Author Archives: Margaret Stieben

The trepidatious return to in-person instruction during the COVID-19 pandemic: valuable lessons applied from online teaching using Lt in the face-to-face classroom

 

To say that the past 20 months of higher education have been a hardship is a gross understatement. The speed at which educators have embraced new technologies to bridge the pivot to virtual instruction has been remarkable.

This has been particularly difficult in courses where hands-on experiences are the norm, such as in anatomy and physiology laboratory courses. Instructors of laboratory courses where students must gain practical skills and experience the process of science found themselves relying on new (to them) technologies to fill the gap in their newfound teaching methods during the forced switch to virtual instruction (1, 4). As such, many platforms stood out amongst a sea of offerings for physiology educators.

Adapting pedagogical approaches in the virtual landscape is not a new phenomenon for anatomy and physiology educators with many successful reports providing best practices to adapt didactic and laboratory methods to online or hybrid learning (2, 3) long before the COVID-19 pandemic. Although online approaches have demonstrated an effectiveness in achieving course objectives, effective combinations of both online and face-to-face instruction must be investigated to help accommodate the convenience that online approaches offer students as we adjust to the return to in-person modalities.

Our experiences at the University of the Incarnate Word (UIW) have mirrored our colleagues in the scramble to identify suitable stand-ins for laboratory courses that still provide as robust an experience as possible. Thanks to a fortuitous introduction during the January 2020 CrawFly Workshop we now host annually at UIW in association with ADInstruments, we were introduced to the Lt suite of laboratory courses, most notably their Human Physiology and Anatomy packages. While we were impressed by the capabilities of their labs and lessons, any thoughts of immediate use were placed on the backburner as we already had the Spring 2020 curriculum planned out – or so we thought.

During the confusing and uncertain switch to virtual instruction in March of 2020, fraught with pandemic panic, we haphazardly pieced together the second half of our virtual lab curriculum relying on any lab simulations we knew of that were free and easily accessible to our students. Following this “dumpster fire” of a semester, we reassessed our future directions for what we were sure was going to be another traipse into the virtual landscape, and we knew that our Frankenstein approach would not be suitable going forward. That is when the decision to completely redesign our Anatomy and Physiology I and II Lab curriculum using Lt was made.

Beginning in the Fall of 2020, 12 laboratory activities were selected from the pre-built modules and lessons available in Lt for human anatomy and physiology that met our pre-determined course objectives for both BIOL 2121 (Anatomy and Physiology I Lab) and BIOL 2122 (Anatomy and Physiology II Lab). We used these pre-built lessons as the outline for each lab and edited the material to accommodate an online lab experience. Where the ADInstruments PowerLab stations, sensors, and electrodes would normally be used for data acquisition with Lt software, we replaced these sections with either videos or descriptions of how data would be collected for each lab. These sections providing the theory and sample protocols were followed by using the Lt sample data sets for students to complete data analysis and formulate conclusions. To help facilitate virtual dissections, we took advantage of the dissection videos and guides provided in the pre-built Lt labs that students could refer to in lieu of having their own specimens at home. The final product allowed us to replace the hands-on experience preferred in an undergraduate anatomy and physiology lab in the best way possible when virtual instruction was our only option.

To gauge student satisfaction with this new platform, and importantly to determine if the educational goals for our students were being met, a survey was designed and administered to students at the end of the semester. This was used to adjust the lab offerings and fine-tune the activities that were used again in proceeding semesters. Figure 1 shows an improvement in the overall rating for Lt where students provided scores in between 1 and 5 with 5 being the highest rating from Fall 2020 to Spring 2021 by just over 8% (from a score of 4.18 to a score of 4.53 in the spring semester). Both semesters were conducted using remote instruction; therefore, the increase is attributed to improvements made to the existing labs in spring based on student feedback.

Moving forward to Fall 2021, our labs returned to mostly in-person instruction with only 30% offered with either asynchronous online or synchronous online instruction. The same Lt Student Survey was administered as the current semester has come to an end and the data demonstrate a further increase in the overall rating for Lt with an average rating of 4.7 (Figure 1). Although we hypothesize that this increase is mostly attributed to the transition back to in-person instruction as students mostly cited comments similar to, “Visually and physically being able to carry out the experiment and dissection labs,” or “Being able to learn things in person and on Lt really helped my learning and broadened my knowledge,” when asked, “What are one to three specific things about the course or instructor that especially helped to support student learning?” This indicated to us that the more hands-on approach with the return to in-person instruction was helping to support our students’ learning.

Importantly, when asked, “If you took an Anatomy and Physiology Lab online in a previous semester, and are currently taking an Anatomy and Physiology Lab in-person with Lt, what about your experience has changed or improved?” students replied with comments such as, “Definitely improved from A&P1 lab, still used Lt in lab but in person as well helped,” or “The labs have definitely improved and the course work… I think that I learned better in person than online.”

Given the data we have collected thus far, we are learning that while students appear to prefer in-person lab instruction, the flexibility provided by the online Lt lab platform still allows for the inevitability of students in quarantine who are unable to attend in-person labs. And although we are still in a period of uncertainty and flux, we think we are finding an effective combination of online and in-person lab instruction to best serve our students and maintain the rigor expected of an undergraduate anatomy and physiology lab experience.

References:

1.       Alves, N., Carrazoni, G. S., Soares, C. B., da Rosa, Ana Carolina,de Souza, Soares, N., & Mello-Carpes, P. (2021). Relating human physiology content to COVID-19: a strategy to keep students in touch with physiology in times of social distance due to pandemic. Advances in Physiology Education, 45(1), 129.

2.       Anderson, L. C., & Krichbaum, K. E. (2017). Best practices for learning physiology: combining classroom and online methods. Advances in Physiology Education, 41(3), 383.

3.       Attardi, S. M., Barbeau, M. L., & Rogers, K. A. (2018). Improving Online Interactions: Lessons from an Online Anatomy Course with a Laboratory for Undergraduate Students. Anatomical Sciences Education, 11(6), 592-604.

4.       Lellis-Santos, C., & Abdulkader, F. (2020). Smartphone-assisted experimentation as a didactic strategy to maintain practical lessons in remote education: alternatives for physiology education during the COVID-19 pandemic. Advances in Physiology Education, 44(4), 579.

Dr. Bridget Ford is an Assistant Professor in the Department of Biology at the University of the Incarnate Word (UIW) in San Antonio, Texas. She obtained her bachelor’s degree at St. Mary’s University in Biological Sciences with a minor in Chemistry. She then went on to earn her Ph.D. in Molecular Medicine at UT Health San Antonio in 2012. Bridget completed her postdoctoral fellowship training at the United States Army Institute of Surgical Research in the Extremity Trauma and Regenerative Medicine task area and at UT Health at San Antonio between the Magnetic Resonance Imaging Division and the Department of Medicine.

 

Bridget serves as the Anatomy and Physiology I and II Lab Course Coordinator and teaches Anatomy and Physiology I and II lecture courses, Endocrinology, and Cell Biology at UIW. She is dedicated to mentoring undergraduates in the research laboratory where her research focuses on understanding the molecular mechanisms involved in renal cell injury in diabetic kidney disease. The overall goal she has for all her trainees is to apply what they learn in the classroom to ask scientific questions in the quest to become independent and creative thinkers.

 
Call for Papers: Physiology Core Concepts

In 2011, Michael and McFarland (1) described 15 core concepts of physiology, as defined by physiology educators. The core concepts provide an objectives-based teaching approach focused on the learning of unifying physiological concepts that can be applied across the discipline. Educators have used the core concepts to design and organize courses (2), as well as physiology-related curricula (3). Over the last 10 years, the core concepts have been further explained (4) and revisited (2). However, there remains a gap in the current understanding about how educators are using and assessing the core concepts in their own classrooms.

Advances in Physiology Education is issuing a Call for Papers to address this gap and highlight the work of educators implementing the core concepts in their teaching. We hope this work will demonstrate whether and how the implementation of the core concepts results in gains in student understanding of physiology. We encourage submissions from diverse perspectives and welcome authors from any career stage or title, a variety of educational institutions, and varying levels of education research experience.

To be considered for this Call, authors must first submit an abstract/pre-submission inquiry for review. If the abstract/pre-submission inquiry is accepted, the authors will receive a formal invitation to submit their article, which will then undergo the regular review process (see ABSTRACT SUBMISSION GUIDELINES below).

POTENTIAL TOPICS FOR MANUSCRIPT SUBMISSIONS:
A broad range of manuscript topics will be considered, including but not limited to:

  1. Impact of core concept-based strategies on student learning;
  2. Successful strategies for the implementation of the core concepts by instructors;
  3. Curricular development centered on the core concepts;
  4. Teaching of core concepts as a tool for more inclusive classrooms.

KEY CHARACTERISTICS OF SUBMISSIONS
Articles reporting original research will be prioritized, but reviews and perspectives submitted as essays will be considered as well. To be publishable in this special collection of Advances, scholarly work must:

  1. Connect in some way to the use of the physiology core concepts with students, instructors, programs, or innovations;
  2. Have implications for the use of core concepts in education research and practice;
  3. Align with one of the established article types currently listed here: https://journals.physiology.org/advances/article-types

ABSTRACT SUBMISSION GUIDELINES
Submitted abstracts should include the following and should be 300-500 words:

  • TITLE
  • AUTHOR(S): Include name(s), institutional affiliation(s) and email address(es); submissions are welcome from all.
  • NARRATIVE: Provide brief description of focus of anticipated manuscript submission, including 1) connection to students, instructors, programs, or innovations, 2) implications for biology education researchers and practitioners, and 3) align with one of the established article types in Advances in Physiology Education.
  • HOW TO SUBMIT ABSTRACTS: Abstracts/pre-submission inquiries should be submitted online by end of January 2022 for evaluation by the Guest Editors at https://advances.msubmit.net/cgi-bin/main.plex/submit
  • SELECT CALL FOR PAPERS: During the online submission process, under the “Keywords & Special Sections” tab, please use the “Category” drop-down menu and select “Call for Papers: Physiology Core Concepts.”
  • ABSTRACT REVIEW: Feedback on all submitted abstracts/pre-submission inquiries will be provided to authors by the end of February 2022 after review by the editorial team to ensure that a range of topics and viewpoints are represented in this special collection.
  • OPPORTUNITIES FOR CLARIFICATIONS AND SUPPORT: Interested authors are welcome to contact Advances Editor-in-Chief Barb Goodman (Barb.Goodman@usd.edu).
  • Contact Ed Dwyer (edwyer@physiology.org) with any submission issues.
  • MANUSCRIPT SUBMISSION: After evaluation of abstracts/pre-submission inquiries, authors who are encouraged to submit a full manuscript should do so by the end of May 2022.

