Category Archives: Curriculum

From a Group to a Team: Medical Education Orientation Curriculum for Building Effective Teams

I am part of a small team of Core Educators in the pre-clerkship undergraduate medical education program at the Lewis Katz School of Medicine at Temple University (LKSOM).  Last year we introduced a new curriculum to our medical students.  Part of this restructuring involved changing the format of the week-long orientation for first year students.  Operating under the new title of Transition to Medical School (TTMS), we introduced education programming amongst traditional orientation activities in which we specifically address the importance of teamwork, while providing a three-part series of 1.5- to 2-hour sessions given over three days to allow the students to get to know each other, learn about team dynamics in education and medicine, and develop their small teams; practice with patient cases to get experience with a type of active learning activities which form part of the backbone of their pre-clerkship education; reflect on the previous two sessions as part of their team’s norming process.  The focus of this blog is to describe the first session of this series, which was designed to dismantle preconceived notions of team learning, highlight the potential impact of high functioning teams, and participate in asset mapping to aid in forming of teams.

A problem which we identified as we transitioned to more case-based learning leading up to the curricular change, and that was particularly highlighted during the transition to virtual and then hybrid teaching and learning during the Covid-19 pandemic, was that medical students often struggle to learn in dysfunctional small groups if they do not first gain the skills to create and sustain high functioning, collaborative teams. Ineffective group dynamics led to limitations in students learning the material and resulted in less buy-in of the value of the case-based activities.  In addition, the downstream effects of dysfunctional team dynamics are well documented and include poor patient outcomes1. This is important as our competencies include preparing students for working in patient care teams.

We began the first education session with a word cloud activity to allow students and faculty to learn about the students’ pre-conceived ideas regarding group work.  Students were asked to submit using software (we used mentimeter.com) a word or phrase that came to mind when we said “group work”; the app then collated and displayed their responses in a figure composed of words.  Words which were submitted by multiple participants appeared larger in the word cloud (see figure for an example of a word cloud).  In our word cloud (not shown) the most frequently submitted words included “collaboration”, “communication”, “stressful”, “teamwork”, “frustrating”, and “compromise”.  Other words and phrases which appeared included “painful”, “judgment”, “overwhelming”, “open minded”, “unequal effort”, “hearing every voice”, “more work”, “understanding”, “innovative”, “constructive”, “helpful” “divide and conquer”, and “mixed bag”.  It was evident and probably not surprising that there was a range of responses from the more skeptical or negative to the more positive and enthusiastic.

Next, we shared information gathered from the literature with regards to the importance of small group, active learning in medical education.  The literature indicates that students who participate in small group learning activities demonstrate improved levels of critical thinking as compared with their peers who participate in lecture-based activities only2-4.  It has also been shown that small group work promotes communication skills5, active learning, cooperation, engagement, and retention of material6.

We then spent a few minutes reviewing the importance of diverse, effective teams in medicine.  The literature indicates that vulnerable patients with multiple chronic conditions have many doctors on their care team.  The number of people involved in a patient’s care is also increased by the nature of interprofessional roles in medicine.  Care teams include physicians (attendings, fellows, residents), medical students, nurses, physician assistants, nurse practitioners, medical assistants, pharmacists, case managers, social workers, physical and occupational therapists, technicians, pathologists, lab specialists, front desk personnel, billing specialists, and many more.  Therefore, it is imperative that students practice their communication and teamwork skills to provide their patients with the best possible care.

We also described to the students the difference between a “group” and a “team”.  A “group” can be defined as a number of people who are associated together in work or activity and has a set leader.  The group members may not work with each other but report directly to that leader, only hold themselves accountable, and rarely assess progress or celebrate successes7.  Revisiting the list above from our students’ word cloud activity, “unequal effort”, “divide and conquer”, and “more work” may be used to describe this kind of group.  In contrast, a “team” includes a small number of people with complimentary skills, who are committed to a common goal and purpose, who set performance goals and hold themselves mutually accountable.  They may share leadership and value open-ended discussion and active problem-solving7.  The terms “open minded”, “hear every voice”, “collaboration”, and “communication” from our students’ word cloud are aspects of a team.

