January 20th, 2020
Best Practices for Success in Teaching Physiology, Part III – Seeing Results
Thomas M. Nosek, Ph.D.
Professor Emeritus, Department of Physiology and Biophysics
Case Western Reserve University

In this final article of the series, the discussion comes to a completion with the remaining aspects that show the results of the tools that were presented in part I and the implementation techniques in pat II.

17. Administer weekly quizzes.
We administer a 10 multiple choice question, computer-based quiz to both resident and Internet students (using the testing function in the CMS) every Monday before class that covers the material from the previous week’s lectures. Grades on these quizzes constitute 15% of the final grade in the course. The intent of the quizzes and their 15% contribution to the final course grade is to encourage students to keep up with the course material.

Advantages
: The courses move along very quickly and if a student gets behind studying the material, they are at a severe disadvantage – there typically is not enough time for the students to catch up. Once a student’s answers are submitted, their grade is immediately reported so the students have immediate feedback on their performance.
Disadvantages: Faculty must write these quiz questions and time must be taken to administer the quizzes. Staff must be available to help students who have problems with the software on the day of the quiz. It is inevitable that a few students will have problems with their computers. Thus, the department has purchased 10 computers dedicated for use by students having difficulty during the quiz/exam administration. A room or group of rooms with Internet service and power sources for computer chargers must be available for the administration of quizzes and exams.


18. Provide weekly Study (Homework) Questions.
At the beginning of each week, we provide approximately 10 multiple choice study questions for each chapter in the assigned textbook that is covered that week. Students are encouraged to work together on these questions; they are free to use the textbook, class notes, and any other learning resource. However, the students are on their honor to enter their own answers to the question in the testing function of the CMS by noon each Saturday. Immediately after the due date for the questions, the answers with detailed explanations are provided to the students. Grades on these Study Questions constitute 15% of the final grade in the course.

Advantages: We have found that students who read the textbook do better than students who do not. These study questions encourage students to read the textbook. They key the students in on the most important points in each chapter helping them prepare for quizzes and exams. This learning resource has been rated very highly by the students.
Disadvantages: These study questions are created each year by the TA’s. Unfortunately, the TA’s are not always experienced in writing questions and many questions must be corrected after they are posted. It is best if these questions are written by faculty or at least reviewed by them before the questions are released to the students.

 

19. Administer computer-based Block examinations.
The textbook we use is organized by organ systems. The course is divided into Blocks by these organ systems. A faculty member is assigned to coordinate each Block. This faculty member is responsible for soliciting quiz and Block exam questions from each of the faculty members lecturing during the Block. At the end of each Block, a computer-based multiple-choice examination is administered through “Exemplify/ExamSoft” which we purchase for each of the students. The Block exam average constitutes 70% of the final course grade. These exams are secure so that they can be used from year to year with only slight modifications to better word questions that are found to be confusing and to modify them to accommodate for different faculty teaching the material.

Advantages: Blocks are typically 4 weeks long and there are 4 Blocks/semester. This breaks up the semester into 4 parts and gives the students 4 opportunities/semester to demonstrate their knowledge of the material. The computer-based exam system gives them immediate feedback on their performance.
Disadvantages: As noted above for quizzes, staff must be available to help students who have problems with the exam software on the day of the exam. As noted above, it is inevitable that a few students will have problems with their computers. Thus, the department has purchased 10 computers dedicated for use by students having difficulty during the exam administration. A room or group of rooms with Internet service and power sources for computer chargers must be available for the administration of Block exams. For the Internet students who cannot come to Cleveland to take the Block exams, we administer the exams through ProctorU, a service paid for by the department. This service uses the CMS to administer the exam through their proprietary software where a proctor observes the students through their computer camera and reports any inappropriate activity.


20. Use a “Difficulty Factor” (DF) to adjust quiz and Block exam grades for difficulty.
It is very difficult to predict how well students will perform on multiple choice quizzes and Block exams. Our expectation is that the median score on each Block exam will be 85% with 100% – 85% = A, 84% – 70% = B, and anything less than 70=C (with a C considered a failing performance in graduate school). Until a track record can be established for an exam, performance on each exam will be used to calculate the DF = the difference between the median on an exam and 85%. For example, if the median on an exam is 80%, 5% points are added to each student’s grade to bring the class median to 85%. If the median on an exam is greater than 85%, the DF = 0. After 3 years of administering a secure exam, the DF is calculated from the average of the DF’s for the previous 3 years.

Advantages: This system of adjusting the Block exam grades has been effective in making the final class average in the course close to 85% and a distribution of grades approximately 50% A’s and 50% B’s with only a few C’s. The students see the grading system as non-competitive; i.e., they do not see themselves as being in competition with other students for a limited number of A’s. Although it has never happened, it is possible for all students to earn an A in the course.
Disadvantages: None


21. As soon as possible after quizzes and Block exams are completed, hold a review session to discuss the correct questions.
Review sessions are conducted by the TA’s immediately after the class that follows the administration of the Monday quizzes and immediately after the Block exams. In these review sessions, the right answers to each question are provided. Students are allowed to contest the answer to a question. All contested questions of substance are taken to the faculty member responsible for the quiz or Block exam for evaluation and possibly changing the right answer or accepting multiple right answers. When this happens, the question is immediately corrected for use on the next year’s quiz/exam.

Advantages: It is very useful for students to have immediate (or near immediate) feedback on their performance on quizzes and Block exams. In this way they can identify concepts that they have not mastered and correct their thinking before moving on to the next topic.
Disadvantages: Steps must be taken to keep quiz and Block exam questions secure during these review sessions.

 

22. Provide faculty advisors to the MSMP students.
Each of the MSMP students is assigned a faculty advisor from the primary and secondary departmental faculty. We limit the number of students assigned to each faculty member to no more than 10/year. The advisors are responsible for writing letters of recommendation for their advisees. Students are encouraged to meet personally with their advisor at the beginning of the program and then at least after each Block exam in the first year core courses. During the second year, they meet with their advisors as needed. Internet students are encouraged to contact their advisor via phone or Skype on the same schedule.

Advantages: Students have access to a faculty member who can advise them on how to best navigate the courses and the MSMP program. Based on the student’s unique situation, they can also advise them on which electives will be most helpful to them when they apply to a medical professional program. Personal meetings are important so that the advisor can write a personalized letter of recommendation.
Disadvantages: Advisors are not equally knowledgeable about the intricacies of getting into professional medical programs and don’t provide the same quality of advice. Students tend to seek advice from the faculty members who have the reputation of being the best advisors, even when they are not assigned to that advisor. It is difficult to recruit enough faculty to be advisors to keep the student/advisor ratio at 10/incoming class.


23. Provide peer advisors.
At the beginning of the academic year, each matriculating MSMP student is assigned a peer advisor from the second year MSMP students. They are encouraged to meet and have social activities together. Each peer advisor is given $10/advisee to defray the cost of a social activity; ex. pizza party, bowling party, etc.

Advantages: Students appreciate meeting second year MSMP students who have successfully completed the first year core courses. Especially at the beginning of the program, this contact helps the incoming students become acclimatized to CWRU, the MSMP program, and Cleveland.
Disadvantages: It is not always easy to recruit enough 2nd year MSMP students to keep the student/advisor ratio at approximately 5.

 

24. Provide Teaching Assistants who have already had the core courses.
At the end of the academic year, we interview students who have successfully completed their first year in the program and who want to be Teaching Assistants (TA’s). Typically, these students have a perfect 4.0 GPA and have had some TA experience during their undergraduate experiences. The TA’s conduct weekly review sessions for the core courses, hold office hours for personalized Question and Answer sessions, administer the quizzes and Block exams, and post the materials provided by faculty in the CMS. Three of the nine TA’s have been assigned to work exclusively with the Internet students, being sure to contact them at least once/week.

Advantages: The TA’s provide an invaluable service to the MSMP program, relieving the AA and faculty from having to deal with many routine administrative duties. This experience is very valuable to the TA’s, greatly enhancing their resumes. This position pays $15/hour for up to 20 hours/week of work thus giving the second year students some income. These TA positions have become very prestigious, especially when considering that every TA has gained admittance to the medical professional program of their choice after graduating with the MSMP degree.
Disadvantages: We hire 9 TA’s/year and this comes with a price tag that must be met by the income generated by the program.


25. Require students to complete a faculty/course/program evaluation at the end of each Block of the course.
At the end of each Block exam in the core courses and at the end of each elective, each student is required to complete a Block/faculty/program evaluation administered through SurveyMonkey. Student grades are not released until they complete all surveys. The Director of the MSMP program creates the template for this survey and the TA’s appropriately modify it and post it online for each Block of the courses.

Advantages: This feedback is provided to the Block coordinators, the MSMP Administration Committee members, the faculty teaching in the Block, and the TA’s. This feedback is coordinated by the AA. The Block coordinator and the members of the MSMP Administration Committee see the full evaluations. The faculty and TA’s only see their own evaluations. This information is very important for faculty and TA’s to know how their interactions are valued by the students and by the Block coordinators and MSMP Administration Committee members to evaluate the courses and program and take steps to continuously improve it.
Disadvantages: The AA must take time to keep track of students who have completed the evaluations and explain to those students who have not completed them why their course grade has not been posted.