References

  1. Michael J, McFarland J. The core principles (“big ideas”) of physiology: results of faculty surveys. Adv Physiol Educ 35: 336–341, 2011. https://doi.org/10.1152/advan.00004.2011.
  2. Michael J, McFarland J. Another look at the core concepts of physiology: revisions and resources. Adv Physiol Educ 44: 752–762, 2020. https://doi.org/10.1152/advan.00114.2020.
  3. Stanescu CI, Wehrwein EA, Anderson LC, Rogers J. Evaluation of core concepts of physiology in undergraduate physiology curricula: results from faculty and student surveys. Adv Physiol Educ 44: 632–639, 2020. https://doi.org/10.1152/advan.00187.2019.
  4. Michael J, Cliff W, McFarland J, Modell H, Wright A. What Are the Core Concepts of Physiology? In: The Core Concepts of Physiology: A New Paradigm for Teaching Physiology, edited by Michael J, Cliff W, McFarland J, Modell H, Wright A. New York, NY: Springer-Verlag, 2017, p. 27–36. https://doi.org/10.1007/978-1-4939-6909-8.

About Advances in Physiology Education

Advances in Physiology Education promotes and disseminates educational scholarship to enhance teaching and learning of physiology, neuroscience, and pathophysiology. The journal publishes peer-reviewed descriptions of innovations that improve teaching in the classroom and laboratory, essays on education, and review articles based on our current understanding of physiological mechanisms. Submissions that evaluate new technologies for teaching and research, and educational pedagogy, are especially welcome. The audience for the journal includes educators at all levels: K–12, undergraduate, graduate, and professional programs.

 

Vale Associate Professor Elizabeth (Liz) Davis

It is with incredible sadness that we announce that Elizabeth (Liz) Davis passed away on October 26th 2021. Liz was enormously valued by everyone in the biomedical community at Monash University – her generosity of spirit, kindness toward others and endless talents as a teacher and mentor have benefited everyone. Liz’s reputation for excellence and leadership in education was recognized both nationally and internationally. Through her roles as the inaugural Chair of the ASCEPT Education Forum and Chair of the IUPHAR Education Section, she raised the profile of pharmacology education. Liz was an active member of the team that developed threshold learning outcomes in pharmacology teaching and identified “core concepts” that underpin pharmacology. The two recent publications of this work (Pharmacology Research & Perspectives), are a fitting recognition of her invaluable contributions to the discipline. In addition to her excellence in pharmacology education, Liz was a long-time reviewer and Editorial Board member of Advances in Physiology Education.  In fact, she was in the process of reviewing two manuscripts for Advances at the time or her death.  Liz leaves a lasting legacy as a much-loved educator by international colleagues and past students.

Desperate times call for desperate measures: Teaching Physiology in a hybrid/online format and block schedule

Physiology and STEM educators at colleges and universities around the world have deployed creative and innovative strategies to preserve class and laboratory instruction during a pandemic.

My residential, liberal arts, undergraduate institution implemented a hybrid learning format, as did many others.  The hybrid format was adopted by the institution because room capacities were reduced to accommodate physical distancing and because we expected that COVID quarantines and isolations would force faculty and students to attend remotely.  Classrooms were outfitted with cameras and microphones in the HyFlex model to facilitate remote participation.  All classes and laboratories were forced to move online during certain blocks as a response to regional COVID rates and some students participated remotely for the entire year—including those who participated from their international homes.

More drastically, we converted our “normal” semester schedule (students complete four courses across a semester) into a block schedule.  Under the block schedule, students enrolled in one course at a time, intensively, for just under four weeks per course.  Courses met for three hours per day, four days per week.  Students completed a forced-choice mini-exam at the end of each unit and larger exams with forced-choice and short answer questions at the middle and end of the course (Table 1).  Laboratories were scheduled as additional meeting times.  Instructors and departments were granted a great deal of flexibility in laboratory scheduling so there were many permutations to lab schedules within a block—sometimes a student attended laboratory for three-hour sessions twice per week, other times a student attended for 1.5 hours four times per week.

In this post, I’ll address the changes that we made to our Human Anatomy and Physiology I and II (Biology 325 and Biology 326) sequence.  I’ll also reflect on the successes and challenges of the revisions and what we have retained in our return to in-person, normal semester scheduling.

Although we no longer utilize the block schedule at my institution, these reflections may be useful to instructors who are considering intensive summer courses and to instructors who would like to facilitate active and remote learning for other reasons.  It is important to note that the difficulties I address below are more likely to affect underserved, underprepared, or otherwise disadvantaged students and faculty, so particular attention to equity is important in considering how to deliver remote and/or intensive learning experiences.

Class (“lecture”) revisions

We adopted a flipped approach to the classroom portion of the course.  We chose this approach primarily in recognition that three-hour time blocks could only be successful with substantial interaction.  The flipped approach also helped us to navigate the hybrid format given that we anticipated technical concerns and/or limited attention spans would negatively impact the quality of meetings for remote students (three hours is an exceptionally long time to attend a Zoom class!).  Four instructors taught the courses each semester.  We divided each semester’s material into four units and each instructor created pre-class lecture videos of the relevant material for their assigned unit (Table 1).  Pre-class lecture videos totaled approximately one hour to 1.5 hours per class meeting.  The instructor also developed in-class materials for their assigned unit—typically case studies and/or worksheets.  Class began with instructors answering questions about pre-class video content and daily class objectives in response to student small group discussions.

Importantly, the block schedule reduced net class meeting hours and required us to prune as much content as possible.  We also integrated units that were previously separate.  For example, rather than address cellular physiology and skeletal physiology in separate units, cellular physiology was delivered using the calcium homeostasis and skeletal physiology for application (Table 1).

Lessons learned:

As noted above, instructors divided video and class material preparation by unit.  This required a high level of trust between instructors, and a willingness to try new ideas and pedagogies.  It worked well because our instructional team is cohesive and, although our pedagogical approaches vary, we value each other’s approaches.  Students benefitted from the lecture styles of four different instructors.

The flipped approach was helpful for practice and application of material.  The block schedule affords little time between class meetings given that classes meet for three hours per day on consecutive days.  Case studies and worksheets that applied lecture content helped students to identify points of confusion and build understanding. Further, students loved the ability to return to pre-lecture videos and rewatch points of confusion.  We now have a wealth of videos and in-class activities in our toolbox.  We continue to use many of the videos and assignments and recommend this approach to others– you might try flipping portions of class meetings as a starting point.

The intensive nature of the block schedule was advantageous in that students focused on one course at a time (so only needed to catch up in one course if COVID forced them to miss class).  A single course was their primary school-related responsibility during a block because they had no other courses and sports were largely on hold.  On the other hand, the intensive schedule left little time to develop content retention and build conceptual mastery.  There was little to no opportunity for spaced repetition.  We are currently seeing under-retention of content from last year in this year’s students.  If others attempt intensive schedule courses, it is important to recognize that content retention may be curtailed but conceptual development could be preserved with sufficient practice and application.

More generally, we are finding that students forgot how to time-manage and study in the block schedule.  They did not need to balance multiple classes or, for the most part, sports and social engagements.  The intensive nature of the block meeting schedule meant that much of their out-of-class time was spent preparing for the next day’s class rather than reviewing and studying material.  Some students (particularly those who are already disadvantaged) balanced this experience with intensified caregiving demands amid COVID restrictions.  Overall, student study habits declined—they are now struggling to optimize location, motivation, strategies, and pacing for self-regulated learning.

Students often operated in semi-isolation last year—often interacting with black boxes on a screen instead of classmates—and struggled to stay engaged via Zoom, even in breakout rooms.  This is a particular struggle for small, residential, liberal arts institutions where learning is typically done in small communities supported by close relationships.  Faculty found it difficult to build relationships with students during a four-week class with 50% remote participation each day and a requirement for meetings via Zoom (office visits were prohibited).  Students were less able to build a sense of STEM identity and belonging given the weaker relationships and reduced laboratory engagement (see below).  Sense of belonging and identity was likely especially challenging for individuals from minoritized groups with already lower STEM identity and belonging.

Lab revisions

All physiology experiments were removed from the laboratory sequence for the 2020/2021 academic year in response to the block schedule and to requirements for physical distancing and reduction of respiratory droplets.  The laboratory sequence consisted entirely of human anatomy.  We immediately recognized that learning a semester’s worth of human anatomy in four weeks—on top of class material—would be near impossible.  Therefore, we proposed a self-paced online anatomy lab experience that students could complete outside of their other coursework across the entire semester.  We utilized the Complete Anatomy platform (Elsevier; https://3d4medical.com/) and required students to submit a schedule for studying and completing practicals based on their own course schedule and other obligations each block.  Instructors held weekly instructional sessions via Zoom and met with students for tutoring as needed.  Instructional sessions were recorded and provided to students.

Lessons learned:

Any online, self-paced instructional platform will be subject to technical difficulties including spotty or slow home internet access and limited computing resources.  In addition, the Complete Anatomy platform posed surprising technical difficulties with gradebook access, content generation, and personal computer compatibility.  There were also notable technical glitches when delivering assessment via the Complete Anatomy platform.  We were able to either troubleshoot or work around each of the difficulties (for example, uploading Complete Anatomy images into our LMS for assessment), but it was labor-intensive and stressful.  Content generation was time-intensive and required a team of undergraduate teaching assistants during each semester and the prior summer.  We were lucky to have an outstanding team of teaching assistants who were so capable that they were awarded as institutional Student Employee Team of the Year (https://www.csbsju.edu/news/student-employee-awards-2021).