Next, we asked the students to move into their assigned teams of 6-7 students for an asset mapping activity.  The goal of asset mapping is to create more equitable team dynamics by having students identify their own assets and share them with their team.  Each team was assigned to stay together for their first semester courses, so this experience not only allowed the students to think about their contributions to the team, but also served as an icebreaker in a classroom setting for the students before they began their first course.  We used an asset map (see figure) we adapted from George Pfeifer and Elisabeth Stoddard from Worcester Polytechnic Institute, who authored “Equitable and Effective Teams: Creating and Managing Team Dynamics for Equitable Learning Outcomes”8 and from Cliff Rouder of Temple University’s Center for the Advancement of Teaching, who authored “Asset Mapping: An Equity-Based Approach to Improving Student Team Dynamics”9.  Students were given time individually to complete their asset map, and then were instructed to share parts of their maps with their teammates.  Anecdotally, we were impressed with the depth of conversations, the degree of engagement and participation with each team, and the enthusiasm the students shared with each other.  An anonymous RedCap survey was given to the students after TTMS ended, and 87% of responding students indicated they found the asset mapping session useful (response rate was 97% of the class).

The Association of American Medical Colleges (AAMC) reports 11% of students in medical schools identify as historically underrepresented in medicine.  At LKSOM, our current M1 and M2 classes are both comprised of ~30% students who are historically underrepresented in medicine.  Our students come from a diversity of backgrounds and lived experiences, and have varying interests, skills, passions, and responsibilities.  Asset mapping provided a mechanism by which our students could initially learn about and from each other, and later led to conversations which allowed the teams to set their goals and expectations, and hopefully work towards providing a more equitable experience.  Asset mapping can be used to reassess team dynamics and for forming new teams as students progress through the curriculum.  This tool can also be used to help students optimize team dynamics for those who are struggling or underperforming.

This is an example of how sharing the literature with respect to the value of small group learning, team dynamics, and the role of asset mapping was useful in the building of teams in the first semester of medical school.  However, these tools could be adapted and used for learners at any level, or for team building within our departments.

The LKSOM Core Educator Team includes: Jill Allenbaugh MD, Bettina Buttaro PhD, Linda Console-Bram PhD, Anahita Deboo MD, Jamie Garfield MD, Lawrence Kaplan MD, David Karras MD, Karen Lin MD, Judith Litvin PhD, Bill Robinson PhD DPT, Rebecca Petre Sullivan PhD

 

References:

