New education method or tool
Open Access

Interdisciplinary case-based teaching utilizing a dual-focused approach with participation from nurse anesthetists and residents in anesthesiology: first experience

Zoltán Szabó[1], Andreas Nilsson[2], Bo Davidsson[3]

Institution: 1. Linköping University Medical Faculty, Institution of Medicine and Health, 2. Linköping University, Faculty of Medicine and Health Sciences, 3. Linköping Municipality Division of Research and Development
Corresponding Author: Dr Zoltán Szabó (
Categories: Medical Education (General), Postgraduate (including Speciality Training)
Published Date: 07/06/2016


We describe here our first experience with two focused case used in inter professional teaching at Linköping University. Both the teachers and the group of participants mirrored the two focuses in the case. At the end of the seminar a short epilogue and two references were given to the students to stimulate their reflection and learning. Two focused case seminar seems to be a useful instrument in inter professional teaching and learning.

Keywords: inter professional learning, case teaching, two focuses case


The case-based teaching was introduced in the 19th century at the Harvard Business school, and soon thereafter it became a popular tool in medical education at Harvard University (Cabot, 1906). Cases usually had high taxonomy (Solo taxonomy 4- 5) and typically had one professional focus (i.e. one presenter is leading the case discussion as described by Johannson (Johansson & Nordquist, 2009)).


We performed a pilot test of a dual-focus case as part of the implementation of case-based teaching in a post-graduate course for nurse anesthetists at Linköping University, Sweden.

The group initially exposed included eight experienced nurses and three anesthesiology residents. The presentation was based on a case of a team managing a critical situation of upper gastro-intestinal hemorrhage in the operating theatre (see Appendix 1). The narrator of the case did not participate in the case discussion. The case described an authentic clinical situation  recalled by the writer from memory, as described  by Hafler (Hafler, 1989) at Harvard University. Our case had two viewpoints: one of Anna and the other of Bertil. The case was written in present tense to more effectively involve the students participating in the case seminar.

We distributed the case to the participants two weeks prior the case seminar. The participants received a student template containing the objectives and the requirements for an approved seminar. The students were expected to show active participation and good preparation, observe and judge complex anesthesiological situations,  judge the risks in critical situations,  be able to participate in a discussion on the basis of evidence based anesthesiological practice and consider the ethical perspectives of the case.

The case seminar

Environment and circumstances

The discussion took place after lunch (13.15-14.45) and was led by two individuals representing the two viewpoints (focuses) of the case: an experienced nurse anesthetist and by an anesthesiologist with long experience in clinical and pedagogic work. First we set the rules for the seminar and the students received a nameplate with their first names, so the discussion leaders could call the participants by name. The lecture hall for case was not a traditional lecture hall but a plain room and the boards were organized in a semi-circle so that all the participants could see each other and the discussion leaders. We used a large whiteboard for notes.

In earlier case seminars, we had good experience with using a warm-up call; the participants were divided into two groups, organized to reflect the team (nurse and anesthesiologist) to discuss the case with each other for 15 minutes. The intensity of the discussion declined within 15 minutes, after which the two groups could begin the discussion together with a general question: Who can summarize what this case is about?

In the first part of the discussion led by the senior anesthesiologist the questions were focused on the medical and safety content and the students were very active. The case contained six decision points which were landmarks for the case leader to navigate by. The case leader’s questions generated discussion between the participants and the discussion was lively and objective. The participants were all engaged approximately to the same extent. The questions focused both on what the participants thought about the actions taken during the real case, and at the same time also what they would have done in the same situation. We also asked the participants to describe how they would have acted during the case at the six different decision points and whether the decisions were perceived as correct and adequate by the participants. If they objected, an alternative solution had to be stated.

After approximately 45 minutes the case was discussed and every main theme was noted on the whiteboard as shown in Figure 1. Thereafter the senior nurse anesthetist took over the leading of the case and the participants began on a new path to discuss behavioral issues that could be a part of an explanation of the decisions that were or were not made. Factors identified that could contribute to actions and decision making in this case were clinical routines, problems with communication, the absence of or insufficient planning for the procedures in the case, and the meaning of responsible acting in clinical practice. The case was closed after a short discussion of ethical issues. At the end of the seminar we summarized the whole case and handed out two references to enhance the understanding of the case.  We also gave the participants a short epilogue as seen in Appendix 2 in order to facilitate post-seminar reading and active reflection.


In this first educational experience the dual focus of the case is reflected by the two teachers who lead the discussions. It appears advisable to discuss first the medical content from different angles with the main focus on clinical decisions: what, why and how-when. The aim of the second part was to raise general questions related to communication and ethics specifically in the context of patient care, while also providing an opportunity to explain things.

After the case one teacher was reflecting with the participating students who were pleased and very positive towards this kind of real-life based teaching.  By using two focuses throughout the entire case, the student group and the teachers generate an atmosphere of team learning and promote an open communication within the team with tangible and direct benefits in clinical work, where improved communication may improve patient outcomes.

In conclusion we describe our successful first experience with case-based teaching utilizing a dual-focused approach.  This may open a new era in high-taxonomy inter-professional teaching and learning. Elements essential towards the success of this approach include the group discussion prior to the case description, and cooperation between the two teachers. Further studies will need to be performed in the future.


Main theme noted on the whiteboard