Download Selected papers from the 7th National Conference on College Teaching and Learning, pp. 79-89, J. A. Chambers (Ed.), Florida Community College of Jacksonville.

CONTEXTUAL LEARNING
FOR PREMEDICAL
: ,;.'..,.
r· " .
;tI;o. ..
:_eivc,~.e~n~~tEe;fi,t~~"· rii;~~:
for the AI.
Th
.
.~
STUDENTS
:
. /~:"·
,.,',.
,.
Penny J . Gilmer
Alison Grogan and Susan Siegel
Florida Stale ,University
INTRODUCTION
F
l"
~
r
,
{
:
Contextual learning for premedical students was
created to provide learning opportunities not normally
available to undergraduate students. Premedical students
often search for ways to gain experience in the medical
field prior to entering medical school. The contextual study
of systemic lupus erythematosus has given the students the
opportunity to study a disease in many of its aspects.
Sources of information for the study ranged from literature
to patients and physicians. The multitude of sources
provided knowledge not only of lupus, but of the medical
profession as well.
The contextual study of systemic lupus
erythematosus began with a conversation between the senior
author and a former middle school science teacher. The
teacher remembered the author's research interest in the
response of the immune system to cancer cells. She
mentioned the surprisingly high number of cases of lupus
in her home town, the rural community of Monticello,
Florida.
At the Monticello Family Medicine clinic, there was
a reported ten cases out of a population between 6,0008,000 people. The authors eventually discovered from
79
Gilmer, Grogan & Siegel
Selected Conference Papers
81
80
th incidence was within range
numerous sources that e
rce but is around 14.6(which vanes from source tod:,u ndi~g on the population
50.8 cases/lOO,OOO people,
pe
'ded a challenge that
I 'ty of lupus provi
possibilities. Sources ranged
tested). The comp eXI
would incorpora~e numero~sl . and use of the Internet to
Journal •artlC es,
I'VV
,
and the physicians who treat
from tex t"~'ks
,
speaking with lupus patients
these patients.
SYSTEMIC LUPUS ERYTHEMATOSUS
to s is an autoimmune
Systemic lupus erythema su ·th the disease form
disease with no. known ~ause. P~:: w~ normal antibody
antibodies agamst their own
. the body and forms
recognizes foreign substance.~ m
ed from the body.
I
hich are remov
immune comp exes w bod ~ rms immune complexes
With lupus, though, the d ~ 0 es thus attacking and
with its own org~s an
ssuolC::ules are known as
I
.
These Immune m
destroy mg.
.
. (ANA) because they attack nuc ear
antinuclear anubodl~s
ells The formation of the
components of their own \ ~welling and scarring of
immune complexes results I . and discomfort associated
tissues. These effects cause pam
with lupus.
. complaint of many lupus
Joint problems are. a major
imilar to rheumatoid
patients. Swelling r.esultsdm Plrob~e,md~:y problems when the
.' Many pauents eve op \U
I
'ng and eventual rena
arthnUs.
immune complexes lead . to I ~ "butterfly" rash on the
failure. Other sympt~ms mcdu e'
fluctuations. With the
d presSIOn an wei ght
·
f
' . often difficult to diagnose. A
face, augue, e
myriad of symptoms, lupus IS ANA test that is specific for
positive immunofluorescence
.
.
the antinuclear antibodies is in the diagnOSIs.
Lupus, as with most other autoimmune disorders, is
more prevalent in women than in men . Women are 10-15
times more likely to develop lUpus. Black women are at
greatest risk, with Asian and white women following.
There is a possible link between high estrogen level and
lupus.
Interestingly, men with lupus typically exhibit a
higher estrogen:testosterone level than men without lUpus.
Men with lupus usually have the discoid form of the
disease. Discoid lupus appears as a red, raised rash which
is often coin-shaped (hence, the name). This rash is often
large and scarring. Women are more susceptible to systemic
lupus which affect~ organ systems of the body. A third
form of the disease is drug-induced. Drug-induced lupus is
caused by some prescription drugs for hypertension aod
irregular heartbeats. The lupus symptoms subside once the
medication is discontinued.
