Category Archives: Active learning

My First Run at Teaching an Integrated Physiology Course: Lessons Learned

One of the primary factors that attracted me to my current position, a tenure-track Assistant Professor of Biology at a small teaching-intensive liberal arts college, was the fact that my new department gave me the freedom to update and, in the end, completely overhaul the existing Anatomy and Physiology (A&P) curriculum. This position allowed great academic freedom, especially to a new professor, and department support for trying new teaching strategies and activities was, and still is, very high. So as a new entrant into the field of physiology education, and as someone who is interested in pedagogical research, this opportunity and level of freedom excited me.

My predecessor, while a fantastic educator, had built the year-long A&P sequence in the traditional form of one to two weeks on a specific topic (e.g. histology, the skeletal system, or the respiratory system) and an exam every so often that combined the previously covered topics. Both the topics covered and the exams could very much stand on their own, and were more like separate units. This course design was exactly the way I took the A&P course, longer ago than I care to admit, although at a different institution. In fact, most of my college courses were taught this way. And while that may be appropriate for some fields, the more I was reading and learning about teaching A&P the more I was starting to convince myself that I wanted teach A&P in an integrated fashion as soon as I got the chance.

So here I was, the bright-eyed and bushy-tailed newly minted Assistant Professor of Biology, with the academic freedom to teach A&P in the best way that I saw fit. One important thing to note: this course sequence (A&P I and II) is an upper-division junior and senior level course at my college, and class sizes are very small (20-24 students) allowing for maximum time for interaction, questions, and instructor guidance both in lecture and lab. (That latter point is key, but we’ll talk more about that in a minute.)

I entered the 2017-2018 academic year with a brand-new, shiny, exciting, and most importantly, integrated A&P course plan and a lot of enthusiasm. Along the way I took meticulous notes on what worked, what didn’t work, and the areas that needed improvement. Now in the 2018-2019 academic year I’m teaching this integrated course sequence for the second time, all while taking those same meticulous notes and comparing student feedback. Below I’ve compiled what I deem (so far) to be some of the most important lessons that I learned along the way:

 1) Use an integrative textbook.

This I was fortunate to do from the start. While this is an A&P course (not just P), I decided to use Physiology: An Integrated Approach by Dee U. Silverthorn as my primary text. Not only is the book already designed to be used in an integrative fashion, but there is ample introductory material which can be used to remind students of previous course material that they need to know (see lesson #2 below) and there are entire chapters dedicated to the integration of multiple systems (e.g. exercise). The assessment questions in the text are also well organized and progressive in nature and can be assigned as homework for practice or pre-reading assignments. Anatomy information, such as the specifics of the skeletal system and joints, muscles, histology, etc., was supplemented through the use of models and other reference material in hands-on lab activities.

2) Start building and assessing students’ A&P knowledge from the ground up, and build incrementally.

There are two important parts to this lesson: A) previous course knowledge that is applicable to this upper-division A&P course, and B) the new A&P material itself.

In my initial run of the course I made the mistake of starting out at a bit too advanced of a content level. I assumed more knowledge was retained from previous courses by the students than actually was. I learned very quickly that I needed to take a step back, but not too far. Instead of re-teaching introductory chemistry, biology, and physics, I took the opportunity to remind them of the relevant key principles (e.g. law of mass action) and then pointed them to pages in the text or provide additional material where they could review.

I applied this same philosophy as we progressed through new material. Lower-order Bloom’s principles should be assessed and mastered first, before progressing to the higher-order skills for each new section. In my second iteration of the course I implemented low-stakes (completion-based grade) homework assignments to be completed before the class or lab period, which were aimed to get a head-start on the lower-order skills. Then in class we reviewed these questions within the lecture or lab and added on with more advanced questions and/or activities. This format of pre-class homework was very well received by the students, and even though it is more work for them, they said that it encouraged them to keep up with the reading and stay-on track in the class. As the class progressed, I added in more advanced homework problems that integrated material from previous chapters. Obviously, if you are going to teach in an integrated fashion then you will need to assess the students in the same way, but a slow-build up to that level and ample low-stakes practice is key.

