Cognition before curriculum: rethinking the integration of basic science and clinical learning

Exploration of the integration of microbiology and immunology emerging topics into undergraduate medical education

PURPOSE

Medical school educators face challenges determining which new and emerging topics to incorporate into medical school curricula, and how to do so. A study was conducted to gain a better understanding of the integration of emerging topics related to microbiology and immunology in the undergraduate medical curriculum (UME).

METHODS

An anonymous survey with 17 questions was emailed to medical school faculty who teach immunology and/or microbiology through the DR-Ed listserv, the American Society for Microbiology (ASM) Connect listserv, and attendees of the Association of Medical School Microbiology and Immunology Chairs (AMSMIC) Educational Strategies Workshop. Participants were asked about experiences, perceptions, and the decision-making process regarding integrating emerging topics into UME.

RESULTS

The top emerging topics that were added to the curriculum or considered for addition in the last 10 years included COVID-19, Zika virus, mRNA vaccines, and Mpox (formerly known as monkeypox). Most respondents reported lectures and active learning as the major methods for topic delivery, with most faculty indicating that formative assessment was the best way to assess emerging topics. Content experts and course directors were the most cited individuals making these decisions. Top reasons for incorporating emerging topics into curricula included preparing students for clinical treatment of cases, followed by demonstrating the importance of basic science, and opportunities to integrate basic science into other disciplines. Challenges for incorporating these topics included making room in an already crowded curriculum, followed by content overload for students.

CONCLUSIONS

This study describes the rationale for integrating emerging topics related to microbiology and immunology into UME, and identifies the current new and emerging topics, as well as the main methods of integration and assessment. These results may be used by medical educators to inform curricular decisions at their institutions. Future studies will include developing innovative learning modules that overcome barriers to integration.

A novel model for curriculum design: Preparation, planning, prototyping, and piloting

Dental education continuously strives to provide students with positive and meaningful learning experiences. Developing or improving a curriculum usually encompasses three main phases: design, implementation, and evaluation. Most research on curriculum development in dental education has focused on the last two phases. Our commentary addresses this gap by describing a new model for curriculum design that effectively guided the design phase of the complete overhaul of the four-year Doctor of Dental Surgery curriculum at the School of Dentistry, University of Alberta. Built on the strengths of pre-existing curriculum design models, the new model provided enough structure and rigour to support the complexity required during a complete curriculum redesign whilst still allowing sufficient consultation and flexibility to encourage stakeholder engagement. The steps of the new 4P's model (preparation, planning, prototyping, and piloting) and main actions within each step are described. Challenges observed in each step and strategies to address them are reported. Other institutions embarking on renewing or redesigning a curriculum at a program level may benefit from using a curriculum design process similar to the 4P's model. Recommendations are discussed including the inclusion of educational consultants in the curriculum renewal committee, the importance of a leadership that effectively supports curriculum reform, purposeful engagement of stakeholders during each step of the design phase and ensuring that project and change management occur concurrently.

Learning pathways composed of core subjects with features of reducing cognitive load have better learning outcomes

BACKGROUND

Changing the course duration or timing of subjects in learning pathways would influence medical students' learning outcomes. Curriculum designers need to consider the strategy of reducing cognitive load and evaluate it continuously. Our institution underwent gradual curricular changes characterized by reducing cognitive load since 2000. Therefore, we wanted to explore the impact of this strategy on our previous cohorts.

METHODS

This cohort study explored learning pathways across academic years of more than a decade since 2000. Eight hundred eighty-two medical students between 2006 and 2012 were included eventually. Learning outcomes included an average and individual scores of subjects in different stages. Core subjects were identified as those where changes in duration or timing would influence learning outcomes and constitute different learning pathways. We examined whether the promising learning pathway defined as the pathway with the most features of reducing cognitive load has higher learning outcomes than other learning pathways in the exploring dataset. The relationship between features and learning outcomes was validated by learning pathways selected in the remaining dataset.

RESULTS

We found nine core subjects, constituting four different learning pathways. Two features of extended course duration and increased proximity between core subjects of basic science and clinical medicine were identified in the promising learning pathway 2012, which also had the highest learning outcomes. Other pathways had some of the features, and pathway 2006 without such features had the lowest learning outcomes. The relationship between higher learning outcomes and cognitive load-reducing features was validated by comparing learning outcomes in two pathways with and without similar features of the promising learning pathway.

CONCLUSION

An approach to finding a promising learning pathway facilitating students' learning outcomes was validated. Curricular designers may implement similar design to explore the promising learning pathway while considering potential confounding factors, including students, medical educators, and learning design of the course.

A critical interpretive synthesis of interprofessional education interventions

Interprofessional practice can look quite different depending on a number of dynamics. Interprofessional education interventions may or may not orient toward this range of practice possibilities. This literature review explores: (1) how interprofessional education interventions relate to different kinds of interprofessional practice and (2) the range of interprofessional practices assumed by interprofessional education interventions. Four databases were searched for articles published between 2011-2021 describing pre-licensure level interprofessional education interventions, resulting in a dataset of 110 articles. Our analysis involved (1) descriptive summaries of the articles, and (2) content analysis of the rationale and description of the intervention. Of the articles, 93% (102/110) of interprofessional education interventions were designed and/or evaluated using the concept of interprofessional education competencies. "Teamwork" was the most relied upon competency. Most articles were not explicit about the different kinds of interprofessional practices that these competencies might be oriented toward. Our study substantiates earlier claims that interprofessional education literature tends to focus on competencies and orient toward undifferentiated understandings of "teamwork." This analysis is particularly important as interprofessional teams are engaging in increasingly complex, fluid, and distributed forms of interprofessional practice that may not be captured in an undifferentiated approach to "teamwork."

Using a boundary crossing lens to understand basic science educator and clinical educator collaboration in instructional design

PURPOSE

Collaborations between basic science educators (BE) and clinical educators (CE) in medical education are common and necessary to create integrated learning materials. However, few studies describe experiences of or processes used by educators engaged in interdisciplinary teamwork. We use the lens of boundary crossing to explore processes described by BE and CE that support the co-creation of integrated learning materials, and the impact that this work has on them.

MATERIALS AND METHODS

We conducted qualitative content analysis on program evaluation data from 27 BE and CE who worked on 12 teams as part of a multi-institutional instructional design project.

RESULTS

BE and CE productively engaged in collaboration using boundary crossing mechanisms. These included respecting diverse perspectives and expertise and finding efficient processes for completing shared work that allow BE and CE to build on each other's contributions. BE and CE developed confidence in connecting clinical concepts with causal explanations, and willingness to engage in and support such collaborations at their own institutions.

CONCLUSIONS

BE and CE report the use of boundary crossing mechanisms that support collaboration in instructional design. Such practices could be harnessed in future collaborations between BE and CE.

The 6 degrees of curriculum integration in medical education in the United States

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the health professions education audience. We further believe that health professions education is ready to move beyond "horizontal" (one-dimensional) and "vertical" (two-dimensional) integration and propose a model of "six degrees of curriculum integration" to expand the two-dimensional concept for future designs of health professions programs and best prepare learners to meet the needs of patients. These six degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond two-dimensional integration to best prepare physicians of the future.

Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation

BACKGROUND

Mixed reality offers potential educational advantages in the delivery of clinical teaching. Holographic artefacts can be rendered within a shared learning environment using devices such as the Microsoft HoloLens 2. In addition to facilitating remote access to clinical events, mixed reality may provide a means of sharing mental models, including the vertical and horizontal integration of curricular elements at the bedside. This study aimed to evaluate the feasibility of delivering clinical tutorials using the Microsoft HoloLens 2 and the learning efficacy achieved.