Dr. Nosek earned his B.S. in Physics from the University of Notre Dame in 1969 and his Ph.D. in Biophysics from The Ohio State University in 1973.  After post-doctoral research in the Cardiovascular Physiology Training Program in the Department of Physiology and Pharmacology at the Bowman Gray School of Medicine of Wake Forest University, he went to the Department of Physiology at the Medical College of Georgia (1976-1997) where he was the Coordinator of the Muscle Cell Biology Research Group (conducting research on the cellular basis of muscle fatigue) and the Coordinator of the Computer Aided Instruction Research Group (editing and being a section author of “Essentials of Human Physiology:  A Multimedia Resource” published by the DxR Group).  He served as Director of the medical physiology course taught to first year medical students and was the Director of the Departments Ph.D. program.  In 1997, he moved to Case Western Reserve University School of Medicine where he was Associate Dean of Biomedical Information Technologies (creating the Computer-Based Integrated Curriculum through 2006) and Professor of Physiology and Biophysics until he retired in 2014 becoming Professor Emeritus.  He served as the department’s Director of Medical Education.  He was founding Director of the MS in Medical Physiology Program at CWRU from 2010 – 2019 when he became Director Emeritus.

January 13th, 2020
Best Practices for Success in Teaching Physiology, Part II – Using the Tools
Thomas M. Nosek, Ph.D.
Professor Emeritus, Department of Physiology and Biophysics
Case Western Reserve University

In last week’s article, 9 aspects were discussed on what to bring to a classroom for the methods of effective teaching of physiology.

10. Encourage all faculty to use PowerPoint presentations during class
These files are made available to the class in the CMS at least a day before each lecture. Sometimes faculty modify these files right before the lecture is given. Therefore, we provide both a pre- and post-lecture PowerPoint presentation in the CMS.

Advantages: Students report that they like PowerPoint presentations. Many will review this file before lecture and take notes on their computers in the pre-lecture PowerPoint during lecture. Faculty have become very creative using the advanced features of PowerPoint, linking to video files, sound files, animations, etc.
Disadvantages: Faculty must create the PowerPoint file for uploading into the CMS at least a few days before the scheduled class. Some students report that they find the presentation of one PowerPoint after another to be monotonous.


11. Encourage all faculty to use computer/Internet-based simulations, sound files, videos, and animations during class.
There are extensive physiological simulations/animations/sound files/videos available on the Internet. We encourage faculty to use these whenever they think they enhance the learning experience. For example, when teaching the nerve action potential, we use a Hodgkin and Huxley nerve simulation computer program. We give students in small groups a series of questions to answer using the simulation. Another example is during the muscle physiology lectures; an animation of action potential conduction along the muscle fiber and into the t-tubules upon activation of the neuromuscular junction is presented and discussed in class along with an animation of the cross-bridge cycle.

Advantages: Active learning is always better for retention than passive learning. When students use computer simulations to answer a set of questions they engage the material to a greater extent and have a deeper understanding of the physiological principles. Viewing animations also helps students to understand difficult concepts. Students rate the use of these learning resources very favorably.
Disadvantages: Students are all required to own a personal notebook computer. They will often have problems installing computer simulations and animations on their personal computers. Thus, a staff member must be available to assist them so that they have access to these learning resources.


12. Provide Learning Objectives for each lecture in the CMS.
A Learning Objective (LO) is a statement of what a student is expected to be able to DO after they have heard a lecture. It is not a statement of what the lecturer presented. For example, “Know the cross-bridge cycle” is not a valid LO. “Be able to draw from memory the 6 stages of the cross-bridge cycle for a typical skeletal muscle” is a valid LO.

Advantages: The students will know exactly what they are supposed to be able to DO after they hear a lecture. We have a policy that no quiz or Block exam question can be asked unless it links to one of the provided LO’s.
Disadvantages: The faculty giving the lecture must create these LO’s for their lectures and make them available to the students far enough ahead of the lecture to be useful. It is not always easy for faculty to write specific LO’s, LO’s that are not too general and therefore useless.

13. Live stream each lecture and record it for posting in the CMS
We are provided a staff member from the university’s Teaching & Learning Support division to be present at all lectures and review sessions to live stream and record each lecture using Echo 360. The recording is posted in the CMS as soon after the lecture as possible. Because the videos must be processed to some extent before they can be posted, this cannot be immediate. Two hours after the lecture is a reasonable time to have these posted online.

Advantages: This year, 26% of the class is taking the MSMP program over the Internet. Only a small percentage of these students are able to view the lectures live and they rely on the recordings to access the material. It is interesting to note that attendance at the live lectures falls off the further into the two semesters of core courses one gets. At times, as much as 50% of the resident students opt to skip class and view the lectures online. Feedback from the students indicates that they do this for many different reasons. Foul winter weather in Cleveland is often cited. However, many students indicate they find it to be a great advantage to be able to speed up the lecture (up to 2x normal speed is available) when a faculty member is lecturing slowly over something they find easy to understand. On the other hand, if they don’t understand something that the professor says in class, they have the option of stopping the video and replaying it and even looking the material up in the textbook so that they will understand what has been presented before they move on with the next aspect of the lecture. Also, students with learning disabilities requiring accommodations report that they are often unable to focus their attention for a 2-hour lecture. Being able to stop the lecture to take a break before refocusing on the material prevents them from wasting time in a lecture setting where they report being totally overwhelmed and lost.
Disadvantages: This resource encourages students to skip the live lectures. Faculty often complain about low student attendance at their presentations. However, there is no evidence that student performance is compromised when they view videos of a lecture rather than physically attending it. Because of the dependence of students on this resource, we have trained all of the Teaching Assistants to back up the staff member charged with making the recordings.


14. Use an audience response system (ARS) during lecture.
We use TurningPoint as our ARS. It seamlessly integrates with PowerPoint. Each student is given a “clicker” at the beginning of the year after making a deposit in the amount of the cost of the clicker. This deposit is refunded when the clicker is returned at the end of the academic year. Faculty are encouraged to stop the lecture approximately every 15 minutes (approximately the length of time a student can effectively concentrate on lecture material) and present a question to the class in PowerPoint. Students are given a few minutes to reflect on the question before they are asked to register their answer to the question via their clicker. The number of students responding is observed on the PowerPoint slide. When a plateau is reached in the number of students responding, the faculty advances the slide to show the right answer to the question. If the class overwhelmingly answers the question correctly, no further discussion is necessary although the faculty member may want to go through each answer and explain why it is right or wrong. However, if less than 50% of the class answers the question correctly, the ARS will have helped the faculty identify a concept that has not been well understood by a majority of the students. This is an opportunity for the faculty not to progress to the answer slide but to further discuss the material. The system allows for revisiting a question, having the students to answer the question a second time after further discussion of the topic. If the students’ answers are split evenly among a number of choices, faculty are encouraged to use the “Peer Instruction” technique discussed below.

Advantages: Many years ago, we tested the effectiveness of an ARS on medical students at CWRU and found that student performance on a standard exam was enhanced by as much as 10% with the use of an ARS. Student feedback from MSMP students indicate that they very much appreciate the use of the ARS. Online students who watch the lectures live are encouraged to register their answers to ARS questions in the streaming software. A TA is always available during class to answer questions from the Internet students or to ask the lecturer questions on behalf of an Internet student. Online students who are watching the lectures asynchronously are encouraged to write down their answers on a piece of paper while they are watching the lecture.
Disadvantages: Students do not always remember to bring their clickers to class. The number of students responding to ARS questions is never equal to the total number of students in attendance. Faculty must create the ARS questions and incorporate them into their lectures. Some faculty do not feel comfortable doing this or just refuse to cooperate even with strong coaxing. TA’s have offered to help faculty create these questions with limited success.

 

15. Utilize “Peer Instruction”
“Peer Instruction” has been popularized by Eric Mazur at Harvard University (Miller et al., 2015 – https://journals.aps.org/prper/abstract/10.1103/PhysRevSTPER.11.010104). When an instructor identifies a topic that the students do not clearly understand (often prompted by the use of an ARS question that generates an ambiguous set of answers), the professor directs the students to gather in small groups of 3-4 where they are sitting in a large or small class setting and discuss among themselves the question. We have used this technique effectively in a large classroom setting with up to 150 students.

Advantages: The hypothesis is that one of the students in the small group will know the answer to the question and will be able to teach their peers the concept even more effectively than the professor. Mazur has reported positive results in students’ comprehension using this technique. Using this technique has the advantage of breaking up the flow of the class and invigorating the students as it actively engages them in the learning process. Our students have rated the use of this technique very favorably.
Disadvantages: Using this technique does take up class time and can disrupt the flow of the lecture. Not all students are willing to actively engage in this process and would prefer a passive learning experience.

 

16. Use the “Flipped Classroom” technique.
By a “Flipped Classroom” I mean providing students with pre-recorded lectures or other learning resources in the CMS that they are required to view/use before class. Class time is reserved for using the ARS to ask students questions over important aspects of the physiology presented in the pre-recorded lecture or in the other supplied learning resource – no lecture is given.

Advantages: The majority of students indicate that they enjoy the “Flipped Classroom” and that the use of ARS questions during the class time helps them to learn the material.
Disadvantages: Faculty must take the time to record this specialized lecture, often without an audience. Only approximately 70% of the students attending a “Flipped” class will have reviewed the assigned material before class. Because there is no lecture, they are not prepared to actively learn from the ARS questions. Some students complain that the required viewing of material before class is an added study time burden from which they do not see a clear benefit.

