I asked students to submit some ideas and from these selected an assignment on case taking. I was particularly interested in this because it might help to show how practical skills may be demonstrated in a written medium.

Context — the Place of this Piece of Work within the Course

I will let the student describe the position of this piece of work in her own words:

The preceding unit . . . dealt with symptoms. What kinds of symptoms are there? Mental, emotional, etc. What is a "generality"? Which were the most important and why? We began practice in translating symptoms into rubrics.

This unit, unit 5, is on case taking. There is input on the topic. In this case, it was by more than one homeopath so we saw different approaches. Each unit requires a heavy dose of readings from the Organon, Kent's Lectures on Philosophy, Roberts, Vithoulkas and in this unit, Schmidt's The Art of Interrogation. An unfortunate title.

To give you more idea of where we were by the time we reached this unit: We complete 7 units in one year (out of a total of 18 in 3 years) provided one studies for 2 1/2 hours per day or 2 full days a week. I will be finished with unit 10 in one year because I have put in more time than that. I also have a nursing background and mastery of medical language which gives me a head-start, too. It must take people who have never seen a patient much longer.

"Mastering the language" is certainly an early hurdle in all areas of study. This is how one text book for tutors explains it:

 . . . unless one has the beginnings of the relevant train of thought already available at the forefront of one's attention there is little the words [of the lecture, seminar, tutorial or book] can trigger off. This is the problem for "beginning" students . . . until they have become launched into the system of discourse. A system of discourse involves concepts, ideas and conventions of explanation. These accumulate round any "expert" analysis of a subject, be it gardening, football tactics, physics or literary criticism . . . Ironically, much of what is absolutely central is often missing from the discussion, precisely because it is so fundamental that "insiders" take it for granted. (Northedge)

If tutors consistently check the meanings of the students and explore the implications of what they themselves contribute, students are more likely to gain access to both the language and the theoretical framework which homeopaths use.

Context — the Place of the Work in Educational Terms

Identifying symptoms is a descriptive task. It is a matter of attaching the correct "label" to a description. "I'm hot" is the description to which we attach the label "general." As a task for the student, this involves assimilating factual knowledge and being able to organise it in some way, that is, to classify it. This is an essential prerequisite for participation in any discussion about materia medica or case histories. It will be very hard to "navigate" such discussions if students do not easily comprehend this aspect of homeopathic language. Note that "comprehension" is the key: understanding and correctly defining terms.

Of course, what happens immediately is that students want to know why this classification exists. As tutors we emphasise the importance of the classification by relating it to practice. Hence: "Which are the most important and why." This immediately involves students in a higher level of homeopathic knowledge. Here the student is discussing not just understanding facts, but evaluating them. Hierarchy is about attaching relative values to symptoms. Educators generally consider making judgments about the relative value of different aspects of factual material a high order skill.

For those who wish to follow the classification of cognitive skills further, you will find Bloom's Taxonomy referred to in many educational books. This is probably the best place to begin as you are likely to be presented with a discussion of the strengths and weaknesses of Bloom's work. I find his classification helps me to orient myself with a range of difficulty. See the bibliography for Bloom's original work.

The Task for the Student

The student was very clear about both her own attitude to the work and what was required. She explained that to me in this way:

[This] . . . question came in a unit which dealt with taking the case. By the way, the assignments aren't really exam questions — at least I don't think of them like that. They are a way for the tutor to check that you have grasped the material. As there are no specific objectives listed, the assignments are not testing those.

It is clear that the student is not being assessed against "specific objectives." These might otherwise be defined as "learning outcomes" or "objectives." It might be that the tutor has a clear list of outcomes to be achieved, but this has not been communicated to the student. I certainly find it useful to know what I'm expecting students to be able to do at the end of a period of learning that they could not do before! I look upon this as part of my contract with students and I like to agree with them. Looking at the whole curriculum, the range of learning outcomes to be achieved defines a pathway and expectations — on the side of both student and tutor — of what will be achieved during the course.

I must say here that learning is a much more haphazard process than neatly arranged progression of learning outcomes might imply! Something to be addressed in a later column, no doubt.

There is a clear sense of dialogue with the tutor. There is also a sense of an informal assessment of progress at work. Students reading this need to know that as tutors we require this feedback from students as much to reflect on our own effectiveness as teachers as we do to assess your progress. This kind of dialogue is essential to both parties. Participating in the discourse of homeopathy — "talking homeopathy" — is a key learning experience.