METHODS

Following receipt of institutional ethical approval, tutorials on preoperative anaesthetic history taking and upper airway examination were facilitated by a tutor who wore the HoloLens device. The tutor interacted face to face with a patient and two-way audio-visual interaction was facilitated using the HoloLens 2 and Microsoft Teams with groups of students who were located in a separate tutorial room. Holographic functions were employed by the tutor. The tutor completed the System Usability Scale, the tutor, technical facilitator, patients, and students provided quantitative and qualitative feedback, and three students participated in semi-structured feedback interviews. Students completed pre- and post-tutorial, and end-of-year examinations on the tutorial topics.

RESULTS

Twelve patients and 78 students participated across 12 separate tutorials. Five students did not complete the examinations and were excluded from efficacy calculations. Student feedback contained 90 positive comments, including the technology's ability to broadcast the tutor's point-of-vision, and 62 negative comments, where students noted issues with the audio-visual quality, and concerns that the tutorial was not as beneficial as traditional in-person clinical tutorials. The technology and tutorial structure were viewed favourably by the tutor, facilitator and patients. Significant improvement was observed between students' pre- and post-tutorial MCQ scores (mean 59.2% Vs 84.7%, p < 0.001).

CONCLUSIONS

This study demonstrates the feasibility of using the HoloLens 2 to facilitate remote bedside tutorials which incorporate holographic learning artefacts. Students' examination performance supports substantial learning of the tutorial topics. The tutorial structure was agreeable to students, patients and tutor. Our results support the feasibility of offering effective clinical teaching and learning opportunities using the HoloLens 2. However, the technical limitations and costs of the device are significant, and further research is required to assess the effectiveness of this tutorial format against in-person tutorials before wider roll out of this technology can be recommended as a result of this study.

An early-curricular team learning activity to foster integration of biochemical concepts and clinical sciences in undergraduate medical education

The ability to connect key concepts of biochemistry with clinical presentations is essential for the development of clinical reasoning skills and adaptive expertise in medical trainees. To support the integration of foundational and clinical sciences in our undergraduate health science curricula, we developed a small group active learning exercise during which interprofessional groups of students use clinical cases to explore the biochemistry, diagnostic strategy, and evidence-based treatment options of inborn errors of metabolism (IEM). We designed multistage learning modules consisting of (1.) low-fidelity case simulations of pediatric patients presenting with IEMs, (2.) guided group discussions on clinical biochemistry, differential diagnoses, and diagnostic strategies, (3.) oral presentations of clinical reasoning strategies, and (4.) discussion of relevant evidence-based medicine topics related to the cases. These modules Scientific Knowledge Integrated in Patient Presentations (SKIPPs) were added to a first-semester foundational sciences course serving five health professions programs. The assessment of learning outcomes by students and faculty shows that SKIPPs sessions are well-received activities that significantly improve trainees' ability to integrate foundational science concepts into clinical scenarios, to practice interprofessional teamwork and to develop clinical reasoning skills.

Use of Clinically Oriented Laboratory Manuals in a Prosection Gross Anatomy Laboratory during COVID-19

Gross anatomy is a critical course for the development of a variety of skills such as anatomical knowledge and spatial, critical, and clinical reasoning. There have been few attempts to integrate clinical applications in gross anatomy, with the majority of these being in the lecture hall and not in the laboratory. Clinical cases and guided questions were added to a laboratory manual (Clinically Oriented Laboratory Manuals (COLMs)) in a first-year medical gross anatomy prosection course during COVID-19. The effectiveness of the COLMs was analyzed using in-laboratory assessments between treatment and control groups, as well as student perceptions. There was no significant difference between in-lab assessment scores between students with or without the COLMs in 2020 (t1304.735= 0.647, p ;= 0.518). Student perceptions demonstrated that 61.6% strongly agreed or agreed that the COLMs were a good way to learn anatomy and 32.0% desired more COLMs in the lab. Overall, COLMs did not increase student knowledge by the end of a session. Students thought the COLMs were a good tool to learn anatomy because they helped become more clinically aware; however, students desired better implementation of the COLMs. The addition of COLMs in the laboratory is a potential method to address the need for clinical applications within the gross anatomy laboratory.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01970-1.

Professional Identity Formation of Medical Science Educators: An Imperative for Academic Medicine

Medical schools increasingly seek the expertise of talented medical science faculty to engage in the educational mission of the school; yet, the professional identity of these individuals is in flux. As courses and departments have become more integrated and less discipline-based, faculty with doctorates in biomedical science disciplines who primarily teach may suffer a loss of connection to their discipline, either in the courses they are teaching or in their home departments. Recent reports suggest that most medical science educators transitioned from the laboratory to the classroom by happenstance-not the most ideal way to build this key segment of the faculty. This article addresses the importance of foundational sciences in medical training, highlights the unique contributions of science educators in medical schools, and makes a case for why the professional identity of medical science educators should be studied. An imperative for academic medicine is to understand the factors that underpin the professional identity formation of medical science educators and to invest in training and nurturing this group of faculty members that are vital to educating the next generation of health professionals.

Integrating basic sciences into clerkship rotation utilizing Kern's six-step model of instructional design: lessons learned

BACKGROUND

It is generally agreed that basic and clinical sciences should be integrated throughout the undergraduate medical education, however, there is still need for continued formal integration of basic sciences into clinical clerkship in many medical schools across the globe.

METHODS

Utilizing Kern's Six-Step Model of Instructional Design, we aimed to develop an intervention that would facilitate cognitive integration of basic and clinical sciences. After problem identification and targeted needs assessment through focused group discussion with the students and faculty, objectives were devised with an implementation plan of using flipped class approach to develop a content-focused and learner-centered teaching strategy. This intervention was piloted in the 2-week cardiology clerkship in Year 5. Evaluation of the content, integration, student and faculty experiences were recorded through in-depth interviews, FGDs and a formative MCQ test.

RESULTS

Flipped classroom based integrated sessions were successfully developed. The implementation phase was met with challenges that primarily stemmed from the diverse teaching styles among faculty members, hesitance to deviate from conventional practices, variations in clinic timings, and demanding schedules. Noteworthy observations were in terms of ownership of the project, the need for faculty development in modern student-centered teaching pedagogies, opportunities for content improvement, scheduling of sessions, and suggestion of revisiting fundamental concepts in basic sciences through a brief boot camp-style session at the onset of the clerkship. The role of flipped case model and clinical cases in integrating basic sciences into clinical sciences were appreciated by the students. Standardization in teaching practices was identified as the major challenge by the faculty.

CONCLUSIONS

A functional, learner-centered framework of cognitive integration of basic sciences in clinical sciences curriculum of cardiology rotation was developed with a potential to be implemented in other clerkship rotations.

Short-Term Training with Basic Science Research Literature Advances Medical Students' Skills for Adaptive Expertise

Physicians must adapt their learning and expertise to the rapid evolution of healthcare. To train for the innovation-efficient demands of adaptive expertise, medical students need to acquire the skill of adaptive self-regulated learning, which includes accessing, interpreting, and synthesizing emerging basic and translational research to support patient care. In response, we developed the course Medical Student Grand Rounds (MSGR). It engages all pre-clerkship students at our institution with self-regulated learning from translational basic research literature. In this report, we describe MSGR's methodology and important outcomes. Students found, interpreted, critically assessed, and presented basic research literature about self-selected clinically relevant topics. In less than one semester and mentored by basic science researchers, they completed eight milestones: (a) search research literature databases; (b) choose a clinical topic using searching skills; (c) outline the topic's background; (d) outline a presentation based on the topic's mechanistic research literature; (e) attend translational research-oriented grand rounds by faculty; (f) learn to prepare oral presentations; (g) write an abstract; and (h) present at Grand Rounds Day, emphasizing their topic's research literature. Graded milestones and end-of-course self-assessments indicated students became proficient in interpreting research articles, preparing and delivering presentations, understanding links among basic and translational research and clinical applications, and pursuing self-regulated learning. Qualitative analysis of self-assessment surveys found most students thought they progressed toward the learning objectives: find scientific information about a research topic (56% positive responses), interpret and critically assess scientific information (64%), and prepare and deliver a scientific presentation (50%). Milestones improve time management and provide a scaffolded method for presenting focused research topics. MSGR equips students with critical thinking skills for lifelong, adaptive, self-regulated learning-a foundation for adaptive expertise. The master adaptive learner cycle of planning, learning, assessing, and adjusting is a conceptual framework for understanding students' MSGR learning experiences.