In the final week of the series, aspects that have been shown to provide a return of investment in the classroom will be discussed.  

Dr. Nosek earned his B.S. in Physics from the University of Notre Dame in 1969 and his Ph.D. in Biophysics from The Ohio State University in 1973.  After post-doctoral research in the Cardiovascular Physiology Training Program in the Department of Physiology and Pharmacology at the Bowman Gray School of Medicine of Wake Forest University, he went to the Department of Physiology at the Medical College of Georgia (1976-1997) where he was the Coordinator of the Muscle Cell Biology Research Group (conducting research on the cellular basis of muscle fatigue) and the Coordinator of the Computer Aided Instruction Research Group (editing and being a section author of “Essentials of Human Physiology:  A Multimedia Resource” published by the DxR Group).  He served as Director of the medical physiology course taught to first year medical students and was the Director of the Departments Ph.D. program.  In 1997, he moved to Case Western Reserve University School of Medicine where he was Associate Dean of Biomedical Information Technologies (creating the Computer-Based Integrated Curriculum through 2006) and Professor of Physiology and Biophysics until he retired in 2014 becoming Professor Emeritus.  He served as the department’s Director of Medical Education.  He was founding Director of the MS in Medical Physiology Program at CWRU from 2010 – 2019 when he became Director Emeritus.

January 7th, 2020
Best Practices for Success in Teaching Physiology, Part I – The Toolbox
Thomas M. Nosek, Ph.D.
Professor Emeritus, Department of Physiology and Biophysics
Case Western Reserve University

I have been actively involved in graduate and medical student education since 1972 – 47 years.  From my first time before the students, I have been searching for the optimal way to engage the students during class time, to provide alternatives to standard lectures, and to encourage active learning – all with the desire to help them understand physiological principles.

Over the years, I have had experience directing the Medical Physiology course team-taught to first year medical students and directing departmental MS and PhD programs.  Since 2011, I have served as the Program Director of a 32-credit hour MS in Medical Physiology program at Case Western Reserve University – a program designed to aid students gain admittance to professional medical programs; MD, DO, POD, DDS, PA, and PhD. It is classified as a Special Post-Baccalaureate program.  The program consists of 20 credit hours of lecture-based core Physiology courses (Medical Physiology I and II, Translational Physiology I and II, and Physiology Seminar I and II) which are designed to be taken in the first year of study to establish a strong understanding of physiological principles.  Twelve credit hours of graduate level electives, preferably taken in the second year of the program in any department at the university, round out the 32 credit hour degree requirement.  The program has grown from 43 students in the first class to 175 this past year, 45 of whom are taking the program over the Internet.  My responsibilities as director of this program and serving as the course director for the core courses have allowed me to test many of my ideas to optimize student learning of physiology, gaining feedback from the students along the way via surveys.

In this series of articles, I will introduce and discuss each of the aspects of the courses/program that I hope my colleagues will find useful as they consider how they may construct or modify the physiology courses/program for which they are responsible.  I will also present the advantages and disadvantages of each of these features.  I prefer to create hyperlinked text so that you can access detailed information only when you want it.  In lieu of that here, I suggest you read the bolded headers below and only read the detailed text that follows if this topic is of interest to you.

1. Have an Administration Committee to help administer the courses/program.
We have a 7 faculty member Administration Committee constituted from our primary and secondary faculty which I chair that established the program and now administers it, conducting constant quality assessments. Members of the committee help to recruit faculty from across the university to present lectures and continue to fill vacancies when they arise.

Advantages: The faculty have a wealth of experience and wisdom that cannot be matched by one person alone trying to administer a course or program. The committee reviews the student evaluations and recommends changes to improve the quality of the course/program.
Disadvantages: Faculty are not always available to meet on a monthly basis to keep a close eye on the courses and the program.


2. Have an Administration Assistant.
An administrative assistant (AA) is essential to process class registrations/program applications, to answer basic student questions about the details of the courses/program – referring detailed or difficult questions to faculty when appropriate, and taking care of administration of the courses. The AA also serves as a liaison with the Graduate School.

Advantages: Many tasks associated with administering a course/program are routine and do not need faculty involvement. An AA can save faculty a great deal of time.
Disadvantages: Of course hiring an AA costs money that hopefully can be recouped from the tuition generated by the course/program. Finding an AA with the right personality who can be understanding but yet firm with the students is challenging.


3. Organize the course around a textbook.
We chose to use Boron and Boulpaep’s “Medical Physiology” as the textbook for the core Medical Physiology courses. We start the courses with Chapter 1 and end it two semesters later with Chapter 62.

Advantages: Faculty are instructed as a minimum to present the material covered in the chapter associated with their assigned lecture. However, they have the academic freedom to teach the material in the order and in the style that they find most effective and consistent with their own personality/teaching style. Unless a professor states otherwise, the textbook becomes the authority in any disputes over quiz, homework, or Block exam questions.
Disadvantages: There are many physiology textbooks to choose from, with none being equally strong on all topics. In a medical physiology course I directed at the Medical College of Georgia many years ago, we tried using monographs for each section of the course, choosing what we thought was the best learning resource for that block of material. This was more expensive than recommending a single textbook and was not viewed favorably by the students.

4. Arrange the course/program so that it can be given over the Internet
For a wide variety of reasons, not all students are able to come to your campus to take courses or to enroll in your program. We recommend that all students come to campus to become immersed in the rich learning environment only physical presence on campus can provide. However, making your course/program available over the Internet gives access and opportunity to many more students. Some students do our entire program over the Internet. The degree requirements and standards of performance are exactly the same for resident and Internet students. A few take the first year of the program over the Internet and then come to Cleveland for the second year so that they can engage in clinical experiences at one of our affiliated hospitals (The Cleveland Clinic, University Hospitals, MetroHealth Medical Center, The Cleveland VA). A few students are resident students for the first year and then move back home to take the elective courses over the Internet. A very few resident students take elective courses as Internet classes even when they are in Cleveland because of scheduling conflicts often caused by recruiting visits to medical school and other health professions programs.

Advantages: This option provides flexibility and availability of the courses/program to students who just are unable to move to Cleveland. This has a positive impact on enrollment. In the 2019 matriculating class, 45 students are taking the MSMP program over the Internet.
Disadvantages: Internet programs must be approved at the level of the university’s academic governing body. Internet courses must also be specifically approved. Extra effort must be expended to make the Internet courses/program as engaging as possible with standards that are equal for resident and Internet students. Students who take the program over the Internet often do so because they are working and cannot afford to leave their jobs. If they agree to decelerate the program (taking no more than 6 credit hours of courses/semester), their performance is essentially equal to resident students. Internet students cannot take advantage of the rich learning community that we have created for the MSMP students nor can they develop the personal friendships that naturally occur among students mutually engaged in a very demanding academic experience.


5. Allow students to begin the program or take the courses any semester.
The preferred starting semester for our program is fall semester. The core courses are available only fall and spring semester and must be taken in sequence. However, we have made the electives offered by the Physiology Department available all semesters. One semester/year, lectures in the electives are given live, are video recorded, and available to both resident and Internet students. The recorded lectures are used in the other two semesters to make the course available only over the Internet.

Advantages: This gives the students the flexibility of beginning the program at any time of the year. Since providing this option, we have increased our enrollment with ~10-15 students starting spring semester and another ~10 starting summer semester.
Disadvantages: When we originally established the program, we designed it to have the students take the core courses before they took the electives. Students starting spring and summer semesters can only take electives these semesters because the core physiology courses must be taken in sequence and are only offered once/year. Although we think that it is somewhat of a disadvantage for students to take electives before they have had the core physiology courses (they have not mastered core physiological principles before taking specialized courses), for some students it is actually an advantage because we can steer them to take elective courses which will better prepare them for the rigorous core physiology courses.

6. Discourage students from working during the course/program.
Our data shows a negative correlation between the number of hours a student works/week and their performance in the core physiology courses. During the second year in the program when students are taking electives, we actually do encourage students to work part time in a medically related position. This often takes the form of involvement in a clinical trial which is a very beneficial experience for our students. Student success in getting into a professional program is contingent upon a very good performance in our program. We consider a good performance being a final GPA of 3.5 and above. Students should be warned that working too many hours can jeopardize their chances of getting into a medical professional program.

Advantages: The MSMP program is essentially the last opportunity students have to enhance their credentials for admittance to a professional medical program. If they do not perform well in the program, they will have to move on to another career. Therefore, we must do everything to optimize their chances of success. Almost all students with a final GPA of 3.6 or above have been successful getting into a medical professional program. As their GPA tends more toward 3.0, their probability of success decreases.
Disadvantages: The students must incur additional debt in order to not work while they are enrolled in our program. If a student absolutely must work, we recommend that they decelerate the program, taking no more than 6 credit hours/semester. This often increases the time it takes the students to complete the program.


7. Choose an Internet-based Course Management System (CMS)All information about the course and learning resources for each lecture are posted at the beginning of the semester in the CMS. We have used both Blackboard and Canvas as CMSs with equal success.

Advantages: There is one easily accessible location where students can find all information about the course. Students expect all their learning resources to be in a CMS – this has become a requirement for all our courses.
Disadvantages: None


8. Provide a course syllabus
The course syllabus details which chapter in the assigned textbook will be covered during each class and lists any supplemental learning resources that will be useful to the students in the calendar of the CMS.

