Success of the EIS and the Case Study Method

Karen Starko writes: Even though I am a former EIS officer I am still amazed by the many successes of the EIS that Mark Pendergrast so clearly details in Inside the Outbreaks, The Elite Medical Detectives of the Epidemic Intelligence Service. As I reflect on the outbreaks and epidemics described in the book and my own experience, I realize that the case study method employed in the training course and the two-year hands-on program plays a critical role in the success of the EIS program.

Picture this: young doctors, nurses, veterinarians, and other health professionals, many barely out of school, come to Atlanta for a three week introductory course in the basics of epidemiology and statistics (for many their first exposure to epidemiologic methods!) During this course they are presented with previous disease outbreaks (cases), actively participate in "figuring out who dun it" or, more formally, determining time, place, person, and (hopefully) cause, and, according to Steve Thacker and colleagues at the CDC, develop "epidemiologic judgment--the reasoning process that indicates when they have sufficient data on which to make public health decisions."(American Journal of Epidemiology Vol. 154, No. 11: 985-992 â¨Copyright © 2001)

The officers then go to their assignments in the real world to find and struggle with serious disease problems and make sense of them as leaders or members of a team where the outcome of their work is truly important, in fact, the outcome may mean life or death.

The success of the case study method of learning is evidenced by the many discoveries that resulted from the EIS officers' investigations described in Pendergrast's book. While the EIS is surely not the first to employ the case study method, it is likely one of the most successful. The case study method has long had proponents. John Dewey in Democracy in Action in 1915 noted: "...careful inspection of methods which are permanently successful in formal education...go back to the type of situation which causes reflection out of school in ordinary life...they give the pupil something to do, not something to learn, and the doing is of such a nature as to demand thinking."

Pendergrast's book is filled with examples of public health problems that demanded both structured and creative thinking when they occurred and he presents many just as they did when they actually happened.

Page 14: Harold Nitowsky, 26, was in remote Trinidad, Colorado, in the summer of 1952, where he was investigating a typhoid epidemic...typhoid causes a rash, tender spleen, high fever, slow pulse, nausea, and diarrhea, the symptoms of six people who had eaten at a local church potluck supper. Nitowsky contacted everyone who had attended the dinner, asking them to recall what they had eaten. He made a chart with the different food and drink items running down a page on the left, and two columns marked ILL and NOT ILL at the top. Basically, this was a modified form of what epidemiologists call a 2 x 2 table...

Page 95: In Douglas, Georgia, children in three successive families who lived in a modest cinderblock home had contracted leukemia.

Page 164: On Monday, August 2, the members of the EIS class of 1976 reported for their first day of duty. At 8:45 a.m., new EIS officer Bob Craven's phone rang in his cubicle in the war room for the National Influenza Immunization Program. "OK, so it's apparently pneumonia. Four dead? 26 more are ill?" His voice rose with every phrase. "And they were all at the convention?" Craven was taking notes furiously. "Please get details and call back as soon as you can."

Page 204: An epidemic broke out in Spain in the first week of May 1981. By the end of the year, it would put over 13,000 people in the hospital, killing 314 of them. It was first recognized in Madrid, where 140 people sought help for respiratory distress within a week. Patients did not respond to antibiotics and soon developed eosinophilia, an abnormally high number of a type of white blood cell...

Page 262: In October 1989, normally athletic Bonnie Bishop, 39, could barely walk into her doctor's office in Santa Fe, New Mexico. A blood test revealed an extremely high level of eosinophils, white blood cells produced by the immune system to fight disease. Her doctor, suspecting cancer, referred her to William Blevins, an oncologist. She became so weak and bloated with fluids that she had to be hospitalized. An operation drained over a gallon of fluid from her body, but there were no tumors, and exploratory biopsies revealed no leukemia. Within a few days, Blevins learned of two other New Mexico women with similar symptoms and eosinophil counts.

Working up cases whether in the classroom using real outbreaks and epidemics as Pendergrast describes or in person demands knowledge, creativity, judgment, and stamina, characteristics difficult to develop during rote classroom learning. All professional students can benefit by exposure to the case study method in the classroom (Inside the Outbreaks is a wonderful place to learn about many interesting and once puzzling cases) and also that additional benefit for students and their communities can be derived from participation in solving real-life current disease problems.

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