Climbing Bloom's taxonomy pyramid: Lessons from a graduate histology course

Transforming histology students from passive lecture listeners into active lecture learners

Traditional academic lectures have long been criticized as providing a passive learning environment to students. Often, they do not capture the audience's attention, resulting in learners being distracted or bored and thereby reducing their learning efficacy. Consequently, they are being abandoned by many schools and universities as an educational modus or modified into more learner-centered experiences. This descriptive article outlines a strategy of inserting active learning PowerPoint slides into traditional histology lectures. Suggestions and advice for adding or improving existing active learning slides are being offered to readers, who are planning to modify their own lecture presentations. The author's experience of using this formative assessment strategy with different types of histology learners is also discussed.

Early practice makes histology masters: The use of a formative assessment quiz to prepare histology learners for a high-stakes final examination

Assessment of learners in the anatomical sciences is a complex task as it not only tests students' fact knowledge, but also the analysis of visual information. Sometimes, novice histology learners must acquire image recognition skills of microscopic structures in a short time frame. This paper describes a strategy of offering first year dental students at the University of Michigan a short, non-grade contributing, formative assessment quiz in order to better prepare them for a high-stakes, final summative histology examination. Data collected over 7 years indicate that students, who made use of this formative assessment opportunity, performed significantly better in their summative examination than students, who did not. Especially early practice quiz users profited most. Students, who used the practice quiz until they achieved a perfect score, also had statistically higher final examination scores. Students, who did not use the practice quiz, had a significantly lower cumulative D1-year Grade Point Average (D1-GPA) than students, who did, indicating that academically weaker students often underuse supporting learning resources. In general, scores from the Dental Admission Test (DAT) were weak predictors of learning success in the DENT 510 histology course. In contrast, the D1-GPA values had a medium strength positive correlation with final histology examination scores. The major problem that was encountered with this practice quiz strategy was that many students waited until close to the day of the final examination before taking advantage of this feedback opportunity, thereby reducing its potential benefit for improving their overall learning strategy for histology.

Validating instructional design and predicting student performance in histology education: Using machine learning via virtual microscopy

As a part of modern technological environments, virtual microscopy enriches histological learning, with support from large institutional investments. However, existing literature does not supply empirical evidence of its role in improving pedagogy. Virtual microscopy provides fresh opportunities for investigating user behavior during the histology learning process, through digitized histological slides. This study establishes how students' perceptions and user behavior data can be processed and analyzed using machine learning algorithms. These also provide predictive data called learning analytics that enable predicting students' performance and behavior favorable for academic success. This information can be interpreted and used for validating instructional designs. Data on the perceptions, performances, and user behavior of 552 students enrolled in a histology course were collected from the virtual microscope, Cytomine®. These data were analyzed using an ensemble of machine learning algorithms, the extra-tree regression method, and predictive statistics. The predictive algorithms identified the most pertinent histological slides and descriptive tags, alongside 10 types of student behavior conducive to academic success. We used these data to validate our instructional design, and align the educational purpose, learning outcomes, and evaluation methods of digitized histological slides on Cytomine®. This model also predicts students' examination scores, with an error margin of <0.5 out of 20 points. The results empirically demonstrate the value of a digital learning environment for both students and teachers of histology.

Transfer of learning in histology: Insights from a longitudinal study

All anatomical educators hope that students apply past training to both similar and new tasks. This two-group longitudinal study investigated the development of such transfer of learning in a histology course. After 0, 10, and 20 sessions of the 10-week-long course, medical students completed theoretical tasks, examined histological slides trained in the course (retention task), and unfamiliar histological slides (transfer task). The results showed that students in the histology group gradually outperformed the control group in all tasks, especially in the second half of the course, η2  = 0.268 (p < 0.001). The best predictor of final transfer performance was students' retention performance after 10 sessions, β = 0.32 (p = 0.028), and theoretical knowledge after 20 sessions, β = 0.46 (p = 0.003). Results of eye tracking methodology further revealed that the histology group engaged in greater "visual activity" when solving transfer tasks, as indicated by an increase in the total fixation count, η2  = 0.103 (p = 0.014). This longitudinal study provides evidence that medical students can use what they learn in histology courses to solve unfamiliar problems but cautions that positive transfer effects develop relatively late in the course. Thus, course time and the complex relationship between theory, retention, and transfer holds critical implications for anatomical curricula seeking to foster the transfer of learning.