Advantages: Students know well ahead of time which lectures covering which textbook chapters will be given on any particular day.
Disadvantages: The details of the course must be established at the very beginning of a semester for posting in the CMS.


9. Only have experts teach their area of expertise
It is our preference to have an expert/active researcher in an area teach that area in the core courses. The electives are typically taught by faculty in their area of expertise.

Advantages: Because they are experts in the areas they teach, lecturers are best able to organize the material, create the learning resources associated with the lecture, write quiz and test questions, and answer student questions.
Disadvantages: This goal is not always achievable because there is not always a faculty member with a particular area of expertise. Therefore, faculty are sometimes asked to lecture outside their area of expertise. Experts in a particular area are not necessarily the best lecturers. Although they know the material, they may not present it in an optimal, engaging way.

Next week, the series will continue with the aspects that are important for implementation of teaching in physiology classrooms!

Dr. Nosek earned his B.S. in Physics from the University of Notre Dame in 1969 and his Ph.D. in Biophysics from The Ohio State University in 1973.  After post-doctoral research in the Cardiovascular Physiology Training Program in the Department of Physiology and Pharmacology at the Bowman Gray School of Medicine of Wake Forest University, he went to the Department of Physiology at the Medical College of Georgia (1976-1997) where he was the Coordinator of the Muscle Cell Biology Research Group (conducting research on the cellular basis of muscle fatigue) and the Coordinator of the Computer Aided Instruction Research Group (editing and being a section author of “Essentials of Human Physiology:  A Multimedia Resource” published by the DxR Group).  He served as Director of the medical physiology course taught to first year medical students and was the Director of the Departments Ph.D. program.  In 1997, he moved to Case Western Reserve University School of Medicine where he was Associate Dean of Biomedical Information Technologies (creating the Computer-Based Integrated Curriculum through 2006) and Professor of Physiology and Biophysics until he retired in 2014 becoming Professor Emeritus.  He served as the department’s Director of Medical Education.  He was founding Director of the MS in Medical Physiology Program at CWRU from 2010 – 2019 when he became Director Emeritus.

December 23rd, 2019
Backward planning of lab course to enhance students’ critical thinking
Zhiyong Cheng, PhD
Food Science and Human Nutrition Department
The University of Florida

Development of critical thinking and problem-solving skills hallmarks effective teaching and learning [1-2]. Physiology serves as a fundamental subject for students in various majors, particularly for bioscience and pre-professional students [1-8]. Whether they plan on careers in science or healthcare, critical thinking and problem-solving skills will be keys to their success [1-8].

Backwards course design is increasingly employed in higher education. To effectively accomplish specific learning goals, instructions are to begin course development with setting learning objectives, then backwardly create assessment methods, and lastly design and deliver teaching and learning activities pertaining to the learning objectives and assessment methods. In terms of development of critical thinking and problem-solving skills, a lab course constitutes an excellent option to provide opportunities for instructors and students to explore innovative paths to their desired destinations, i.e., to accomplish specific learning goals.

In a traditional “cookbook” lab setting, detailed procedures are provided for the students to follow like cooking with a recipe. Students are usually told what to do step-by-step and what to expect at the end of the experiment. As such, finishing a procedure might become the expected goal of a lab course to the students who passively followed the “cookbook”, and the opportunity for developing critical thinking skills is limited. In a backwards design of a lab course; however, the instructor may engage the students in a series of active learning/critical thinking activities, including literature research, hypothesis formulation, study design, experimental planning, hands-on skill training, and project execution. Practically, the instructor may provide a well-defined context and questions to address. Students are asked to delve into the literature, map existing connections and identify missing links for their project to bridge. With the instructor’s guidance, students work together in groups on hypothesis development and study design. In this scenario, students’ focus is no longer on finishing a procedure but on a whole picture with intensive synthesis of information and critical thinking (i.e., projecting from generic context to literature search and evaluation, development of hypothesis and research strategy, and testing the hypothesis by doing experiments).

An example is this lab on the physiology of fasting-feeding transitions. The transition from fasting to feeding state is associated with increased blood glucose concentration. Students are informed of the potential contributors to elevated blood glucose, i.e., dietary carbohydrates, glycogen breakdown (glycogenolysis), and de novo glucose production (gluconeogenesis) in the liver. Based on the context information, students are asked to formulate a hypothesis on whether and how hepatic gluconeogenesis contributes to postprandial blood glucose levels. The hypothesis must be supported by evidence-based rationales and will be tested by experiments proposed by students with the instructor’s guidance. Development of the hypothesis and rationales as well as study design requires students to do intensive information extraction and processing, thereby building critical thinking and problem-solving skills. Students also need to make sound judgments and right decisions for their research plans to be feasible. For instance, most students tend to propose to employ the hyper-insulinemic-euglycemic clamp because the literature ranks it as a “gold standard” method to directly measure hepatic gluconeogenesis. However, the equipment is expensive and not readily accessible, and students have to find alternative approaches to address these questions. With the instructor’s guidance, students adjust their approaches and adopt more accessible techniques like qPCR (quantitative polymerase chain reaction) and Western blotting to analyze key gluconeogenic regulators or enzymes. Engaging students in the evaluation of research methods and selection helps them navigate the problem-solving procedure, increasing their motivation (or eagerness) and dedication to learning new techniques and testing their hypotheses. Whether their hypotheses are validated or disproved by the results they acquire in the end, they become skillful in thinking critically and problem solving in addition to hands-on experience in qPCR and Western blotting.

Evidently, students can benefit from backwards planning in different ways because it engages them in problem-based, inquiry-based, and collaborative learning — all targeted to build student problem solving skills [1-8]. For a typical lab course with pre-lab lectures; however, there is only 3-6 hours to plan activities. As such, time and resources could be the top challenges to implement backwards planning in a lab course. To address this, the following strategies will be of great value: (i) implementing a flipped classroom model to promote students’ pre- and after-class learning activities, (ii) delivering lectures in the lab setting (other than in a traditional classroom), where, with all the lab resources accessible, the instructor and students have more flexibility to plan activities, and (iii) offering “boot camp” sessions in the summer, when students have less pressure from other classes and more time to concentrate on the lab training of critical thinking and problem solving skills. However, I believe that this is a worthwhile investment for training and developing next-generation professionals and leaders.

References and further reading

[1] Abraham RR, Upadhya S, Torke S, Ramnarayan K. Clinically oriented physiology teaching: strategy for developing critical-thinking skills in undergraduate medical students. Adv Physiol Educ. 2004 Dec;28(1-4):102-4.

[2] Brahler CJ, Quitadamo IJ, Johnson EC. Student critical thinking is enhanced by developing exercise prescriptions using online learning modules. Adv Physiol Educ. 2002 Dec;26(1-4):210-21.

[3] McNeal AP, Mierson S. Teaching critical thinking skills in physiology. Am J Physiol. 1999 Dec;277(6 Pt 2):S268-9.

[4] Hayes MM, Chatterjee S, Schwartzstein RM. Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit. Ann Am Thorac Soc. 2017 Apr;14(4):569-575.

[5] Nguyen K, Ben Khallouq B, Schuster A, Beevers C, Dil N, Kay D, Kibble JD, Harris DM. Developing a tool for observing group critical thinking skills in first-year medical students: a pilot study using physiology-based, high-fidelity patient simulations. Adv Physiol Educ. 2017 Dec 1;41(4):604-611.

[6] Bruce RM. The control of ventilation during exercise: a lesson in critical thinking. Adv Physiol Educ. 2017 Dec 1;41(4):539-547.

[7] Greenwald RR, Quitadamo IJ. A Mind of Their Own: Using Inquiry-based Teaching to Build Critical Thinking Skills and Intellectual Engagement in an Undergraduate Neuroanatomy Course. J Undergrad Neurosci Educ. 2014 Mar 15;12(2):A100-6.

[8] Peters MW, Smith MF, Smith GW. Use of critical interactive thinking exercises in teaching reproductive physiology to undergraduate students. J Anim Sci. 2002 Mar;80(3):862-5.

Dr. Cheng received his PhD in Analytical Biochemistry from Peking University, after which he conducted postdoctoral research at the University of Michigan (Ann Arbor) and Harvard Medical School. Dr. Cheng is now an Assistant Professor of Nutritional Science at the University of Florida. He has taught several undergraduate- and graduate-level courses (lectures and lab) in human nutrition and metabolism (including metabolic physiology). As the principal investigator in a research lab studying metabolic diseases (obesity and type 2 diabetes), Dr. Cheng has been actively developing and implementing new pedagogical approaches to build students’ critical thinking and problem-solving skills.

December 9th, 2019
Building bridges: Medical physiology teaching in China
Ryan Downey, Ph.D.
Assistant Professor
Co-Director, Graduate Physiology Program
Team Leader, Special Master’s Program in Physiology


Department Pharmacology and Physiology
Georgetown University Medical Center
Washington, D.C.