  1. Mitchell R, Parker V, Giles M, Boyle B. The ABC of health care team dynamics: understanding complex affective, behavioral, and cognitive dynamics in interprofessional teams. Health Care Manage Rev. 2014 Jan-Mar;39(1):1-9. doi: 10.1097/HCM.0b013e3182766504. PMID: 24304597.
  2. Tiwari, Agnes & Lai, Patrick & So, Mike & Yuen, Kwan. (2006). A Comparison of the Effects of Problem-Based Learning and Lecturing on the Development of Students’ Critical Thinking. Medical education. 40. 547-54. 10.1111/j.1365-2929.2006.02481.x.
  3. Charles Engel (2009) An Internet Guide to Key Variables for a Coherent Educational System Based on Principles of Problem-Based Learning, Teaching and Learning in Medicine, 21:1, 59-63, DOI: 10.1080/10401330802384888
  4. Kamin, Carol & O’Sullivan, Patricia & Younger, Monica & Deterding, Robin. (2001). Measuring Critical Thinking in Problem-Based Learning Discourse. Teaching and learning in medicine. 13. 27-35. 10.1207/S15328015TLM1301_6.
  5. Walton H. Small group methods in medical teaching. Med Educ. 1997 Nov;31(6):459-64. doi: 10.1046/j.1365-2923.1997.00703.x. PMID: 9463650.
  6. Van Amburgh JA, Devlin JW, Kirwin JL, Qualters DM. A tool for measuring active learning in the classroom. Am J Pharm Educ. 2007 Oct 15;71(5):85. doi: 10.5688/aj710585. PMID: 17998982; PMCID: PMC2064883.
  7. Katzenbach, JR & Smith, DK. (2005). The discipline of teams. Harvard business review. 83. 162-+.
  8. Pfeifer, Geoffrey and Elisabeth A. Stoddard (2019). “Equitable and Effective Teams: Creating and Managing Team Dynamics for Equitable Learning Outcomes” in Kristin Wobbe and Elisabeth A. Stoddard, eds. Beyond All Expectations: Project-Based Learning in the First Year.
  9. Rouder, C (2021). Asset Mapping: An Equity-Based Approach to Improving Student Team Dynamics.  Temple University Center for the Advancement of Teaching.  https://teaching.temple.edu/edvice-exchange/2021/03/asset-mapping-equity-based-approach-improving-student-team-dynamics.
Dr. Rebecca Petre Sullivan earned her Ph.D. in Physiology from the Lewis Katz School of Medicine at Temple University and completed a Post-Doctoral Fellowship in the Interdisciplinary Training Program in Muscle Biology at the University of Maryland School of Medicine.  She taught undergraduate biology courses at Ursinus College and Neumann University.  As an Associate Professor of Physiology in the Department of Biomedical Education and Data Science and the Department of Cardiovascular Sciences, and as a Core Basic Science Educator, she is currently course director in the Pre-Clerkship curriculum at LKSOM and at the Kornberg School of Dentistry; in addition to teaching medical and dental students, she also teaches physiology in Temple’s podiatry school, in the biomedical sciences graduate program, and in the physician assistant program.  She is a member of Temple University’s Provost’s Teaching Academy.  She was the recipient of the Mary DeLeo Prize for Excellence in Basic Science Teaching in 2020, the Golden Apple Award in 2017 and 2021, and the Excellence in Education Award, Year 2 in 2020 from LKSOM, and the Excellence in Undergraduate Teaching Award from Neumann University in 2012.
Flipped and Distant Multi-Section Teaching: An A&P Course Director’s Perspective, Pandemic Plan, and Transition Back to the Classroom.
Historically, flipped classrooms have been around since the mid-2000s and began as bottom-up pilot experiments in a single classroom or section of a course at the will of an inventive instructor. With a robust body of literature deeming these modern content delivery models effective in achieving student success in the classroom and beyond, many educators in the sciences have adopted this approach to active learning. However, I doubt very few decided the pandemic-forced transition to distance learning was the right time to pull the trigger on flipped classroom implementation at the course director level in a multi-section course. I’m happy to share my wild idea and the wild ride we (myself and the A&P faculty at Jefferson) have been on while we were “building the plane as we flew it” over the past 2 years.

I direct A&P undergraduate courses at Thomas Jefferson University and manage a large staff (12 faculty) consisting of myself and a largely part-time adjunct workforce serving about 300 undergrads spread across 12 sections of lecture and 20 sections of lab. Since 2019 when I took the job at Jefferson we have been ballooning with growth and the demand for A&P courses has nearly doubled in the past 3 years. I was just getting used to the new course director role, when we were all challenged in March of 2020. Overnight I went from settling into my new job, to calling upon every skill and resource I had in my academic tool bag.

This unique choice to flip at the director level was borne out of pandemic-generated necessity for a means to deliver a single series of digital content of core A&P concepts, remotely, to all students to ensure an equitable experience across sections. The A&P courses at Jefferson have historically been face-to-face only with the exception of a few “snow days” with “take-home” assignments across the Spring semester during hard Philadelphia winters. The decision to flip a classroom in general aligns well with Jefferson’s active (Nexus) learning approaches, however a flipped distant digital classroom taught in a course director-led multi-section, multi-instructor course is something only a pandemic makes one crazy enough to dream up.