Chatbot responses suggest that hypothetical biology questions are harder than realistic ones

The biology education literature includes compelling assertions that unfamiliar problems are especially useful for revealing students' true understanding of biology. However, there is only limited evidence that such novel problems have different cognitive requirements than more familiar problems. Here, we sought additional evidence by using chatbots based on large language models as models of biology students. For human physiology and cell biology, we developed sets of realistic and hypothetical problems matched to the same lesson learning objectives (LLOs). Problems were considered hypothetical if (i) known biological entities (molecules and organs) were given atypical or counterfactual properties (redefinition) or (ii) fictitious biological entities were introduced (invention). Several chatbots scored significantly worse on hypothetical problems than on realistic problems, with scores declining by an average of 13%. Among hypothetical questions, redefinition questions appeared especially difficult, with many chatbots scoring as if guessing randomly. These results suggest that, for a given LLO, hypothetical problems may have different cognitive demands than realistic problems and may more accurately reveal students' ability to apply biology core concepts to diverse contexts. The Test Question Templates (TQT) framework, which explicitly connects LLOs with examples of assessment questions, can help educators generate problems that are challenging (due to their novelty), yet fair (due to their alignment with pre-specified LLOs). Finally, ChatGPT's rapid improvement toward expert-level answers suggests that future educators cannot reasonably expect to ignore or outwit chatbots but must do what we can to make assessments fair and equitable.

Designing a Massive Open Online Course (MOOC) in face-to-face sessions. A blended design to teach practical histology

Teaching histology, through virtual microscopy in educational strategies, undeniably moved towards the digitization and distancing of teaching. The setting up of the Massive Open Online Course (MOOC) entitled "Introduction to Histology: exploring the tissues of the human body" made it possible to exploit the potential to share digital resources with a wider audience while being integrated into the teaching on-campus students. This article described the pedagogical choices prevailing during the design of the MOOC and its combination with face-to-face sessions to achieve specific learning outcomes. The pedagogical alignment of learning outcomes described according to their cognitive levels, with online and face-to-face learning activities and evaluation methods has been demonstrated. The impact of such a blended design into an academic program has been ascertained using perception and performance data. Student satisfaction and engagement as well as motivational cues were identified. The level of performance was maintained in the educational strategy implemented and made it possible to achieve the objectives expected by the teachers. The benefits of integrating a MOOC with classroom-based teaching were highlighted, as well as barriers that could hinder the successful implementation.

Designing formative assessments to improve anatomy exam performance

Formative assessments are primarily used as a tool to gauge learning throughout an anatomy course. They have also been demonstrated to improve student mastery and exam performance, although the precise nature of this relationship is poorly understood. In this study, it is hypothesized that formative assessment questions targeting higher cognitive levels, integrating topics from multiple lessons, and including visuospatial elements will increase student exam performance. Formative and summative questions provided to students during the Clinical Anatomy block at the University of Arizona College of Medicine-Phoenix between 2015 and 2018 were assessed for cognitive level, integration of targeted learning objectives, and presence or absence of visuospatial elements. These variables were entered into a hierarchical linear model along with demographic variables for each cohort to assess the relationships between these variables and cohort performance on exam questions. The best predictor of exam performance was the inclusion of constituent learning objectives within the formative assessment. Additionally, students performed better on exam questions with visuospatial elements when the targeted learning objectives were also associated with visuospatial elements on the formative assessment. Surprisingly, the cognitive level of formative questions and the integration of learning objectives within them were not correlated with student exam performance. This study demonstrates the importance of including a broad range of topics in formative assessments and highlights a potential benefit of adopting consistent question formats for formative assessments and exams.

Histology as a paradigm for a science-based learning experience: Visits by histology education spirits of past, present, and future

The term "histology" was coined a little over 200 years ago and the subject has always relied on microscopy as its defining technology. Microscopy was and still is an essential approach for the description of cellular components and their arrangements in living organisms. For more than a century and a half, histology or microanatomy has also been part of the basic science education for biomedical students. Traditionally, it has been taught in two major components, a didactic transfer of information, either in a lecture or self-learning format, and in active-learning laboratory sessions. These two modes of histology instruction conform with the dual-processing theory of learning, one being more automatic and depending mainly on rote memorization, whereas the other is analytical, requiring more advanced reasoning skills. However, these two components of histology education are not separate and independent, but rather complementary and part of a multi-step learning process that encourages a scientific analysis of visual information and involves higher-level learning skills. Conventional, as well as modern electronic instruction methods (e-learning) have been used in complementary ways to support the integrated succession of individual learning steps as outlined in this manuscript. However, as recent curricular reforms have curtailed instructional time, this traditional format of teaching histology is no longer sustainable and a reflective reassessment of the role of histology in modern biomedical education is a timely necessity.

The Michigan Histology website as an example of a free anatomical resource serving learners and educators worldwide

With anatomical education becoming a global endeavor, free online resources offered via the Internet or other electronic venues are of increasing importance for teaching and learning communities worldwide. Students and instructors from developing countries, often limited in access to modern instructional resources by infrastructural and financial constraints, are frequent users of such online learning tools. During the recent Covid-19 pandemic when all academic institutions were forced to quickly switch to a non-contact mode of teaching, free online instructional resources were often essential for continuing the educational mission. However, there are a number of obstacles and issues that need to be considered when creating and offering such learning resources. These include the type, quality, and completeness of the content, their educational purpose, access to technical and financial resources, copyright and ethical issues, and more. Educators, who plan to generate and maintain free online resources, should also be aware that such projects usually require a considerable long-term time commitment. In this article, these issues are discussed using the Michigan Histology website as an example. The discussion also addresses how e-learning resources like the Michigan Histology website supported online learning during the recent Covid-19 pandemic.