Use of Virtual Interactive Patient Encounters to Prepare First-Year Medical Students for Clinical Practice

PROBLEM

With the dissolution of the Step 2 Clinical Skills exam, medical programs have a greater responsibility to teach and assess clinical skills in the preclerkship years. Clinical teaching this early has traditionally been avoided because of insufficient integration with biomedical sciences, curricular time constraints, and concerns about overwhelming novice learners with clinical learning objectives. To overcome these barriers, the authors created a clinical framework for the biomedical science curriculum by integrating a series of virtual interactive patient (VIP) videos.

APPROACH

Matriculating first-year medical students were enrolled in a clinically integrated biomedical science course that used VIP videos to teach and assess clinical skills. The VIP videos were enhanced with interactive pop-in windows, and at the conclusion of each video, students performed a clinical documentation task and received immediate feedback. The authors implemented 7 VIP cases during fall 2021 in which first-year medical students wrote the patient care plan, problem representation statement, or clinical reasoning assessment. Student responses were independently evaluated by course faculty using a 4-level scoring scale. The authors calculated the pooled mean scores for each documentation task and examined student feedback.

OUTCOMES

Seven VIP encounters were assigned to 124 students (mean response rate, 98.5%). Pooled mean scores on the clinical documentation tasks showed that most students were able to achieve levels 3 or 4 when writing the patient care plan (97 [82%] to 113 [94%]), addressing social determinants of health (80 [67%]), writing an accurate problem representation statement (113 [91%] to 117 [94%]), and performing clinical reasoning skills (48 [40%] to 95 [82%]).

NEXT STEPS

VIP encounters were feasible to produce, effective at integrating course content, successful at assessing student clinical documentation skills, and well received. The authors will continue to produce, implement, and study the VIP as an integrating learning tool in undergraduate medical education.

Structure and function: how to design integrated anatomy and physiology modules for the gross anatomy laboratory

Physicians must be able to integrate knowledge across disciplines. Therefore, educators need to provide opportunities for students to cognitively integrate information across the medical school curriculum. Literature has shown that specifically pointing out these connections helps students create cause and effect models and ultimately improve their performance. The gross anatomy laboratory provides an excellent environment for students to integrate information by establishing structure and function relationships. This article presents simple steps to create modules which help students cognitively integrate physiology and anatomy at the session level in the gross anatomy laboratory. Driven by backward design, these steps include establishing objectives, creating assessments, and developing activities that can be implemented in a specific learning environment. An example of a flexible module which could be implemented in a number of gross anatomy lab settings (e.g., prosection, dissection, models, virtual) is presented along with a template for the design of future modules. This is followed by a discussion of challenges encountered by educators attempting to integrate structure and function in the gross anatomy lab. Each of these considerations will be addressed with potential solutions for educators seeking to implement these types of integrated activities.

Connecting Biochemistry Knowledge to Patient Care in the Clinical Workplace: Senior Medical Students' Perceptions about Facilitators and Barriers

Phenomenon: Medical students have difficulties applying knowledge about biomedical mechanisms learned before clerkships to patient care activities. Many studies frame this challenge as a problem of basic science knowledge transfer predominantly influenced by students' individual cognitive processes. Social cognitive theory would support extending this framing to the interplay between the individual's cognition, the environment, and their behaviors. This study investigates senior medical students' experiences of biochemistry knowledge use during workplace learning and examines how their experiences were influenced by interactions with people and other elements of the clinical learning environment. Approach: The authors used a qualitative approach with a constructivist orientation. From September to November 2020 they conducted semi-structured interviews with 11 fourth-year medical students at one institution who had completed the pre-clerkship curriculum, core clinical clerkships, and the United States Medical Licensing Exam Step 1. The authors identified themes using thematic analysis. Findings: Participants reported that they infrequently used or connected to biochemistry knowledge in workplace patient care activities, yet all had examples of such connections that they found valuable to learning. Most participants felt the responsibility for making connections between biochemistry knowledge and activities in the clinical workplace should be shared between themselves and supervisors, but connections were often recognized and acted on only by the student. Connections that participants described prompted their effort to retrieve knowledge or fill a perceived learning gap. Participants identified multiple barriers and facilitators to connecting, including supervisors' behaviors and perceived knowledge, and "patients seen" in clerkships. Participants also reported learning biochemistry during USMLE Step 1 study that did not connect to patient care activities, underscoring a perception of disconnect. Insights: This study identifies specific personal, social, and physical environmental elements that influence students' perceived use of biochemistry during patient care activities. Though these findings may be most significant for biochemistry, they likely extend to other basic science disciplines. Students' self-directed efforts to connect to their biochemistry knowledge could be augmented by increased social support from clinical supervisors, which in turn likely requires faculty development. Opportunities for connection could be enhanced by embedding into the environment instructional strategies or technologies that build on known authentic connections between biochemistry and "patients seen" in clerkships. These efforts could strengthen student learning, improve clinical supervisors' self-efficacy, and better inform curriculum design.

Integrating Foundational and Clinical Science Remotely by Combining Team-Based Learning and Simulation

Integrating foundational and clinical science in medical and other professional healthcare degree programs has been well established as a means to enhance learning. However, implementation remains challenging, and a significant gap exists in guidance for non-professional degree programs to effectively accomplish both types of integration. Additionally, many modalities described in the literature are resource-intensive, scale poorly to larger groups, and are widely inaccessible. We present an online modality combining team-based learning and a simulation-based learning experience that fosters vertical and horizontal integration of physiology, pharmacology, and clinical science. The tools utilized include a vital sign simulator, video conferencing software, and a document-sharing platform. The activity demonstrated improved knowledge comparing pre- and posttests and evidence that the activity helped students integrate physiology, pharmacology, and clinical medicine. The novel structure is effective and accessible, uses open-source software and standard equipment available to most undergraduate and graduate faculty, and is adaptable to in-person, hybrid-remote, and fully remote delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01817-9.

Integration of physiology in a curriculum on human structure: a snapshot of the cardiovascular block

With the gradual shift from discipline-based to competency-based medical education, the integrated curriculum has become a popular model for connecting basic science and clinical content in undergraduate medical education. Despite its popularity, there are concerns that important physiological concepts are not adequately addressed. We describe the spiral integration of physiology content in the 5-week Cardiovascular block of our Homeostasis course at the Zucker School of Medicine. We also describe our approach to incorporating physiology into an integrated, constructed response, short-answer assessment format. Our approach to spiral integration consists of rotating lab stations that highlight the distinction between normal and abnormal states, linked with appropriate clinical interventions. Physiology is at the core of integration in any curriculum and the basis of all applied fields of medicine, hence our approach is that teaching structural relationships would not be valuable without consideration of its functions, which can then be utilized in discussion of clinical presentations, imaging, and relevant pathologies. Likewise, our integrated assessments require the students to compose their answers to the questions from scratch, which creates a shift in mode of students' preparation from rote memorizations to more cognitive processing that enhances critical thinking.