Additional rationale for the implementation of the flip in Fall of 2020 was to seize the day, using March of 2020 as an opportunity to fully revamp a dated class, albeit in a very stressful crisis mode. At that very infamous time, during widespread lockdown, emergency recordings of A&P lectures over slides were the go-to tool to preserve the integrity of the course. With a small amount of course director forethought and rock star faculty teamwork, those initial post-spring break A&P II content videos were recorded with the thought and intention to not waste any effort as the entire sequence would in all likelihood need to be converted to a digital format to carry the FA20/SP21 rising cohort of students though the standard 2 semester A&P sequence.

While I can currently say from the perspective of the course director/major course designer that the goal of generating a flipped classroom that works both at distance and in person was absolutely, successfully, met.  I cannot yet speak to the experience of the faculty members who were handed the curricula and directed to teach in a new modality adopted over a short summer break in July of 2020. In hindsight, the A&P faculty ended up being tested much more than the students with little prep time, and direction to teach in a way they may be unfamiliar with, the flipped classroom, online. A plan for reflection and a revelation of the faculty member experience is in the works.

To better describe the design, active learning is implemented both equitably and autonomously across sections. All sections share the same assignment types, but not necessarily identical assignments nor the same instructor. All students must give two “teach-back” presentations where the student is tasked with becoming an expert on a single learning outcome (LO), and then “teaching-back” that learning outcome to a classroom audience of students. “Teach backs” account for about 25-30% of synchronous class time. The other 70-75% of synchronous class time is devoted to reviewing core concepts, demonstrating study strategies, and facilitating active learning activities. The active learning activities are curated by the course director with the intention that the individual instructors modify and adjust activities as they go, but have a safety net of resources to deliver the course as is.

Noteworthy, not all activities were totally unknown to the faculty with institutional knowledge when the new core curricula materials were shared. There were some upcycled former laboratory activities that were really “dry” classroom friendly labs. For example, basic sensory tests could be done at home with any willing quarantine mate. Activities requiring materials did have to wait for in person days. The future goal is to add more in-house generated collaborative work to the shared instructor pool to elevate each iteration of the course. However, “not fixing anything that wasn’t already broke” was deemed a resourceful jumping off point.

The course, now, is robust and both A&P I & II lab and lecture have run online in FA2020/SP2021. The course is now mid re-test during our first in person semester back, FA2021/SP2022, with the same content and resources generated in crisis mode March 2020-Summer2020-Fall 2020. We, transitioned synchronous lecture back to masked-face-to-masked-face in person learning in Fall of 2021 and the course is running as planned. No major changes needed to be made to Canvas sites housing core lecture content to make the shift back to in person. Courses were relatively easy to share and copy over to individual instructors prior to the start of the semester to allow time for autonomous course personalization.

The story is still in progress as we have only just begun to experience Spring of 2022. The course is being tested in another way now, with a virtual start and a mid-semester transition back to in person as the pandemic distance learning challenges keep coming. At this point I’m very grateful to say the course can also seamlessly transition with little notice from remote-to-face-to-face and back again. Collaborative drawing activities on white boards work on digital white boards with screen sharing. Paper worksheets can also be completed digitally and collaboratively in small digital break out rooms. Not every activity will transfer perfectly, but that is what makes a growing pool of shared instructor resources important and valuable. The flipped classroom does not have to be grassroots anymore. A growing body of generous teacher networks, education organizations, and professional societies continue to share and widely make active learning resources available to all and often, free.  And finally, there is also nothing like a global pandemic bearing down under uncompromising deadlines to force a little creativity and development of new ideas to share back to the community.