Teaching Cellular Architecture: The Global Status of Histology Education

Histology or microanatomy is the science of the structure and function of tissues and organs in metazoic organisms at the cellular level. By definition, histology is dependent on a variety of microscope techniques, usually light or more recently virtual, as well as electron microscopy. Since its inception more than two centuries ago, histology has been an integral component of biomedical education, specifically for medical, dental, and veterinary students. Traditionally, histology has been taught in two sequential phases, first a didactic transfer of information to learners and secondly a laboratory segment in which students develop the skill of analyzing micrographic images. In this chapter, the authors provide an overview of how histology is currently taught in different global regions. This overview also outlines which educational strategies and technologies are used, and how the local and cultural environment influences the histology education of medical and other students in different countries and continents. Also discussed are current trends that change the teaching of this basic science subject.

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

For the last two centuries, the scholarly education of histology and pathology has been based on technology, initially on the availability of low-cost, high-quality light microscopes, and more recently on the introduction of computers and e-learning approaches to biomedical education. Consequently, virtual microscopy (VM) is replacing glass slides and the traditional light microscope as the main instruments of instruction in histology and pathology laboratories. However, as with most educational changes, there are advantages and disadvantages associated with a new technology. The use of VM for the teaching of histology and pathology requires an extensive infrastructure and the availability of computing devices to all learners, both posing a considerable financial strain on schools and students. Furthermore, there may be valid reasons for practicing healthcare professionals to maintain competency in using light microscopes. In addition, some educators may be reluctant to embrace new technologies. These are some of the reasons why the introduction of VM as an integral part of histology and pathology instruction has been globally uneven. This paper compares the teaching of histology and pathology using traditional or VM in five different countries and their adjacent regions, representing developed, as well as developing areas of the globe. We identify general and local roadblocks to the introduction of this still-emerging didactic technology and outline solutions for overcoming these barriers.

Integration of virtual microscopy podcasts in the histology discipline in osteopathic medical school: Learning outcomes

Virtual microscopy podcasts (VMPs) are narrative recordings of digital histology images. This study evaluated the outcomes of integrating the VMPs into teaching histology to osteopathic medical students. The hypothesis was that incorporating virtual microscopy podcasts as supplementary histology resources to the curriculum would have a positive impact on student performance and satisfaction. Sixty-one podcasts of dynamic microscopic images were created using screen recordings of the digital slides. The VMPs were integrated as supplementary histology resources in multiple courses during the first and second years of the medical curriculum for three classes, a total of 477 osteopathic medical students. A voluntary and anonymous survey was obtained from the students using a questionnaire that included two open-ended questions. The overall performance of the three classes on the histology content of the preclinical course examinations was compared to historical controls of the previous two classes that did not have access to the VMPs. Most students indicated that the podcasts enabled more efficient study time and improved their confidence in the histology content on examinations. The findings indicated a positive association between podcast viewing and efficient study time utilization and class performance. The class average scores of the three consecutive cohorts that used the VMPs progressively increased by 7.69%, 14.88%, and 14.91% compared to the controls. A summary of students' feedback and academic performance supported that integration of the VMPs into Histology teaching improved the learning experience. The findings align with previous studies on the effectiveness of multimedia-based teaching in histology laboratory modules.

Teaching Histology Using Self-Directed Learning Modules (SDLMs) in a Blended Approach

INTRODUCTION

New technologies like virtual microscopy have revolutionized histology education. However, first-year students often require additional assistance with virtual slides. Online self-directed learning modules (SDLMs) were developed to provide such support to learners by offering them short instructional videos that are uploaded to YouTube and the instructional website. The purpose of this study was to determine the effectiveness of SDLMs and to sample students' opinions about SDLMs.

METHOD

Over a 3-year time span, SDLMs were used to augment histology lessons, and their effectiveness (on learning outcomes) was measured by using traditional steeple-chase and/or virtual slide assessments. Average percentage scores for both methods of assessment were compared using paired or independent t-tests. Student opinions about SDLMs were collected using an anonymous survey. The survey results were analyzed by average scores and thematic analysis of the narrative responses.

RESULTS

Using SDLMs in a blended approach showed significant improvement in students' academic performance - irrespective of the method of assessment. There was a strong positive correlation with the performance when students were assessed using the virtual slide method. However, a standalone approach using SDLMs did not positively impact learning outcomes. Survey results indicated that most students perceived the videos as helpful for understanding the subject better and as quick review opportunities.

CONCLUSION

The results support the use of SDLMs in a blended instructional approach and as an adjunct resource to conventional microscopy. This use of SDLMs was positively received by learners and significantly improved the learning outcome.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01669-9.

