GERD: Gastroesophageal Reflux Disease: Role of Saliva & Gastric Acid in Digestion & Erosive Disorders Affecting Tooth, Stomach, and Esophagus
|Tutorial, Case||9266||1||November 14, 2012|
This student-centered, small-group activity supports goals set forth in Report IX, Contemporary issues in medicine: oral health education for medical and dental students. The exercise uses disorders of gastric acidity to (i) highlight oral-systemic connections in collaborative patient care, and also to (ii) impart requisite foundational knowledge and clinical reference that enable an understanding of the oral manifestations of systemic diseases and oral-systemic interactions. The target audience is any health professions student who seeks to attain those cross-cutting competencies that promote the common attitudes, knowledge, and skills necessary to prepare for effective practice and interprofessional collaboration in today’s health care environment. Imparting these competencies to students will contribute to the general aim of Building Oral Health Capacity (BOHC) in our health care delivery system.
GERD happens when a LES (lower esophageal sphincter) defect permits gastric acid reflux to the esophagus. The consequences and/or complications include: heartburn, cough (irritated throat, larynx, epiglottis), asthma (bronchial irritation), dental erosion, bad breath, bad tastes, and more serious, a precancerous condition known as Barrett’s Esophagus, and ultimately esophageal cancer. A careful oral examination, whether by physician or dentist, can provide the initial GERD diagnosis, which is key to preventing progressive illness. This exercise addresses key issues in the biochemistry, physiology, pharmacology, and management of gastric acidity. A clinical vignette, The Case of Gerdy Williams, unfolds along with these scientific issues.
This is a highly-constrained, student-centered, activity consisting of a take-home tutorial (instructional text, questions, detailed answers) on GERD and its scientific underpinnings plus a small-group activity in which instructors are to act as group facilitators—not purveyors of knowledge. The included student-resources (scientific content with clinical reference, study-questions, detailed answers) enable instructor-independent study at home. This “homework” prepares the student for small group activity. The instructor-resources (step-by-step session timeline, pre-written quizzes, answers, and listed learning issues) create conditions for productive, student-centered discussion that can be facilitated by non-expert faculty (group leaders). A novel 3-quiz paradigm, included in the session timeline, provides incentives for students to do each of three important things: (i) study at home so as to arrive prepared, (ii) share knowledge in the group discussion, and (iii) and profit from the discussion by actively engaging peers in thoughtful give and take.
King S. GERD: Gastroesophageal Reflux Disease: Role of Saliva & Gastric Acid in Digestion & Erosive Disorders Affecting Tooth, Stomach, and Esophagus . MedEdPORTAL; 2012. Available from: www.mededportal.org/publication/9266
- To define what GERD is and contrast it to silent-GERD.
- To describe the reversible and irreversible oral manifestations of GERD.
- To describe the common purpose of tooth and acid in the digestive process.
- To explain how the parietal cell makes HCl, and how this process is regulated.
- To describe the specializations that make the stomach more acid-resistant than the esophagus and how compromise of these protections will lead to disease.
- To explain non-medical interventions that a patient can use to ameliorate GERD symptoms.
- To describe medical treatments and interventions that a physician can recommend or perform to ameliorate gastric acidity and GERD symptoms.
- GERD (MeSH), Gastric Ulcer (MeSH), Digestion (MeSH), Stomach (MeSH), Esophagus (MeSH), Omeprazole (MeSH), Bisphosphonate, Helicobacter Pylori, Tooth Decay, Gastric Acid, Building Oral Health Capacity (BOHC) Collection
- Family Medicine
- Assessment, Diagnosis & Treatment
- Establishment & Maintenance of Oral Health
- Patient Care
- Medical Knowledge
- Patient Care
- Practice-based Learning & Improvement
- Basic Sciences
- Biochemistry/Cell Biology
- Clinical Sciences
- Clinical Skills/Doctoring
- Oral Health
- Gastrointestinal system
- Professional School
- Dental Student
- Medical Student
- Independent Study
- Team-based Learning
Authors & Co-Authors
Steven C. King, PhD
Oregon Health & Science University School of Medicine
Sponsorship or Funding Source
This project is sponsored in part by funding from the Health Resources and Services Administration/Maternal Child Health Bureau grant #U44MC20223.