**Illustration by Andrea Rochat, MFA

Dr. Nanette J. Tomicek is an Assistant Professor of Biology in the College of Life Sciences at Thomas Jefferson University, East Falls where she has been a faculty member since 2019. Currently, she directs the undergraduate introductory A&P courses serving a variety of basic science, and clinical-track majors. Dr. Tomicek specializes in large lecture course, and multi-section course management and has previously done so at both Penn State (2006-2017) and Temple Universities (2017-2019). Her current work focuses on pedagogy, active learning, laboratory, and excellence in biology education. Dr. Tomicek is also an adjunct faculty member for Penn State World Campus in the Eberly College of Science. She has been teaching a special topics course, The Biology of Sex for almost 10 years and is an expert in reproductive physiology and digital course delivery. Past doctoral work at Penn State and research interests include developing targeted cardiovascular therapeutics for aging women, examining downstream estrogen receptor signaling pathways in the heart in an ovariectomized rat model of aging and estrogen deficiency. Dr. Tomicek earned her Ph.D. in Spring of 2012 at Penn State in the Intercollege Graduate Degree Program in Physiology, and is a proud active member of the Human Anatomy and Physiology Society.
Expanding “normal” in physiology

We are not formal authorities, rather informal allies who have enacted a few small classroom and content related changes related to diversity and inclusivity in our medical school. We hope that our experience will help you in your pursuits in the education of all students.

It took someone in power (a Departmental Leader and Course Director) to act. Author KSC recognized that key person group diversity content was missing and that societal and student sentiment had shifted. This was in the early fall following the 2020 “Black Lives Matter” demonstrations.  Knowing that even with firm institutional commitment, change would take time, author KSC inserted intentional diversity and inclusivity curricular time into the Cardiovascular Systems course (USA medical year 2, 5-week Fall course) in 2020. The social determinants of healthcare and related topics received some curricular coverage but were less present in foundational coursework. Three required elements were added to the course that would both have learning objectives and corresponding assessment items, as assessment often indicates importance in coverage and content to students.

Having passion and insight does not mean that this person must deliver the content. Author TEW was the person selected to deliver the material since the topic of “normal” had been informing his teaching for several years, especially in developing physiology content for Pediatrics and Gerontology medical blocks and an understanding that 50% of people could be excluded if sex as a biological variable is not included.  In 2017, author TEW also led a teaching workshop at the International Union of Physiological Sciences in Brazil with the goal of challenging physiology educators from across physiology societies to include sex and lifespan material in physiology education and to teach these differences not as special topics but as “normal” physiology.

The three elements covered included: sex, lifespan (older and younger), and USA person groups with historic health disparities. One lecture (“Normal” physiology and how it changes across the lifespan and between sexes – covering respiratory, renal, and cardiovascular systems) and 6 podcasts (Selected sex-specific issues in BP control & hypertension, Selected race & ethnicity issues in BP control & hypertension, An innovative approach to hypertension care in African American males, Sex-specific physiology: CV signs and symptoms, Sex-specific physiology: Heart disease, and CV epidemiology delineated by race and ethnicity) were incorporated and spaced within an integrative organ-based content.  We attempted to have material that was race/culture-informed but not race/culture based, which allows some separation of social constructs, the individual vs. person group, and a determinant vs. prevalence. In other Year 2 medical courses, Department physiologists added information on historical bias in normative prediction equations (pulmonary function testing and glomerular filtration rate) as well as environmental justice and air quality.  These other additions were in the form of one to a few formally presented slides, part of a case presentation, or as a brief class discussion topic.

Were the additions easy? No. It took curricular time, administrative support, and a great deal of learning on our part. Documents such as APS Medical Physiology Learning Objectives do not directly address diversity and inclusivity to guide the field in what is important to include.  Perhaps as a Society this is a change we can implement.  Some take-homes for physiology educators: 1) no matter your background, you can contribute (very few people have formal training in this area), 2) collaborate with other faculty, 3) obtain feedback from all person groups and from students, as perception and intent can be quite different, 4) be intentional and precise with wording, and 5) implement small changes. We encourage you to expand “normal” physiology in one or two ways this upcoming semester, but do not be surprised if students are quite interested and request more.

 

 

 

 

 

Ken Campbell is a Professor and Director of Graduate Studies in the Department of Physiology. He also in the Co-course Director of the Cardiovascular Course in the Year 2 medical curriculum University of Kentucky College of Medicine.

 

 

Thad Wilson is a Professor and Director of the Graduate Certificate in Physiology Teaching in the Department of Physiology. He also is the Co-course Director of the Respiratory Course in the Year 2 medical curriculum and teaches physiology in several of the other medical courses at University of Kentucky College of Medicine.