Flipped anatomy classroom integrating multimodal digital resources shows positive influence upon students' experience and learning performance

Anatomy is shifting toward a greater focus on adopting digital delivery. To advance digital and authentic learning in anatomy, a flipped classroom model integrating multimodal digital resources and a multimedia group assignment was designed and implemented for first-year neuroanatomy and third-year regional anatomy curricula. A five-point Likert scale learning and teaching survey was conducted for a total of 145 undergraduate health science students to evaluate students' perception of the flipped classroom model and digital resources. This study revealed that over two-thirds of participants strongly agreed or agreed that the flipped classroom model helped their independent learning and understanding of difficult anatomy concepts. The response showed students consistently enjoyed their experience of using multimodal digital anatomy resources. Both first-year (75%) and third-year (88%) students strongly agreed or agreed that digital tools are very valuable and interactive for studying anatomy. Most students strongly agreed or agreed that digital anatomy tools increased their learning experience (~80%) and confidence (> 70%). The third-year students rated the value of digital anatomy tools significantly higher than the first-year students (p = 0.0038). A taxonomy-based assessment strategy revealed that the third-year students, but not the first-year, demonstrated improved performance in assessments relating to clinical application (p = 0.045). In summary, a flipped anatomy classroom integrating multimodal digital approaches exerted positive impact upon learning experience of both junior and senior students, the latter of whom demonstrated improved learning performance. This study extends the pedagogy innovation of flipped classroom teaching, which will advance future anatomy curriculum development, pertinent to post-pandemic education.

Histology education in an integrated, time-restricted medical curriculum: Academic outcomes and students' study adaptations

In an ever-changing medical curricular environment, time dedicated for anatomical education has been progressively reduced. This happened at the University of Michigan Medical School starting in 2016-2017 when preclinical medical education was condensed to one year. Histology instruction remained integrated in organ system courses but reduced to a lecture-only format without scheduling time for laboratory exercises, requiring students to study virtual histology slides on their own time. In accordance with the shortened instructional time, the number of histology examination questions was reduced more than twofold. This study analyzed students' histology examination results and assessed their motivation to learn histology and use of educational opportunities before and after these curricular changes were implemented. Students' motivation to learn histology and their evaluation of histology lectures increased in the new curriculum. However, students devoted less study time to studying histology. Students' cumulative histology examination scores were significantly lower in the new curriculum and the number of students with overall scores <75%, defined as a substandard performance, increased more than 15-fold. Academically weaker students' histology scores were disproportionately more affected. As medical educational strategies, priorities, and curricular frameworks continue to evolve, traditional didactic topics like histology will need to adapt to continue providing educational value to future health care providers.

Toward Identifying Sustainability Leadership Competencies: Insights from Mapping a Graduate Sustainability Education Curriculum

Graduate sustainability programs are tasked with educating and preparing the next generation of leaders to address the causes and effects of global climate change. As the urgency of addressing sustainability challenges like climate change has grown, including through higher education sustainability education, so has the attention on the competencies students ought to master to become sustainability leaders. Yet little is known about which sustainability leadership competencies are critical to bring about change or how curricula are addressing them. We used course descriptions from the University of Michigan’s School for Environment and Sustainability, to identify the sustainability leadership competencies targeted across its historically successful graduate curriculum, along with faculty members’ associated cognitive processing expectations following Bloom’s Taxonomy. The programs’ courses varied in the extent to which they addressed ten leadership competencies but were consistent in terms of associated cognitive processing expectations. We recommend that other sustainability education programs similarly examine their curricula and ensure that students regardless of their specializations have the opportunity to graduate with the knowledge, skills, and mindsets to affect change.

Shift to emergency remote preclinical medical education amidst the Covid-19 pandemic: A single-institution study

The Covid-19 pandemic disrupted medical education, shifting it towards emergency remote delivery. This cross-sectional study aimed to assess the impact of the pandemic on preclinical medical education and identify predictors of the virtual learning experience and perceived stress. An anonymous survey was delivered electronically to the students of the authors' medical school that attended either histology or pathology. This survey contained two scales, the virtual learning experience (VLE) and the perceived stress scale-10 (PSS-10). A total of 173/255 (68%) responded, showing a positive perception towards the remote delivery of both courses. An exploratory factor analysis was performed on the VLE scale items and four new dimensions were formed: "course quality and learning outcomes", "student motivation", virtual against F2F learning", and "virtual laboratory sessions". The following significant predictors of enhanced VLE, in at least one dimension, were identified: female gender, pathology course, final examination grade >80%, lower perceived stress levels, studying in home country, and holding of another degree before medical school. In addition, the following predictors were significantly associated with higher levels of student perceived stress: female gender, pathology course, studying away from home, and suboptimal internet connection. Notably, the quality of internet connection was significantly associated with the students' final examination performance. Concerning the best mode for future delivery of both courses, most students proposed a blended, rather than an entirely on-campus or online approach. In conclusion, despite its problems, a high-quality remote preclinical medical education was possible in the authors' school and offered tremendous opportunities for future improvement.