We were hopeful that the 3D visualization aspect of the platform (https://cdn.3d4medical.com/media/complete-anatomy-3/2019/screens.mp4) would help students improve mental 3D visualization abilities given that this has been a struggle for past students.  This did not seem to occur, although it is difficult to be sure given that most student work was completed away from instructors.  This year we paired Complete Anatomy software with physical models for in-person lab instruction and the combination works well.  We value Complete Anatomy as a study tool but some technical difficulties have continued, making it less suitable for assessment.  Online anatomy assessment was, of course, also limited because we had no way of enforcing a closed-book requirement.

Instructors observed that students did not retain as much content compared to previous years.  This is likely a result of multiple factors, including procrastination and approaches to learning.  Regardless of the original schedule developed by each student, many procrastinated and completed a flurry of practicals near the end of the semester.  Clearly those students were not practicing the spaced repetition that is important for learning.  Additionally, students often approached practicals as an item to be checked off a to-do list rather than a learning task.  When we hold laboratory sessions in-person, we can motivate and encourage students toward deep-, rather than surface-, learning in a way that we were unable to do remotely.  If we were to repeat the self-paced structure, we would enforce the students’ planned schedules more strictly.

Summary

We are happy to be back to a normal schedule with in-person instruction—made possible (thus far) by an institutional vaccination requirement for students and faculty and by masking requirements.  We have retained tools and strategies from last year, including flipped instructional materials and Complete Anatomy as a study tool.  We have moved away from other tools and strategies.  However, we (and others) may continue to offer intensive online summer options in which many of these approaches may be retained.

Table 1:  Class schedule

Pre-class video topics In-class activities
Unit 1 Day 1 ·       Course introduction

·       Homeostasis

·       Endocrine system

 ·       Osteoporosis case part 1

·       Study plan
Day 2 ·       Cellular signaling

·       Microscopic structure of bone

·       Bone remodeling mechanisms

·       Bone remodeling regulation

 ·       Osteoporosis case study part 2
Mini-exam 1
Day 3 ·       Cellular junctions

·       Passive membrane transport

·       Active membrane transport

·       Ca++ transport (osteoclast and intestinal epithelial cell)

 ·       osteoporosis case study part 3
Day 4 ·       Bone growth and fracture repair ·       Osteoporosis case study part 4

·       Bone growth disorders activity
Mini-exam 2
Unit 2 Day 5 ·       Resting membrane potentials ·       Resting membrane potential worksheet and practice questions
Day 6 ·       Neuron functional anatomy

·       Graded potentials

 ·       Neuron functional anatomy worksheet

·       Graded potentials worksheet
Mini-exam 3
Day 7 ·       Action potentials

·       Action potential propagation

 ·       Action potential worksheet and practice questions
Day 8 ·       Synapses and synaptic transmission

·       Synapses and synaptic integration

 ·       Synapses and synaptic integration worksheet and practice questions
Exam 1
Unit 3 Day 9 ·       Nervous system introduction

·       CNS protection

 ·       Brain trauma case study
Day 10 ·       Functional brain anatomy ·       Brain regions functional scenarios activity
Mini-exam 4
Day 11 ·       Receptor physiology (somatosensation)

·       Pain

 ·       Neanderthal pain discussion (Zeberg et al., 2020)
Day 12 ·       Vision

·       Autonomic nervous system

 ·       Autonomic nervous system case studies
Mini-exam 5
Unit 4 Day 13 ·       Control of movement

·       Functional skeletal muscle anatomy

 ·       Brain machine interface worksheet (Flesher et al., 2016; Moritz et al. 2008; O’Doherty et al., 2011; Sasada et al., 2014)

·       Muscle functional anatomy worksheet
Day 14 ·       Sliding filament theory

·       Neuromuscular junction

·       Excitation contraction coupling

 ·       Neuromuscular junction worksheet

·       Malignant hyperthermia case study
Mini-exam 6
Day 15 ·       Graded contractions

·       Muscle metabolism and fiber types

 ·       Motor recruitment worksheet

·       Muscle training worksheet
Exam 2

 

Jennifer Schaefer is an Associate Professor of Biology, the Biology Department Chair, and the Neuroscience Minor Director at the College of St. Benedict/St. John’s University.  She earned her B.A. in Biology from St. Olaf College in 2002 and her Ph.D. in Physiological Sciences from the University of Arizona in 2010.

Jennifer’s teaching expertise is in anatomy & physiology and neurobiology.  Her research in the science of teaching and learning investigates the interaction between metacognition and self-efficacy for student academic performance.  Jennifer collaborates on an ongoing national collaboration to develop a consensus set of core concepts for undergraduate neuroscience education and her research in neurobiology investigates motor control circuits in Drosophila.

Jennifer is a member of the American Physiological Society, Society for Neuroscience, Faculty for Undergraduate Neuroscience, and Phi Beta Kappa

Jennifer E. Schaefer

Associate Professor of Biology

College of Saint Benedict and Saint John’s University
Physiology as an Interpretive Lens for the Clinician’s Dilemma

Clinicians are faced with a dilemma – the need to make decisions based on a universal set of evidence and experience that usually does not explicitly include that individual. My understanding of the clinician’s dilemma germinated while working toward my professional Master’s in Physical Therapy and became clear during graduate course work in epidemiology. I didn’t have a chance to write about it and propose some vague abstract solutions until 2005,[i] and didn’t propose tangible solutions until 2014 which are embedded into a curriculum I developed for a new Doctor of Physical Therapy (DPT) program at Plymouth State University (2015-2017) and were then published in 2018.[ii] And to be clear, no one has solved this dilemma. At best we have some inkling of the types of reasoning that make it less poignant, or at least enable a clinician to have a rationale for decisions. There’s a gulf between a clinical researcher saying “Your practice is not evidence based”, and the clinician saying in response “Your research isn’t practice based”. A hardline stance of evidence-based practice not including mechanistic causal reasoning and only including (or giving strong priority to) randomized controlled trials that focus on outcomes as the primary determinant of the best treatment is not practice based.[iii]

The CauseHealth[iv] project considers the problem in their book Rethinking Causality, Complexity and Evidence for the Unique Patient[v]. Clinicians must be able to inquire and reason about unique situations and consider what, whether, how, when, and to what extent clinical practice guidelines and evidence from systematic reviews and randomized controlled trials apply in that particular situation. Clinicians consider mechanisms as causes underlying particular situations even when they are part of a unique arrangement of a complex system and when the observation of prior situations exist, or the ability to repeat the situation is limited.

In physical therapy this requires a depth and breadth of physiological understanding that starts with the core concepts and proceeds to integrated, complex, mechanistic causal relationships. Physical therapists “diagnose and treat individuals of all ages, from newborns to the very oldest, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives” (APTA).[vi] A core component to the knowledge used in practice for this profession is physiological knowledge. Beyond understanding pathophysiology, physical therapists must be able to reason through the consequences of various situations – when is physiology as expected vs. not as expected and how does a set of expectations (or non expectations) influence our understanding of the current particular situation. In other words, clinicians are reasoning through causal models, either implicitly or explicitly. And often, much of what happens at the causal model level of knowledge for practice includes physiology.

My writing and teaching promote the use of causal models as representations of knowledge for clinical reasoning, and the use of graphical causal models for the clear articulation and sharing of such knowledge. This approach is helpful for the consideration of how universal concepts learned through an empirical process and thought to be true for a population can be applied in a particular situation. When teaching DPT students how to use physiology in clinical reasoning we approach causal models of physiological mechanisms as an interpretive lens for the clinician’s dilemma.

Clinical research utilizes statistical inference to estimate, from a sample, what a population characteristic or cause-effect relationship may be. The cause-effect relationship may be intervention-outcome, or it may be exposure-disease. The patient in front of a clinician was usually not in the original sample. The question then becomes, is this patient part of the population that this study (or these studies) represent via statistical inference? And is this patient part of that population in a manner that is important given the physiological mechanisms involved in the cause-effect relationship? This is a physiological question. We immediately can consider whether the inclusion and exclusion criteria of the research includes or excludes this particular patient. Those are obvious reasons to question whether the patient you are working with is part of the same population to which these studies inferred. We naturally look at age, sex, comorbidities and severity of the situation. All of these considerations imply variation in the underlying physiological state of the particular patient from the inferred population. But even if the particular patient is similar to the inferred population on all of these considerations, underlying physiological assumptions based on the mechanisms remain and should be considered.

For example, research demonstrates that electrical stimulation of the major skeletal muscles involved in walking is causally associated with positive outcomes in people with chronic heart failure such as maximum oxygen consumption (VO2max), six minute walk distance (6MWD) and even, to a lesser extent, health related quality of life (HRQOL).[vii]  Figure 1 depicts the simple graphical causal models that the clinical research (randomized controlled trials) has investigated as part of an evidence-based practice empirical approach to understanding the relationship between interventions and outcomes (made with DAGitty).[viii] Even when assuming a particular patient would be included (based on meeting inclusion criteria and not meeting exclusion criteria for these studies), there are several very poignant physiological mechanisms when considering the use of electrical stimulation in practice that impact the probability of the intended outcome.

No one assumes that electrical simulation directly improves health related quality of life, or six minute walk distance, or even oxygen consumption. There are physiological and even psycho-physiological, behavioral and cultural mechanisms involved in the connection between electrical stimulation and these three outcomes, and these three outcomes are very likely connected to one another.  Figure 2 is one possible graphical causal model that fills in some of the possible mechanisms.2

The clinician is working with many competing hypotheses, and is “faced with all sources of variation at the same time and must deal constantly with the full burden of the complex system.”1  Let’s take a closer look at the many causal assumptions of the model in Figure 2. As a graphical causal model, the first thing to realize is that all edges in the graph with an arrow encode the knowledge that one variable causes the other (and the lack of an arrow implies no causal connection). This does not have to be a definite causal connection; in fact, most of them are probabilistic and can be stated as conditional probabilities. For example, this graph encodes the knowledge that ES acts as a cause on muscle function. Which can be stated as a conditional probability: the probability of improved muscle function given ES is greater than the probability of improved muscle function given no ES. The model in Figure 2 also includes additional interventions since ES would rarely be considered the only intervention available. In fact, the patient in the condition where ES is the only intervention available probably would not be in the inferred population (for example, there are no studies on the use of electrical stimulation with patients with chronic heart failure that were not ambulatory or were unable to do other forms of exercise). This model includes aerobic training (AT), resistance training (RT), ES, adaptive equipment (AE), inspiratory muscle training (IMT), all as possible interventions for improving 6MWD, VO2max, and HRQOL in people with HF.