 

 
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.

 

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.
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.
Pandemic, Physiology, Physical Therapy, Psychology, Purpose, Professor Fink, Practical Exams, and Proficiency!

Pandemic

To say that the COVID-19 pandemic has affected education would be an understatement.  Physical distancing measures that were introduced across the world to reduce community spread of SARS-CoV-2 (the COVID-19 pathogen), necessitated a cessation or reduction of in-person instruction, and the introduction of what has come to be known as “emergency remote education”(1, 2).  Emergency remote education or teaching (ERE or ERT) is different from remote or online education in that, it is not planned and optional, but rather, a response to an educational emergency (3).

Physiology for Physical Therapy Students

Against the backdrop of the COVID-19 pandemic, as I was trying to keep my primary research program on regenerative and rehabilitative muscle biology moving forward (4), engaging with the scientific community on repurposing FDA-approved drugs for COVID-19 (5, 6), and working on the Biomaterials, Pharmacology, and Muscle Biology courses that I teach each year; I was requested to take on a new responsibility.  The new responsibility was to serve as the course master and sole instructor for a 3-credit, 15-week course on Physiology and Pathophysiology for Professional Year One (PY1) Doctor of Physical Therapy (DPT) students.  I had foreseen taking on this responsibility a couple of years down the road, but COVID-19 contingencies required that I start teaching the course in January 2021.  I had always believed that within the Physical Therapy curriculum, Anatomy, Physiology and Neuroscience, were courses that could only be taught by people who were specialists – i.e. you had to be born for it and should have received a level of training needed to become a master of Shaolin Kung Fu (7).  With less than a year to prepare for my Physiology and Pathophysiology course, and with the acknowledgment that I was not trained in the martial art of Physiology instruction, I looked for inspiration.  The Peter Parker Principle from Spider-Man came to mind – “With great power comes great responsibility” (8).  Unfortunately, I realized that there was no corollary that said “With great responsibility comes great power”.  Self-doubt, anxious thoughts, and frank fear of failure abounded.

Psychology and Purpose

Call it coincidence, grace, or anything in between; at the time when I started preparing to teach Physiology and Pathophysiology, I had been working with a psychological counselor who was helping me process my grief following my father’s passing a couple of months before COVID-19 was declared a pandemic.  In addition to processing my grief, through counseling, I had also started learning more about myself and how to process anxious thoughts, such as the fear of failing in my new superhero role of teaching Physiology and Pathophysiology to Physical Therapy students.  Learning how to effectively use my “wise mind” (an optimal intersection of the “emotional mind” and “reasonable mind”), writing out the possible “worst outcomes” and “likely outcomes”, practicing “self-compassion”, increasing distress tolerance, working on emotional regulation, and most importantly embracing “radical acceptance” of the things I cannot change, helped me work through the anxiety induced by my new teaching responsibility.  This does not mean that my anxiety vanished, it just means that I was more aware of it, acknowledged it, and worked my way through it to get to what I was supposed to do.  I also learned through counseling that purpose drives motivation.  I realized that my anxiety over teaching Physiology was related to the value I placed on the teaching and learning of Physiology in Physical Therapy and other health professions.  Being a Physical Therapist and Physiologist who is committed to promoting movement-centered healthcare, I found motivation in the prospect of training Physical Therapists to serve as health educators with the ultimate goal of improving human movement.  Therefore, the idea of developing a course that would give my students a solid foundation in the Physiology and Pathophysiology of Human Movement began to excite me more than intimidate me.  The aspects of my personality that inspired me to publish a paper on the possible pathophysiological mechanisms underlying COVID-19 complications (5), stirred in me the passion to train the next generation of Physical Therapists, who through their sound knowledge of Physiology would likely go on to transform healthcare and promote healthier societies through movement (9).