Considerations and strategies for effective online assessment with a focus on the biomedical sciences

The COVID-19 pandemic in 2020 caused many universities to rapidly transition into online learning and assessment. For many this created a marked shift in design of assessments in an attempt to counteract the lack of invigilation of examinations conducted online. While disruptive for both staff and students, this sudden change provided a much needed reconsideration of the purpose of assessment. This review considers the implications of transitioning to online assessment providing practical strategies for achieving authentic assessment of students online, while ensuring standards and accountability against professional accrediting body requirements. The case study presented demonstrates that an online multiple choice assessment provides similar rigor in assessment to invigilated examination of the same concepts in human physiology. Online assessment has the added benefit of enabling rapid and specific feedback to large cohorts of students on their personal performance, allowing students to target their weaker areas for remediation. This has implications for improving both pedagogy and efficiency in assessment of large cohorts where the default is often to assess basic recall knowledge in a multiple choice assessment. This review examines the key elements for implementation of online assessments including consideration of the role of assessment in teaching and learning, the rationale for online delivery, accessibility of the assessment from both a technical and equity perspective, academic integrity as well as the authenticity and structure of the assessment.

Training Radiology Residents, Bloom Style

Bloom's Taxonomy, an integral component of learning theory since its inception, describes cognitive skill levels in increasing complexity (Remember, Understand, Apply, Analyze, Evaluate, and Create). Considering Bloom's Taxonomy when writing learning objectives and lecture material, teaching residents at the workstation and creating multiple choice questions can increase an educator's effectiveness. The incorporation of higher Bloom levels aids in cultivating critical thinking skills vital to image interpretation and patient care, and becomes increasingly important as the radiologist's role evolves with the continued development of artificial intelligence. Following established tenets of multiple choice question writing, involving trainees in the question writing process, and incorporating audience response systems into lectures are all strategies in which higher Bloom level skills can be accomplished.

Examining Bloom's Taxonomy in Multiple Choice Questions: Students' Approach to Questions

BACKGROUND

Analytic thinking skills are important to the development of physicians. Therefore, educators and licensing boards utilize multiple-choice questions (MCQs) to assess these knowledge and skills. MCQs are written under two assumptions: that they can be written as higher or lower order according to Bloom's taxonomy, and students will perceive questions to be the same taxonomical level as intended. This study seeks to understand the students' approach to questions by analyzing differences in students' perception of the Bloom's level of MCQs in relation to their knowledge and confidence.

METHODS

A total of 137 students responded to practice endocrine MCQs. Participants indicated the answer to the question, their interpretation of it as higher or lower order, and the degree of confidence in their response to the question.

RESULTS

Although there was no significant association between students' average performance on the content and their question classification (higher or lower), individual students who were less confident in their answer were more than five times as likely (OR = 5.49) to identify a question as higher order than their more confident peers. Students who responded incorrectly to the MCQ were 4 times as likely to identify a question as higher order than their peers who responded correctly.

CONCLUSIONS

The results suggest that higher performing, more confident students rely on identifying patterns (even if the question was intended to be higher order). In contrast, less confident students engage in higher-order, analytic thinking even if the question is intended to be lower order. Better understanding of the processes through which students interpret MCQs will help us to better understand the development of clinical reasoning skills.

Higher-Order Assessment in Gross Anatomy: A Comparison of Performance on Higher- Versus Lower-Order Anatomy Questions between Undergraduate and First-Year Medical Students

Gross anatomy is considered by many the backbone of medical education. While learning anatomy has a reputation of requiring mainly rote memorization, modern day anatomy education often involves instruction and assessment at cognitive levels that foster higher-order thinking. In many instances, these higher-order anatomical concepts are taught to graduate students in healthcare-related fields, such as medicine. At this level, students are expected to apply and analyze anatomical information since that is what will ultimately be expected of them as professionals. In contrast, undergraduate anatomy education is typically more introductory in nature and often takes place in the setting of a large-enrollment course that serves as a prerequisite for many health sciences degree programs. In this study, variables related to the assessment of higher-order concepts in clinical anatomy were compared between first-year medical students and undergraduate students enrolled in an upper-level human gross anatomy course. Results demonstrate that undergraduate students perform lower than medical students overall, but the degree of difference in how they perform on higher- versus lower-order questions is comparable. The most notable exception is on practical examinations, where undergraduate students tend to struggle more with applying and analyzing information. Exploration of additional variables provides insight into how the cognitive level being assessed affects the time it takes to answer a question and how different practical examination question types and formats influence student performance. Findings presented in this study have implications for designing anatomy courses and underscore the importance of blueprinting assessments.

What faculty write versus what students see? Perspectives on multiple-choice questions using Bloom's taxonomy

BACKGROUND

Using revised Bloom's taxonomy, some medical educators assume they can write multiple choice questions (MCQs) that specifically assess higher (analyze, apply) versus lower-order (recall) learning. The purpose of this study was to determine whether three key stakeholder groups (students, faculty, and education assessment experts) assign MCQs the same higher- or lower-order level.