Effectiveness and Significance
The exercise self-assesses. Students who struggle on the 1st quiz tend to perform measurably much better on the 3rd quiz—a gratifying outcome for student and instructor alike. On average, it is found that (i) the group performs better than the individual, and (ii) individuals perform 20 percent better on Quiz 3 than on Quiz 1. Students who truly struggled on Quiz 1 often perform several hundred percent better on Quiz 3. Thus, the 3-Quiz paradigm not only identifies struggling students, but goes the extra mile by measurably improving their knowledge in the short-term. Long-term retention is encouraged by writing midterm examination questions that focus precisely on weaknesses identified by quizzing (although this use of the midterm exam is not formally part of the exercise).
This unique student-centered exercise (on GERD, gastroesophageal reflux disease) does two important things: (i) it minimizes the instructor's traditional role as a purveyor of knowledge, and (ii) it evaluates its own effectiveness each time it is used. The learning experience begins with a self-contained take-home assignment that includes (i) knowledge content, (ii) multiple-choice questions to focus and self-evaluate on key issues, and (iii) narrative explanation of each multiple-choice. Next, the students break into small groups (6-8 students, and participate in a novel 3-quiz paradigm that is designed to keep the student intellectually engaged during three separate phases in the learning process: (i) during self-study at home, (ii) during small group discussion, and (iii) during evaluation (quizzing). Quiz 1 discriminates against the cohort of students that profit little from the take-home assignment (encourages engagement at home). Quiz 2 is a group effort that allows students to help one another with difficult content, and helps struggling students come up to speed. Quiz 3 encourages active engagement in the discussion, and evaluates session effectiveness by demonstrating the extent to which students know more than they did on Quiz 1. TYPICAL OUTCOME: On average, students perform about 20 percent better on Quiz 3 compared to Quiz 1. Importantly, students who accomplished little at home often perform several hundred percent better on Quiz 3—an outcome that is gratifying to the student and instructor alike, the latter feeling that he has made a difference for students that ordinary assessments would have identified as deficient without taking steps to ameliorate the deficiency.
Currently, we are in the midst of a global GERD epidemic. In 2000-2001, a US Ambulatory Medical Care Survey found that 22 percent of primary care visits were related to GERD in some way. GERD prevalence stands at 25 percent on a rising trend of 4 percent per year between 1995 and 2005. Understanding disorders that affect gastric acidity (e.g., GERD) is very much a multi-disciplinary enterprise. This exercise explores an array of basic science issues that underpin disorders of gastric acidity and their clinical management.
Special Implementation Guidelines or Requirements
1. Rooms for small group discussion are best, but with creativity this could be arranged in almost any setting.
2. Multiple-choice quizzes are easiest to process if scanning equipment is available to automatically score multiple choice.
1. Group Construction: make groups too small for anyone to become an anonymous non-participant (6-8 students). Try by some estimate to construct groups of equal academic talent.
2. Quiz Questions: Should be multiple-choice and similar to those in the take-home exercise—rewards studying the assignment. Quiz difficulty should be sufficient to create some disagreement as to correct answers—forms basis for discussion.
3. Instructor Role: Guard against lecturing, which destroys student-discussion. Instead, ask leading questions that you think will remind students about relevant content in the take-home exercise.
4. Democracy: it has no place in the group’s discussion of Quiz2 multiple-choice questions. Discourage students from casting aside logic and reason, selecting choice B because 4 out of 6 peers favor B. Remind students that the one person who knows he is correct should argue his case. It’s up to his peers to listen to good sense—if not they lose group points and will henceforth be more open to sensible minority opinions.
5. Answer-form economy: re-use the same scan forms all term. If today’s exercise used only 8 questions, students readily adapt to beginning the next session on question 9 in the scan-form answer sheet even though the first question begins with 1. If a separate scan-form answer sheet is provided for each quiz, then separate statistics will be available to compare outcomes of quizzes one, two, and three.