The Chinese Society of Pathophysiology hosted the 2019 Human Functional Experiment Teaching Seminar and the Second Human Physiology Experimental Teaching Training Course 25-27 October. Across two and a half days, educators from across China met at Jinzhou Medical University in the province of Liaoning to discuss and workshop the latest ideas in active learning and interactive teaching techniques. In many ways, especially in terms of the esteem in which this meeting is held by its attendees, this meeting was not dissimilar from the APS Institute on Teaching and Learning, which will hold its next biennial meeting this coming June in Minneapolis. For the 2019 meeting, the organizers decided to invite an international speaker, which is how I found myself on a plane headed to China. As part of my visit, not only did I get to attend the workshop hosted at Jinzhou Medical University, but also I was hosted by several of the meeting organizers at their home institutions to see their facilities. In this writeup, I will reflect on some of the observations that I made during the many different conversations that I had with the educators participating in the meeting.

The most common question that I got from my hosts was, “What kinds of technology do you use in your classrooms and labs and how do you use them?” What surprised me the most about this question wasn’t the actual question itself, but the perception that many of the educators at the meeting held that they were lagging behind in the implementation of using technologies as   teaching and learning tools. The large majority of teaching spaces that I visited were equipped with much the same technology as any classroom or lecture hall that I would find in an American university: computers, projectors, large-screen LCD displays, and power at every seat to accommodate student personal electronic devices. While there was the occasional technological oddity, such as a computer here or there that was still running Windows XP, the technology available to these educators was very much on par with the technology I would expect at any modern university, which is why I was surprised that the educators had the perception that they were behind in implementing different technologies. In my conversations with them, I discussed the use of audience response systems like iClicker and PollEverywhere as well as interactive elements like gamification through websites such as Kahoot!, but my emphasis in these conversations was exactly the same as I have with educators at home: we need to make sure that there is a sound pedagogical basis for any engagement we use with our students and that the technology doesn’t matter. I can use 3×5 colored  index cards to create an audience response system that functions as well as (or sometimes even better!) than clickers because no one has any problems with the WiFi while using a 3×5 card. The technology facilitates our instruction and should never drive it for the sake of itself.

A common thread of many discussions was the use of internet technologies in teaching. While there is much to be said about the limitations of the ‘Great Firewall’ of China and the amount of government regulation that occurs over their communications, it’s important to note how little these limitations affect the day-to-day activities of the majority of citizens. There are Chinese versions of almost every single internet convenience that we would take for granted that function at least as well as our American versions. Their social media system has grown to the point that many international users are engaging on their platforms. There are food delivery apps and the local taxi services have all signed on to a common routing system (at least in Beijing) that functions in a similar way to Uber or Lyft. In a side-by-side comparison between my phone and one of the other meeting participants, there is near feature parity on every aspect. From an educational standpoint, however, there are some notable differences. The lack of access to Wikipedia is a notable gap in a common open resource that many of us take for granted and there is not yet a Chinese equivalent that rivals the scope or depth that Wikipedia currently offers. Another key area in which internet access is limited is their access to scholarly journals. This lack of accessibility is two-fold, both in the access to journals because of restrictions on internet use as well as the common problem that we are already familiar with of journal articles being locked behind paywalls. The increasing move of journals to open access will remove some of these barriers to scholarly publications, but there are still many limits on the number and types of journal articles that educators and learners are allowed through Chinese internet systems.

The most common request that I received while attending the educators meeting was, “Tell me about the laboratories you use to teach physiology to your medical students.” I think this is the largest difference in teaching philosophy that I observed while in China. The teaching of physiology is heavily based on the use of animal models, where students are still conducting nerve conduction experiments with frogs, autonomic reflex modules with rabbits, and pharmacological studies in rats. These are all classic experiments that many of us would recognize, but that we rarely use anymore. One key area of the workshops were modules designed to replace some of these classic animal experiments with non-invasive human-based modules, such as measuring nerve conduction velocities using EMG. My response that the majority of our physiology teaching is now done through lecture only was met with a certain degree of skepticism from many of them because the use of labs is so prevalent throughout the entire country. Indeed, the dedication of resources such as integrated animal surgical stations runs well into the hundreds of thousands of dollars per laboratory room set up, and to facilitate the entirety of students each year, there are multiple labs set up at each university. As the use of non-invasive human experiments expands, an equal amount of space and resources are being given to setting up new learning spaces with data acquisition systems and computers for this new task. In this area, I think that we have much to gain from our Chinese counterparts as many of the hardest concepts in physiology are more easily elucidated by giving students the space to self-discover in the lab while making physiological measurements to fully master ideas like ECG waves and action potential conduction.

Upon returning home, I have been asked by nearly everyone about my travel experiences, so I think it may be worth a brief mention here as well. I cannot overstate the importance of having a good VPN service setup on all of your electronic devices before traveling. Using a VPN, I had near-normal use of the internet, including Google and social media. My largest problem was actually trying to access local Chinese websites when my internet address looked like I was outside of the country. I have had good experience with NordVPN, but there are several other very good options for VPN service. Carrying toilet paper is a must. There are lots of public restrooms available everywhere in the city, but toilet paper is either not provided or available only using either social media check-ins or mobile payments. For drinking water, I traveled with both a Lifestraw bottle and a Grayl bottle. This gave me options for using local water sources and not having to rely on bottled water. The Lifestraw is far easier to use, but the Grayl bottle has a broader spectrum of things that are filtered out of the water, including viruses and heavy metals, which may be important depending on how far off the tourist track you get while traveling. My final tip is to download the language library for a translator app on your mobile device for offline use so that you can communicate with others on the streets. When interacting with vendors and others not fluent in English, it was common to use an app like Google Translate to type on my device, show them the translated results, and they would do the same in reverse from their mobile device.

One of the themes across the meeting was building bridges — bridges between educators, bridges between universities, bridges across the nation and internationally. I’m glad to have had the opportunity to participate in their meeting and contribute to their conversation on building interactive engagement and human-focused concepts into the teaching of physiology. Overall, the time that I spent talking to other educators was useful and fantastic. Everyone I met and interacted with is enthusiastic and excited about continuing to improve their teaching of physiology. I left the meeting with the same renewed energy that I often feel after returning from our ITL, ready to reinvest in my own teaching here at home.

Ryan Downey is an Assistant Professor in the Department of Pharmacology & Physiology at Georgetown University. As part of those duties, he is the Co-Director for the Master of Science in Physiology and a Team Leader for the Special Master’s Program in Physiology. He teaches cardiovascular and neuroscience in the graduate physiology courses. He received his Ph.D. in Integrative Biology from UT Southwestern Medical Center. His research interests are in the sympathetic control of cardiovascular function during exercise and in improving science pedagogy. When he’s not working, he is a certified scuba instructor and participates in triathlons

November 25th, 2019
Make Cooperation Great Again: Peer Assisted Learning as a Strategy to Develop Collaboration in Medical Education
Oriana Escobar-López 
Last year medical student
Universidad de los Andes, School of Medicine

In medical school, it is somewhat of a tradition to learn entirely new concepts from multiple disciplines in a single day. And of course, we are being assessed on these topics frequently. Sometimes, you encounter an idea you don’t get. You feel like you are the only one of your classmates who doesn’t understand, and you feel too ashamed to ask the professor a question. Before you know it, you find yourself cramming all the content the night before the test, searching on YouTube for videos that explain the subject, and even start to wonder if you honestly need to become a doctor at this point in your life. 

As medical students, we are continually facing challenges when it comes to learning, and we are regularly seeking different methods to approach new subjects in ways that can help us understand in a better and more efficient fashion. In that process, we often find ourselves lost, without knowing where to begin or which course materials are best. Professors usually try to help. Yet we sometimes feel they do not quite understand our concerns. At this point, only another student who understands the struggles, someone who recently faced the same challenges can help us get through it. There comes a time when we, the students, must not only own up to our education process but to that of our peers. This is the core of Peer-Assisted Learning (PAL). This learning methodology is not new. Ancient philosophers used to question each other as a way of discovering new truths (1). It has since been developed and implemented in several disciplines, including medical learning.

For the past decade, we have seen an explosion in the amount of literature exploring the benefits (and challenges) that come along with PAL. Many medical schools have implemented some variation of it in their programs. For instance, at our school, the Universidad de los Andes, students who excel in a subject are hired as teaching assistants, to help with the organization of the course and act as a sort of counselor for students. 

Interestingly, a variation of this approach has been implemented in our medical pharmacology and physiology courses. In our strategy, students with higher grades tutor their peers who have inadequate performance. This strategy appears to help underperforming students to improve their grades and study methods, and has been received with great enthusiasm by the students.

But what makes this so appealing? To answer that question, we must first know a bit of the theory behind PAL. Peer Assisted Learning is defined by Topping as “the acquisition or knowledge and skill through active helping and supporting among status equals as matched companions” (2), and its main traits are the shared background of tutors and tutees and the fact that tutors are not experts in teaching. These two qualities give way to a more informal setting that offers tutees the confidence to express their concerns and freely ask questions (3).

There are several benefits of PAL for both tutors and tutees, and even some for the schools. For tutors, the time and effort it takes to prepare each teaching session makes them review the material and reinforce the concepts. After all, “to teach is to learn twice” (Joseph Joubert). On top of that, it appears that teaching modifies the way a person approaches certain topics, which might lead to a better understanding (2). Tutors also develop a set of abilities, such as leadership, self-confidence, and empathy, all necessary in the medical field. Being taught by peers also brings advantages for tutees; the atmosphere is much more relaxed, which helps them overcome their fears and express their opinions with more confidence. Furthermore, tutors act as role models and this may encourage tutees to become tutors themselves as well. Finally, for schools, PAL may be seen as a cost-effective and practical strategy to tend to the necessities of a growing student body (2).

