor‐patient communication have received little attention as a potential but a remediable cause of health hazards, especially in a setting like this one in South Asia. Communication during the medical interaction among the health practitioner and the patient has a pivotal role in creating a positive health impact that includes drug adherence, future decision making on the interventions and modifying the health behaviours of the patient. We consider the cost and the negative impact on the outcome of the health from poor communication, which includes non-adherence to drugs regimens that will increase the burden of the cost of the total drug therapy, poor health outcomes, and unnecessary treatment and investigations. Different measures need to be considered to improve the communication between doctors and patients which would improve the overall health outcome. The measures include providing communication skills training to health care professionals and regular evaluation of communication skills of these professionals by interviewing the patients after a consultation.

Clear communication is vital in the proper treatment of the patient especially against the background of rampant illiteracy in countries such as Nepal in South Asia. Poor Communication may lead to life-threatening complications, as in our patients. For better communication practice, proper communication training to health care professionals including pharmacists is paramount.

Informed consent for publication of their clinical details, in the form of a fingerprint, was obtained from the patients.

Data availability

[version 1; peer review: 2 approved]

Funding Statement

This study was supported by the Wellcome Trust (106680).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Reviewer response for version 1

Jill allison.

1 Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

This article provides two cases where a lack of information and clear understanding of prescription medication contributed to morbidity and unnecessary suffering for the patients. The cases are linked to a lack of health professional engagement with the patient and failure to ensure full understanding of medication instructions. The cases and events surrounding are clearly described. The outcomes are also clearly described.
The clinical scenario is well described but it would be helpful to know what steps were taken with these two patients to prevent similar circumstances. There is no mention of what was done to educate and inform the patient or their families on discharge. Was there an interdisciplinary team involved to try to ensure the patient got sufficient information and how was their level of comprehension assessed?
There is a bit of repetition in the discussion and not many concrete suggestions for improving the skills of physicians in this area. Continuing medical education? Cultural competency teaching?
There are a few grammatical errors that could be corrected to improve the paper.
Overall, an important concept for discussion and excellent examples of why the discussion must happen.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Sharad Onta

1 Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

2 Nepal Public Health Foundation, Kathmandu, Nepal

Introduction:

This section should focus on contextual facts about the central issue of the manuscript, communication in clinical practice in the present context. It is better to avoid assessment of the contents of the cases and conclusion with recommendation.
The statement “ The cases discussed here highlight the importance of proper communication, how such unfortunate events could have been prevented with good communication skills” indicates to the assessment of upcoming contents of the manuscript. It seems inappropriate in the introduction. (It better fits in the discussion).
The last phrase of this section “ Thus, a concerted effort needs to be made to improve the communication skills of health professionals in South Asia” carries a notion of recommendation, which seems premature for this section of the manuscript. (It can be moved to the conclusion).
It will be better to highlight the objective and rationale of presenting cases in this section. It provides the space for the authors to justify importance of communication in clinical practice.
Adequate exploration of the facts as the evidence of poor communication in health service/clinical practices and highlights of these facts (findings) are necessary in presentation of the cases for justification of explanations narrated in the section of discussion. The cases in the manuscript look weak, as the communication aspects are not adequately elaborated on. Elaboration of communication dimension in the case presentation is desirable and, hence, suggested.
As emphasized in the discussion section, and in the conclusion, of the manuscript, socio-economic characteristics of the service seekers are not clearly mentioned in the cases. Therefore, rationalization of importance of communication in the basis of these attributes is not well justifiable.

Discussion:

Few examples:

In case 1 – it should be explored in depth whether the attitude and faith of patients to recover earlier by getting medicine in more (frequently) quantity than prescribed dose could be the reason for this situation.
In case 2 – role of poor communication is not established clearly. Other possible reasons for not taking ATT like unavailability of medicines, distance to the health centres, and so on should be excluded to establish the role of communication. If prednisolone was the underlying cause of complication of the case, it should be analyzed, whether dispensing prednisolone alone without AT medicines to the patient was a right practice/protocol and correlate with the communication.