METHODS

In Phase 1, stakeholders' groups assigned 90 MCQs to Bloom's levels. In Phase 2, faculty wrote 25 MCQs specifically intended as higher- or lower-order. Then, 10 students assigned these questions to Bloom's levels.

RESULTS

In Phase 1, there was low interrater reliability within the student group (Krippendorf's alpha = 0.37), the faculty group (alpha = 0.37), and among three groups (alpha = 0.34) when assigning questions as higher- or lower-order. The assessment team alone had high interrater reliability (alpha = 0.90). In Phase 2, 63% of students agreed with the faculty as to whether the MCQs were higher- or lower-order. There was low agreement between paired faculty and student ratings (Cohen's Kappa range .098-.448, mean .256).

DISCUSSION

For many questions, faculty and students did not agree whether the questions were lower- or higher-order. While faculty may try to target specific levels of knowledge or clinical reasoning, students may approach the questions differently than intended.

Assessment Question Characteristics Predict Medical Student Performance in General Pathology

CONTEXT.—

Evaluation of medical curricula includes appraisal of student assessments in order to encourage deeper learning approaches. General pathology is our institution's 4-week, first-year course covering universal disease concepts (inflammation, neoplasia, etc).

OBJECTIVE.—

To compare types of assessment questions and determine which characteristics may predict student scores, degree of difficulty, and item discrimination.

DESIGN.—

Item-level analysis was employed to categorize questions along the following variables: type (multiple choice question or matching answer), presence of clinical vignette (if so, whether simple or complex), presence of specimen image, information depth (simple recall or interpretation), knowledge density (first or second order), Bloom taxonomy level (1-3), and, for the final, subject familiarity (repeated concept and, if so, whether verbatim).

RESULTS.—

Assessments comprised 3 quizzes and 1 final exam (total 125 questions), scored during a 3-year period (total 417 students) for a total 52 125 graded attempts. Overall, 44 890 attempts (86.1%) were correct. In multivariate analysis, question type emerged as the most significant predictor of student performance, degree of difficulty, and item discrimination, with multiple choice questions being significantly associated with lower mean scores (P = .004) and higher degree of difficulty (P = .02), but also, paradoxically, poorer discrimination (P = .002). The presence of a specimen image was significantly associated with better discrimination (P = .04), and questions requiring data interpretation (versus simple recall) were significantly associated with lower mean scores (P = .003) and a higher degree of difficulty (P = .046).

CONCLUSIONS.—

Assessments in medical education should comprise combinations of questions with various characteristics in order to encourage better student performance, but also obtain optimal degrees of difficulty and levels of item discrimination.

A Web-Based Virtual Microscopy Platform for Improving Academic Performance in Histology and Pathology Laboratory Courses: A Pilot Study

Virtual microscopy (VM) has been utilized to improve students' learning experience in microscope laboratory sessions, but minimal attention has been given to determining how to use VM more effectively. The study examined the influence of VM on academic performance and teacher and student perceptions and compared laboratory test scores before and after VM incorporation. A total of 662 third-year students studying histology and 651 fourth-year students studying pathology were divided into two groups. The light microscopy (LM) group used a light microscope in 2014 and 2015, while the LM + VM group used the VM platform and a light microscope in 2016 and 2017. Four factors positively predict laboratory scores (R square, 0.323; P < 0.001): (i) the pathology course and test-enhanced learning, (ii) the VM platform and experience, (iii) medical students and lecture scores, and (iv) female students. The LM + VM group exhibited less score variability on laboratory examinations relative to their mean than the LM group. The LM + VM group was also associated with fewer failing grades (F grade; odds ratio, 0.336; P < 0.001) and higher scores (A grade; odds ratio, 2.084; P < 0.001) after controlling for sex, school, course, and lecture grades. The positive effect of the VM platform on laboratory test grades was associated with prior experience using the VM platform and was synergistic with more interim tests. Both teachers and students agreed that the VM platform enhanced laboratory learning. The incorporation of the VM platform in the context of test-enhanced learning may help more students to master microscopic laboratory content.

How students choose E-learning resources: The importance of ease, familiarity, and convenience

Electronic learning resources are popular with today's students. However, how students choose their favorite e-learning resources is not well-understood. The popular SecondLook TM histology self-review tool was offered in three different interfaces to students participating in two histology courses (Cell and Developmental Biology [CDB] 450/550 and DENT 510). These interfaces included PowerPoint files, an online website, and a mobile application (app). Identical in content, each interface had specific advantages and disadvantages with respect to compatible devices, user features, and access limitations. Upon the conclusion of the courses, students were surveyed about their interface preference, reasons for their selection, and general usage of the SecondLook TM resource. With a 91.4% overall survey participation rate, only 3 out of 213 participating students never used the resource. Many students (46.3% CDB 450/550, 62.9% DENT 510) tried only one interface, with PowerPoint being the most popular final choice (56.5% CBD 450/550, 65.7% DENT 510). Although the interactive website and mobile app offered additional user-friendly features, they only garnered between 16% and 24% final popularity. "Convenience," "larger screen," and "easy to use" were most often reported as reasons for students' interface preference. The accessibility of where and when the SecondLook TM resource can be used was also frequently cited. This availability encouraged some students to forgo other learning resources and to use the mobile app in distractive environments. The results of this study suggest that today's students are in fact less motivated to seek out high-tech e-learning resources than commonly believed and instead often select interfaces with which they are already familiar.

