Here is our first case study. It describes the designing of an educational visit to a doctor and to a patient at home. The substance of the story is from an article (Earl, Everwijn and de Melker, 1980) in Medical Education. It will introduce you step by step to the activities illustrated in Fig. 1. In this way you will have a better idea of where the learning experience design step fits into the whole picture of activities at the micro level of design decision-making.
Students in law, social science, engineering, hotel management, food processing, laboratory science and many other studies are often required to spend short periods in the field’ observing the profession which they will eventually join at work. Such periods are potentially important learning encounters. They are a challenge to the learner, who must integrate what is seen in practice with the theory that has so far been learned. They are also a challenge to the professional, who must fulfil the role of tutor in the ‘hurry scurry’ of an everyday work situation, and to the learning experience designer, who must see that both student and professional like and value their time together. This case study illustrates how one such instructional design challenge was met.
In 1977 a project was set up to evaluate (activity 1, Fig. 1) and if necessary redesign an educational encounter for medical students in their third year of study at the University of Utrecht. The encounter involved a required visit by students to a practice and to a patient at home. The visit lasted five half-days. Up to study year 1977 only medical students who wished to be general practitioners (GPs) had to meet the requirement. In study year 1978 the requirement would be extended to all third-year students. Some 240 students would then have to make individual visits to a general practice and to a patient.
The staff of the Department of General Practice at the university were aware of some weaknesses in the existing encounter. An evaluation of the design of this existing encounter was begun. The group leaders involved wanted to be certain that the learning experience of the new generation of students would be effective, valued, liked and efficient.
The critical problem was that students found the experiences in the field emotionally overwhelming. After two years of basic medical science they were suddenly confronted with the reality of practising medicine. The emotional problem was detracting from the students’ basic liking for this ‘encounter with reality’ in the third year. It interfered with their ability to observe well. In discussion groups (before and after the visit to a practice and a patient), discussion tended to focus on popular issues such as what the GP’s attitude to a patient should be.
The clinical reality of general practice got, as a result, too little attention. Some students tended to become too judge-mental about what they saw, and this interfered with the learning side of the experience. A number of group leaders at the university, and GPs in the region fulfilling the role of ‘guest doctor’ to students, had limited experience of working with students. Many doctor/patient consultations were too short to serve as any sort of learning experience.
A ‘Go’ or ‘No Go’ decision to redesign the existing learning experience now had to be made. It took little time for the members of the design group to make a ‘Go’ decision. There was, for example, little or no opportunity to help group leaders and host GPs to perfect their skills as student tutors and so solve the problem via a non-design (No Go) decision. The solution to the problem was to redesign the existing learning experience of the third-year students. The time had come to go ahead and look more closely at the needs of students, group leaders and host GPs alike. It was time to move to activity 2 in the design activities cycle.
The needs analysis (activity 2, Fig. 1) revealed several things. If students, it was decided, were to observe critically and analyse effectively what they saw, they needed some frame of 
reference, into which they could fit what they observed and out of which they could ask critical questions of the professionals with whom they would come in contact. This need for a frame of reference was seen as a critical one. There was also a need for more structure and clear intent in the discussions which the group leader had with her or his group, both before the visit to practice and patient and following these visits. Host GPs themselves needed to know what was expected of them. Inexperienced group leaders needed a ‘group leader’s guide’ to help steer the group discussions and the exchange of experiences between students on return from the field. Some means of evaluating the quality of the individual student’s observation was also needed.
As a design group we had work to do. It was the second week of March 1977. September — the month in which the new encounter had to be ready — seemed a relatively long way away. It was closer than we thought!
By the end of March 1977 we faced the task of creating a link between the analysis of the needs and the learning experience design step. This was the task of specifying the needs (activity 3, Fig. 1) in terms of five things: 
- The specific end goal or learning objective.
- The evaluation criteria that would be used to signal satisfactory or non-satisfactory completion of the mini-course.