3) Create a detailed course outline, and then be prepared to change it.

This lesson holds true for just about any course, but I found it especially true for an integrated A&P course. As an instructor, not only did I need to be well versed in A&P, but I also needed to see the big picture and connect concepts and ideas both during the initial course construction and as the course progressed. I went into the course with an idea of what I wanted (and needed) to cover and during the course students helped guide what topics they struggled with and/or what they wanted to learn more about. So while still sticking to covering the basics of a course, I was still able to dive a bit deeper into other topics (such as exercise) per student interest. This also helped boost motivation for student learning when they feel they have some agency in the material.

Another aspect of the lesson is the addition of what I call “flex days”. Students will find this style of teaching and learning challenging and some will need more time and practice with the material. I found it very helpful to add in a “flex day” within each unit where no new material was covered, but instead time was dedicated to answering questions and additional practice with the concepts. If a full class day can’t be dedicated, even 30 minutes can be put to great use and the students really appreciate the extra time and practice.

 

4) Constantly remind your students of the new course format.

Students will want to revert back to what they are comfortable with and what has worked for them in the past. They will forget that information needs to be retained and applied later in the course. I found that I needed to constantly remind students that their “cram and forget” method will not serve them well in this course. But, simply telling them is not enough, so I allowed for practice problems both in and outside of class that revisited “older” material and prepared them for the unit exams with integrative questions which combined information from different chapters. I even listed the textbook chapters at the end of the question so that they would know where to find the material if needed.

Along with this, I found that tying material back to central themes in physiology (e.g. structure-function, homeostasis, etc.) also helped the students connect material. I am fortunate that the entry level biology courses at this college teach using the Vision and Change terminology, so the basic themes are not new to them, making integration at least on that level a bit more approachable.

 

5) Solicit student feedback.

Students love to be heard and they love to know that their input matters. And in the design of a new course I want to know what is working and what is not. I may think something is working, but the students may think otherwise. Blank notecards are my best friend in this instance. I simply have a stack at the side of the room and students can or cannot fill them out and drop them in a box. I often ask a specific question and solicit their input after an activity or particularly challenging topic. Of course, the second part of this step is actually reading and taking their input seriously. I’ve often made some last minute changes or revisited some material based on anonymous student feedback, which also ties back to lesson #3.

 

6) Be prepared to spend a lot of time with students outside of the classroom.

Some students are great about speaking up in class and asking questions. Other students are more comfortable asking questions outside of class time. And of course, I found that students of both flavors will think that they know a particular concept, and then find out, usually on an exam, that they do not (but that is probably not unique to an integrative course). So, after the first exam I reached out to every student inviting them to meet with me one-on-one. In these meetings we went through not only the details of the exam, but study skills. Every student needed to be reminded and encouraged to study a little bit every day or at least every other day to maximize retention and success. This also helped create an open-door policy with students who needed and wanted more assistance, increasing their comfort level with coming to office hours and asking for help.

 

As you may have inferred, teaching this type of course takes a lot of time. I’ll be honest and say that I wasn’t necessarily mentally or physically prepared for the amount of time it took to design and run this course, especially in my first year of teaching, but I made it work and I learned a lot. During this process I often discussed course ideas with department colleagues and A&P instructors at other universities. I perused valuable online resources (such as LifeSciTRC.org and the PECOP Blog) for inspiration and guidance. I also found that I spent a lot of time reflecting on just about every lecture, activity, and lab to ensure that the content connections were accurate, applicable, and obtainable by the students. And while I know that the course still has a ways to go, I am confident in the solid foundation I have laid for a real integrative A&P course. And, just as I am doing now with its second iteration, each run will be modified and improved as needed to maximize student learning and success, and that is what makes me even more excited!

Now I turn the conversation over to the MANY seasoned educators that read this blog. Do you have experience designing and teaching an integrated A&P course? What advice do you have for those, like me, that are just starting this journey? Please share!