The characterization of the intervention (exposure, cause) in this model is discrete (yes/no), but it does not need to be discrete; it can be continuous and can include any of the considered important parameterizations of ES. Also, the effect muscle function is discrete but can be continuous and include any of the important parameterizations of muscle function. In other words, the causal model can encode as much of the ontological information about reality (its variables) as the user would have it encode. As attributed to George Box, “All models are wrong, some models are useful.”

The mathematical and logical implications of the causal model go on to include the multivariable considerations such as the chain rule of conditional probabilities (VO2max), identification of confounders (balance as a confounder), blocking variables (anaerobic threshold), and adjustment sets (6MWD).

My point here is to answer the question—“Isn’t this the same as concept map?” No. Causal models depicted as graphs are based on graph theory and adhere to a set of logical and mathematical rules that allow logical and mathematical implications to be proposed and tested. But they do share concepts. We could say that all causal models are concept maps, but not all concept maps are causal models; therefore, they are not equivalent since equivalence implies bidirectional implication.

Concept maps of physiological mechanisms are great teaching and learning tools. The next step, to use physiology as an interpretive lens for the clinician’s dilemma, is to consider encoding them as graphical causal models. In fact, this is the logical step from the core physiology concept of causation.

Another consideration for the clinician is that no single study has confirmed these causal connections all at the same time. But, a corpus of studies has tested these causal associations. The model in Figure 2 represents knowledge for practice; practicing based on this model is an example of using physiology to help in reasoning through whether to use an intervention with a particular patient. For example, if a particular patient has a problem with balance unrelated to muscle function then the probability of ES improving their 6MWD and even HRQOL is likely lower than in a particular patient without such a problem. And if a particular patient’s problem is mostly from the direct reduction in cardiac output associated with chronic heart failure, then a change in muscle function from ES may have less of an impact than in a particular patient with stronger contribution of muscle function in their reduction in oxygen consumption. And if the particular patient has low inspiratory muscle strength (IS), then IMT may be the best approach to start with – despite the fact that there are no clinical trials that investigate the intricacies of when to use ES vs. IMT. Thus, causal models of physiological mechanisms are an interpretive lens for applying clinical research in clinical practice. And this involves reasoning through causal models of complex physiological mechanisms.

The question is not whether this is already being done in practice (because it is, though usually implicitly not explicitly). The question is how are we teaching future clinicians and students? Is there a way to teach it that expedites the transition from classroom reasoning to clinic reasoning? Effective teaching often includes pulling back the curtain and explicitly revealing that which has been implicitly occurring. When a student asks me how their Clinical Instructor was able to come to some particular conclusion, the answer is usually that they were implicitly reasoning through some assumed causal model. Causal models can explicitly bridge the gap between learning physiology from a standard medical physiology textbook, doing a case study in a clinical course, and seeing a patient in a clinic.

The next step in my journey of using causal models for clinical pedagogy is the relationship between narratives, stories and causal models. If causal models are a more complex depiction of the reality underlying evidence-based causal claims; then narratives and stories are a more complex depiction of the reality underlying causal models. If you’re interested in discussing this further, please let me know.

Thank you to all of my colleagues (which includes all of the DPT students) at Plymouth State University for trusting this vision enough to take a chance on a new DPT program; and thank you to my closest dialogue partners in this and my upcoming work in the causal structure of narratives, Drs. Kelly Legacy and Stephanie Sprout (Clinical Assistant Professors of Physical Therapy); and Dr. Elliott Gruner (Professor of English/Director of Composition).

[i] Collins SM. Complex System Approaches: Could They Enhance the Relevance of Clinical Research? Physical Therapy. 2005;85(12):1393-1394. doi:10.1093/ptj/85.12.1393

[ii] Collins SM. Synthesis: Causal Models, Causal Knowledge. Cardiopulmonary Physical Therapy Journal. 2018;29(3):134-143.

[iii] Howick JH. The Philosophy of Evidence-Based Medicine. John Wiley & Sons; 2011.

[iv] CauseHealth Blog https://causehealthblog.org/ (Accessed 10/15/2021)

[v] Anjum RL, Copeland S, Rocca E. Rethinking Causality, Complexity and Evidence for the Unique Patient: A CauseHealth Resource for Healthcare Professionals and the Clinical Encounter. Springer Nature; 2020.

[vi] American Physical Therapy Association https://www.apta.org/your-career/careers-in-physical-therapy/becoming-a-pt (Accessed 10/15/2021)

[vii] Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical Therapy. 2020;100(1):14-43. doi:10.1093/ptj/pzz127

[viii] Textor J, van der Zander B, Gilthorpe MS, Liśkiewicz M, Ellison GT. Robust causal inference using directed acyclic graphs: The R package “dagitty.” International Journal of Epidemiology. 2016;45(6):1887-1894. doi:10.1093/ije/dyw341

Figure Legends

Figure 1: Simplified Causal Associations Tested in Clinical Trials (Abbreviations: ES, electrical stimulation; 6MWD, 6-minute walk distance; VO2_max, maximum oxygen consumption; HRQOL, health-related quality of life)

Figure 2: Complex Causal Associations Necessary for Clinical Practice (Abbreviations: AT, aerobic training; (a-v)O2, arteriovenous oxygen difference; IMT, inspiratory muscle training; IMS, inspiratory muscle strength; PaO2, partial pressure of oxygen in the arterial blood; RT, resistance training; Ve, minute ventilation; VQ matching, ventilation perfusion matching )

Sean Collins is a Professor of Physical Therapy at Plymouth State University and was the founding chair and director of the Doctor of Physical Therapy Program.  He earned an ScD in Ergonomics (work physiology focus) and epidemiology at the University of Massachusetts Lowell. He teaches a three-course series on Clinical Inquiry, as well as a course in Clinical Physiology and a course on physical therapy practice with patients that have complex medical and cardiopulmonary conditions. From 2015 through 2021 he served as the Editor of the Cardiopulmonary Physical Therapy Journal, was co-leader and co-author of the American Physical Therapy Association (APTA) Heart Failure Clinical Practice Guideline from 2014-2019, and in 2018 was honored with the Linda Crane Lecture Award by the Cardiovascular and Pulmonary Section of the APTA for his work on using causal models as tools to teach and to join clinical research and practice.

 

Course-based Research Experiences Help Transfer Students Transition

As transfer student numbers increase at 4-year institutions, we need to provide opportunities for the formation of learning communities and research experience. Course-based research experiences allows for both. Students receive course credit toward their degree, work on independent research, and engage with peers and faculty in a small setting.

Several studies have been conducted to show the advantages of undergraduate research as a value-added experience. (1,2,4,6,8). As an R1 university, we have a tremendous amount of resources devoted to STEM research – but we are unable to accommodate all of our undergraduates who are looking for lab experience. The development of course-based research experiences (CUREs) across colleges and universities has increased the availability of research opportunities for undergraduates. (1,3,5). In addition, they have provided an increased sense of community and interaction with faculty – two factors that were highly valued by all students. The question for us was how can we provide more of these courses given space and personnel constraints and are there student populations that might benefit more directly from these courses?

Several years ago, we increased the number of transfer students we accepted from community colleges and elsewhere. But there was no transfer-specific programming for those students and they had little sense of community. Transfer students tend to be a much more diverse student population in several ways. Their average age is higher than our incoming first-year class, they are more likely to be PELL Grant-eligible (40% of transfer vs 20% of first-year students), first-generation college students (30% of transfer vs 15% of first-year students) and are more likely to work and live off-campus. Although they recognize the value of community and research experience according to surveys, they often state they don’t have the time to invest as they are trying to graduate as quickly as possible.

We received a grant through HHMI (in part) to train faculty to develop CUREs specifically for transfer students. STEM courses that “counted toward graduation” was a way to get buy-in from the students and to be funded by grants and aid. All transfer students needed additional life science courses to complete their degree, and this was a course that wasn’t transferred in through the community colleges so there was space in their degree audits. These were small enrollment courses that lent themselves to forming cohorts of student learning communities as they proposed hypotheses, designed and implemented their experiments, and presented their findings to the class. This allowed transfer students to receive course credit toward graduation in a lower-stress way during that first transition semester.

Course-based Research Experiences Help Transfer Students Transition

Lisa Parks 9.30.2021

Figure 1

Cell Biology CURE Example:

Testing whether environmental compounds or other chemicals induce cell death

Protocols Provided:  Cell seeding and growth, Cell counting, Measuring cytotoxicity, Bradford Assay, Western Blot, Immunofluorescent Analysis

There are thousands of chemicals and compounds that either potentially affect cell growth, metabolism, and death.

This project has a lot of room for student individuality. Students could do endocrine disruptors, for example, or Parkinson’s disease related compounds (i.e., things that kill mitochondria), environmental toxicants, heavy metals, etc. They could test across cell types, concentrations, diseases, etc.  They could use the cancer cells and we could get a screen of compounds. Or they can pre-dose with a potential protectant (GSH?) and then expose the cells to something toxic to see if cell death can be attenuated.

This is particularly important because one issue we struggle with is that students with a 2-year associates degree automatically receive credit for all general education requirements through the NC Articulation Agreement. This means that transfer students are left with stacks of required difficult STEM courses with little opportunity to balance their course load for their remaining semesters. In addition, they are often trying to graduate “on time” so they are starting at a new, much larger, state university with little formal introductory programming and often, unfairly heavy STEM course loads. This isn’t the best way to set these students up for success. We found our transfer students falling behind in GPA and time to graduation. Tracking transfer students that take these first-semester CUREs will help us see if this approach increases student retention in the STEM majors, their graduation rates, and through surveys, their feelings of community at NCSU.