The Question

Students were asked to describe questions they would use to help a patient explore an acute presentation. In this case, a cough.

The Answer

General

• Tell me more about your cough?
  
• How would you describe it?
  

Location

• Whereabouts do you feel the cough?
  
• Is your whole chest affected?
  
• Show me where it hurts when you cough.
  
• Do you feel anything else when you cough?

Causation

• What was happening in your life when the cough started?

• How were you feeling before you got this cough?
  
• Were there any changes in your life about that time?
  
• Have you had this type of cough before?
  
• Has anyone else in the household got this cough?
  
• What sort of work do you do?
  
• What is your work environment like?
  
• Is there anything you connect with this cough?
  
• Why do you think you cough?

Modalities

• What sort of phlegm do you bring up?
  
• When do you cough?
  
• Is there anything you do that makes it better?
  
• Is there anything you do that makes it worse?
  
• How does it affect your sleep?
  
• What position helps or hinders?
  
• What happens when you eat or drink?
  
• What happens when you go outdoors?
  
• Have you taken anything for it?

Exploring the Answer

The first thing I notice is that the task is addressed clearly. Listening to the patient's story and facilitating sufficient qualification of the material to provide good prescribing information is a fundamental skill: "A case well-taken . . . " This is about acquiring facts about the patient, information gathering. The more colourful and descriptive the better. The task set for the student is to describe how they would go about that process. Acquiring information places this task low down in the classification of skills. It is appropriately placed in the first year of the course and pursuing an acute presentation is likely to gel with most students' experience at this stage. Other opportunities will be taken to pursue information in this open-ended way, as in " . .  continue to explore."

Second, the student is aware of what makes a complete description in homeopathy. A "complete symptom" has causation, location, sensation, extension, modality and concomitant (or alternation). The material is presented in this format, though not all the categories are highlighted.

The pattern is from the general to the specific. First this student will invite the patient to tell her more about the cough and to describe it further. Later on you see the use of more specific questions to clarify the homeopathically useful details: modality, sensation and so on.

The questions under the "Location" and "Causation" show the student participating in the discourse. The questions are appropriate to the headings, they are used in the right context. They are both understood and applied correctly.

The section on "Modalities" is more problematic, in my view. This contains questions about concomitant symptoms ("What kind of phlegm?") and generals ("How is your sleep affected?"). I would want to check that the student has a classification of symptoms which can be applied to listening to the patient's story.

In the context of acute case-taking, I would also like to know how the student proposes to move from the patient's main concern — the cough — to the general state that goes with it, including psychological changes (mental and emotional concomitants of the acute) and generals like fever, thirst, appetite changes and so on. This has not been made clear. However, it may not have been the intention behind this assignment.

The student's background is likely to influence her approach, particularly at this early stage in the course. The confidence with direct questions is likely to stem from nursing practice. I would want, in time, to see equal emphasis and confidence develop in a more open- ended, passive approach that provides space for the patient to fill. This is more akin to the early — exploratory — stages of a counseling session. This is a good example of how — as tutors — we use the feedback we get from assignments in planning our teaching. It might be useful to introduce students at this stage to a richly illustrated book on the counseling encounter and support this with experiential sessions in class.

Summary

This is a good answer to the question. It shows an excellent understanding and application of homeopathic ideas, particularly around the specifics of the acute symptoms. It is weaker in moving on to more general areas of the history, both in what appears to be possible (What symptoms might I expect? What kind of things am I looking for?), and in a strategy to approach this area of the history (How do I get from the cough to the patient?).

I hope this has helped to expose the processes of teaching, learning and assessment to scrutiny. I look forward to hearing comments from tutors and students, either to me direct, or via letters to Homeopathy Online. Let's make this column a place for discussion.

Acknowledgement: I would like to acknowledge the help of the brave soul who submitted her work for all to see. Thank you. I hope you have broken the ice successfully and now others will start fishin'.

Bibliography

Bloom, B. S., Taxonomy of Educational Objectives: Handbook I — the Cognitive Domain. Longman, 1956.

Bloom, B.S., et. al., Handbook on Formative and Summative Evaluation of Student Learning. McGraw-Hill, 1971.

Kratwohl,N., editor, Taxonomy of Educational Objectives: Handbook II — the Affective Domain. Longman, 1964.

Northedge, Andy, Returning to Study, in Thorpe and Grugeon,1987.

Thorpe and Grugeon, Open Learning for Adults. Longman, 1987.