Case-based blended eLearning scenarios—adequate for competence development or more?

Comprehension: Through presentation of visual graphs and guided through a question-based feedback-system the student learns to understand disease-related pathomechanisms: The classical conditioning model is recapitulated with the presentation of the conditioned stimulus to an animal, secondary coupling with the unconditioned stimulus and fear as the result of sole presentation of the previously neutral conditioned stimulus [6]. In this context, the amygdala as central site of plasticity and fear learning is presented [7]. Furthermore, pathways involved in fear conditioning like signaling through the inhibitory GABAergic and stimulatory glutamatergic connections [8, 9], or dopaminergic and glucocorticoid pathways are discussed [10, 11]. Herewith, a model representing molecular basic principles, precisely depicted through visual data and connected with a literature database created for the case, is generated and serves as a central translational element of this case-based exercise. In this section of the e‑case many interactive questions are inserted always providing the arguments why something is right or wrong. The students can utilize this section interatively, links to reading material or lectures on basic knowledge are provided in order to be able to attend the specific lecture and ask the experts directly.

Application: Based on the previous information, the student has to identify the trauma type of the patient according to Leonie Terr [12]. In addition, students are tested about predictors of the development of PTSD [13].

Clinical decision-making is required from the student at the end of the exercise to initiate adequate therapy and to decide for the best integrative options, whereby interdisciplinary therapy is essential. Cases are further presented in seminars where students are supervised and have the opportunity to train communicative skills. The topic of exploration is then trained in supervised seminars, further (psycho)therapeutic consequences are focused in supervised small group seminars with simulated patients. The main advantage of training within an affectively wholesome and secure learning environment where students can work, try, experience all challenging demands of working with severely disturbed patients, is that they also get feedback on their performance especially from the patient’s view given by a sufficiently trained simulated patient.

Synthesis: To study disease complexity and associated morbidity, the case points to incipient risk factors like hypertension. It is supposed that repetitive or continuous stress disturbs the autonomic nervous system, the hypothalamic–pituitary–adrenal axis, metabolism and further the cardiovascular and immune systems [14, 15]. There is a high relationship of PTSD and cardiovascular disease, psychosocial factors being even a higher risk factor than for e.g. hypertension, diabetes or obesity [16]. However, PTSD and depression is strongly associated with cardiovascular risk factors [17, 18]. Herein, endothelial dysfunction is proposed to be one of the underlying causes [15]. A pro-inflammatory state due to lower peripheral cortisol levels [19] is discussed leading to endothelial activation [15]. Furthermore, a decrease in nitric oxide [20] and increase in oxidative stress [21] as well as vasoconstrictors [22, 23] are proposed as contributing factors [15]. Through the description of the complex disease pattern, cross-linking thinking is trained, and current research questions are pointed out. Each student has to conduct his or her own portfolio and work out several questions, own thoughts and research ideas, sometimes research gaps.

Analysis: PTSD and associated co-morbidities remain a major burden and preventive measures are of great importance. Hence it is necessary for physicians to be alert to signs of cardiovascular risk factors and to initiate adequate medical treatment. It could be shown that residents included in case-based learning programs showed higher baseline knowledge in their field [24]. The e‑learning cases are further valuable in consistent representation of best practice cases linking to updated guidelines and consensus statements. A further step integrated in the Viennese curriculum is the gathering of clinical practice in seminars with actors simulating key clinical symptoms and lectures for each topic represented in the online case collection [25]. “Gathering of clinical experience” via bed-side training and with simulation situations, training of clinical reasoning, functions as a best-practice example, that can be provided via eLearning in a consistent way. By providing feedback, metacognition is trained as a process to avoid cognitive errors and promote analytic reasoning [26]. Reflexion on feedback from teachers, colleagues, researchers has to be written into the portfolio.

Evaluation: The programmed question-driven feedback-system serves at each step of the case as checkpoint to allow critical reflection and developing of metacognitive competences. Recapitulation of previously presented information should serve as a basis for plasticity in synaptic connections and hippocampal long-term potentiation [27].