She was diagnosed with Type 2 diabetes at the age of 50 and has managed her Give the two causes of hyperglycemia in diabetes mellitus. …
The Team Based Learning process is aimed at teaching students to apply
knowledge To accomplish this they are first tested to assure that they
understand the concepts they are applying This is followed by a test
written in case vignette form that is the application of the concepts
Although the entire process could be carried out by testing each student
individually, the process becomes a more powerful learning experience if
they are tested in teams Proper safeguards exist to prevent any one
student from relying on others to do all the work The motivation for the
students comes from the opportunity or necessity to earn points from this
effort Some of these points are earned from individual effort, some from
team problem solving effort, and some awarded by members of the group for
participation
Step 1 - What is the application I want to develop?
The most efficient way to develop a team learning activity is to start
with the application For a two hour total time period, this should not
exceed three question sets
The question sets could all pertain to one case if you can derive that
many, or they could just come from separate vignettes; note that it
consumes extra
time to read each vignette
A sample case is attached You will notice that all three question sets
pertain to just this one vignette
Some question templates are attached that will help you in formulating
your test questions
Step 2 - What is the core knowledge needed to solve the case vignettes?
Now you will need to write from 3 to 5 regular exam questions for the RAT
that test on basic knowledge; these dont need to be comprehensive, just
a sample is needed
The questions are based on the answer choices for your case analysis; if
the students are going to be deciding on a correct answer for your case
questions, they need to understand them
A sample of five of these questions is also attached; compare these
questions to the answer choices in the case
Step 3 - How do I help the students prepare for the TBL activity?
The students should already be prepared for the activity since you are
testing on what you have been teaching
Since students work under tight schedules, specific learning objectives
will help them to focus on the knowledge that pertains directly to the
team learning activity
Write a list of learning objectives, starting with
your RAT questions
Then add any additional objectives if the students need to review any
special aspects of the material Keep in mind that the learning is
confined just to the material you are teaching with minimal introduction
of new concepts
The easiest way to write learning objectives is to write them as short-to-
medium length essay questions
Sample Case Application Question
A 74 year old female has come to your office suffering from
hyperventilation, malaise, dizziness, and muscle pains She was diagnosed
with Type 2 diabetes at the age of 50 and has managed her disease
successfully with diet, exercise, and hypoglycemic agents She was
initially put on a hypoglycemic agent called an oral sulfonylurea
chlorpropamide, but recently was switched to metformin which is better
tolerated in the elderly Her blood pH is 72 and her serum lactate is 10X
normal levels Her creatinine clearance and serum creatinine concentrations
indicate diminished renal function
1 This patient has a blood pH of 72 because
A ketones from excess fat mobilization are making her blood acidic
B increased glycolysis and reduced TCA cycle activity leading to excess
lactate formation
C hypoxia resulting from inhibition of electron transport is creating
excess carbon dioxide
D increased blood sugar increasing glycolysis and lactate production in
red blood cells
2 Metformin action in the production of lactic acidosis is most analogous
to which of the following?
A Fluoride
B Pentachlorophenol
C Cyclic AMP
D Oligomycin
3 Metformin-induced lactic acidosis in this patient was precipitated by
A reduced renal function due to glycosylation of renal membrane
proteins
B acceleration of glycolysis due to the increased concentration of
glucose in the blood
C resistance to insulin leading to uncontrolled fat mobilization
D accelerated gluconeogenesis in the liver due to insulin resistance
Readiness Assurance Test RAT
Give the single best answer
1 Which of the following would NOT produce lactic acidosis?
A Carbon monoxide poisoning
B Impaired gluconeogenesis
C Impaired pentose phosphate shunt
D Impaired pyruvate oxidation
E Cyanide poisoning
2 The rate of glycolysis is increased by:
A glucose 6-phosphate
B fructose 2,6 bisphosphate
C citrate
D lactate
E acetyl-CoA
3 Which of the
following best describes the role of lactate dehydrogenase?
A disposal of excess NADH in fast twitch muscle cells
B utilization of lactate for energy in red cells
C conversion of lactate into TCA cycle intermediates
D synthesis of pyruvate during hypoxia
E shunt pathway for pyruvate to enter gluconeogenic pathway
4 Which of the following is true for the nonenzymatic glycosylation of
proteins?