However I believe, that overall the most essential element that PAL provides is generating a culture of cooperation, solidarity and empathy among the learners. We need to start shifting the current paradigm that forces students to compete with each other as a strategy to promote learning. Collaboration between peers may bring far more advantages than competing not only in terms of personal gain but also for the entire learning community. Robert D. Putnam, an American sociologist and political scientist developed a theory centered around the importance of investing in Social Capital; “the features of social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit” (4). 

Even though Putnam developed his work in the field of civil engagement and the decline in forms of association in the United States in the last few decades, I consider that the concept of Social Capital also applies to the medical learning setting. If we create an environment in which older or more experienced students feel it is their responsibility to share what they know with others, and students who are struggling feel confident enough to ask for help, then the faculty as a whole benefit from this cooperation. 

Medical school isn´t what most people would call easy, and I have come to learn that no one is good at every single thing. And, eventually, you will come across a challenge. But that does not mean you must face it alone. More often than not, you will find someone who already went through the same experience. Peer-Assisted Learning provides a framework that allows students to connect and work in a level that offers an atmosphere of collaboration, and as we have seen, a broader culture of cooperation. Furthermore, in the future, you will no longer be a student, but you will (hopefully) become a resident and someday you will have to guide others as you once needed to be guided yourself. Perhaps if we make cooperation a habit, we wouldn´t struggle as much in an already difficult (yet rewarding, I must add) career. 

References:

  1. Walberg HJ. Foreword. In: Topping K, Ehly S, editors. Hrsg. Peer-Assisted Learning. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 1998. p. ix–xi. 
  2. Herrmann-Werner A, Gramer R, Erschens R, Nikendei C, Wosnik A, Griewatz J, et al. Peer-assisted learning (PAL) in undergraduate medical education: An overview. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen. 2017;121:74–81.
  3. Loda T, Erschens R, Loenneker H, Keifenheim KE, Nikendei C, Junne F, et al. Cognitive and social congruence in peer-assisted learning – A scoping review. Plos One. 2019Sep;14(9)
  4. Putnam, Robert (1995) ‘Bowling Alone: America’s Declining Social Capital’, Journal of Democracy 6. 
  5. Gillinson S. Why Cooperate? A Multi-Disciplinary Study of Collective Action. Overseas Development Institute [Internet]. 2004Feb [cited 2019Oct21]; Available from: https://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/2472.pdf

The idea for this blog was suggested by Ricardo A. Pena Silva M.D., Ph.D. Professor of Physiology and Pharmacology at The Universidad de los Andes, College of Medicine, who provided guidance to Oriana in the writing of this entry. For further discussion on this topic he can be contacted at rpena@uniandes.edu.co. Twitter: @medicinart

Oriana Escobar is a last year medical student at the Universidad de los Andes School of Medicine in Bogotá, Colombia. There, she has been a teaching assistant for the course of pharmacology numerous times. She is interested in medical education and public health, as well as anesthesiology. Outside the medical setting, she enjoys reading, swimming and traveling.

November 11th, 2019
Which Level of Students are Best Suited for Flipped Learning?
Chaya Gopalan, PhD, FAPS
Associate Professor, Departments of Applied Health, Primary Care and Health Systems
Southern Illinois University Edwardsville

The flipped classroom (FC) is a student-centered teaching method that is embraced by educators in recent years for several reasons. According to Bergmann and Sams (2012), FC accommodates students’ busy schedules, helps struggling students, and allows self-pacing. In this teaching method, students are exposed to content prior to class in the form of assignments and the class time is structured to include mini-lectures so that students have opportunities to ask questions and engage with teachers. Additionally, the instructors can also administer learning activities, such as quizzes and group work so that students can gain a much deeper understanding of the content when compared to lectures alone. Khan Academy is an example of a FC that can be utilized by students ranging from elementary to high school.

A similar situation is true in the higher education arena where FC is introduced in courses ranging from community college all the way up to the graduate level courses in a wide variety of programs and professions. However, it is unclear as to which level, in particular, would benefit from the FC model the most. Ideally, college freshmen are open-minded and are able to adapt quickly to the FC approach thus being better prepared for the rest of their college years. Nevertheless, in a study conducted in China, for example, Li (2018) found that many freshmen do not utilize pre-class assignments and therefore are not prepared for in-class activities. For some freshmen, FC is not a new teaching method because they experienced it in their high schools. Introducing FC in the third and fourth years of undergraduate education, once again, could be argued as either “too late” because they have not been exposed to FC thus far, or “most ideal” because these students are more mature and do their pre-class work more reliably.   

Students’ experiences of the FC model can vary greatly. As part of an NSF-funded project, data collected from freshmen and sophomore STEM classrooms at a community college suggested that students’ perceptions, such as “learned more in the FC classroom” and “more engaged” were far less common when compared to the same level of students in a four-year institution. At the same time, when doctoral students entering a Nurse Anesthesia program were given a similar experience with FC, the response was overwhelmingly positive. On the other hand, for senior students in the Exercise Science program, their perception of FC was stronger than the freshmen-sophomore group but not as strong as that of the graduate students. Since the age of the freshmen-sophomore students at the community college varies considerably, assessing the most critical determinant can be challenging.

In summary, the students that achieve higher levels of educational experience seem to be able to utilize the FC method to the fullest extent. It must be noted that the majority of our students are experiencing FC for the very first time. Since this instructional approach demands regular study habits and time commitment while minimizing procrastination, students may take time to develop new learning strategies to be able to value their experience. Whether students respond similarly, provided they are exposed to FC classes more frequently across the curriculum, is yet to be seen.

Acknowledgements: Part of the data shared in this blog is funded by NSF-IUSE grant DUE – 1821664 “Examining Faculty Attitudes and Strategies that Support Successful Flipped Teaching”.

References

Bergmann, J., & Sams, A. (2012). Flip your classroom: Reach every student in every class every day. Eugene, Or: International Society for Technology in Education.
Li, Yi. (2018). Current problems with the prerequisites for flipped classroom teaching—a case study in a university in Northwest China. Smart Learning Environments, 5:2

Dr. Chaya Gopalan received her PhD in Physiology from the University of Glasgow, Scotland. Upon completing two years of postdoctoral training at Michigan State University, she began her teaching career at St. Louis Community College. After a short tenure at St. Louis College of Pharmacy, Dr. Gopalan joined the departments of Applied Health, Primary Care and Health Systems at Southern Illinois University Edwardsville. Her teaching is in the areas of anatomy, physiology, and pathophysiology at both undergraduate and graduate levels. Dr. Gopalan has been practicing evidence-based teaching where she has tested team-based learning methodology, case-based learning methodology and most recently, the flipped classroom. She has received several research grants in pursuing her research interests.

October 28th, 2019
Emerged Idea Led to a Unique Experience in Elephant’s City
Suzan A. Kamel-ElSayed, VMD, MVSc, PhD
Associate Professor, Department of Foundational Medical Studies
Oakland University

In May 2019, the physiology faculty at the Oakland University William Beaumont School of Medicine Department of Foundational Medical Studies received an email from Dr. Rajeshwari, a faculty member in JSS in a Medical College in India.

While Dr. Rajeshwari was visiting her daughter in Michigan, she requested a departmental visit to meet with the physiology faculty. Responding to her inquiry, I set up a meeting with her and my colleagues where Dr. Rajeshwari expressed her willingness to invite the three of us to present in the 6th Annual National Conference of the Association of Physiologists of India that was held from Sept. 11-14, 2019, in Mysuru, Karnataka, India.

The conference theme was: “Fathoming Physiology: An Insight.” My colleague then suggested a symposium titled “Physiology of Virtue,” where I could present the physiology of fasting since I fast every year during the month of Ramadan for my religion of Islam. To be honest, I was surprised and scared at my colleague’s suggestion. Although I fast every year due to the Quranic decree upon all believers, I was not very knowledgeable of what fasting does to one’s body. In addition, I faced the challenge of what I would present since I did not have any of my own research or data related to the field of fasting. Another concern was the cultural aspect in talking about Ramadan in India and how it would be received by the audience. However, willing to face these challenges, I agreed and admired my colleague’s suggestion and went forward in planning for the conference.

After Dr. Rajeshwari sent the formal invitation with the request for us to provide an abstract for the presentation, I started reading literature related to fasting in general. Reading several research articles and reviews, I was lost in where to begin and what to include. I began to ponder many questions: How will I present fasting as a virtue? Should I bring in religious connections? Will I be able to express spiritual aspects from a Muslim’s perspective? I decided that the aim of my presentation would be to describe how a healthy human body adapts to fasting, and the outcomes that practicing fasting has on an individual level and on the society as a whole. In addition, I found that focusing on the month of Ramadan and etiquettes of fasting required from Muslims had many physiological benefits and allowed me to have a real-world example in which fasting is present in the world.

Visiting India and engaging with physiologists from all over India was a really rich experience. The hospitality, generosity and accommodation that were provided was wonderful and much appreciated. The conference’s opening ceremony included a speech from the University Chancellor who is a religious Hindu Monk, along with Vice Chancellors, the organizing chair, and the secretary. In addition, a keynote speech on the physiological and clinical perspectives of stem cell research was presented by an Indian researcher in New Zealand. I was also able to attend the pre-conference workshops “Behavioral and Cognitive Assessment in Rodents” and “Exercise Physiology Testing in the Lab and Field” free of charge.