Jennifer Ann Stokes is an Assistant Professor of Biology at Centenary College in Shreveport, LA. She received her PhD in Biomedical Sciences from the University of California, San Diego (UCSD). Following a Postdoctoral Fellowship in respiratory physiology at UCSD, Jennifer spent a year at Beloit College (Beloit, WI) as a Visiting Assistant Professor of Biology to expand her teaching background and pursue a teaching career at a primarily undergraduate university. Now at Centenary College, Jennifer teaches Human Anatomy and Physiology I and II (using an integrative approach), Nutritional Physiology, Medical Terminology, and Psychopharmacology. Jennifer is also actively engaged with undergraduates in basic science research (www.stokeslab.com) and in her free time enjoys cycling, hiking, and yoga.
Teaching for Learning: The Evolution of a Teaching Assistant

An average medical student, like myself, would agree that our first year in medical school is fundamentally different from our last, but not in the ways most of us would expect. Most of us find out that medical school not only teaches us about medicine but it also indirectly teaches us how to learn. But what did it take? What is different now that we didn’t do back in the first year? If it comes to choosing one step of the road, being a teaching assistant could be a turning point for the perception of medical education in the long run, as it offers a glimpse into teaching for someone who is still a student.

At first, tutoring a group of students might seem like a simple task if it is only understood as a role for giving advice about how to get good grades or how to not fail. However, having the opportunity to grade students’ activities and even listen to their questions provides a second chance at trying to solve one’s own obstacles as a medical student. A very interesting element is that most students refuse to utilize innovative ways of teaching or any method that doesn’t involve the passive transmission of content from speaker to audience. There could be many reasons, including insecurity, for this feeling of superficial review of content or laziness, as it happened for me.

There are, in fact, many educational models that attempt to objectively describe the effects of educating and being educated as active processes. Kirkpatrick’s model is a four-stage approach which proposes the evaluation of specific aspects in the general learning outcome instead of the process as a whole (1). It was initially developed for business training and each level addresses elements of the educational outcome, as follows:

  • Level 1- Reaction: How did learners feel about the learning experience? Did they enjoy it?
  • Level 2- Learning: Did learners improve their knowledge and skills?
  • Level 3- Behavior: Are learners doing anything different as a result of training?
  • Level 4- Results: What was the result of training on the business as a whole?

Later, subtypes for level 2 and 4 were added for inter-professional use, allowing its application in broader contexts like medicine, and different versions of it have been endorsed by the Best Evidence in Medical Education Group and the Royal College of Physicians and Surgeons of Canada (1) (2).  A modified model for medical students who have become teachers has also been adapted (3), grading outcomes in phases that very closely reflect the experience of being a teaching assistant. The main difference is the inclusion of attitude changes towards the learning process and the effect on patients as a final outcome for medical education. The need for integration, association and good problem-solving skills are more likely to correspond to levels 3 and 4 of Kirkpatrick’s model because they overcome traditional study methods and call for better ways of approaching and organizing knowledge.

Diagram 1- Modified Kirkpatrick’s model for grading educational outcomes of medical student teachers, adapted from (3)

These modifications at multiple levels allow for personal learning to become a tool for supporting another student’s process. By working as a teaching assistant, I have learned to use other ways of studying and understanding complex topics, as well as strategies to deal with a great amount of information. These methods include active and regular training in memorization, deep analysis of performance in exams and schematization for subjects like Pharmacology, for which I have received some training, too.

I am now aware of the complexity of education based on the little but valuable experience I have acquired until now as a teacher in progress. I have had the privilege to help teach other students based on my own experiences. Therefore, the role of a teaching assistant should be understood as a feedback process for both students and student-teachers with a high impact on educational outcomes, providing a new approach for training with student-teaching as a mainstay in medical curricula.