A It is a fast and reversible reaction
B It forms a stable reaction product
C It involves the formation of ester bonds
D Glycosylated sites are genetically determined
E Sorbitol is the final form of the sugar attached
5 Which of the following best describes fat mobilization in the diabetic?
A Lipolysis leads to ketoacidosis in Type 2 diabetes
B Lipolysis only occurs in the Type 1 diabetic
C Lipolysis is due to activation of lipoprotein lipase
D Metformin would likely suppress lipolysis in adipose tissue
E Formation of ketones can be regulated in the liver
Learning Objectives, Supplementary Information,
I Learning Objectives Sources are: lecture notes from Block 1; pp 303-
304, Meisenberg; Supplementary Information below; pp 653-657,
Meisenberg
A Give a definition for lactic acidosis At what pH does a patient enter
acidosis?
B Describe the steps leading to increased lactate production resulting
from hypoxia
C List the various causes of hypoxia
D Describe the action of rotenone, amytal, antimycin A, oligomycin, and
pentachlorophenol in the mitochondrion
E Describe the action of fluoride on glycolysis
F Describe the metabolism of lactate by the liver in the normal patient
G Describe the steps involved in the nonenzymatic glycosylation of
proteins What is the effect of this process in renal glomeruli?
H Describe the activity of the polyol pathway in type 2 diabetics
I Compare the effect of insulin on gluconeogenesis in a normal patient
and a patient with Type 2 diabetes
J Give the two causes of hyperglycemia in diabetes mellitus
K Compare fat mobilization in type 1 and type 2 diabetes
II Supplementary Information Also, see pp 653-657 in Meisenberg
Diabetes supplementary facts
Type 2 diabetes occurs in nearly 19 of those between 65 and 74
Nearly half of those with Type 2 diabetes are over 60 and half of those
are undiagnosed
Risk factors for
Type 2 diabetes are visceral adiposity, increasing age,
and lack of physical activity
Type 2 patients develop impaired renal function
Type 2 diabetes is characterized by insulin resistance:
o Insulin is present in the blood, but is required at higher
concentrations than normal
o The intracellular signal that is produced when insulin binds to its
cell surface receptor is diminished
Elevated blood sugar is largely due to inability to suppress
gluconeogenesis in the liver
Metformin therapy - supplementary information:
The specific action of metformin is not known with certainty, but it
seems to work generally by increasing insulin sensitivity, ie increasing
the intracellular signal response to insulin
Metformin inhibits gluconeogenesis from whence it gets its common name,
glucophage Thus, it prevents lactate conversion to glucose in the
liver; lactic acidosis is a side effect
Metformin is also thought to inhibit oxidative phosphorylation This
would reduce ATP production and cause an increase in NADH concentrations
Metformin and reduced renal function occur together with most cases of
lactic acidosis
Reduced renal function causes circulating
metformin concentrations to
increase causing a functional overdose of this drug
Generic Question Templates
1 How is ________ like ________ ?
2 How are ________ and ________ different?
3 Compare ________ before and after ________
4 What caused ________ ?
5 What is another possible cause of ________ ?
6 In what sequence did ________ happen?
7 Break ________ down into its component parts
8 Give an example of ________
9 Into what groups can you organize the following?
10 What information is needed?
11 Is the following information relevant?
12 What is the relationship between ________ and ________ ?
NBME Question Templates1
Sample Templates For Learning Objectives And/Or Test Questions
a Make a simple paraphrased definition of [terms]
b What concepts are related to [terms]?
c List causes and/or effects of [terms]
d Compare or contrast [terms] with one or more [terms]
e Describe the relationship between [terms] and [terms]
f Explain the function of each step in a sequence or a process
g What do [terms] have in common and how are they different?
h What symptoms would be produced if process, structure, etc were
defective?
Sample Item-Writing Templates and Lead-Ins
Gross Anatomy Items
1 Item Stem Patient Vignette: Describe a patient with a problem
2 Lead-In: A defect is most likely to be present in which of the following
structures/processes?
3 Options: List of structures/processes
Also the following are general problem set-ups
Insert patient vignette describing a patient with a problem Which of the
following is the most likely disorder of the knee?
Insert patient vignette describing a patient with a problem Which of the
following is the vessel into which contrast medium should be injected
during fluoroscopy to visualize the site of the abnormality?
Insert patient vignette describing a patient with a problem Which of the
following gastrointestinal disorders is the most likely cause of these
findings?