Integration of respiratory physiology and clinical reasoning in the early years of a medical curriculum: engaging with students in a large classroom setting

Medical graduates are expected to apply scientific principles and explain the processes underlying common and important diseases. Evidence shows that integrated medical curricula, which deliver biomedical science within the context of clinical cases, facilitate student learning in preparation for practice. However, research has also shown that the student's perception of their knowledge can be lower in integrated compared to traditional courses. Thus the development of teaching methods to support both integrated learning and build student confidence in clinical reasoning is a priority. In this study, we describe the use of an audience response system to support active learning in large classes. Sessions, delivered by medical faculty from both academic and clinical backgrounds, were designed to build on the knowledge of the respiratory system in both health and disease through the interpretation of clinical cases. Results showed that student engagement was high throughout the session and students strongly agreed that the application of knowledge to real-life cases was a better way to understand clinical reasoning. Qualitative free text comments revealed that students liked the link between theory and practice and the active, integrated method of learning. In summary, this study describes a relatively simple but highly effective way of delivering integrated medical science teaching, in this case respiratory medicine, to improve student confidence in clinical reasoning. This educational approach was applied within the early years of the curriculum in preparation for teaching within a hospital setting, but the format could be applied across many different settings.NEW & NOTEWORTHY The development of teaching methods that support integrated learning and build student confidence is a priority. An audience response system was used to engage early year medical students in large classes in preparation for teaching within a hospital setting. Results showed high levels of student engagement and a greater appreciation for the link between theory and practice. This study describes a simple, active, and integrated method of learning that improves student confidence in clinical reasoning.

Students' Perspectives on Basic and Clinical Science Integration When Step 1 is Administered After the Core Clerkships

Phenomenon: According to adult learning theories, effective cognitive integration of basic and clinical science may promote the transfer of knowledge to patient care. The placement of the U.S. Medical Licensing Examination (USMLE) Step 1 after the core clerkships is one strategy intended to facilitate cognitive integration, though learner experiences with this model are unexplored. The purpose of this study is to understand students' perspectives on basic and clinical science integration in a post-clerkship Step 1 curriculum. Approach: Focus groups were conducted between August and September 2020 with senior medical students from the University of California, San Francisco School of Medicine and University of Michigan Medical School. Data were analyzed using a constructivist approach to thematic analysis. Findings: Thirty-three students participated in six focus groups. Participants described multiple barriers to cognitive integration in the clerkship learning environment, though they also identified examples of teaching and learning that facilitated integration. Early in their clerkships, students struggled to integrate because of their tenuous basic science foundation, cognitive overload, and difficulty perceiving the relevance of basic science to patient care. They felt that educators primarily focused on clinical science, and many basic science teaching sessions during clerkships felt irrelevant to patient care. However, students also described experiences that made the connection between basic and clinical science more explicit, including modeling by educators and clerkship learning activities that more overtly encouraged the application of basic science to clinical care. In addition, the return to basic science studying during the post-clerkship dedicated Step 1 study period offered powerful integration opportunities. These facilitators of cognitive integration helped students recognize the value of integration for enduring learning. Insights: There are myriad barriers to cognitive integration of basic and clinical science during clerkships in a post-clerkship Step 1 curriculum. The relevance of basic science to patient care needs to be made more explicit to students through modeling by clinician educators to augment the potential benefits of curricular change. The post-clerkship Step 1 study period appears to offer a unique opportunity for cognitive integration later in a learner's trajectory that may be related to curricular design. When learners recognize the applicability of basic science to patient care, they may more intentionally transfer basic science knowledge to clinical practice.

Does Gender, Academic Status, Years of Teaching Experience, and Discipline Affiliation Affect Strategies Used to Promote Creativity in Medical Education at King Abdulaziz University?

Background This study aimed to explore the effect of gender, academic status, years of teaching experience, and discipline affiliation on strategies used to promote creativity in medical education. Methodology This study was conducted in the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. Faculty teaching in both the basic sciences and clinical disciplines was included. A 15-item electronic survey was created. The frequencies were obtained for the demographic and academic characteristics of the participants. For each question (Q5-Q15), the mean and SD of participant responses were obtained. The chi-square test was used to compare all categorical variables. This included the comparison of the participants' demographic characteristics with their academic characteristics. The chi-square test was also used for the comparison of participant characteristics among the categorical questions (Q5-Q15). Results A statistically significant association was determined between academic status, years of teaching experience, faculty's perception of the curriculum, tasks used in teaching, and the suitability of the used assessment strategies in promoting creativity. Teaching in clinical disciplines was statistically associated with using real-life problems, challenging students, and deliberately creating chaos or disorder in the classroom. Conclusions Academic status, years of teaching experience, and discipline affiliation are more likely to affect how faculty members promote creativity in medical education.

Adaptive Expertise in Undergraduate Pharmacy Education

Pharmacy educators are grappling with concerns around curriculum overload and core pharmacist competencies in a rapidly changing and increasingly complex healthcare landscape. Adaptive expertise provides a conceptual framework to guide educators as they design instructional activities that can support students on their journey towards becoming pharmacists who can perform procedural tasks efficiently, as well as creatively handle new and difficult-to-anticipate problems that arise regularly in pharmacy practice. This article explores undergraduate pharmacy education through a cognitive psychology lens and foregrounds three instructional design strategies which support the development of adaptive expertise: (1) cognitive integration, (2) productive failure, and (3) inventing with contrasting cases. These three evidence-based strategies cultivate long-term learning and provide a practical mechanism to combat curriculum overload and backwards-facing assessments. Pharmacy education can encourage the development of procedural and conceptual knowledge and position pharmacy students to excel as they move into more complicated and ambiguous roles in our healthcare system.

How Medical Students Apply Their Biomedical Science Knowledge to Patient Care in the Family Medicine Clerkship

Medical students enter clerkships with the requisite biomedical science knowledge to engage in supervised patient care. While poised to apply this knowledge, students face the cognitive challenge of transfer: applying knowledge learned in one context (i.e., preclinical classroom) to solve problems in a different context (i.e., patients in the clinic). To help students navigate this challenge, a structured reflection exercise was developed using Kolb's experiential learning cycle as an organizing framework. Students selected a patient encounter (concrete experience), wrote and addressed biomedical science learning objectives related to the care of the patient (reflective observation), reflected on how addressing the learning objectives influenced patient care (abstract conceptualization), and described their attending engaging in a similar process (active experimentation). A directed content analysis of students' written reflections revealed that most students wrote clinical science learning objectives in addition to biomedical science learning objectives. When viewed through the lenses of knowledge encapsulation theory and illness script theory, some students recognized knowledge encapsulation as a process beginning to occur in their own approach and their attendings' approach to clinical reasoning. Students readily applied their biomedical science knowledge to explain the pathophysiologic basis of disease (fault illness script domain) and signs and symptoms (consequence illness script domain), with fewer addressing predisposing conditions (enabling conditions illness script domain). Instances in which students observed their attending applying biomedical science knowledge were rare. Implications for using structured reflective writing as a tool to facilitate student application of their biomedical science knowledge in clerkships are discussed.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01697-5.

Development and Implementation of a Medical School Course Integrating Basic, Clinical, and Health Systems Sciences

OBJECTIVE

In recent years, significant steps have been made in integrating basic science and clinical medicine. There remains a gap in adding the third pillar of education: health systems science (HSS). Core clerkships represent an ideal learning venue to integrate all three. Students can experience the value of integrating basic science as they learn clinical medicine in environments where HSS is occurring all around them.

METHODS

We outline the creation of Sciences and Art of Medicine Integrated (SAMI), a course that runs parallel with the clerkship year and integrates basic science and HSS with clinical medicine. A complete description of the planning and implementation of SAMI is provided. We include the participants and educational setting, the goals and objectives, and the structure of each session. To encourage the integration of basic science, HSS, and clinical medicine, students utilize a series of tools, described in detail. Examples of each tool are provided utilizing a case of a patient presenting with obstructive sleep apnea.