References

  1. Roland D. Proposal of a linear rather than hierarchical evaluation of educational initiatives: the 7Is framework. Journal of Educational Evaluation for Health Professions. 2015;12:35.
  2. Steinert Y, Mann K, Anderson B, Barnett B, Centeno A, Naismith L et al. A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40. Medical Teacher. 2016;38(8):769-786.
  3. Hill A, Yu, Wilson, Hawken, Singh, Lemanu. Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. Advances in Medical Education and Practice. 2011;:157.

The idea for this blog was suggested by Ricardo A. Pena Silva M.D., Ph.D. who provided guidance to Maria Alejandra on the writing of this entry.

María Alejandra is a last year medical student at the Universidad de Los Andes, School of Medicine in Bogota, Colombia, where she is has been a teaching assistant for the physiology and pharmacology courses for second-year medical students. Her academic interests are in medical education, particularly in biomedical sciences.  She is interested in pursuing a medical residency in Anesthesiology. Outside medical school, she likes running and enjoys literature as well as writing on multiple topics of personal interest.
Stress and adaptation to curricular changes

 

 

 

…there was a teacher interested in enhancing the learning process of his students. He wanted to see them develop skills beyond routine memorization. With the support of colleagues and the education team at his university, he succeeded and chose a semi-flipped classroom approach that allowed him to introduce novel curricular changes that did not generate much resistance on the part of the students.

The change was made. The students apparently benefited from the course. They worked in groups and learned cooperatively and collaboratively. Students evaluated peers and learned to improve their own work in the process. They not only learned the topics of the class, but also improved their communication skills.

At some point the institution asked the teacher to teach another course. He happily did so, and based on his experience introduced some of the changes of his semi-flipped classroom into the new course. The students in this course were slightly younger and had not been exposed to education in biomedical sciences. To the teacher’s surprise, the students showed a lot of resistance to change. The sessions moved slowly, the test scores were not all that good, and students did not reach the expected outcomes. It was clear that the teacher and the students were going through a period of considerable stress, while adapting to the new model. Students and teachers worked hard but the results did not improve at the expected rate.

Some time ago this was my experience and as I wandered looking for solutions, I started to question the benefits of active learning and the role of stress in educational practice.

Advantages and challenges of active learning

Evidence says that active learning significantly improves student outcomes (higher grades and lower failure rates) and may also promote critical thinking and high level cognitive skills (1, 2). These are essential components of a curriculum that attempts to promote professionalism. However, it may be quite problematic to introduce active learning in settings in which professors and students are used to traditional/passive learning (2).

Some of the biggest challenges for teachers are the following:

  • To learn about backward design of educational activities
  • To think carefully about the expected accomplishments of students
  • To find an efficient way to evaluate student learning
  • To spend the time finding the best strategies for teaching, guiding, and evaluating students.
  • To recognize their limitations. For example, it is possible that despite their expertise, some teachers cannot answer the students’ questions. This is not necessarily bad; in fact, these circumstances should motivate teachers to seek alternatives to clarify the doubts of students. At this point, teachers become role models of professionals who seek to learn continuously.
  • To learn about innovations and disruptive technologies that can improve the teacher role.

Some of the challenges for students include:

  • Understanding their leading role in the learning process
  • Working hard but efficiently to acquire complex skills
  • Reflecting on the effectiveness of their learning methods (metacognition). Usually reading is not enough to learn, and students should look for ways to actively process the information.
  • Trusting (critically) on the methods made available by the teachers to guide their learning. For example, some tasks may seem simple or too complex, but teachers have the experience to choose the right methodology. A work from our team showed that strategies that seem very simple for the student (clay modeling) have a favorable impact on learning outcomes (3).
  • Seeking timely advice and support from teachers, tutors and mentors.

Working to overcome these challenges may generate a high level of stress on students and teachers. Without emphasizing that stress is a desirable trait, I do find that some disturbance in the traditional learning process and risk taking motivate teachers and students to improve their methods.