Treatment of the disease is as complex as the disease
itself. The variety of drugs needed to treat the multiple
symptoms all have some potential damage. Corticosteroids
are commonly prescribed for treating internal changes
caused by lupus by decreasing inflammation. Cytotoxic
drugs are used in extreme cases when the patient fails to
respond to corticosteroids. Rest and avoidance of sun are
also highly recommended for patients.
CONTEXTUAL LEARNING
In the contextual study of lupus, many sources were
used in gathering information, including books, journals,
and patient files. With patient files, the issue of ethics in
medicine and patient-physician confidentiality was pursued.
Gilmer, Grogan & Siegel
Selected Conference Papers
82
.
.
e above interviews were conducted .to
h)\Iowmg th
. '
f the study began WIth
ontain additional data. ThIs phasetl'tI~oner at the Monticello
.
.
·th a general prac
.
f th
a dIscussIon WI
.'
us an overvIew 0
e
for on patient charts. He
Family Medicine. chOlc. He
disease and explamed what to
tI'ents had to go to
. ed that most lupus pa
. .
also explam
.
t rns Another phySICIan
specialisL~ .fo~ some of th~: ::~: to ~ne of his p~tien~.
at the chnlc mtroduced
d ted with speciahsts \0
Interviews were also co:n~c chiatry, as well as with
rheumatology, nephrology, FI ';?'da State University.
an immunology professor at 0 great benefit to the study.
Patient involvement was a
.
.
and verbal
.'
. questionnaIres
Written commu~lcatlOn .vla
'ded insights into the
communication 10 mte~lews ~~~ lupus is not a visible
. '~~I •
personaI aspects of the dIsease.,
.
·&..... ~tions are 10..... .
be
many of Its manl.......
.
th
dIsease,
cause.
.
·th s about havlOg e
Patients shared theIr feehngs WI u
f::
disease.
I
ttended LupuS Foundation of
The authors a so a
.th people there At the
( sand met WI
.
.
Amenca local mee 109 . Is spoke about lupus-related
meetings, health p~ofess\O~a pecialty We had a chance to
to ics based on theIr area 0 s
..
m~t patients and to hear their questIons.
THE PAPER SOURCES
books
Much has been written about lUpus. ~any ~<nH:ts
.d . f r mation about the vanouS ~r­
and journals pr~vl ~ 1O.0
Talbot, 1993), epidemiology
of lUpus, inc1udlOg Its hl~ory ~ O'Dell 1995' Pollak and
~d ~athoge~esis ~~tzl~~), sympt~ms (S~hU~,
1993):
PlraOl, .1993, W
,
Hahn, 1993; Quismono, 1993,
diagnOSIs and treatment (
I 1993) as well as the
Wallace, 1993; Wallace et. a.,
'
83
pathology of the disea.~ (Dieppe et. aI., 1986) and its many
manifestations within the body. All sources agree that lupus
is mysterious and unpredictable. No two people have
exactly the same form of lupus. It cannot be determined
prior to diagnosis which body systems will be affected.
Only involvement of the kidney can possibly be ruled out.
After diagnosis, if kidney involvement has not occurred
within the first six months, the patient is unlikely to
develop symptoms of renal failure.
A firm background of the disease was developed
from written sources. Pictures in these books brought the
images of rashes, scarring of organ systems, and joint
inflammation (Dieppe et. aI., 1986). Views within the body
allowed us to "see" lupus as not possible from the outside.
The Internet was also a great source of information.
The Lupus Home Page (1996) provided an overview of
lupus, and a number of other web sites led to further
learning. The Lupus Home Page revealed basics of the
. disease, including types and symptoms of lupus. It also
identified the prevalence of the disease in women and
associated disease "flare-ups" with menstruation. The home
page was optimistic about the prognosis of the disease.
Only in extreme cases was it identified as fatal, and new
research continues to provide information for treatment and
coping with the illness.
Patient files at the Monticello Family Medicine
clinic were reviewed, and measures were taken to insure
confidentiality. The importance of ethics in medicine
became apparent and the relationship between doctor and
patient were respected. Nine available patient files were
examined--all females--which provided the first glimpse of
. bow differently lupus affects people.
The authors traced the disease from symptoms to
f'dUl~:>Sis in each patient. The course of treatment provided
Gilmer, Grogan & Siegel
Selected Conference Papers
84
for each patient was followed through the doctors' notes
and the laboratory data. Each individual patient had a
different pathway of symptoms and treatments. Often,
months and years passed before an official diagnosis of
lupus was made.