Teams of tenured or tenure-track research faculty and teaching-track faculty along with a handful of post-docs continue to develop these courses. As you can imagine, COVID interrupted this effort as we scrambled to go online and closed our lab spaces to undergraduates, but the CURE development continued.  Anecdotally, we noticed an increased collaboration and a sense of community among the faculty that extended beyond the workshop training. This has been seen in several studies at other institutions (7,9). As these labs have been developed, it has led to increased team teaching, research projects, and publications. Teaching faculty have had another mechanism for staying current and being engaged in research and literature while giving them another outlet for scholarly work. Research faculty have had another mechanism for exploring side projects that they may not have had the time or funds to pursue in their own labs and allowing them an opportunity to get into the classroom.

Faculty write up or discuss a proposal with each other – an idea that they wish they had time or space to devote to. It’s typically no more than a page. Students take it from there. They spend the first third of the semester learning techniques and protocols, and writing their experimental designs. The rest of the semester is devoted to implementing their experiments, presenting results and receiving feedback at weekly lab meetings, and re-working or replicating their experiments. Final findings are presented as a poster session in our main lobby where all faculty and students are encouraged to stop by. A sample CURE is provided in the box.

As this approach to teaching has increased in our department, it has begun to influence space allocation within the buildings. We are beginning to influence how future buildings are designed and how renovations to existing space can accommodate this approach. We have begun to question whether we need large amphitheaters for 300+ students in a classroom and we are starting to see how we can divide up that space into learning labs and rooms with moveable chairs and tables – facilities that will promote the formation of learning communities and critical thinking skills as opposed to memorization of content.

Thank you to Dana Thomas and Jill Anderson for collecting and providing data about our transfer students.

REFERENCES

  1. Auchincloss LS, Laursen SL, Branchaw JL, Eagan K, Graham M, Hanauer DI, Lawrie G, McLinn CM, Pelaez N, Rowland S, Towns M, Trautmann NM, Varma-Nelson P, Weston TJ, Dolan EL. Assessment of Course-Based Undergraduate Research Experiences: A Meeting Report. CBE Life Sci Educ 13(1):29-40, 2014.
  2. Banasik MD, Dean JL. Non-Tenure Track Faculty and Learning Communities: Bridging the Divide to Enhance Teaching Quality. Inn Higher Educ 41: 333-342, 2016.
  3. Bangera G, Brownell SE. Course-Based Undergraduate Research Experiences Can Make Scientific Research More Inclusive. CBE Life Sci Educ 13: 602-606, 2014.
  4. Beckham J, Metola P, Strong L. Year-long Research Experiences in Drug Discovery May lead to Positive Outcomes for Transfer Students. FASEB Journal 31:S1. 589.8, 2017.
  5. Eagan MK, Hurtado S, Chang MJ, Garcia GA, Herrera FA, Garibay JC. Making a Difference in Science Education: The Impact of Undergraduate Research Programs. Am Educ Res J 50:683-713, 2013.
  6. Griswold W. Launching Sustainability Leadership: Long-Term Impacts on Educational and Career Paths in Undergraduate Research Experiences. J Coll Sci Teach 49:19-23, 2019.
  7. Kezar A. Spanning the Great Divide Between Tenure-Track and Non-Tenure-Track Faculty, Change: The Magazine of Higher Learning, 44:6, 6-13, 2012. DOI: 10.1080/00091383.2012.728949
  8. Nagda BA, Gregerman SR, Jonides J, von Hippel W, Lerner JS. Undergraduate Student-Faculty Research Partnerships Affect Student Retention. Rev of Higher Educ 22:55-72, 1998.
  9. Ward HC, Selvester PM. Faculty Learning Communities: Improving Teaching in Higher Education, Educational Studies, 38:1, 111-121, DOI: 10.1080/03055698.2011.567029
Lisa Parks is a Professor of Teaching and Director of Undergraduate Programs in Biological Sciences at North Carolina State University. In addition to her regular teaching load of cell biology and advanced human physiology, she has helped develop several courses and is currently developing several course-based research opportunities for transfer students. She has been a participant, a mentor, and a current grant recipient with the Howard Hughes Medical Institute where she was bitten by the “research as pedagogy – inquiry-based learning – critical thinking” bug. She gladly drops what she is doing to talk about this. Lisa received her BS in Zoology from Duke University and her PhD in Biology with a concentration in cell physiology at Georgia State University.
Together or Apart? Lecture with Laboratory, or Taken Separately?

Think back to your days as a college student majoring in science. Was your college on the smaller scale such that your professor met with you weekly for both your lecture and laboratory in chemistry, biology and physics? Or was your university on the large size, and while you sat among dozens or even hundreds of your peers in an auditorium where your professor lectured, you then met weekly in a smaller laboratory session conducted by teaching assistants? Our past experiences as students may or may not bear similarities to our professional career teaching environment at present.

As college professors in biology, or related science disciplines, our student enrollment in the major and the headcount of part-time versus full-time faculty have likely dictated the course schedule each semester. Such quantitative data, meshed with the physical resources of chairs in a classroom and square footage of laboratory space for teaching purposes, may be the major drivers of curricular practices. Pedagogical tradition perhaps accounts for science course scheduling practices as well. Budgetary matters too weigh heavily on decisions to maintain the status quo, or to experiment with test piloting the implementation of emerging course designs.

I teach at a mid-sized public university that offers graduate degrees alongside our more populous undergraduate majors. Our biology majors number approximately 1,000. Our faculty include part-time adjuncts, full-time lecturers and tenured/tenure-track professors. We do not have graduate teaching assistants in the classroom. Most often the assigned faculty teach both their lecture and laboratory sessions for a given course. A recent trend in our college has been to identify traditional lecture/laboratory courses that could be split such that students enroll in completely separate courses for the lecture versus the laboratory. For example, our microbiology course that used to be one combined course meeting twice weekly for lecture and once weekly for laboratory is now two distinct courses, laboratory versus lecture, although both are taken in the same semester, each course posts an individual grade on the transcript.

When asked to consider if any of the courses I teach would or would not be appropriate for separation of lecture from laboratory, I went to the pedagogical literature to see what I could find on the topic. Where science courses are combined into a single course (one grade) with lecture and laboratory, the lecture may be to a large scale audience, while the labs are disseminated into smaller break out groups led by either the lecture faculty or else another faculty member or teaching assistant. On the other hand, a science “course” may have a completely separate course number where students enroll and earn a grade for lecture, and a distinctly different course number where they enroll and earn a separate grade for the laboratory. Knowing these two variations exist, the literature reveals other alternatives as well.

A paper in the Journal of Scholarship of Teaching and Learning evaluated college introductory biology courses where either the same instructor teaches both the lecture and laboratory sessions versus those where there are different instructors for the lecture versus the lab. The author reports “no general trend indicating that students had a better experience when they had the same instructor for both lecture and laboratory than when the lecture and laboratory instructor differed (Wise 2017).” In fact, he states that students may even benefit from having different lecture and laboratory instructors for the same course as such would afford students exposure to instructors with different backgrounds and teaching styles (this paper’s doi: 10.14434/josotl.v17i1.19583).

When I was a teaching assistant during my graduate school days, I developed my teaching style by trial and error as the TA for the laboratory session break outs from the professor-led large auditorium style lectures for the undergraduate first year students majoring in biology. That was the early 1990s, and it was a mid-sized private university where at the same time they were “experimenting” with upper level undergraduate laboratory classes that were lab only. They called them “super labs” and they were not attached to a concurrent lecture course. Indeed, a 2005 paper in Biochemistry and Molecular Biology Education by D.R. Caprette, S. Armstrong and K. Beth Beason entitled “Modular Laboratory Courses” details such a concept whereby the laboratory course is not linked to a lecture (doi/epdf/10.1002/bmb.2005.49403305351). These modular laboratory-only courses are shorter in duration, ranging from a quarter to a half of semester, for 1 or 2 academic credits. Their intent is to apply the learning of specific skills, methods and instrumentation in their undergraduate biology and biochemistry curriculum. Of note, they recognized that their transition to such modular short-term laboratory courses was eased by their academic program already having their traditional curriculum with individual laboratory courses separate from the lecture courses.

Studio courses had in my mind been those taken by the art majors and other fine arts students. In the literature, however, there is an integrated “studio” model for science courses. A paper in Journal of College Science Teaching details how a small private college converted their Anatomy & Physiology I course, among others, from traditional lecture/laboratory courses to the integrated studio model. Their traditional twice weekly 75 minute lectures with 60 students and 150 minute breakout laboratories with 16 students per section, was reconfigured to 30 students meeting with the same instructor and teaching assistant twice weekly, each for 2 hours. These longer duration class sessions each consisted of, for example, 20 minutes lecture followed by 30 minutes of a context-linked laboratory, and then 20 minutes lecture followed again by 40 minutes of a linked laboratory They report fewer course withdrawals and unsatisfactory grades and cite that students felt “engaged and active” as did instructors who spoke of “immediate application and hands on” activity in the interactive classroom (Finn, Fitzpatrick, Yan 2017; https://eric.ed.gov/?id=EJ1155409).

Based on my experience with comprehension by students with the content delivery, I have decided to redesign my upper level undergraduate Cell Physiology course such that the cell physiology lecture will be a standalone 3 credit course, and students will be encouraged to take either during the same semester or the following semester, the 1 credit cell physiology laboratory course. When viewed thru the course scheduling and facilities lenses, this “split” will afford more students to enroll in a single lecture course section, while then having multiple smaller capacity laboratory course sections. As this is an upper level elective, students may find that a 3 + 1 credit option as well as a 3 credit only option suits their needs accordingly. And they can decide for themselves, together or apart, lecture with laboratory, or taken separately.

Laura Mackey Lorentzen is an associate professor of biology at Kean University in Union, NJ, where her teaching emphasis is general biology for majors as well as cell physiology, neuroscience and senior capstone. She earned a PhD in Biomedical Sciences/Molecular Physiology and Biophysics from Baylor College of Medicine in Houston TX, an MS in Cellular & Molecular Biology from Duquesne University in Pittsburgh PA, and a BS in biology from The University of Charleston, WV. She is a past president of the New Jersey Academy of Science (NJAS) and past editor-in-chief of AWIS Magazine, for the Association of Women in Science.
An Alternative Assessment Approach to be More Inclusive and Inspiring

I want to propose a different grading system that I think is more encouraging to some students and will be particularly useful for supporting diversity in physiology classes and in science general education classes.  Two separate influences converged to give me insight in creating this grading system.