Inclusion of MCQs written by radiology residents in their annual evaluation: innovative method to enhance resident's empowerment?

AIM

We hypothesized that multiple-choice questions written by radiology residents (MCQ^resident) for their weekly case presentations during radiology staff meetings could be used along with multiple-choice questions written by radiology teachers (MCQ^teacher) for their annual evaluation. The current prospective study aimed at determining the educational characteristics of MCQ^resident and at comparing them with those of MCQ^teacher.

METHODS

Fifty-one radiology residents of the first to the fifth year of training took the 2017 exam that contained 58 MCQ^resident and 63 of MCQ^teacher. The difficulty index, the discrimination power, and the distractor's quality were calculated in the two series of MCQs and were compared by using Student t test. Two radiologists classified each MCQ according to Bloom's taxonomy and frequencies of required skills of both MCQ series were compared.

RESULTS

The mean ± SD difficulty index of MCQ^resident was statistically significantly higher than that of MCQ^teacher (0.81 ± 0.1 vs 0.64 ± 0.2; p < 0.0001). The mean ± SD discrimination index of MCQ^resident was statistically significantly higher than that of MCQ^teacher (0.34 ± 0.2 vs 0.23 ± 0.2; p = 0.0007). The mean number of non-functional distractors per MCQ^resident was statistically significantly higher than that per MCQ^teacher (1.36 ± 0.9 vs 0.86 ± 0.9; p = 0.0031). MCQ^resident required recalling skills more frequently than MCQ^teacher which required more advanced skills to obtain a correct answer.

CONCLUSIONS

Educational characteristics of MCQ^resident differ from those of MCQ^teacher. This study highlights the characteristics to optimize the writing of MCQs by radiology residents.

Overcoming Barriers in a Traditional Medical Education System by the Stepwise, Evidence-Based Introduction of a Modern Learning Technology

INTRODUCTION

Histology teaching in India and in other developing countries has not changed much over the past decades and has not joined the global movement of using virtual microscopy (VM). Many factors may have contributed to this academic inertia-including curricular requirements for traditional microscopy (TM) skills, assessments that are heavily based on TM, and unfamiliarity with modern technology among faculty, as well as infrastructural shortcomings. This study is aimed at overcoming these roadblocks by using a blended approach combining VM with TM in a tradition-centered curricular setting.

METHODS

For validation of this approach, the authors conducted a non-randomized controlled trial with a crossover design on first year medical students at the Government Medical College, Thiruvananthapuram, India. Examination scores and responses of a student group taught with VM as an adjunct to TM were compared with a student group taught with TM only.

RESULTS

The test group had significantly better results when compared to the control group for knowledge-based tests (p = 0.012; analysis of co-variance) and for an unannounced visual-based test conducted 1 month later (p = 0.001; Mann-Whitney U test). Feedback collected from students showed highly favorable responses to the use of VM for teaching histology.

CONCLUSION

This study should encourage Indian medical colleges and schools in other developing countries to start using VM as a supplementary approach for their histology education programs. Furthermore, as the Medical Council of India recommends the introduction of new competency-based integrated curriculum in India starting in 2019, the use of VM may facilitate more effective learning in the new scenario.

TRIAL REGISTRATION

CTRI/2018/04/012928.

Development of a short and universal learning self-efficacy scale for clinical skills

Background

Learning self-efficacy, defined as learners’ confidence in their capability to learn specific subjects, is crucial for the enhancement of academic progress, because it is positively correlated with academic achievements and effective learning strategy use. In this study, we developed a universal scale called the Learning Self-Efficacy Scale (L-SES) for Clinical Skills for undergraduate medical students and validated it through item analysis and content validity index (CVI) calculation.

Design

The L-SES was developed based on the framework of Bloom’s taxonomy, and the questions were generated through expert consensus and CVI calculation. A pilot version of the L-SES was administered to 235 medical students attending a basic clinical skills course. The collected data were then examined through item analysis.

Results

The first draft of the L-SES comprised 15 questions. After expert consensus and CVI calculation, 3 questions were eliminated; hence, the pilot version comprised 12 questions. The CVI values of the 12 questions were between .88 and 1, indicating high content validity. Moreover, the item analysis indicated that the quality of L-SES reached the qualified threshold. The results showed that the L-SES scores were unaffected by gender (t = −0.049; 95% confidence interval [−.115, .109], p > .05).