6. There would be no harm in encouraging group collaboration in preparation for quiz 1.
FAQs from FACULTY
Q: Wouldn’t it be better to engage students in a traditional “discussion” rather than employing this odd and highly-constraining, 3-Quiz regimen?
A: We have successfully employed traditional discussion sessions. However, the more multi-disciplinary and integrative a particular exercise became, the more problems we encountered with the traditional discussion format. The self-contained, student-driven nature of the GERD exercise solves many of these problems, allowing just about anyone to get students engaged in “integrated and/or multi-disciplinary” GERD exercise without the need to find faculty who feel equally comfortable with hydroxyapatite, omeprazole, urease, parietal cell regulation, and Barrett’s Esophagus. Here are examples of some fairly serious problems that we encountered.
A. Faculty Volunteerism. Would you volunteer to engage students with “talking point script” on some far-flung topic in somebody else’s area of expertise—say COSMOLOGY? Probably not. You would demand a highly-constrained structure that makes it safer for a non-expert to handle the session? Faculty discomfort is a pragmatic reality that one faces when a discrete exercise crosses many lines of expertise. Faculty volunteers have a need to feel safe—or they don’t volunteer.
B. Student Perceptions... the small groups are “not fair!” Why not? Because Dr. X’s discussion group was so much better... Dr. Y told us wrong in his discussion session, and Dr. X is an expert, and so... everyone in his group got the midterm question right, and we all got it wrong, and... it’s not fair!” This too is the pragmatic reality faced when a discrete exercise crosses many lines of expertise. Students need to feel that the different groups are reasonably equal, and strong constraints on instructor-input imposes this sense of group-to-group equality.
C. Can I get another copy of that? This is how the student tells his instructor that far from being well-prepared for today’s discussion, he has not even looked at the materials! So you ask, “Well how are you going to participate in the discussion then?” And he answers logically, “Well, nobody really spent much time on it since the instructors always go over it anyway.” Predictably the students are either silent, or make superficial stabs in the dark. Sensing doom, the non-cosmologist instructor (see A above) hatefully provides an inadequate cosmology lecture (problem B, above), and never again volunteers for something outside his comfort zone (problem A, above). Solution? The highly-constrained 3-Quiz paradigm takes a lot of heat off the reluctant, non-expert faculty who would otherwise be reluctant to volunteer in the numbers needed—for fear of being expected to lecture. There is absolutely no room for lecturing in this timeline—inherent safety for the reluctant instructor. NOTE: Since the take-home assignment is entirely self-contained, there is no actual need for a lecture, and students feel satisfied that all sessions are reasonably equal.
Q: How does the 3-Quiz paradigm enhance student-learning and participation?
A: The quizzes would be unnecessary if we had model students to whom we could productively say, “Please study the handout for small group discussion next week.” In practice, however, many students engage more completely at several different stages of the exercise when they have “points” on the line (3 quizzes)
1. Quiz1 provides incentive to study the handout (homework), and arrive prepared for discussion.
2. Quiz2 provides incentive to share relevant knowledge in discussion of Quiz1.
3. Quiz3 provides incentive to pay attention to peers, and learn from the peer discussion.
A related point is that the Quizzes need to be predictable—so that students are well-rewarded for diligent preparation and participation. The Quiz-like “look and feel” of the take-home tutorial enhances the predictability of what Quiz1 would be likely to cover.
Q: Why does the take-home exercise consist mainly of questions and answers rather than narrative?
A: The purpose of each question is to convey information to “Generation Y” students, who as a group do not value reading assignments, and tend to run their eyes passively across narrative pages, absorbing little. We have fought against this problem by letting the narrative masquerade as questions. The choices A-D typically present information in the same order in which one might discuss the topic if he were lecturing on it. And thinking about choice A helps the student understand choice B, which in turn helps to understand choice C, etc. Having paused to consider the choices, students are better able to extract information from the “answers” given in narrative form at the end of the exercise.
This information is made available under the Creative Commons license.