In many of my courses, I value 3 different aspects of student participation and work: their attendance, their homework and their project work. My dilemma was how to grade in such a way that a student had to do all 3 well in order to get an A. If each aspect was weighted equally, then a student could get 100% on two parts, would only need 70% on the third part, which did not suit my purpose (see Figure 1A).  If each part has different weights, then the student can get even less than 70% on the part that has the least weight, only making matters worse.  I then tried to use the geometric mean, taking the cube root of the product of the percentages on the different parts (see Figure 1B).  While that improved things somewhat, it still did not achieve quite what I wanted and it was a bit confusing to the students. Finally, I tried  multiplying the grades in each area; while this was an improvement, if I stayed with the 90%, 80%, 70% cutoffs, this was too harsh a system (see Figure 1C).

The other influence that occurred was that our university started an incentive program to get people to be more active. If a person walked a million steps in 1 year, they would get a pay bonus. In talking to a colleague about this, the colleague pointed out that behavioral economists would argue that the incentive program would be more effective if the university handed out the bonus in January and said, if you do NOT walk at least 1 million steps this year, we will take back the incentive in December; basically, people will work harder not to lose something than to get something they do not yet have (3, 5, 6, 7).

My grading system is to tell the students they have 1,000 points on the first day of class and that 900 points is required for an A.  They lose 25 points for every class absence, they lose 25 points for every homework assignment not done satisfactorily, and up to 300 points if the final project or assessment is not satisfactory, see Figure 1D.  Consider a course that meets 3 times per week for 15 weeks and has homework for each class. If a student misses 5 classes (11%) then they cannot get an A.

If a student has more than 5 unsatisfactory homework assignments, then they cannot get an A.

If they lose more than ⅓ of the points on the project, they cannot get an A.

If they miss 2 classes and have 3 unsatisfactory homework assignments, they cannot get an A.

The conventional system in which a student gets x points for this assignment and y points for that assignment makes some assumptions (1, 9).  One assumption is that the response is additive and independent; there are plenty of phenomena in physiology that we know are synergistic and not additive.  My system is more like requiring a properly functioning heart, lungs and brain in order to consider the organism to be properly functioning, whereas the conventional system would be analogous to weight a properly functioning heart as much more important that properly functioning lungs.

Many students taking science classes suffer from imposter syndrome (4, 8, 10).  By making it clear that the student is starting the class with an A, I hope to make them realize that they do belong.  I reinforce this by saying that I view myself as their coach and I want them to succeed. But as a coach, it doesn’t help them if I do all the practice, they have to put in some work-hence the reward for attendance and homework.  (In classes where I have TAs, I refer to them as assistant coaches-again, to stress that we are there to help them get better and to emphasize that they have to do some work and not just watch us.)   Of course, some students worry that the project is a “gotcha” assignment.  I get around this by using an idea from Mittell (as quoted in 2).  If the project gets a not satisfactory evaluation, the student can revise and resubmit.  I use Mittell’s analogy that in my class “not satisfactory” is like when their parents say, “your room is not satisfactorily cleaned for you to go out” (as quoted in 2).

A business school colleague objected to my grading system because he felt students should earn their grade.  I appreciate and respect that point of view and I think it depends on the student, the class, and the teacher.  My analogy is, for a sports team, before the season starts, is the team undefeated or winless?

There are several reasons why I give credit for attendance:

I encourage discussions and brainstorming in class.  Students not present cannot learn from these interactions.  Furthermore, the rest of the class loses the absent student’s insights and questions which would enrich and diversify the interactions.

I am a bit more interested in developing lifelong habits that will serve the students well than in having them memorize information and theories, in part because some of the accepted information and theories are likely to change over their lifetime. To me, learning to attend class is a bit like learning how to get, and stay, in shape. Part of that is the ability to set aside time to exercise and to do it even on days when one is not in the mood.  For me, process is at least as important as short-term results. So I wanted a grading system that rewarded the behaviors I wanted (9).

A colleague also pointed out that if a student can get an A in a class without being in attendance, then, apparently, class time was not necessary for learning for that student (or, perhaps more accurately, class time was not necessary for passing the exams for that student).

Finally, I have a selfish reason for giving credit for attendance. I think the class works better when most students are there; I certainly find it more rewarding and enjoyable to be in front of a full class than when half of the students do not attend.

As I developed this grading system, it made me reflect again on what were my goals for the course.

Was I more interested in results or process? Taking my coaching analogy, if I were coaching physical fitness or flexibility, was having the student be able to run one mile in under 5 minutes or being able to touch their toes the goal of the semester or was it to help them develop habits, get in better shape than they started, and learn to enjoy the satisfaction of being in shape? For me, the analogous traits are to develop solid learning habits, to learn to critically think, to improve their ability to discuss and brainstorm about concepts and mechanisms, and to learn to enjoy the satisfaction that comes with thinking deeply about a problem.

In reading about other approaches to evaluation, I also realized that my previous approach to grading rewarded those who came into the course with a better background (2).  This did not seem fair to me. I am still struggling with the best way to account for the different skills and levels of the students when they enter the course.  Going back to the physical fitness training analogy, if a student comes into the course being able to run a 5 minute mile and finishes the course running a mile in 4:50 should they get a better grade than a student who entered the course not being able to run a complete mile and finishes the course running a complete mile in 10 minutes? (2)

One small difficulty with the approach is the dissonance of reading a fine assignment and then entering 0 in that grade column. Similarly, some students initially get concerned seeing a 0 in the grade column, so now I remind them when I reveal the grades for the first few evaluations that a 0 means they have done a satisfactory (or better) job.

I have found that the students find this grading system reduces their anxiety and makes them more comfortable in taking creative risks when doing their assignments.  It also makes evaluation an easier process as I am focused on helping the students improve and not on ranking them.

In summary, I hope some readers find that the ideas and questions that prompted me to adopt this grading system may help them reflect on how well their goals for the course match up with how they evaluate and reward students, even if they are not interested in adopting this grading system.

REFERENCES

  1. Elbow P, Ranking, Evaluating, and Liking: Sorting out Three Forms of Judgment. College English 55: 187-206, 1993
  2. Jones JB. Experimenting with Specifications Grading Chronicle of Higher Education, March 23, 2016 https://www.chronicle.com/blogs/profhacker/experimenting-with-specifications-grading/61912 accessed 8/17/2021
  3. Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica. 47:263–91, 1979
  4. McGill BM, Foster MJ, Pruitt AN, Thomas SG, Arsenault ER, Hanschu J, Wahwahsuck K, Cortez E, Zarek K, Loecke TD, Burgin AJ. You are welcome here: A practical guide to diversity, equity, and inclusion for undergraduates embarking on an ecological research experience. Ecol Evol. 11(8):3636-3645, 2021.
  5. Morewedge CK, Giblin CE. Explanations of the endowment effect: an integrative review. Trends Cogn Sci. 19(6):339-48, 2015.
  6. Ogdie, A, Asch, DA. Changing health behaviours in rheumatology: an introduction to behavioural economics. Nat Rev Rheumatol 16, 53–60, 2020.
  7. Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Framing. Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults: A Randomized, Controlled Trial. Ann Intern Med.164(6):385-94. 2016 .
  8. Persky AM. Intellectual Self-doubt and How to Get Out of It. Am J Pharm Educ. 82(2):6990, 2018
  9. Potts, G. A Simple Alternative to Grading . The Journal of the Virginia Community Colleges 15 (1):29-42, 2010.
  10. Winzeler EA. An improbable journey: Creativity helped me make the transition from art to curing malaria. J Biol Chem. 294(2):405-409, 2019.

Figure legend.

Outcomes from different grading systems. In all 4 cases, the course has 3 different areas (e.g., attendance, homework, and project). The percent of the total points possible for each area is determined. The right column (in red) are the percentages obtained in one area and the top row are the percentages obtained in the two other areas. Using the traditional cutoffs of 90%, 80%, for grades, the orange shaded areas would get A’s, the purple shaded areas B’s, and the blue shaded areas C’s.

A). Outcomes from an additive or average grading system.  In this system, one takes the average of the 3 areas. In this case, someone could get as low as 70% in one area and still get an A if they get 100% in the other two areas.

  1. B) Outcomes from a geometric mean grading system. In this system, one takes the cube root of the product of the grade in each of the 3 areas. In this system, getting 80% in one area and 100% in the other two still gets an A, but 70% in one area and 100% in the other two is now a B.
  2. C) Outcomes from a multiplicative system. Here one multiplies the percentages from each area. In this system, there are many fewer A’s.
  3. D) Outcomes from a loss aversion or endowment system. In this system, each student starts with 1,000 points and loses points when they do not satisfactorily complete an assignment in any area.  In this system, a student can only lose 10% of the points in one area and still get an A.  Even if the student gets 100% in two areas and 80% in the third area, they get a B.

    Mark Milanick

    		 Mark grew up in Novelty, OH and went to high school in Harmony, PA.  He attempted to double major in physics and English literature at Swarthmore, but ended up just majoring in English. He took a year abroad at the University of St. Andrews, taking pure Maths, Pharmacology and Modern Literature. After doing lab rotations with Ed Taylor and Richard Miller, he did his PhD with Bob Gunn in the Biophysics and Theoretical Biology at the University of Chicago.  His postdoctoral training was with Joe Hoffman in physiology at Yale.  He had over 20 years of NIH funding on red blood cell membrane transport and physiology. He particularly enjoys teaching physiology and general education classes, such as Toxins, the Good, the Bad and the Beautiful; Bodily Fluids and their Functions; Filtering Fact from Fiction in TV Crime and Medical Dramas; and the Science of Sex, Drugs, and Rock’n’Roll.

 

The Capstone Experience: Implementing lessons learned from a pandemic educational environment to create inspirational real-world educational experiences
Historically, physiology undergraduate students across the world have undertaken a laboratory-based, fieldwork or critical review research project, their educational purpose for students to gain research experience. However, decreasing numbers of physiology graduates are going onto careers in research, many are leaving science altogether. It is therefore imperative that we, as educators, better prepare the majority of our students, through their projects, for the diverse range of careers they go onto.