PHYSICIAN SOURCES
From the paper sources came sufficient information
to form an intelligent basis for discussion with others,
namely three specialty physicians. Each physician provided
a background of the disease manifestation in the particular
organ system. The doctors explained diagnosis and
treatment of conditions.
One of the three, a rheumatologist in Tallahassee,
had a number of lupus patients. He gave us a brief history
of lupus and explained that it does not usually occur
vertically within families; i.e., a child and her aunt may
have the disease rather than a child and her mother,
although the latter is possible. Joint involvement in lupus
most often leads to symmetric polyarthritis of the small
joints (hands and feet). Pain is caused by inflammation due
to formation of the immune complexes in the joint area.
Over-the-counter medications such as asplfln are
recommended in mild cases, while corticosteroids are
prescribed in more severe cases.
A second physician, 11 rheumatologist and expert in
lupus from the University of Florida, gave a seminar at
Florida State University at which he spoke about a
particular antinuclear antibody specific for DNA. This antiDNA antibody is found in patients with kidney
involvement. He described an immunofluorescence test on
kidney tissue, in which every nucleus fluoresced, indicating
85
the ~resence of the antinuclear antibodies. The formation of
the Immune complexes causes extensive scarring and can
lead to renal failure.
.
". nephrologist in Tallahassee provided additional
mfor~tJon abo~t kidney involvement in lupus patients. He
explamed ~at kl~ey involvement is rare in patients over
~5-40. A bIOpsy aIds in the diagnosis of the severity of the
t1lness. Se~ere kidney involvement leads to renal failure
when .scarnng damages the microscopic glomulerli, which
are kidney filters needed to make proper urine. When
filtering capability is decreased, substances essential to the
~y such as amino acids and glucose are lost in the urine
whtle w~ products are retained in the body. Dialysis is
often u~ m ~ases of renal failure to increase the amount
of q~ahty unne excreted from the patient. He further
exp.lamed that kidney ~ansplants were occasionally an
option. ImmunosuppressIve drugs are given to the patient
to help prevent rejection of the transplanted organ. Lupus
does not often reoccur to damage a transplanted kidney.
A Psyc~iatrist in Tallahassee spoke to the authors
. about ~e emotional aspects of dealing with lUpus. Althougb
lupus IS not always fatal, it is hardly curable. Symptoms
~y vary fro~ day to day, and the pain can be tremendous.
~?, uncertamty, and fatigue often lead to depression. He
indlca~ that most lupus-related depression sufferers have
no hl~ry of depression. Antidepressants are often
prescnbed to control depression.
.
PATIENT SOURCES
Communication with lupus patients was initially
.b.and~ed .through a ~uesti~nnaire. The answers provided
information about dIagnOSIs and manifestations of lUpus.
Selected Conference Papers
86
Two of the patients indicated that they were willing to meet
with two of the authors about their experiences with lUpus.
All communication between the authors and the patient was
through the physician.
Two female patients in their 50's were interviewed
at the Monticello Clinic. Both were well educated about
their condition. Self-awareness is touted to be important in
coping with the disease, and these women demonstrated it.
Each had years of symptoms before her diagnosis. The
symptoms differed in each case, but both had multiple
symptoms. Both agreed that stress worsened their
symptoms.
Speaking with patients gave lupus a face. Seeing
how patients coped with lupus provided insight into how it
feels to have lupus. One of the patients introduced the
authors to a book entitled "Living with Lupus" (Blau,
1993). Another guide for patients is by Wallace (Wallace,
et. aI., 1993). Understanding patients needs and feelings
appears to be an enormous factor in caring for them.
Gilmer, Grogan & Siegel
other and by recogn "
r
living with lupus.
Izmg lterature SOurces dealing with
CONCLUSIONS
.
The study of lupus led throu h
mterweaving of SOurces bU'Jt
g many pathways. The
disease as the authors tt I upon the complexity of the
it--as we learned more a e"Tted to analyze and understand
to others. The sourc~s w~u:;f~ beaer able ~o explain it
another. A patient described p
as one thing lead to
her doctor and the tr tm a symptom and told us about
~mptom and the treat:ente:;d· the doctor e~plained the
JOurnal led to further reti
suggested a Journal... the
knowledge and
~rences ... which led to more
doctors.
more quest/ons for the patients and the
Interest grows with th
Everything expands and in th. e wealth of knowledge.
one relative point, I~pus.