RESULTS

We successfully implemented this course with positive reception from students.

CONCLUSION

This course represents a step not only toward the integration of HSS with basic science and clinical medicine but also an advancement in training future clinicians to provide high-value care. Future curricular development must consider the validation of a measure of clinical reasoning that assesses a student's ability to think in a cognitively integrated fashion about basic science, HSS, and clinical medicine demonstrated by enhanced justification of clinical reasoning and a more holistic approach to planning patient care.

Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society

Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward critically reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally-whether alone or together-requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Educating for adaptive expertise: case examples along the medical education continuum

Adaptive expertise represents the combination of both efficient problem-solving for clinical encounters with known solutions, as well as the ability to learn and innovate when faced with a novel challenge. Fostering adaptive expertise requires careful approaches to instructional design to emphasize deeper, more effortful learning. These teaching strategies are time-intensive, effortful, and challenging to implement in health professions education curricula. The authors are educators whose missions encompass the medical education continuum, from undergraduate through to organizational learning. Each has grappled with how to promote adaptive expertise development in their context. They describe themes drawn from educational experiences at these various learner levels to illustrate strategies that may be used to cultivate adaptive expertise.At Vanderbilt University School of Medicine, a restructuring of the medical school curriculum provided multiple opportunities to use specific curricular strategies to foster adaptive expertise development. The advantage for students in terms of future learning had to be rationalized against assessments that are more short-term in nature. In a consortium of emergency medicine residency programs, a diversity of instructional approaches was deployed to foster adaptive expertise within complex clinical learning environments. Here the value of adaptive expertise approaches must be balanced with the efficiency imperative in clinical care. At Mayo Clinic, an existing continuous professional development program was used to orient the entire organization towards an adaptive expertise mindset, with each individual making a contribution to the shift.The different contexts illustrate both the flexibility of the adaptive expertise conceptualization and the need to customize the educational approach to the developmental stage of the learner. In particular, an important benefit of teaching to adaptive expertise is the opportunity to influence individual professional identity formation to ensure that clinicians of the future value deeper, more effortful learning strategies throughout their careers.

Development and evaluation of an online integrative histology module: simple design, low-cost, and improves pathology self-efficacy

Integration of core concepts is an important aspect of medical curriculum enhancement. Challenges to improving integration include the risk of curtailing the basic sciences in the process and the push to decrease contact hours in medical curricula. Self-paced learning tools can be developed that deliberately relate basic and clinical sciences to aid students in making interdisciplinary connections. The purpose of this project was to develop, implement, and evaluate a self-paced learning module that would be applicable to integration of different disciplines in medical education. The module was intended to improve integration between histology and anatomic pathology before a respiratory pathology laboratory session. Qualtrics XM, a survey software commonly available at educational institutions, was used in a novel manner to create the module. Module activities included pre- and post-module quizzes; four short videos emphasizing normal histological features and recalling associated pathologies; three categorization activities designed for students to recognize normal versus abnormal characteristics of lung specimens; and post-activity feedback. Preliminary data from first-year medical students showed that post-module quiz scores were significantly higher than pre-module quiz scores (p < 0.001) and that module users' pre-laboratory pathology self-efficacy was significantly higher than non-users (p < 0.05). These data suggest that module use facilitated short-term knowledge gain and improved pathology self-efficacy before the laboratory session. Online modules can be developed affordably using Qualtrics XM to integrate anatomical sciences with other disciplines, while providing students interactive learning resources without increasing contact hours. The module presented in this report focused on normal versus abnormal morphology, guiding students through recognizing the continuum from healthy to disease states before learning about the pathologies more in depth. A similar module design would likely be effective in integrating other disciplines in medicine, especially in disciplines that require recognition of changes in morphology.

Beyond the tensions within transfer theories: implications for adaptive expertise in the health professions

Ensuring trainees develop the flexibility with their knowledge to address novel problems, and to efficiently build upon prior knowledge to learn new knowledge is a common goal in health profession education. How trainees come to develop this capacity to transfer and transform knowledge across contexts can be described by adaptive expertise, which focuses on the ability of some experts to innovate upon their existing knowledge to develop novel solutions to novel problems. While adaptive expertise is often presented as an alternative framework to more traditional cognitivist and constructivist expertise models, it is unclear whether the non-routine and routine forms of transfer it describes are distinct from those described by other accounts of transfer. Furthermore, whether what (e.g., knowledge) is transferred and how (e.g., cognitive processes) differs between these views is still debated. In this review, we describe various theories of transfer and present a synthesis clarifying the relationship between transfer and adaptive expertise. Informed by our analysis, we argue that the mechanisms of transfer in adaptive expertise share important commonalities with traditional accounts of transfer, which when understood, can complement efforts by educators and researchers to foster and study adaptive expertise. We present three instructional principles that may better support transfer and adaptive expertise in trainees: i) identifying and incorporating meaningful variability in practice, ii) integrating conceptual knowledge during practice iii) using assessments of trainees' transfer. Taken together, we offer an integrative perspective to how educational systems and experiences can be designed to develop and encourage adaptive expertise and transfer.

Advanced Integrated Science Courses: Building a Skill Set to Engage With the Interface of Research and Medicine

Scientific research has been changing medical practice at an increasing pace. To keep up with this change, physicians of the future will need to be lifelong learners with the skills to engage with emerging science and translate it into clinical care. How medical schools can best prepare students for ongoing scientific change remains unclear. Adding to the challenge is reduced time allocated to basic science in curricula and rapid expansion of relevant scientific fields. A return to science with greater depth after clinical clerkships has been suggested, although few schools have adopted such curricula and implementation can present challenges. The authors describe an innovation at Harvard Medical School, the Advanced Integrated Science Courses (AISCs), which are taken after core clerkships. Students are required to take 2 such courses, which are offered in a variety of topics. Rather than factual content, the learning objectives are a set of generalizable skills to enable students to critically evaluate emerging research and its relationship to medical practice. Making these generalizable skills the defining principle of the courses has several important advantages: it allows standardization of acquired skills to be combined with diverse course topics ranging from basic to translational and population sciences; students can choose courses and projects aligned with their interests, thereby enhancing engagement, curiosity, and career relevance; schools can tailor course offerings to the interests of local faculty; and the generalizable skills delineate a unique purpose of these courses within the overall medical school curriculum. For the 3 years AISCs have been offered, students rated the courses highly and reported learning the intended skill set effectively. The AISC concept addresses the challenge of preparing students for this era of rapidly expanding science and should be readily adaptable to other medical schools.

A small‐group activity to enhance learning of cardiovascular drugs for health science students

This small‐group activity provides two cases in cardiovascular pharmacology to engage students in a medical or other health professions curriculum. The goal of this activity is to apply students' basic knowledge of physiology and pharmacology to clinical case scenarios. Students were provided with the cases 1 week in advance and were encouraged to use their lecture notes and/or other references of their choosing to answer as many of the questions as possible and prepare to discuss the answers with their classmates at the session. Facilitators were provided with detailed notes and a video that explain the answers and provide suggestions for engaging and challenging the students. For the 2021 academic year, 201 students (139 first‐year medical students and 62 second‐year pharmacy students) at UC San Diego participated in the small‐group activity. Eighteen facilitators were recruited to lead this 110‐min session. Students' performance was assessed on the final exam of their integrated cardiovascular physiology‐pharmacology course. Students achieved 84% (SD 17.54) on questions related to the small‐group session compared to 78% (SD 15.60) on other cardiovascular pharmacology questions not related to the activity. Student perceptions of the facilitators leading the small‐group activity were very positive (average of 4.7 on a 5‐point Likert Scale). Using this approach, we demonstrate that a small‐group activity with clinical scenarios helps students master the pharmacology content related to cardiovascular drugs. The small‐group activity included constructed response questions to foster conceptual understanding.