Histology/Cell Biology Items
Insert description of action Which of the following cellular organelles
is most directly involved?
A Golgi complex
B Lysosome
C Peroxisome
D Mitochondria
E Nuclear envelope
F Secretory zymogenic granule
G Rough endoplasmic reticulum
H Smooth endoplasmic reticulum
Lab Vignette Example
Several contiguous cells are labeled with a fluorescent dye that
cannot
cross cell membranes One cell is experimentally bleached with a light that
destroys the dye but soon recovers dye fluorescence This recovery is best
explained by the presence of which of the following structures between the
bleached cell and its fluorescent neighbors?
A Basal lamina
B Desmosomes maculae adherentes
C Gap junctions
D Glycosaminoglycans
E Tight junctions zonulae occludentes
Template for Mechanisms
Item Stem Patient Vignette: Describe a patient with a problem
1 Lead-In: Which of the following mechanisms is the most likely cause of
the patients findings?
2 Options: List of mechanisms
Additional Templates
A patient description has a type of injury and location Which of the
following structures is most likely to be affected?
A patient description has history findings and is taking
medications Which of the following medications is the most likely cause
of his one history, PE or lab finding?
A patient description has abnormal findings Which [additional]
finding would suggest/suggests a diagnosis of disease1 rather than
disease 2?
A patient description has symptoms and signs These observations
suggest that the disease is a result of the absence
or presence of which
of the following enzymes, mechanisms?
A patient description follows a specific dietary regime Which of the
following conditions is most likely to occur?
A patient description has symptoms, signs, or specific disease and is
being treated with drug or drug class The drug acts by inhibiting which
of the following functions, processes?
A patient description has abnormal findings Which of the following
positive laboratory results would be expected?
time period after a event such as trip or meal with certain foods, a
patient or group description became ill with symptoms and signs Which
of the following organisms, agents is most likely to be found on
analysis of food ?
Following procedure, a patient description develops symptoms and
signs Laboratory findings show findings Which of the following is the
most likely cause?
A patient description dies of disease Which of the following is the
most likely finding on autopsy?
A patient has symptoms and signs Which of the following is the most
likely explanation for the findings?
A patient description has symptoms and signs Exposure to which of
the toxic agents is the most likely cause?
Which
of the following is the most likely mechanism of the therapeutic
effect of this drug class in patients with disease?
A patient has abnormal findings, but normal findings Which of the
following is the most likely diagnosis?
1 NBME Item Writers Guide, wwwnbmeorg
Resources for Application Level Questions
Underground Clinical Vignettes - A series of Step 1 books with topic
oriented case vignettes Published by Blackwell Science
Step-Up and Step-Up to the Bedside A systems based Step 1 review set of
books with case vignettes Published by Lippincotts
Mosbys Rapid Review Series A series of Step 1 review books with 400-500
questions per book; heavy emphasis on Step 1 type case vignettes Published
by Mosby, Inc
McGraw-Hill Pretest Series A series of Step 1 review books composed
entirely of questions with annotated answers Many questions are case
vignette type
Medscapecom http://wwwmedscapecom/px/urlinfo A web site with access to
cases and other clinical material Content may be adapted to basic science
level learning
A Taxonomy of Learning1
1 Evaluation - What is predicted? [clinical treatment and management]
2 Inference - What is
concluded? [diagnosis]
3 Comparison - How are patterns related?
4 Analysis - How are facts grouped into patterns?
5 Recall - Just the facts maam
Note that each level uses the levels below it
Sample learning objectives for learning taxonomy:
Evaluation - Develop a treatment plan for a type 2 diabetic
Inference - Justify your diagnosis of type 2 diabetes
Comparison - Explain how type 1 and type 2 diabetes are different
Analysis - Give the characteristics of type 1 diabetes
Recall - Define hyperglycemia, ketoacidosis, glycosylation
1 Quellmalz taxonomy of learning, see attached documents obtained from the
Internet
Writing Learning Objectives
Learning objectives ask for a specific behavior that demonstrates learning
Goals are broad outcomes that do not demonstrate a specific behavior
Examples:
Objective - Compare the pathologic outcomes of type 1 and type 2 diabetes
Goal - Understand type 2 diabetes
To write a learning objective:
1 Refer to the taxonomy of learning to determine the level of learning
required
2 Phrase the learning objective as an essay test question; if you could
not answer the objective as an essay test question, start over