IS case, It all goes back to
LUPUS FOUNDATION OF AMERICA
The Lupus Foundation of America (LFA) has
chapters which provide support services to individuals with
lupus and for their families. LFA is a volunteer-driven
nonprofit organization. In Tallahassee, it meets once a
month from January to September. Guest speakers at the
meetings discuss different aspects of lupus and effects of
treatment, both good and bad. In October, which is lupus
awareness month, the Tallahassee-Big Bend chapter
conducts a large meeting with numerous speakers. LFA
provides encouragement to patients by supporting each
87
REFERENCES
Blau, S. (1993). living with Lu
.
Med to help yourself. R d' pus. All the knowledge you
. ea 109, MA: Addison-Wesley.
Diewe, P. A., Bacon P A B ...
(1986). Atlas of Cli~cai
amIJI, A. N., and Watt, I.
Medical Publishing, pp. 8.4 9W;:U9010gy. London: Bower
, "
.3, & 9.6.
I
I
I
I
Rk
I
Selected Conference Papers
88
Hahn, B. H. (1993) Management of Systemic Lupus
Erythematosis. In W.N. Kelley, E.D: Harris, Jr., S.
Ruddy .. & C.B. Sledge (Eds.), TextbookojRheum(J(ology,
4th Edition, Volume \I (pp. 1045-1055). Philadelphia: W.
B. Saunders.
Gilmer, Grogan & Siegel 89
Wallace, D. J. (1993) An'
.
Wallace & B. H.' Ha:::alanal therapies. In D. J.
Erythemarosis. 4th &fti
(Eds.), Dubois Lupus
& Febiger.
I on (pp. 563-564). Philadelphia: Lea
Kotzin, B. L, & O'Dell, I. R. (1995) Systemic Lupus
Erythematosis. In M. Frank, F. Austen, H. Clamall, & E.
Uranul (Eds.), Samtt'r's Immunologic Disease (pp. 667692). Boston: Little Brown.
Wallace. D. J., Hahn B H
.
A patient's guide to Lup~s E~ QUlsm~rio, F., Jr. (1993).
& B. H. Hahn (EdS) Dubo' ematosls. In D. J. Wallace
Edition (pp. 542-552).'
IS Lupus Erythemarosis. 4th
Lupus Home Page. (1996). Author (on line). Available:
< http://www.iesd.auc.dkrIupus/index.html>
Pollak, V. E., & Pirani, C. L. (1993). Lupus Nephritis:
Pathology, pathogenesis, clinicopathologic correlations and
prognosis. In D. J. Wallace & B. H. Hahn (Eds.), Dubois
Lupus Erythematosis. 4th Edition (p. 533). Philadelphia:
Lea & Fellinger.
Quismorio, F., Jr. (1993). Systemic corticosteroid therapy
in Systemic Lupus Erythematosis. In D. J. Wallace & B.
H. Hahn (Eds.), Dubois Lupus Erythemarosis. 4th Edition
(p. 533). Philadelphia: Lea & Febinger.
Woods, V. L. Jr. (1993) Patho
.
Erythematosis. In W. N.· Kelle genesIs of Systemic Lupus
Ruddy , & C ' B
. Sledge (Eds) Toy, bE. D. Harris ' Ir ., S .
4th edition, Volume II
" ext OokojRheumarology.
B. Saunders.
(pp. 999-1015). Philadelphia: W.
I
I
I
I
I
I
Schur, P. H. (1993). Clinical features of SLE. In W. N.
Kelley, E. D. Harris, Jr" S. Ruddy, & C. B. Sledge
(Eds.), Textbook (?f Rheumatology. 4th edition, Volume II
(pp. 1017-1039). Philadelphia: W. B. Saunders.
Talllot, I. H. (1993). Historical Ilackground of Discoid and
Systemic Lupus Erythematosis. In D. I. Wallace & B. H.
Hahn (Eds.), Duhois Lupus Erythematosis. 4th Edition (p.
4). Philadelphia: Lea & Felliger.
I
I
I