Intermediate disturbance hypothesis and stress in education

In the twentieth century, the work of Joseph H. Connell became famous for describing factors associated with the diversity of species in an ecosystem (4). Some of his observations were presented in Charles Duhigg’s book “Smarter Faster Better” which discusses circumstances related to effective teamwork (5). Duhigg reports that Connell, a biologist, found that in corals and forests there might be patches where species diversity increases markedly. Curiously, these patches appear after a disturbance in the ecosystem. For example, trees falling in a forest can facilitate the access of light to surface plants and allow the growth of species that otherwise could not survive (5). Connell’s work suggests that species diversity increases under circumstances that cause intermediate stress in the ecosystem. In situations of low stress, one species can become dominant and eradicate other species, whereas in situations of high stress, even the strongest species may not survive. But if, an intermediate stress where to appear, not very strong and not very weak, the diversity of species in an ecosystem could flourish.

I propose that the hypothesis of the intermediate disturbance can also be applied in education. In traditional learning, an individual (ecosystem) learns to react to the challenges presented and develops a method for passing a course. In situations of low stress, memorization (evaluated at the lower levels of Miller´s pyramid) may be enough to pass a course. In high stress level situations, students may drop out or feel inadequate. However, courses that involve active learning may include moderate challenges (intermediate disturbance). These well-managed challenges can motivate the student to develop more complex skills (diversity of species) that lead to effective learning and a broader professional development.

 

 

 

 

 

 

 

 

 

Figure 1. Intermediate disturbance hypothesis in education.

 

In the book “Problem-based learning, how to gain the most from PBL”, Donald Woods describes the challenges and stresses associated with the incorporation of active learning (PBL) in a curriculum (6). He describes the stages of grief that a student (and I add, a teacher) must go through while adapting to the new system. This adaptation can take months and generally is characterized by the following phases:

  • Shock
  • Denial
  • Strong emotion (including depression, panic and anger)
  • Resistance to change
  • Acceptance and resignation to change
  • Struggle to advance in the process
  • Perception of improvement in the expected performance
  • Incorporation of new habits and skills to professional practice

 

 

 

 

 

 

 

 

 

Figure 2. Performance adjustment after curricular changes. Adapted and modified from (6).

 

Properly managing stress and finding strategies to advance in the process are rewarded by achieving better performance once the students become familiar with the new method of active learning. However, to better adapt to curricular or pedagogical changes, it is important for all the education actors to recognize the importance of deliberate work and to have clear goals. In addition, students and teachers should have access to institutional strategies to promote effective time, and anger and frustration management.

Stress is not ideal, but some stress may motivate students and teachers to reevaluate their methods and ultimately work together for a classroom focused on professional excellence. The critical question is how big is the intermediate disturbance needed to improve learning outcomes. As is commonly concluded in papers, more research is needed to answer this question, and we can learn a lot from the theories and methods from our colleagues in Biology.

References

  1. Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, et al. Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A. 2014;111(23):8410-5.
  2. Michael J. Where’s the evidence that active learning works? Adv Physiol Educ. 2006;30(4):159-67.
  3. Akle V, Pena-Silva RA, Valencia DM, Rincon-Perez CW. Validation of clay modeling as a learning tool for the periventricular structures of the human brain. Anat Sci Educ. 2017.
  4. Connell JH. Diversity in Tropical Rain Forests and Coral Reefs. Science. 1978;199(4335):1302-10.
  5. Duhigg C. Smarter Faster Better: Random House; 2016.
  6. Woods DR. Problem Based Learning: How to gain the most from PBL. 2nd. ed1997.
Ricardo A. Peña-Silva M.D., PhD is an associate professor at the Universidad de los Andes, School of Medicine in Bogota, Colombia, where he is the coordinator of the physiology and pharmacology courses for second-year medical students. He received his doctorate in Pharmacology from The University of Iowa in Iowa City. His research interests are in aging, hypertension, cerebrovascular disease and medical education. He works in incorporation and evaluation of educational technology in biomedical education.

He enjoys spending time with his kids. Outside the office he likes running and riding his bicycle in the Colombian mountains.