Pre-pandemic opportunities

Over the last twenty years, physiology and the broader global bioscience educator community, recognizing this diversity of graduate career destinations, have been expanding the range of projects available to their students, introducing for example, public engagement, educational development or enterprise projects.  However, the focus and purpose of these projects remained for students to gain research experience. They were traditional research projects but outside of the laboratory. The literature and Accrediting Bodies project criterion still talked about students undertaking “hypothesis-driven research” and “project/research-based assignments”.

Whilst these traditional research projects may have been relevant fifty years ago, they do not enable the majority of current Bioscience graduates to be “work-place ready”. The world is currently going through its fourth industrial revolution (4IR), a world and workplace governed by robotics, artificial intelligence, digitization and automation. Graduate recruiters require graduates with different skillsets, the so-called 4th Industrial Revolution (4IR) skills1.

I recognized that radical change was required, not only in my School of Biomedical Sciences, but across bioscience Higher Education globally. Collectively, bioscience educators needed to rethink the purpose, practices and outcomes of undergraduate research projects in order to better prepare our students for an increasingly challenging 21st Century global workplace.

My solution was to introduce project-based capstone experiences into my program. their purpose to provide students with opportunities for personal and professional development, and to gain real life work experience.

A highly experienced science communicator, I facilitated ethical debates in High Schools.  I realized that this would make an ideal opportunity for my undergraduates – something different as their research project. Starting small, I collaborated with one of my project mentees to co-create and co-deliver an ethics-focused workshop for High School students at the 2005 Leeds Festival of Science2. The capstone experience, as an alternative to traditional research projects, was born.

Over the last sixteen years, I have progressively expanded the range of capstone opportunities in my course. Colleagues within my School of Biomedical Sciences at the University of Leeds (UK), recognizing the benefits of capstones to students, joined me. In partnership with our students, we have created a sector-leading portfolio of traditional research projects offered alongside science or industry-focused capstones, and those with a civic or societal focus in the same course (Figure 1)3. Students select the project that best addresses their individual developmental needs and/or future career intentions. By offering this broad portfolio of sixteen opportunities, it is inclusive, there is something for each and every student to realize their full academic potential and personal goals.

 

Figure 1: Research and capstone project opportunities available to students

My students have wholeheartedly grasped this opportunity, excelling academically.  Their course marks are significantly higher than students undertaking traditional research projects (2020: mean ± SD = 71.4±4.4% vs 68.4±5.8%, p<0.05).  In 2020-21, 27% selected capstones as their first choice of project, a massive cultural shift given we are a research-intensive (R1) Institution where laboratory projects have traditionally been viewed by both students and Faculty as the “gold-standard”.

Our work as a team has resulted in the award of a prestigious national (UK) higher education prize, an Advance HE Collaborative Award for Teaching Excellence.

My work came to the attention of other Bioscience educators. I was invited to run workshops at Institutions across the UK seeking to introduce capstones into their program. I re-wrote one of the two UK Bioscience Accrediting Bodies project accreditation criteria, incorporating my capstone ideas.

And then Covid struck!

With restricted or no access to research facilities, Bioscience educators globally struggled to provide alternatives to traditional research projects.  To support colleagues across the world, in partnership with Sue Jones (York St John University, UK) and Michelle Payne (University of Sunderland, UK), I ran virtual workshops, sharing my capstone ideas and resources.  I created and shared globally, guides for students4 and educators5, and resource repositories6,7. The workshops were attended by over 1000 educators from as far afield as Australia, Africa and America. The resources viewed 12,000 times from over 50 countries.

A year on, we surveyed both students and Faculty globally. All responding institutions had introduced capstone projects into their programs in 2020-21. More importantly, they are here to stay. Recognizing the benefits to their future employability and careers, a massive 94% of students wanted capstones to be provided alongside traditional research projects. Faculty thought the same. All are not only keeping capstones, but more importantly, are broadening their portfolios going forward. Each new format developing different skill sets and attributes, and therefore preparing students for additional career destinations. We have inspired sector-wide curriculum change!

Going forward, we cannot return to our old ways!

As the world opens up and returns to a new “normal”, we cannot go back to our old ways of just offering traditional research projects. We would be massively letting our students and wider Society down. We need to take the best from what we have learnt and achieved, both before and during the pandemic, and continue to develop and evolve our collective capstone provision going forward.

We are at the start of an exciting Global journey.  Capstones across the world are predominantly conservative in nature, for example taught courses, senior seminar series or extended essays. Educators globally have yet to fully realize the transformative (massive uplift in skills and attributes) and translational (preparation for the workplace) potential of capstones.

We need to create capstones that are more representative of the work place for example, multi-disciplinary teams and sub-teams working on the same capstone, and capstones that run over multiple years, with current students taking the previous year’s project outputs and outcomes to the next stage.  The events of the past two years have made Universities realize they need to better address their local and global civic and societal responsibilities and missions, so capstones that facilitate societal engagement. We need to move away from traditional dissertations or reports to more authentic real-world assessments.

Within my School of Biomedical Sciences and the broader University of Leeds, we have started down this journey. Ninety percent of the capstones in my course are now team-based. Students choose their primary assessment method (e.g. academic paper, commercial report, e-portfolio) – the one most suited to their particular capstone format and which best showcases their knowledge, skills and attributes. I have introduced Grand Challenges capstones where students work as to teams to create evidence-driven solutions to global Grand Challenges or UN Sustainable Development Goals (SDG). The intention to develop these into trans-national educational opportunities, where students from the Global North and South work collaboratively on the same SDG or Grand Challenge capstone. We have an Institutional requirement that all undergraduate students, regardless of discipline, must undertake a major research-based assignment in their final year of study. I have been awarded a Leeds Institute of Teaching Excellence to work with Faculty across the University to introduce capstones into their programs and to create pan-university multi-disciplinary capstone opportunities for our students.

I do not do things by halves. My vision is not just limited to Leeds, the UK or the Biosciences, but Global!

I have created a global Community of Practice for stakeholders across the world to work collaboratively together, sharing ideas, expertise and resources, to co-create and introduce inspirational multi-disciplinary, multi-national team-based capstone projects that address globally relevant issues into undergraduate and taught postgraduate degree programs across the world.  I want to make it a truly global and inclusive community, to include all stakeholders- students, alumni, educators, employers, NGOs, social enterprise, Global North or South, all disciplines or sectors….The list is endless.

If you would like to join this Community of Practice and be part of this exciting journey, please email me (d.i.lewis@leeds.ac.uk). Please share this opportunity amongst your colleagues, networks and across your Institution. The broader the membership, the greater the collective benefits for all.

If we pull this off, the benefits for students, other stakeholders and Society will be phenomenal. Our graduates would be truly global graduates, equipped with the skills and attributes to become leaders in whatever field they enter. As Faculty, we would be providing an exceptional educational experience for our students, properly preparing them for the workplace. Universities, through student capstones, would be better able to address their civic and societal responsibilities and missions. Employers would have graduates able to take their businesses forward and to thrive in an increasingly competitive global marketplace. We would be creating solutions to some of the complex problems facing mankind.

Figure 1: Research and capstone project opportunities available to students

1.    Gray, A. (2016). The 10 skills you need to thrive in the Fourth Industrial Revolution. World Economic Forum. https://www.weforum.org/agenda/2016/01/the-10-skills-you-need-to-thrive-in-the-fourth-industrial-revolution/

2.    Lewis DI (2011) Enhancing student employability through ethics-based outreach activities and OERs. Bioscience Education 18, 7SE https://www.tandfonline.com/doi/full/10.3108/beej.18.7SE

3.    Lewis DI (2020a). Final year or Honours projects: Time for a total re-think? Physiology News 119: 10-11.

4.    Lewis DI (2020b). Choosing the right final year research, honours or capstone project for you. Skills career pathways & what’s involved. https://bit.ly/ChoosingBioCapstone

5.    Lewis DI (2020c). Final year research, honours or capstone projects in the Biosciences. How to Do it Guides. https://bit.ly/BiosciCapstones

6.    Lewis DI (2020d) E-Biopracticals (Collection of simulations & e-learning resources for use in Bioscience practical education. Available at: https://bit.ly/e-BioPracticals

7.    Lewis DI (2020e) Open access data repositories (Collection of large datasets, data analysis & visualization tools).  Available at: https://bit.ly/OADataRep.

 

Dr. Dave Lewis is currently a Senior Lecturer (Associate Prof) in Pharmacology and Bioethics in the School of Biomedical Sciences, University of Leeds, UK. A student education focused colleague, he creates inspirational educational and professional educational interventions designed to promote learner personal and professional development, and prepare them for the workplace.  He is the architect of the introduction of capstone projects into Bioscience programs across the UK and beyond.  He also Chairs the International Union of Basic & Clinical Pharmacology’s Integrative & Organ Systems Pharmacology Initiative, working with Professional and Regulatory Bodies, and NGOs in India, China and across Africa to co-create and co-deliver professional education in research animal sciences and ethics.

In recognition of his exceptional contribution to Bioscience Higher Education globally, he has received multiple prestigious education awards including a UK Advance HE National Teaching Fellowship and its Collaborative Teaching Excellence Award, the (UK) Biochemical Society’s Teaching Excellence Award, the (UK) Physiological Society’s Otto Hutter Teaching Prize, and Fellowship of the British Pharmacological Society & its Zaimis Prize.
The Olympics, sex, and gender in the physiology classroom
The recent Tokyo Olympic Games present an opportunity for a number of intriguing discussions in a physiology classroom.  Typical discussion topics around the Olympic Games involve muscle strength, muscle power, aerobic fitness, bioenergetics, and a number of other physiological factors that determine athletic performance.  Coronavirus, immunity, disease transmission, and similar topics may be unique areas of discussion related to the Tokyo Olympic Games.  Another topic that has been prevalent in the news for the Tokyo Olympic Games is the role of sex and gender in athletic competition.