For my presentation, I included the definition, origin and types of fasting. In addition, I focused on the spiritual and physical changes that occur during Ramadan Intermittent Fasting (RIF). Under two different subtitles, I was able to summarize my findings. In the first subtitle, “Body Changes During RIF,” I listed all the changes that can happen when fasting during Ramadan. These changes include: activation of stress induced pathways, autophagy, metabolic and hormonal changes, energy consumption and body weight, changes in adipose tissue, changes in the fluid homeostasis and changes in cognitive function and circadian rhythm. In the second subtitle, “Spiritual Changes During RIF,” I presented some examples of spiritual changes and what a worshipper can do. These include development of character, compassion, adaptability, clarity of mind, healthy lifestyle and self-reflection. To conclude my presentation, I spoke of the impacts RIF has on the individual, society, and the global community.

In conclusion, not only was this the first time I visited India, but it was also the first time for me to present a talk about a topic that I did not do personal research on. Presenting in Mysuru not only gave me a chance to share my knowledge, but it allowed me to gain personal insight on historical aspects of the city. It was a unique and rich experience that allows me to not hesitate to accept similar opportunities. I encourage that we, as physiology educators, should approach presenting unfamiliar topics to broaden our horizons and enhance our critical thinking while updating ourselves on research topics in the field of physiology and its real-world application.  Physiology education is really valued globally!

Suzan Kamel-ElSayed, VMD, MVSc, PhD, received her bachelor of Veterinary Medicine and Masters of Veterinary Medical Sciences from Assiut University, Egypt. She earned her PhD from Biomedical Sciences Department at School of Medicine in Creighton University, USA. She considers herself a classroom veteran who has taught physiology for more than two decades. She has taught physiology to dental, dental hygiene, medical, nursing, pharmacy and veterinary students in multiple countries including Egypt, Libya and USA. Suzan’s research interests are in bone biology and medical education. She has published several peer reviewed manuscripts and online physiology chapters. Currently, she is an Associate Professor in Department of Foundational Medical Studies in Oakland University William Beaumont School of Medicine (OUWB) where she teaches physiology to medical students in organ system courses. Suzan is a co-director of the Cardiovascular Organ System for first year medical students. Suzan also is a volunteer physiology teacher in the summer programs, Future Physicians Summer Enrichment Program (FPSP) and Detroit Area Pre-College Engineering Program (DAPCEP) Medical Explorers that are offered for middle and high school students. She has completed a Medical Education Certificate (MEC) and Essential Skills in Medical Education (ESME) program through the Association for Medical Education in Europe (AMEE) and Team-Based Learning Collaborative (TBLC) Trainer- Consultant Certification. She is also a member in the OUWB Team-Based Learning (TBL) oversight team. Suzan is an active member in several professional organizations including the American Physiological Society (APS); Michigan Physiological Society (MPS); International Association of Medical Science Educators (IAMSE); Association of American Medical Colleges (AAMC); Team Based Learning Collaborative (TBLC); Egyptian Society of Physiological Sciences and its Application; Egyptian Society of Physiology and American Association of Bone and Mineral Research (ASBMR).

October 14th, 2019
Using Quests to Engage and Elevate Laboratory Learning
Sarah Knight Marvar, PhD
American University

My students, like me, enjoy a challenge. Occasionally this challenge comes in the form of staying on track, using our lab time efficiently to achieve the learning outcomes and staying engaged with the material. There are specific topics that we cover in our undergraduate human anatomy and physiology course, such as the skeletal system, that had become a little dry over time. Classes occasionally included students sitting at desks looking disinterestedly at disarticulated bones glancing at their lab manual and then checking their phones. I felt that the students were not getting enough out of our laboratory time and weren’t nearly as excited as I was to be there!

With other faculty members I recently devised some new laboratory activities that include a series of quests that closely resemble a mental obstacle course, to try to encourage engagement with the material and make our learning more playful and memorable. There may also be some healthy competition along the way.

I teach an undergraduate two semester combined anatomy and physiology course, in which I lead both the lecture and laboratory portions. Students who are enrolled in this course are majoring in Biology, Neuroscience, Public Health and Health Promotions. Many of the enrolled students are destined for graduate school programs such as Medicine, Nursing, Physical Therapy, Physicians Assistant and PhD Programs. An example of the quest format we used recently in a bone laboratory is described here.

The Quests

The laboratory is set up with multiple quest stations that each represent a multi-step task on areas within the overarching laboratory topic. All of the tasks are designed to enable students to achieve the learning outcomes of the laboratory in an engaging way. The quest stations are designed to encourage the students to physically move around the laboratory in order to interact with other students, touch the exhibits, explore case studies, complete illustrations and build models. Each student begins with a quest guide which provides instructions and upon which they take notes, answer questions and complete drawings. Students move at their own pace and work in self-selected pairs or groups of three. They are able to ask for assistance at any stage of a quest from either of two faculty members present.   

Clinical case studies

Because of the students’ interest in patient care, we use clinical case studies as a major component of the obstacle course. X-ray images of a variety of pathological conditions as well as healthy individuals challenged students’ ability to identify anomalies in bone structure and surgery outcomes. The images that we used included a skull of a newborn showing clearly the fontanelles, an example of osteoporosis and joint replacement surgery. Students are required to identify anatomical location of the image as well as any anomalies, pathology or points of interest. Because of the student demographic of this class, many of them are destined to enter healthcare professions, they are particularly interested in this quest and are invested in solving the mystery diagnoses.

The Creative Part

Illustrations

An example of a student’s histological drawing.

The coloring pencils and electric pencil sharpener have come into their own in the laboratory and like Grey’s Anatomy illustrator Henry Vandyke Carter created before them, amazing anatomically accurate drawings are appearing on the page. Histology has been a particularly challenging aspect of our course for students with little previous exposure to sectioned specimens. In an attempt to allow students to really process what they are looking at and reflect on the tissue function I have asked students to draw detailed images of the histological specimens, label cell types and reflect on specific cell functions. This exercise aims to elevate the student’s ability to look closely at histological specimens and gain a better understanding of what they are observing and contemplate specific cell function.

Another quest involves categorizing bones and making illustrations of them, making note of unique identifying features and their functions.

3-D Modeling

Student synovial joint models with notes on function

Reminiscent of scenes from my three year old’s birthday party, I brought out the modeling clay and tried to stifle the reflex instruction to “don’t mix the colors”! Students were tasked with creating a 3-dimensional model of structures such as synovial joints. This is a particularly successful exercise in which students work with colored modeling clay to construct models of joints and label parts of the joint and describe the function of each part. This allows students to consider the relationship between the structure and function and move beyond looking at two-dimensional images from their textbooks and lecture slides. Students submit images of their completed models to the faculty for successful completion of the quest.

Other quest stations that were part of this particular laboratory session included Vertebrae Organizing, Mystery Bone Identification and Bone Growth Mechanisms.

One of the primary things that I learned from this exercise was that designing game-like scenarios in the classroom is far more enjoyable and entertaining for me as well as for the students, a win-win scenario. Overall from the perspective of the teaching faculty, the level of engagement was significantly increased compared with previous iterations of the class. The quality of the work submitted was high and in addition, this quest-based laboratory design is suitable for a wide range of topics and activities. I am currently designing a muscle physiology laboratory in a similar format that will include an electromyogram strength and cheering station as well as a sliding filament muscle contraction student demonstration station. In reflection I feel that my personal quest to find a novel and interesting way for the students to learn about bones was successful. Now onto the next quest……

Sarah Knight Marvar received her BSc in Medical Science and PhD in Renal Physiology from the University of Birmingham, UK. Sarah is currently a Senior Professorial Lecturer and Assistant Laboratory Director in the Biology Department at American University in Washington DC. Sarah teaches undergraduate Anatomy and Physiology, general biology classes as well as a Complex Problems class on genetic modification to non-majors as part of the AU Core program. Sarah’s research interests include using primary research literature as a teaching tool in the classroom, open educational resources and outreach activities.

October 1st, 2019
Physiology Bumper Stickers for Teaching and Learning
Alice R. Villalobos, BS, PhD
Texas Tech University

As teachers we hope students remember and apply all the physiology they learned in our class.  However, many undergraduate students hope simply to get through this semester of physiology and their other courses.  They dread the amount of material and that ‘so many things go on in the body at one time.’  I asked myself what could be integrated into lecture or lab to help students better learn material in class, study more effectively on their own and ideally, improve recall when taking exams.  Around this time, I attended a teaching workshop focused on short activities and simple tools that could be incorporated into lectures to facilitate learning and recall.  One tool was the ‘bumper sticker’. 

Similar to an actual bumper sticker, the teaching bumper sticker is a short memorable phrase or slogan that encapsulates a thought, principle, or concept.  In this case, a bumper sticker helps students learn and remember a concept or principle.  In all areas of life, we use short sayings or one-liners often of unknown derivation that convey a profound or funny, classic or clever, instructional or encouraging thought.  ‘Righty tighty, lefty loosey.’ means turn the screw to right to tighten and left to loosen.  “I before E except after C.” with the addendum, “… and in words, such as protein or weight.”  Could bumper stickers work in a physiology course?  I already borrowed “Water follows sodium; sodium doesn’t follow water.” from my undergraduate professor.  We all develop short phrases while working on lectures, reading physiology papers and books, or on the fly during lecture.  