Conclusion

The L-SES is a short, well-developed scale that can serve as a generic assessment tool for measuring medical students’ learning self-efficacy for clinical skills. Moreover, the L-SES is unaffected by gender differences. However, additional analyses in relevant educational settings are needed.

A gross anatomy flipped classroom effects performance, retention, and higher-level thinking in lower performing students

A flipped classroom is a growing pedagogy in higher education. Many research studies on the flipped classroom have focused on student outcomes, with the results being positive or inconclusive. A few studies have analyzed confounding variables, such as student's previous achievement, or the impact of a flipped classroom on long-term retention and knowledge transfer. In the present study, students in a Doctor of Physical Therapy program in a traditional style lecture of gross anatomy (n = 105) were compared to similar students in a flipped classroom (n = 112). Overall, students in the flipped anatomy classroom had an increase in semester average grades (P = 0.01) and performance on higher-level analytical questions (P < 0.001). Long-term retention and knowledge transfer was analyzed in a subsequent semester's sequenced kinesiology course, with students from the flipped anatomy classroom performing at a higher level in kinesiology (P < 0.05). Student's pre-matriculation grade point average was also considered. Previously lower performing students, when in a flipped anatomy class, outperformed their traditional anatomy class counterparts in anatomy semester grades (P < 0.05), accuracy on higher-level analytical anatomy multiple-choice questions (P < 0.05) and performance in subsequent course of kinesiology (P < 0.05). This study suggests that the flipped classroom may benefit lower performing student's knowledge acquisition and transfer to a greater degree than higher performing students. Future studies should explore the underlying reasons for improvement in lower performing students.

Role of comprehension on performance at higher levels of Bloom's taxonomy: Findings from assessments of healthcare professional students

The first four levels of Bloom's taxonomy were used to create quiz questions designed to assess student learning of the gross anatomy, histology, and physiology of the gastrointestinal (GI) system. Information on GI histology and physiology was presented to separate samples of medical, dental, and podiatry students in computer based tutorials where the information from the two disciplines was presented either separately or in an integrated fashion. All students were taught GI gross anatomy prior to this study by course faculty as part of the required curriculum of their respective program. Student responses to the quiz questions were analyzed to assess both the validity of Bloom's cumulative hierarchy and the effectiveness of an integrated curriculum. No statistically significant differences were found between quiz scores from students who received the integrated tutorial and from those who received the separate tutorials. Multiple regression analyses provided partial support for a cumulative hierarchy where scores on the lower levels of Bloom's taxonomy predicted scores on higher levels. Notably, in the majority of regression analyses, the comprehension score was the key foundational predictor for application and analysis scores. This study supports the suggestion that educators increase the number of comprehension level questions, even at the expense of knowledge level questions, in course assessments both to evaluate lower order cognitive skills and also as a predictor of success on questions requiring application and analysis levels of the higher order cognitive skills of Bloom's taxonomy. Anat Sci Educ 11: 433-444. © 2018 American Association of Anatomists.

Pushing Critical Thinking Skills With Multiple-Choice Questions: Does Bloom's Taxonomy Work?

Medical school assessments should foster the development of higher-order thinking skills to support clinical reasoning and a solid foundation of knowledge. Multiple-choice questions (MCQs) are commonly used to assess student learning, and well-written MCQs can support learner engagement in higher levels of cognitive reasoning such as application or synthesis of knowledge. Bloom's taxonomy has been used to identify MCQs that assess students' critical thinking skills, with evidence suggesting that higher-order MCQs support a deeper conceptual understanding of scientific process skills. Similarly, clinical practice also requires learners to develop higher-order thinking skills that include all of Bloom's levels. Faculty question writers and examinees may approach the same material differently based on varying levels of knowledge and expertise, and these differences can influence the cognitive levels being measured by MCQs. Consequently, faculty question writers may perceive that certain MCQs require higher-order thinking skills to process the question, whereas examinees may only need to employ lower-order thinking skills to render a correct response. Likewise, seemingly lower-order questions may actually require higher-order thinking skills to respond correctly. In this Perspective, the authors describe some of the cognitive processes examinees use to respond to MCQs. The authors propose that various factors affect both the question writer and examinee's interaction with test material and subsequent cognitive processes necessary to answer a question.

Construction and validation of a distance Basic Life Support Course

ABSTRACT Objective: to describe the content construction and validation process of the Distance Education Basic Life Support Course. Method: methodological study, developed through literature review, outlined in the light of the Bloom's Taxonomy and Ausubel's Meaningful Learning Theory. For validation, the analysis was performed with judges, using a structured tool. Results: the construction of the distance course was complex and challenging, since it was tried to develop it with logical-methodological coherence, considering the constructivist perspective, representing an advance in the process of dissemination of the Urgency and Emergency teaching culture. As for the content validation process, it was verified that of the 16 suggestions made by the judges, 14 were accepted and two rejected. Conclusion: the course had its contents validated by experts.