Before and during the Tokyo Olympic Games several athletes were featured in news headlines due to either gender identity or differences of sexual development (DSD, also sometimes called disorders of sexual development).  Male-to-female transgender athletes competing in women’s sports in the Tokyo Olympic Games include weightlifter Laurel Hubbard, archer Stephanie Barrett, cyclist Chelsea Wolfe, soccer player Quinn, and volleyball player Tifanny Abreu, (1, 2).  There have also been news stories about Caster Semenya, Christine Mboma, and Beatrice Masilingi being ineligible to participate in the Olympics due to their DSD causing their serum testosterone concentrations to be above the allowed limits for female athletes (3, 4).  In addition to physiology sex and gender are interwoven with culture, religion, and politics, so how to discuss sex and gender in the physiology classroom needs to be carefully considered by each instructor depending on the campus climate, policies, and individual comfort level with walking into these potential minefields.  However, sex and gender in sports are very appropriate topics to discuss from a physiological perspective.

Although sex and gender have been used interchangeably in common conversation and in the scientific literature, the American Psychological Association defines sex as “physical and biological traits that distinguish between males and females” (5) whereas gender “implies the psychological, behavioral, social, and cultural aspects of being male or female (i.e., masculinity or femininity)” (6).  Using these definitions can be helpful to draw a clear distinction between gender (and/or gender identity) as a social construct and sex as a biological variable, which can help focus the discussion on physiology.

As reviewed by Mazure and Jones (7) since 1993 the NIH puts a priority on funding research that includes women as well as men in clinical studies and includes an analysis of the results by sex or gender.  Mazure and Jones (7) also summarized a comprehensive 2001 Institute of Medicine sponsored evaluation that concluded that every cell has a sex.  A 2021 Endocrine Society scientific statement provides considerable information on the biological basis of human sexual dimorphism, disorders of sexual development, and lack of a known biological underpinning for gender identity (8).  On August 12, 2021 a PubMed search using the term “Sex Matters” (in quotation marks) returned 179 results, with many of the linked papers demonstrating the importance of sex for health, disease, and overall biological function (without quotation marks there were 10,979 results).  Given that there have been various discussions in the news media and across social media blurring the distinction between sex and gender, it is very important that students in physiology understand that sex in humans is an important biologically dimorphic trait of male or female.

Relevant to a discussion of the Olympic Games, the differences in performance between male and female running has been analyzed for world’s best and world’s 100th best (9), annual world’s best performance (10), world record performance (11-13), Olympic and elite performance (13-16), High School performance in CA, FL, MN, NY, and WA (17), and 100 all-time best Norwegian youth performance (18).  Hilton and Lundberg (19) also provided an excellent review of the large differences in athletic performance between men and women in numerous sports.  Overall, by mid-puberty males outperform comparably aged and trained females by 10-60%, depending on the sport (see figure 1 of Hilton and Lundberg, reproduced here with no changes under the Creative Commons license https://creativecommons.org/licenses/by/4.0/).

 

Hilton and Lundberg (19) also reviewed the present state of research regarding the effects of male-to-female hormone treatment on muscle strength and body composition and concluded that men typically have 45% more muscle mass than women, and male-to-female hormone treatment reduces muscle mass by ~5%.  These authors also concluded that men typically have 30-60% higher muscle strength than women, and male-to-female hormone treatment reduces muscle strength by 0-9%.  Overall, Hilton and Lundberg (19) conclude that transwomen retain considerable advantages over cisgender women even after 1-3 years of male-to-female hormone treatment.  Harper at al. (20) also reviewed the research regarding the effects of male-to-female hormone treatment on muscle strength and body composition and came to the same conclusions as Hilton and Lundberg.  Harper et al. (20) further concluded that male-to-female hormone treatment eliminates the difference in hemoglobin concentrations between cisgender men and women.  In a single research project, Roberts et al. (21) observed that before transition male-to-female members in the US Air Force completed a 1.5 mile running fitness test 21% faster than comparably aged cisgender women.  After 2.5 years of male-to-female hormone treatment the transwomen completed the 1.5 mile running fitness test 12% faster than comparably aged cisgender women. (Figure 1 Hilton and Lundberg)

All of the previously mentioned information is important to consider when asking if transwomen can be fairly and safely included in women’s sports.  It is also important to note that the effects of male-to-female hormone treatment on important determinants of athletic performance remain largely unknown.  Measurements of VO2max in transwomen using direct or indirect calorimetry are not available.  Measurements of muscle strength in standard lifts (e.g. bench press, leg press, squat, deadlift, etc.) in transwomen are not available.  Nor have there been evaluations of the effects of male-to-female hormone therapy on agility, flexibility, or reaction time.  There has been no controlled research evaluating how male-to-female hormone treatment influences the adaptations to aerobic or resistance training.  And there are only anecdotal reports of the competitive athletic performance of transwomen before and after using male-to-female hormone treatment.

The safe and fair inclusion of transgender athletes and athletes with DSD in women’s sports is a topic being debated in many states and countries, and by many sporting organizations including the International Olympic Committee.  In the end, whether it is safe and fair to include transgender athletes and athletes with DSD in women’s sports comes down a few facts that can be extrapolated, lots of opinions, and an interesting but complicated discussion.  This is a worthwhile discussion in a physiology classroom because it allows a good review of the biologically dimorphic nature of human sex.  However, the safe and fair inclusion of transgender athletes and athletes with DSD in women’s sports is also a discussion that should be approached with caution due to the many opinions this topic entails that reside outside of physiology.

 

 

1.    The Economist explains: Why are transgender Olympians proving so controversial? The Economist. https://www.economist.com/the-economist-explains/2021/07/16/why-are-transgender-olympians-proving-so-controversial. [Accessed: August 12, 2021, 2021].

2.    Pruitt-Young S. Live Updates: The Tokyo Olympics Canadian Soccer Player Quinn Becomes The First Out Trans And Nonbinary Gold Medalist NPR. https://www.npr.org/2021/08/06/1025442511/canadian-soccer-player-quinn-becomes-first-trans-and-nonbinary-olympic-gold-meda. [Accessed: August 12, 2021, 2021].

3.    The Clock Ticks on Caster Semenya’s Olympic Career https://www.nytimes.com/2021/06/28/sports/olympics/caster-semenya-olympics-gender.html. [Accessed: August 12, 2021, 2021].

4.    Tokyo 2020: Two Namibian Olympic medal contenders ruled ineligible for women’s 400m due to naturally high testosterone levels CNN. https://www.cbs58.com/news/tokyo-2020-two-namibian-olympic-medal-contenders-ruled-ineligible-for-womens-400m-due-to-naturally-high-testosterone-levels. [Accessed: August 21, 2021, 2021].

5.    APA Dictionary of Psychology: sex. American Psychological Association. https://dictionary.apa.org/sex. [Accessed: August 12, 2021, 2021].

6.    APA Dictionary of Psychology: gender. American Psychological Association. https://dictionary.apa.org/sex. [Accessed: August 12, 2021, 2021].

7.    Mazure CM, and Jones DP. Twenty years and still counting: including women as participants and studying sex and gender in biomedical research. BMC Womens Health 15: 94, 2015.

8.    Bhargava A, Arnold AP, Bangasser DA, Denton KM, Gupta A, Hilliard Krause LM, Mayer EA, McCarthy M, Miller WL, Raznahan A, and Verma R. Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement. Endocr Rev 2021.

9.    Sparling PB, O’Donnell EM, and Snow TK. The gender difference in distance running performance has plateaued: an analysis of world rankings from 1980 to 1996. Med Sci Sports Exerc 30: 1725-1729, 1998.

10.  Tang L, Ding W, and Liu C. Scaling Invariance of Sports Sex Gap. Front Physiol 11: 606769, 2020.

11.  Cheuvront SN, Carter R, Deruisseau KC, and Moffatt RJ. Running performance differences between men and women:an update. Sports Med 35: 1017-1024, 2005.

12.  Thibault V, Guillaume M, Berthelot G, Helou NE, Schaal K, Quinquis L, Nassif H, Tafflet M, Escolano S, Hermine O, and Toussaint JF. Women and Men in Sport Performance: The Gender Gap has not Evolved since 1983. J Sports Sci Med 9: 214-223, 2010.

13.  Sandbakk O, Solli GS, and Holmberg HC. Sex Differences in World-Record Performance: The Influence of Sport Discipline and Competition Duration. Int J Sports Physiol Perform 13: 2-8, 2018.

14.  Millard-Stafford M, Swanson AE, and Wittbrodt MT. Nature Versus Nurture: Have Performance Gaps Between Men and Women Reached an Asymptote? Int J Sports Physiol Perform 13: 530-535, 2018.

15.  Seiler S, De Koning JJ, and Foster C. The fall and rise of the gender difference in elite anaerobic performance 1952-2006. Med Sci Sports Exerc 39: 534-540, 2007.

16.  Nuell S, Illera-Dominguez V, Carmona G, Alomar X, Padulles JM, Lloret M, and Cadefau JA. Sex differences in thigh muscle volumes, sprint performance and mechanical properties in national-level sprinters. PLoS One 14: e0224862, 2019.

17.  Higerd GA. Assessing the Potential Transgender Impact on Girl Champions in American High School Track and Field. In: Sports Management. PQDT Open: United States Sports Academy, 2020, p. 168.

18.  Tonnessen E, Svendsen IS, Olsen IC, Guttormsen A, and Haugen T. Performance development in adolescent track and field athletes according to age, sex and sport discipline. PLoS One 10: e0129014, 2015.

19.  Hilton EN, and Lundberg TR. Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage. Sports Med 2020.

20.  Harper J, O’Donnell E, Sorouri Khorashad B, McDermott H, and Witcomb GL. How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation. Br J Sports Med 2021.

21.  Roberts TA, Smalley J, and Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med 2020.

Dr. Greg Brown is a Professor of Exercise Science in the Department of Kinesiology and Sport Sciences at the University of Nebraska at Kearney where he has been a faculty member since 2004. He is also the Director of the General Studies program at the University of Nebraska at Kearney. He earned a Bachelor of Science in Physical Education (pre-Physical Therapy emphasis) from Utah State University in 1997, a Master of Science in Exercise and Sport Science (Exercise Physiology Emphasis) from Iowa State University in 1999, and a Doctorate of Philosophy in Health and Human Performance (Biological Basis of Health & Human Performance emphasis) from Iowa State University in 2002. He is a Fellow of the American College of Sports Medicine and an American College of Sports Medicine Certified Exercise Physiologist.