- The content through which this objective would be achieved.
- The method and media to be used.
- The constraints (the time, the number of host GPs available, etc) which had to be respected when making the design decision.
The end goal specified was that on completion of the programme the student would be able to give meaningful answers to seven critical questions:
- Who is the ‘general practitioner’?
- What does she or he do?
- What sort of decisions is a GP typically involved with, and how does she or he make them?
- With whom does the GP need to cooperate?
- Are all the activities typically ‘medical’ or not?
- What factors influence the decision-making and activities?
- To what purpose is the work of a GP directed?
The evaluation criteria for a successful encounter, it was decided, should be a report written by the student on her or his visit to the patient. The report had to cover the medical, psychological and social aspects of the patient’s illness. These ‘end reports’ were very important in the eyes of the Department of General Practice. Together with satisfactory attendance at group meetings and a group end test, they were made the basis for the end grade that the student would be given. The content was not formally specified. This was seen as unnecessary since it is implied in the seven questions and, with the help of an appropriate design, would have to emerge during group meetings and the visits to the practice and patient. The method needed was the existing method: group meetings (guided by a tutor who was also a practising GP) plus individual observation. The media needed were a group leader’s guide, student hand-outs (cases, examples, schemas, etc), transparencies for an overhead projector, the projector itself and a video for showing filmed consultations. The constraints which had to be respected when a design decision would be made were: 240 students were expected in study year 1978 in the programme; only four half-days were available for group meetings before the visits, and the same number for exchange of experience and discussion after the visits; 12 group leaders and 100 host GPs were available; and the programme would have to operate with 20 groups of 12 students. Past difficulties had been scrutinized. The needs were clear. The goals were clear. Constraints were known. Content was not explicit but clearly implied in the seven critical questions. The design group had reached the learning experience design step (activity 4, Fig. 1 in the activities cycle.
What design (plan, structure and strategy of instruction) would be best? Ideas chased and contradicted each other. Intuition, creativity and logical thinking set to work in thinking up a design (activity 4.1). There were several initial ideas; each member in the design decision-making team had her or his own ideas. The tension and excitement of thinking up a design had begun. In the many discussions which followed, we were alerted to the importance of the frame of reference mentioned earlier: the frame of reference into which the student could fit what she or he sees and out of which she or he can ask critical questions. Our thinking switched to the question of what this frame of reference might be. Several ideas were brought up, remained for a time in favour and were again rejected. Thoughts vibrated back and forth. Eventually an idea was hit upon which signaled a road to completion of our task of thinking up a design. This idea was to arm the student with a concept of general practice before going into the field. Initially there were different ideas about what this concept should be. Finally it was agreed that it should be a concept consisting of five elements, as illustrated in Fig. 2.
Figure 2 A visualized concept of general practice
The five elements in the concept are five things which have a critical influence in shaping an individual GP’s care for the patient and in shaping the way in which a practice is run.
With the frame of reference in Fig. 2 in mind, we were able to see what plan, structure and strategy of instruction was needed to generate an ‘effective’, ‘valued’, ‘liked’ and ‘efficient’ encounter. We had our design. It was time to move on to activity 4.2 and give the idea for a design its concrete form. It was time to work out the design.
In the third week of April we worked with the concept of general practice and the specification of the student needs made during activity 3 and worked out the thought-up design (activity 4.2). The thought-up design required the concept of general practice to be established in the student’s thinking prior to the excursion into the field. It could then be used as an ‘anchoring idea’ that could facilitate observation and promote meaningful discussion with the host GP. The concept, the thought-up design told us, should be taught with the help of cases on paper, consultations on film, group discussions, informative hand-outs and other stimuli.
Table 1 presents an overview of the thought-up worked-out design. It lists the topics, exercises and discussions that would occur prior to and following the visits to the practices. At the heart of the design and sequencing of the events in this educational encounter was the concept of general practice with its five elements: the needs of the patient, medical/paramedical assistance available, and so on. During the visit itself the concept was to be used to help the student see and discuss things in an effective way with the host GP.