Recently, I began using bumper stickers in a more organized manner.  I took a sheet of lined paper, wrote ‘Bumper Stickers for A&P-II’ on the top, and made plenty of copies.  On the first day of class I discussed tips to improve learning and study habits.  I explained the bumper sticker was a teaching/learning tool and gave each student a sheet.  I admitted it was an experiment, but my intention was to give them short phrases to refer to and contemplate when studying on their own or spark a memory on an exam.  That very day we started glycolysis.  The first bumper sticker was “You must spend an ATP to make ATP.”  I explained the first step in glycolysis is phosphorylation, using a phosphate from ATP.  Despite some initial skepticism, bumper stickers caught on and helped many students. 

Rather than repeating your explanation verbatim, students must accurately explain concepts to themselves and others in their own words.  When students study with a partner or in groups, they can refer back to the bumper sticker along with lecture notes, diagrams and textbook to explain the respective concept to each other in their own words and peer-correct.  When students are teaching each other, they are truly ‘getting it’.  Granted, it is essential that students use more exact and scientific vocabulary to describe a mechanism or concept, as is true for any discipline.  For most students this won’t happen the very first time they explain the concept.  Learning physiology or any subject is a process; developing the vocabulary is part of that process.  A memorable bumper sticker is a prompt for stimulating discussion – verbal communication in the context of learning a given physiological mechanism and developing the vocabulary of physiology. 

There is no established technique for the initial delivery of a bumper sticker phrase.  However, its two-fold purpose as a teaching/learning tool is to help students understand and remember a concept; thus, the phrase and initial proclamation must be memorable.  Based on my hits and misses, here are several tips.  First, keep it short, ideally 10 words or less.  Second, timing is key.  Similar to a joke, timing is important but varies with topic and teaching style.  Some use the phrase as a teaser to introduce a topic; others use it to summarize key points.  Third, be as direct as possible and capture students’ full attention.  Some write the phrase on the board or slide and make an announcement, “Listen up.  Write this down.”  Fourth, look directly at your students and state the phrase clearly with meaning, effective voice inflection, dramatic tone, appropriate pause, facial expression, hand gesturing, and/or a little physical comedy.  Fifth, use accurate and scientific terms to explain the meaning of the phrase as it applies to the physiological concept.  This is absolutely critical.  Left to interpretation, students might misunderstand the actual physiological concept.

Bumper stickers for better study and testing strategies

*Use common sense at all times, especially on test day.* At times, students forget obvious and intuitive things.  For example, when applying Boyle’s Law to respiration, don’t forget to breathe.  I remind students that lung volume and intrapulmonary pressure will change such that when we inhale air flows in, and when we exhale air flows out.  Physical laws applied to physiological mechanisms explain relationships among different components of a mechanism, e.g., the pressure of a quantity of gas to its volume.  I assure them, they can and will learn the fundamental physics on which Boyle’s law is based, but keep it simple and remember – when you inhale air flows in, when you exhale air flows out. 

            *Understand the question, before you answer it.* My PhD advisor shared this pearl of wisdom before my qualifying exam.  I encourage students to calmly, slowly and deliberately read the entire question.  On any multiple choice or essay exam, they must be certain of what is being asked, before answering a question.  Do not stop reading the question until you come to a period, question mark or exclamation point.  Students are concerned about wasting precious time.  Slowing down just a bit to answer correctly is worth the time and decreases the odds of second guessing or having to go back to the question.  I make another pitch for reading the text book.  It is a way to practice reading calmly and deliberately and catching differences in font or formatting, e.g., print style, italics, bold, underline, that may indicate key terms for an exam question. 

Bumper stickers for general principles in physiology

*Enough, but not too much.* Many students think every physiological end point is maintained at a constant value.  I explain that various parameters are regulated such that they gently fluctuate within a narrow range.  Plasma sodium must be ‘enough’; if it drops too low osmolarity decreases.  If sodium is ‘too much’, osmolarity increases; plasma volume increases; blood pressure increases.  If an endpoint falls below range, regulatory mechanisms bring it back up into range; should it increase above normal range, regulatory mechanisms bring it back down into range.  

*It’s not a mathematical equation; it’s a relationship.* Many students confess they are ‘really bad at math’ or ‘hate math’.  CO, MAP, renal clearance, alveolar ventilation rate – all math.  Understanding and passing physiology requires math.  I tell students math describes physiological relationships between different factors that regulate or dictate a given endpoint, similar to interactions and relationships among friends or a team.  Actual equations represent precise relationships, e.g., CO = HR x SV.  In that case, cardiac output will increase and decrease in direct proportion to heart rate and stroke volume.  Then there is Poiseuille’s Equation.  Students are not required to memorize that equation, but they must learn and apply the principles of the equation: F α DP, F α 1/R and F α r4.  I clarify the α symbol means ‘in proportion to’, not equals.  I repeat, ‘It’s not a mathematical equation; it’s a relationship.”  I suggest they view a as a hug, and embrace the dependence of blood flow on the pressure gradient, vascular resistance, and the luminal radius.  The 4 means when radius changes even just a little, flow changes a lot!  I provide a more technical explanation of how blood flow can decrease significantly with gentle vasoconstriction and increase with gentle vasodilation; this showcases the essential regulatory role of vascular smooth muscle.  This particular bumper sticker serves to remind them math is critical to our understanding of physiology and hopefully, ease their anxiety.  More math awaits in respiratory physiology, and they revisit and apply F α DP, F α 1/R and F α r4 to air flow.

*Know what abbreviations mean, and don’t make up abbreviations.* I explain the names of hormones, especially, are rich in information.  These names indicate source, stimulus for release, and mechanism of action.  For example, atrial natriuretic peptide, ANP, is a peptide hormone secreted from atrial tissue when plasma volume increases that increases urine output (-uretic) and sodium (natri-) excretion.  Not too creative, but self-explanatory.  Couple it with “Water follows sodium …”; problem solved.  

Bumper stickers for chronological order or sequence

For many cellular and organ mechanisms, there is a strict chronological order of events.  During the cardiac cycle, there is a distinct chronological order for each of several different phenomena that occur simultaneously and interdependently.  I use bumper stickers to teach a basic concept of cardiac physiology that help students learn the cardiac cycle – the electrical~mechanical relationship.  First, I show the entire Wiggers diagram and explain it tracks the series of interrelated electrical and mechanical events as they occur in the same timeline of one heartbeat.  I assure them we will take one panel at a time and pull it altogether at the end.  I start with the relationship of the ECG to the 4 ventricular phases, using a set of bumper sticker phrases that I write on the board.  We review the electrical events of P (atrial depolarization), QRS (ventricular depolarization) and T (ventricular repolarization) deflections.  Then, I say, “Pay attention.  Write down each phrase.”

*Electrical then mechanical.* I explain emphatically that first an electrical signal is transmitted and received, then the atrial or ventricular muscle responds.  In the cardiac cycle, electrical events P, QRS, and T each precede atrial or ventricular responses.  

*Depolarizeàcontract.  Repolarizeàrelax.* I explain depolarization triggers contraction; repolarization leads to relaxation.  P wave signals atrial contraction; QRS complex signals ventricular contraction; T wave signals ventricular relaxation.

*Depolarizeàcontractàincrease pressure.  Repolarizeàrelaxàdecrease pressure.*  I remind them changes in pressure gradients across the atrioventricular and semilunar valves determine whether valves open or close and consequently, whether blood flows into or out of the ventricle.  Depolarization leads to ventricular contraction and in turn, an increase in pressure; repolarization leads to ventricular relaxation and in turn, a decrease in pressure. 

*The AV valve is the fill valve; the semilunar valve is the ejection valve.*  A student thought of this phrase!  She explained, “When the AV valve – tricuspid or mitral – is open during diastole, the ventricle fills with blood from the atrium.  When the semilunar valve – pulmonary or aortic – is open during systole, blood is ejected.”  In that moment I thought my work as a teacher was done; my student is teaching herself and others.  I give her full credit, but use her bumper sticker.  I further explain when the ventricle relaxes and pressure drops below the atrial pressure, the AV valve will open, and blood enters the ventricle; when it contracts ventricular pressure exceeds atrial pressure and the AV valve closes; as it continues to contract, eventually ventricular pressure exceeds aortic pressure, the aortic valves opens, and blood is ejected into the aorta. 

Bumper stickers might not be the right tool for every teacher, student, or topic, or be appropriate for undergraduate versus graduate course.  If you decide to implement this tool, you might not have a bumper sticker for every basic or general physiology concept or mechanism or a set of bumper stickers for every organ system.  You might only use a bumper sticker phrase once or twice in a whole semester.  When used appropriately, they truly can make a difference.  On the other hand – if how you teach is working just fine and your students are getting it – then all I have to say is, “If it ain’t broke, don’t fix it!”

Alice Villalobos received her Bachelors of Science in biology from Loyola Marymount University and her PhD in comparative physiology from the University of Arizona-College of Medicine.  For the past several years, she has taught Anatomy & Physiology-II and Introduction to Human Nutrition in the Department of Biology at Blinn College and guest lectured at Texas A&M University on the topics of brain barrier physiology and heavy metal toxicology.  She recently relocated to Texas Tech University to join the Department of Kinesiology & Sport Management where she teaches Physiological Nutrition for Exercise.