Problem representation and diagnostic accuracy during an OSCE

PURPOSE

The National Academy of Medicine has called for "identifying opportunities to improve the diagnostic process". We studied the association between problem representation and diagnostic accuracy during an objective structured clinical exam (OSCE).

MATERIALS AND METHODS

We conducted a non-randomized controlled trial during a ten-case OSCE. We measured whether a summary statement prompt increased the likelihood that the student listed the correct diagnosis and whether better summary statements were correlated with diagnostic accuracy.

RESULTS

114 students provided 1135 responses. The non-prompted control group yielded 631 responses, listing the correct diagnosis first 73% of the time and within the top three slots 85% of the time. The intervention group exposed to the prompt yielded 453 responses listing the correct diagnosis first 72% of the time (P = 0.617) and within the top three slots 84% of the time (P = 0.760). Summary statements were scored on a 0, 0.5, or 1 rubric. When grouped according to summary statement score, students listed the correct diagnosis first 74%, 70%, and 72% of the time respectively (P = 0.666). The correct diagnosis was included within the top three slots 88%, 82%, and 83% of the time (P = 0.238).

CONCLUSIONS

Prompting students to form a summary statement did not improve diagnostic accuracy. Better summary statements were not correlated with diagnostic accuracy.

Transfer of anatomy during surgical clerkships: an exploratory study of a student-staff partnership

OBJECTIVES

This qualitative study aims to explore how fourth-year medical students on the surgery course perceived a clinical anatomy workshop organised by near-peer student teachers in partnership with faculty.

METHODS

Forty-seven medical students participated in a workshop on clinical anatomy in the dissection laboratory. A voluntary response sampling method was used. The students' perceptions of the workshop were explored through a thematic content analysis of transcribed, semi-structured group interviews and written comments.

RESULTS

A majority of the students had not revisited the dissection laboratory since their second year, and all students described the workshop as a unique opportunity to vertically integrate anatomical knowledge. Four main themes were identified as most valuable for the students' learning experience, namely that the workshop 1) was taught by knowledgeable and friendly near-peer tutors (NPTs), 2) consisted of highly relevant anatomical content, 3) offered a hands-on experience of cadavers in the dissection laboratory, and 4) was taught in a focused session in the middle of the surgery course.

CONCLUSIONS

 This study shows how hands-on workshops in clinical anatomy, developed in student-staff partnerships and taught by NPTs, can enable senior medical students to recall and vertically integrate anatomical knowledge during surgical clerkships. The results have implications for curriculum design, giving voice to senior students' wishes for spaced repetition and vertical integration of pre-clinical anatomy knowledge during their clinical training. Moreover, this study may inspire other students and faculty to develop similar near-peer teaching activities through student-staff partnerships.

"What is the mechanism?": Cues, barriers, and opportunities to discuss foundational science during internal medicine rounds

BACKGROUND

Repeated application of foundational science (FS) during medical reasoning results in encapsulation of knowledge needed to develop clinical expertise. Despite proven benefit of educating learners using a FS framework to anchor clinical decision making, how FS is integrated on clinical rotations has not been well characterized. This study examines how and when FS discussion occurs on internal medicine teaching rounds.

MATERIAL AND METHODS

We performed a convergent mixed method study. Six internal medicine teams at a quaternary hospital were observed during rounds and team members interviewed. Transcripts were analyzed using thematic analysis. Descriptive statistics provided a summary of the observations.

RESULTS

Our study revealed that rounds used a teacher-centered model where FS knowledge was transmitted as pearls external to the clinical context. FS content arose primarily when the patient was complex. Barriers preventing FS discussion were lack of time and perceived lack of personal FS knowledge.

CONCLUSION

Our study describes scenarios that commonly elicit discussion of FS on inpatient medicine rounds highlighting a 'transmission' model of FS knowledge. We suggest a learner-centered model that engages students in the practice of integrating FS into clinical reasoning.

Closing the Integration Gap: A Pilot for Incorporating Foundational Sciences, DEI-Decision Making, Empathy, and Communication for Congestive Heart Failure and Arrhythmia Management by Pharmacy Students

Pharmacists must integrate foundational sciences with pharmacy practice for providing optimal patient care. Pharmacy students need to be trained to provide culturally competent, linguistically accessible, and empathetic care while integrating foundational science principles. However, such holistic integration is challenging to achieve and assess. To bridge this gap, we implemented and assessed an “integrated cardiovascular simulation” (ICS) module for P2 students, employing case-based and team-based learning. ICS focused on congestive heart failure with preexisting arrhythmia and incorporated patient counseling relating to diversity factors such as cultural competency, linguistic challenges, and the impact of population diversity on cardiac diseases. Students learned the SBAR communication technique (situation, background, assessment, and recommendation) and recommended therapy while elaborating on drug MOA and adverse effects. ICS was assessed through pre-and post-session quizzes and perception data immediately after the activity, and after two years, when students progressed to the cardiovascular APPE block. Student performance improved on a post-test (80.2%) compared to the pre-test (66.9%), p < 0.01 paired student t-test, with an increase in symptom and arrhythmia pattern recognition (41.2% and 36.7%, respectively). ICS was effective for teaching (1) arrhythmia pathophysiology (85%), (2) EKG interpretation (89%), (3) drug adverse effects (93%), (4) DEI-clinical decision making (92%), and (5) communication skills (85%).

Applying activity theory to undergraduate medical curriculum reform: Lessons in contradictions from multiple stakeholders' perspectives

PURPOSE

Medical school curricula require regular updating. We adopted an activity theory lens to conduct a holistic, multiple stakeholder-informed analysis of curricular reform, aiming to understand how the social relations between groups contribute to unanticipated tensions and outcomes.

METHODS

A research assistant conducted semi-structured interviews with purposively sampled (N = 19) administrative staff, faculty course leads, faculty tutors, curriculum developers, change leaders and student leaders. The team applied a framework analysis to guide within and between stakeholder comparisons.

RESULTS

Participants reported unique (N = 21) and cross-cutting (N = 17) contradictions underscoring emerging drivers of current and potential change. Unique contradictions raised by 1-2 groups represented seeds of change that had the potential to spread across all groups. By contrast, two general types of cross-cutting contradictions arose when one group had a dominant, confirming voice or two or more groups had contrasting perspectives.

CONCLUSIONS

While finding contradictions was expected, our analysis profiled their nature and some of the specific tensions they raised across and within stakeholder groups. The activity theory lens provided an accessible way to unravel curricular reform into manageable units of analysis. Systematically identifying contradictions arising from curricular reform will help stakeholders collaborate with a shared purpose toward positive, sustained change.

Seeing is Believing: Inclusion of Biomedical Scientist Educators as Observers on Clinical Rounds

Increasingly, medical school curricula seek to integrate the biomedical and clinical sciences. Inclusion of the basic sciences into the clinical curricula is less robust than including clinical content early in medical school. We describe inclusion of biomedical scientists on patient care rounds to increase the visibility of biomedical sciences, to nurture relationships between clinicians and biomedical scientists, and to identify additional opportunities for integration throughout medical school.

The impact of small-group virtual patient simulator training on perceptions of individual learning process and curricular integration: a multicentre cohort study of nursing and medical students

BACKGROUND

The COVID-19 pandemic has precipitated rapid changes in medical education to protect students and patients from the risk of infection. Virtual Patient Simulators (VPS) provide a simulated clinical environment in which students can interview and examine a patient, order tests and exams, prioritize interventions, and observe response to therapy, all with minimal risk to themselves and their patients. Like high-fidelity simulators (HFS), VPS are a tool to improve curricular integration. Unlike HFS, VPS require limited infrastructure investment and can be used in low-resource settings. Few studies have examined the impact of VPS training on clinical education. This international, multicenter cohort study was designed to assess the impact of small-group VPS training on individual learning process and curricular integration from the perspective of nursing and medical students.