Confidentiality:

In case 1 – name of the referring hospital as National Medical College and Teaching Hospital is mentioned whereas in the case 2 – it is mentioned as another tertiary level hospital in Kathmandu . It is better to maintain the consistency.

Conclusion:

The conclusion is not well based in facts of cases. The manuscript has justified the importance of communication (in Nepal) in the background of rampant illiteracy . However, literacy and other socio-economic status of the patients in both cases are not known.
Language could be improved.
Manuscript has addressed very relevant and useful issues. It should be considered for indexing after improvement incorporating all comments.

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MUTIARA HOSPITAL: CASE STUDY
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Hospital Case Study: Option 3
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The Teaching Hospital
The Teaching Hospital1. Dr. Robert Uric was the head of the Renal Medicine Unit at a large university. medical school and teaching hospital. The teaching hospital, a regional medical center, had over 1000 beds and was considered a reasonably prestigious medical facility. There was a steady undercurrent of hostility and competition between the.
Case Analysis: The Teaching Hospital
The Self-Fulfilling Prophecy Effect. Since the reputation of the teaching hospital as a whole was tarnished, the employees would have relatively low morales which may also dampen their productivity. If the managers were somehow able to bring back and maybe even raise the reputation of the teaching hospital higher, it would have a very positive ...
Case Library
The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives. Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs.
Teaching hospital planning: a case study and the need for reform
Organizational Case Studies. Queensland. Academic teaching hospitals and their networks can best serve patients and other stakeholders by achieving critical mass and scope of clinical services, teaching and research. Successful hospital reconfigurations are associated with a convincing case and majority clinician buy-in. The inscrutable po ….
Grady Memorial
Recognized as a leading teaching hospital, Grady trains more than 800 physician residents and fellows annually, and it provides training in nursing, pharmacy, imaging technology, prehospital medicine, and medical interpretation services. The system also provides holistic preventive and wellness care in Georgia's historically marginalized ...
Asante Teaching Hospital: Activity-Based Costing Case Study Solution [7
Asante Teaching Hospital: Activity-Based Costing case study will help professionals, MBA, EMBA, and leaders to develop a broad and clear understanding of casecategory challenges. Asante Teaching Hospital: Activity-Based Costing will also provide insight into areas such as - wordlist , strategy, leadership, sales and marketing, and negotiations.
Teaching hospital planning: a case study and the need for reform
Successful hospital reconfigurations are associated with a convincing case and majority clinician buy-in. The inscrutable political decision to relocate services away from a major teaching hospital campus and into a merged Queensland Children's Hospital was determined without broad stakeholder consultation or a transparent and accountable ...
The Intricate Relationship Between a Medical School and a Teaching
In this case, the teaching hospital has monopsony power over the medical school. ... The tension existing between a medical school and a teaching hospital observed in this study has been previously reported. [6,7] Although Mulago hospital serves as the teaching hospital for the medical school, the hospital belongs to the Ministry of Health ...
Teaching hospital planning: A case study and the need for reform
Abstract. Academic teaching hospitals and their networks can best serve patients and other stakeholders by achieving critical mass and scope of clinical services, teaching and research. Successful ...
Case study: Design for teaching hospital with FGI acoustical criteria
Case studies may include any of the following: standby power generators for data center, university cafeteria, and dining hall, coffee grinding and packaging shop within a grocery market, exercise ...
Case Study The Teaching Hospital
Case Study the Teaching Hospital - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. The main problem is a lack of motivational stimulus in the workplace due to issues like unclear financial arrangements and compensation structures. There are communication gaps between employees due to personalities of managers like Dr. Conrad who creates a ...
Simulation-Based Education Improves Quality of Care During ...
Simulation-Based Education Improves Quality of Care During Cardiac Arrest Team Responses at an Academic Teaching Hospital A Case-Control Study. Diane B. Wayne, MD . ... This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical ...
CASE ANALYSIS THE TEACHING HOSPITAL.docx