The didactical design generated by the idea of the five-element concept was given its ‘medical content’ by three GPs in our design group. It was decided to compile a Teacher’s Guide to help individual group leaders run sessions 1 to 10 and 11 to 16. The guide contained all the materials needed for the group sessions and also suggestions on how each session might be conducted. Host GPs (it was decided) should be introduced to the five-element concept and its intended use in a tutors’ orientation meeting.
The following is a description of the teaching-learning activities which one of the sessions involved. This description will give you an idea of the sort of things which had to be scheduled, made and arranged when working out the design of the pre-visit sessions. In working out a thought-up design the designer’s task is to prepare the ‘scenario’ for learning and assign teacher, materials and learners their various roles.
Influencing factors (session 9): time c. 60 min
Session 9 concentrates on element 5 in the concept: ‘influencing factors’. These are factors which influence, or can influence, what a particular GP does and what decisions he makes. The exercises in this session are related closely to what has been covered in the preceding session. In session 8 the students have been introduced to and have discussed the various activities which characterize general practice and distinguish it from hospital practice.
Session 9 involves the analysis of the decision that a GP has made in three separate incidents. The incidents are described in a hand-out that each student receives. The student’s task is to identify independently what, in her or his opinion, are the factors that influenced the decisions that were taken.
The first incident concerns a GP’s non-referral of a 70-year¬old woman to an orthopaedic surgeon for correction of ‘hammer toes’.
The second incident concerns a GP’s decision not to visit a patient in the early hours of the morning despite the angry message that the caller would get another GP to come.
The third event involves a GP’s response to a patient with symptoms of rheumatoid arthritis and a depression which is disturbing her three young children. Accompanying the description in this last item are two quite independently given opinions by two GPs on what the GP in the case might best do next. The opinions differ. The students must identify what factors might account for such a difference of opinion.
To end session 9, the leader hands out the list of influencing factors, given in Table 2.
The group leader emphasizes that such a list is never complete but can be helpful to have when the student is visiting the practice and the patient at home. It can help identify what factors are playing, or have played, a role in the host GP’s decision-making.
By September 1977 we were ready. It was time to test and revise (activity 4.3) the thought-up worked-out design. We did this with the help of the third-year students entering the programme in September. We were wishing hard for a high rating against the Emax Vmax Lmax E’max criteria, and a minimum of revision work.
We scored high on some counts and lower on others. In principle, the learning experiences in the programme (pre-field trip meetings, visits to the practice and patient, and post-field trip meetings) were valued and liked by the learners. Points emerging from discussions with students about the use, or non-use, of the concept as a frame of reference for analysis and discussion of the things they met showed that thought was still needed about how to make the concept’s use more effective and more efficient. The score for the whole learning experience looked, as a result, something like this:
Students suggested that the concept was most useful after (rather than during) the consultation with patients, and after the visit to the patient at home. For the latter, many students felt that a second concept for viewing illness ‘through the eyes of the patient’ would be helpful. The concept they were using was mainly helpful in seeing the illness ‘through the eyes of the GP’ involved with the case.
The conclusions we drew from this try out of the design were that:
- The conditions must be present in the observing situation for such a concept to function, and
- the individual student must, in principle, value the concept’s content and want to use it.
The redesigned learning experience was installed as a required encounter in the third-year curriculum with effect from September 1977. The most critical thing which had to be made clear to group leaders at the time of its installation (activity 5,Fig. 1)
was that each (when the time came) would face the challenge of teaching the concept in a way that was not too directive but at the same time directive enough to give the student confidence that she or he could use the concept as a frame of reference for observation and discussion.
The results of a first end evaluation (activity 1 Fig. 1,) told us that we should not be unhappy at the end result of our instructional design activities at the micro level of design decision-making!