METHODS

We conducted a multi-centre, international cohort study of nursing and medical students. Baseline perceptions of individual learning process and curricular integration were assessed using a 27-item pre-session questionnaire. Students subsequently participated in small-group VPS training sessions lead by a clinical tutor and then completed a 32-item post-session questionnaire, including 25 paired items. Pre- and post-session responses were compared to determine the impact of the small-group VPS experience.

RESULTS

Participants included 617 nursing and medical students from 11 institutions in 8 countries. At baseline, nursing students reported greater curricular integration and more clinical and simulation experience than did medical students. After exposure to small-group VPS training, participants reported significant improvements in 5/6 items relating to individual learning process and 7/7 items relating to curricular integration. The impact of the VPS experience was similar amongst nursing and medical students.

CONCLUSIONS

In this multi-centre study, perceptions of individual learning process and curricular integration improved after exposure to small-group VPS training. Nursing and medical students showed similar impact. Small-group VPS training is an accessible, low-risk educational strategy that can improve student perceptions of individual learning process and curricular integration.

Guiding Preclinical Medical Students in Finding, Synthesizing, and Communicating Translational Basic Research Literature: Roles for Basic Science Research Mentors

PROBLEM

Understanding and communicating medical advances driven by basic research, and acquiring foundational skills in critically appraising and communicating translational basic research literature that affects patient care, are challenging for medical students to develop.

APPROACH

The authors developed a mandatory course from 2012 to 2018 at Texas A&M University College of Medicine to address this problem. Medical Student Grand Rounds (MSGR) trains first-year students to find, critically assess, and present primary research literature about self-selected medically relevant topics. With basic science faculty mentoring, students completed milestones culminating in oral presentations. Students learned to search literature databases and then choose a clinical subject using these skills. They outlined the clinical subject area background and a mechanistic research topic into a clinical problem based on deeper evaluation of primary research literature. "Mechanistic" was defined in this context as providing experimental evidence that explained the "how" and "why" underlying clinical manifestations of a disease. Students received evaluations and feedback from mentors about discerning the quality of information and synthesizing information on their topics. Finally, students prepared and gave oral presentations, emphasizing the primary literature on their topics.

OUTCOMES

In the early stages of the course development, students had difficulty critically assessing and evaluating research literature. Mentored training by research-oriented faculty, however, dramatically improved student perceptions of the MSGR experience. Mentoring helped students develop skills to synthesize ideas from basic research literature. According to grades and self-evaluations, students increased proficiency in finding and interpreting research articles, preparing and delivering presentations, and understanding links among basic and translational research and clinical applications.

NEXT STEPS

The authors plan to survey fourth-year students who have completed MSGR about their perceptions of the course in the context of clinical experiences in medical school to guide future refinements.

Improving Integration of Basic Science into Clinical Medicine: Vertical Integration into Clinical Education (VICE) Activity

The integration of basic science into clinical clerkships continues to be a challenge in medical curricula. We developed an integrated session for 3rd year medical students enrolled in OB-Gyn/Pediatric Block. The session focused on transplacental and perinatal infections, and consisted of a student-driven pedagogy activity in which students were required to explain the basic science principles behind the pathophysiology of the clinical presentations, the work-up, and the treatment of the infections. This approach helps students understand how basic science knowledge informs clinical practice and potential increase clerkship-level students' confidence as it makes them serve as leaders of active learning modules.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01485-7.

Diagnostic reasoning in cardiovascular medicine

Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.

Making Concepts Material: A Randomized Trial Exploring Simulation as a Medium to Enhance Cognitive Integration and Transfer of Learning

BACKGROUND

Simulation affords opportunities to represent functional relationships between conceptual (eg, anatomy) and procedural knowledge (eg, needle insertion technique) in ways that make them accessible to our many senses. Despite deprioritizing realism, such simulations may encourage trainees to create cognitive connections between these knowledge (ie, cognitive integration), which may improve transfer of learning. However, the impact of such "integrated instruction" has not been examined in simulation-based training. We developed integrated video- and simulator-based instructional modules for lumbar puncture training and compared their impacts on participants' retention, transfer, and conceptual knowledge.

METHODS

During 1 hour of simulation-based training, we randomized 66 medical students to receive either (a) video-based procedural-only instruction, (b) integrated video-based instruction, or (c) integrated simulator-based instruction. One week later, we tested participants' retention and transfer performances and their conceptual knowledge on a written test.

RESULTS

Simple mediation analyses revealed that compared with participants receiving procedural-only instruction, participants receiving integrated instruction had superior retention and transfer outcomes, mediated by gains in conceptual knowledge (all P < 0.01). We found no significant differences between the integrated groups for retention, transfer, or conceptual knowledge (all P > 0.01).

CONCLUSIONS

We extended previous findings, showing integrated instruction (video- or simulator-based) improved trainees' conceptual knowledge, which mediated their improved retention and transfer. As an innovation, we demonstrated how simulators can facilitate cognitive integration by making abstract conceptual-procedural relationships material. In suggesting how researchers might capitalize further on simulator-based integration, we offer an alternative framework for designing simulations that emphasizes cognitive processes rather than simulator fidelity.

Artificial Intelligence in Undergraduate Medical Education: A Scoping Review

PURPOSE

Artificial intelligence (AI) is a rapidly growing phenomenon poised to instigate large-scale changes in medicine. However, medical education has not kept pace with the rapid advancements of AI. Despite several calls to action, the adoption of teaching on AI in undergraduate medical education (UME) has been limited. This scoping review aims to identify gaps and key themes in the peer-reviewed literature on AI training in UME.

METHOD

The scoping review was informed by Arksey and O'Malley's methodology. Seven electronic databases including MEDLINE and EMBASE were searched for articles discussing the inclusion of AI in UME between January 2000 and July 2020. A total of 4,299 articles were independently screened by 3 co-investigators and 22 full-text articles were included. Data were extracted using a standardized checklist. Themes were identified using iterative thematic analysis.

RESULTS

The literature addressed: (1) a need for an AI curriculum in UME, (2) recommendations for AI curricular content including machine learning literacy and AI ethics, (3) suggestions for curriculum delivery, (4) an emphasis on cultivating "uniquely human skills" such as empathy in response to AI-driven changes, and (5) challenges with introducing an AI curriculum in UME. However, there was considerable heterogeneity and poor consensus across studies regarding AI curricular content and delivery.

CONCLUSIONS

Despite the large volume of literature, there is little consensus on what and how to teach AI in UME. Further research is needed to address these discrepancies and create a standardized framework of competencies that can facilitate greater adoption and implementation of a standardized AI curriculum in UME.

What Were You Thinking? Medical Students' Metacognition and Perceptions of Self-Regulated Learning

PHENOMENON

As a component of self-regulated learning, metacognition is gaining attention in the medical education research community. Metacognition, simply put, is thinking about one's thinking. Having a metacognitive habit of mind is essential for healthcare professionals. This study identified the metacognitive competencies of medical students as they completed a conceptual learning task, and provided insight into students' perceptions of self-regulated learning in their curriculum. Approach: Eleven third-year medical students from a Dutch University were purposively sampled to participate in this qualitative study. The study design included a think-aloud assignment followed by a semi-structured interview. During the assignment, participants were instructed to think aloud while solving questions about medical physiological concepts such as blood flow, pressure, and resistance. Think-aloud data were collected through audiotaping and used to identify participants' metacognitive competencies. The assignment also served as a prompt for an interview in which participants were questioned about metacognitive knowledge, monitoring, experiences, and perceptions of self-regulated learning in their curriculum. All data were transcribed verbatim and analyzed iteratively using a template analysis. Findings: Students differed in their use of metacognitive skills, with an overall focus on monitoring and, to a lesser extent, on planning and evaluation. Additionally, differences were found in students' metacognitive knowledge and metacognitive experiences. There was apparent use of inefficient, superficial predictive cues. Regarding perceptions of self-regulated learning skills, some students felt no need to develop such skills as they perceived medical education as an exercise in memorizing facts. Others emphasized the need for more insight into their actual level of knowledge and competence. Insights: Pre-clinical medical students require explicit teaching of metacognitive skills to facilitate self-regulated learning. Educators should aim to integrate metacognition in the everyday discourse of the classroom to foster an environment in which students discuss their own learning.

Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1889559.

Design, Implementation, and Evaluation of a Distance Learning Framework to Adapt to the Changing Landscape of Anatomy Instruction in Medical Education During COVID-19 Pandemic: A Proof-of-Concept Study

This study presents the design of a DL-framework to deliver anatomy teaching that provides a microfiche of the onsite anatomy learning experience during the mandated COVID-19 lockdown. First, using nominal-group technique, we identified the DL learning theories to be employed in blueprinting the DL-framework. Effectiveness of the designed DL-framework in anatomy teaching was demonstrated using the exemplar of the Head and Neck (H&N) course during COVID-19 lockdown, in the pre-clerkship curriculum at our medical school. The dissemination of the DL-framework in the anatomy course was informed by the Analyse, Design, Develop, Implement, and Evaluate (ADDIE) model. The efficiency of the DL-framework was evaluated using the first two levels of Kirkpatrick's model. Versatility of the DL-framework was demonstrated by aligning its precepts with individual domains of key learning outcomes framework. The framework's blueprint was designed amalgamating principles of: Garrison's community inquiry, Siemens' connectivism and Harasim's online-collaborative-learning; and improved using Anderson's DL-model. Following the implementation of the DL-framework in the H&N course informed by ADDIE, the framework's efficiency was evaluated. In total, 70% students responded to the survey assessing perception toward DL (Kirkpatrick's Level: 1). Descriptive analysis of the survey results showed that the DL-framework was positively received by students and attested that students had an enriched learning experience, which promoted collaborative-learning and student-autonomy. For, Kirkpatrick's Level: 2 i.e., cognitive development, we compared the summative assessment performance in the H&N course across three cohort of students. The results show that the scores of the cohort, which experienced the course entirely through DL modality was statistically higher (P < 0.01) than both the other cohorts, indicating that shift to DL did not have an adverse effect on students' learning. Using Bourdieu's Theory of Practice, we showed that the DL-framework is an efficient pedagogical approach, pertinent for medical schools to adopt; and is versatile as it attests to the key domains of students' learning outcomes in the different learning outcomes framework. To our knowledge this is the first-study of its kind where a rationale and theory-guided approach has been availed not only to blueprint a DL framework, but also to implement it in the MBBS curriculum.

PRIME Immunology: Self-directed Introduction to Medical School Immunology

INTRODUCTION

Medical students find immunology difficult to understand and relate to clinically and are often frustrated by the amount of detailed material. We created PRIME Immunology: Preview or Review of Important Material for Everyone: (i) video modules, (ii) Instagram site, and (iii) vocabulary files called Immunology Language.

METHODS

The self-paced modules introduced key topics in immunology for students to complete prior to their instructional block.

RESULTS AND CONCLUSIONS

Use of PRIME Immunology during a 3-year period suggested that providing students with an overview of key topics before the start of their course may (i) reduce student angst about immunology and (ii) improve retention of immunology.

Precision Cancer Medicine: Dynamic Learning of Cancer Biology in a Clinically Meaningful Context

PURPOSE

Precision medicine is revolutionizing healthcare practices, most notably in oncology. With cancer being the second leading cause of death in the USA, it is important to integrate precision oncology content in undergraduate medical education.

METHODS

In 2015, we launched a Clinical Cancer Medicine Integrated Science Course (ISC) for post-clerkship medical students at Vanderbilt University School of Medicine (VUSM). In this ISC, students learned cancer biology and clinical oncology concepts through a combination of classroom and patient care activities. Student feedback from mid- and end-of-course surveys and student match data were analyzed and used to develop ongoing course improvements.

RESULTS

To date, 72 medical students have taken the Clinical Cancer Medicine ISC. Over 90% of students who completed end-of-course surveys agreed or strongly agreed that this course advanced their foundational science knowledge in clinical cancer medicine, that clinical relevance was provided during non-clinical foundational science learning activities, and that foundational science learning was embedded in course clinical experiences. Students who took this course most commonly matched in Internal Medicine, Pathology, Pediatrics, and Radiation Oncology. VUSM students who matched into Pathology and Radiation Oncology were more likely to take this ISC than students who matched in other specialties.

CONCLUSION

The Clinical Cancer Medicine ISC serves as a model for incorporating precision oncology, cancer biology foundational science, and oncology patient care activities in undergraduate medical education. The course prepares students to care for oncology patients in their fields of interests during their future career in medicine.

Integration of clinical anatomical sciences in medical education: Design, development and implementation strategies

For the last 20 years, undergraduate medical education has seen a major curricular reform movement toward integration of basic and clinical sciences. The rationale for integrated medical school curricula focuses on the application of knowledge in a clinical context and the early ability to practice key skills such as critical thinking and clinical problem-solving. The method and extent of discipline integration can vary widely from single sessions to entire programs. A challenge for integrated curricula is the design of appropriate assessments. The goal of this review is to provide a framework for clinical anatomy educators with definitions of integration, examples of existing integration models, strategies, and instructional methods that promote integration of basic and clinical sciences.

Near-Peer Learning During the Surgical Clerkship: A Way to Facilitate Learning After a 15-Month Preclinical Curriculum

OBJECTIVES

To investigate the performance and perspectives of third-year medical students (MS3s) participating in near-peer learning (NPL) sessions during their core surgical clerkship following a 15-month preclerkship curriculum.

DESIGN

An evaluation study of 7 NPL sessions developed and implemented by fourth-year medical students (MS4s) held from March 2019 to February 2020. MS4s taught 1-2 sessions per rotation that included test taking strategies, illness script development, radiology review, case-based multiple-choice questions, and rapid review. Participants completed a questionnaire with 11 seven-point Likert and open-ended questions after each session. Analyses included quantitative comparison of shelf score averages between NPL participants and nonparticipants and qualitative content analysis for open-ended questions.

SETTING

Surgical clerkship at the University of California, San Francisco.

PARTICIPANTS

Forty-eight (32%) MS3s participated, with an average attendance of 10 students per rotation. Thirty-three (69%) participants completed the questionnaire.

RESULTS

MS3s enjoyed the session (6.9 ± 0.4), improved their knowledge (6.8 ± 0.5), and felt more prepared for the surgery shelf examination (6.5 ± 0.6). MS4 leaders found that MS3s always wanted radiology review, and their interest in test taking strategies and illness script development declined across the clerkship year. Participants had lower shelf exam scores compared to nonparticipants (68.1 vs 71.4, respectively; p = 0.04, ES = 0.03). Shelf exam scores increased over time in both cohorts. Each group had 2 shelf exam failures. Qualitative analysis suggests that MS3s appreciated the NPL's tailored approach and exam demystification, with a desire for increased NPL integration into the clerkship.

CONCLUSION

Students participating in NPL were satisfied with the sessions. Participants may have been students who struggled as indicated by shelf exam scores and appreciated the support. The shift in preferred topics across the blocks reflects the students' development during clerkships. Near-peer teachers should adjust sessions over time to fit students' evolving needs.