REQUIREMENT: I. Identify the barriers to communication in this case, and describe their impact on the hospital's effectiveness. II. Compare and contrast the two doctors' styles of management and the apparent reflections of Theory X and Theory Y assumptions of each doctors. III. Relate various motivational theories, such as McClelland's drives, Herzberg's two-factor theory, and the ...
Barriers and enablers in implementing an electronic incident ...
Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia Int J Health Plann Manage. 2022 Mar ... Methods: This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before ...
PDF A CASE STUDY: PATIENT-CENTERED HOSPITAL DESIGN
multi-hospital health system, is currently building a 160-bed hospital in Wexford, Pennsylvania to provide patient-centered care to their communities. The patient-centered design of Wexford Hospital includes a variety of unique facility and technology features such as the rooftop garden, smart television, mobile app, and patient room control.
Mergers of teaching hospitals: three case studies
During the 1990s, several of America's leading teaching hospitals merged. To learn what forces drove these institutions together and how the mergers had progressed, I studied three of them by interviewing 237 doctors and administrators a total of 303 times, usually at their hospitals and medical schools or occasionally by telephone.
PDF Innovation Management Models in Teaching Hospitals Case-study Teaching
Case-study - Teaching Hospital of Fernando Pessoa University (TH - FPU)" and its objective is the analysis of the importance of the management model for innovation in the Teaching Hospital. The research problem was expressed through the following questions: What factors are in
Asante teaching Hospital
ASANTE TEACHING HOSPITAL CASE STUDY SOLUTIONS Q1. Perform a strengths, weaknesses, opportunities, and threats (SWOT) analysis. What implications can you draw for the pricing strategy alternatives? What are the implications to the SWOT if Asante continues with itemized pricing or switches to bundles pricing? SWOT ANALYSIS
The role of place on healthcare quality improvement: A qualitative case
In doing so, it contributes to the overlooked interplay between the physical, social, and symbolic dimensions associated with a hospital's place. The study draws on 46 in-depth semi-structured interviews conducted at a large teaching hospital in Portugal formed by two buildings. Interview transcripts were analysed inductively using thematic ...
US Teaching Hospital
This case study of a leading US teaching hospital shows how Covidence has improved the systematic review process and empowered library staff to support researchers deliver the best quality evidence-based research possible. Ready to find out more? Download your copy now! First name
Experiences of medical students and faculty regarding the use of long
To explore the experiences of medical students and faculty regarding the use of the Long Case Study as a formative assessment method at a tertiary care teaching hospital in a low-resource setting. Methodology. A qualitative study design was used. The study was conducted at Makerere University, a low-resource setting.
CASE 2 THE TEACHING HOSPITAL FINAL.docx
began to analyze what had happened and what could be done to put the renal unit as well the hospital's reputation back together. III. Problem Analysis Relevant Case Facts Teaching Hospital Medical School Ran east- west, 8 eight stories high on the south State- supported hospital. Ran east- west, 10 tenth floor high on the north side State school -The teaching hospital had over 1, 000 bed ...
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Courtesy of IMK Architects. Text description provided by the architects. Occupying the lower slopes of a hill within Symbiosis International University's 260-acre estate in Lavale, Symbiosis ...
Poor communication by health care professionals may lead to life
A study in 2008 by Bartlett G et al. concluded that communication problems with patients lead to increased preventable adverse effects which were mostly drug-related 3. It has been estimated that 27% of medical malpractice is the result of the communication failures. ... In case 1 - name of the referring hospital as National Medical College ...
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Open-access journal of teaching and learning resources. Connect With Us Contact Us; AAMC Communities Network; Sign up for AAMC Newsletters; View all Social Media; Association of American Medical Colleges. 655 K Street, NW, Suite 100 Washington, DC 20001-2399 202-828-0400. Terms & Conditions ...
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The Teaching Hospital

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Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study

Introduction

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Study participants

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Data analysis

Study results

Themes that emerged

Theme 1: Ward placement

Theme 2 Case presentation

Theme C: Case assessment and feedback

Conclusions

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