The point about purpose being a positive driver of motivation, mentioned above, has been known to educational psychologists for a while.  When students see that the purpose of learning something is bigger than themselves, they are more motivated to learn (10).  So, rather than setting up my course as a generic medical physiology course, I decided to set it up as a Physiology and Pathophysiology of Human Movement course that is customized for human movement experts in training – i.e. Student Physical Therapists.  I set my course up in four modules – Moving the Body (focused on muscle and nerve), Moving Materials Around the Body (focused on the cardiovascular and pulmonary systems), Fueling Movement (focused on cellular respiration and the ATP story), and Decoding the Genetics of Human Movement (focused on how genetic information is transcribed and translated into proteins that make movement possible).

Professor Fink

For those of you who have not heard of Professor Steven Fink, you should look him up (11).  A Ph.D.-trained Physiologist and former member of the American Physiological Society (APS), Professor Fink has posted over 200 original educational videos on YouTube, covering Anatomy, Physiology, Pharmacology, and other subjects.  I had found his YouTube videos several years ago, while looking for good resources for my Pharmacology course, and never stopped watching them ever since then.  I would watch his videos while exercising, and listen to them during my commute (and sometimes even during my ablutions!).  There were two topics in Physiology that scared me the most – cellular respiration and genetics.  I had learned these topics just well enough to get me through high school, four years of Physical Therapy School, one year of Post-Professional Physical Therapy training, six years of Ph.D. training in a Physiology laboratory, six years as a Postdoctoral Fellow (also in a Physiology laboratory), and several years as an Assistant Professor in Physical Therapy.  However, despite the “few years” I had spent in academia and my 10+ years being a member of the APS, I never felt that I had gained mastery over the basic physiology of cellular respiration and genetics.  So, when I started preparing to teach Physiology, I decided to up my number of views on Professor Fink’s videos on cellular respiration and genetics.  Furthermore, I reached out to Professor Fink and asked him if he would serve as a teaching mentor for my new course and he very kindly agreed.  I am fortunate to be a teacher-scholar in a department and university, which places a high priority on teaching, and supports training in pedagogy and the scholarship of teaching and learning through consultation with experts within and outside the university.  As part of our mentoring relationship, Professor Fink gave feedback on my syllabus, course content, testing materials and pedagogical strategies.  He also introduced me to “Principles of Anatomy and Physiology, 16th Edition, by Gerard J. Tortora, Bryan H. Derrickson, which proved to be a useful resource (ISBN: 978-1-119-66268-6).  Through all these interactions, Professor Fink demonstrated that a person can be a “celebrity professor” and still be a kind and gentle human being.  Having him as my teaching mentor played a significant role in building my confidence as a physiology teacher.  Research shows that academic mentoring is related to favorable outcomes in various domains, which include behavior, attitudes, health, interpersonal relations, motivation, and career (12).

Practical Exams

As the COVID-19 pandemic rolled on through the Winter, Spring/Summer, and Fall semesters of 2020, it became certain that I would have to teach my Physiology and Pathophysiology course in a virtual environment come January 2021.  I had to figure out a way to make sure that the learning objectives of my course would be met despite the challenges posed by teaching and testing in a virtual environment.  Therefore, I came up with the idea of virtual practical exams for each of the four modules in my course.  These practical exams would be set up as a mock discussion between a Physical Therapist and a referring health professional regarding a patient who had been referred for Physical Therapy.  Students would take the exam individually.  On entering the virtual exam room, the student would introduce themselves as a Student Physical Therapist and then request me (the referring healthcare professional) to provide relevant details regarding the patient, in order to customize assessment, goal setting and treatment for the patient.  With the patient’s condition as the backdrop, I would ask the student questions from the course content that was relevant to the patient’s condition.  A clear and precise rubric for the exam would be provided to the students in keeping with the principles of transparency in learning and teaching (13).

Proficiency

As we went through the course, the virtual practical exams proved to be an opportunity to provide individualized attention and both summative and formative feedback to students (14).  As a teacher, it was rewarding to see my Physical Therapy students talk about cellular respiration and gene expression with more confidence and clarity than I could do during my prior 12+ years as a Ph.D.-trained Physiologist.  It was clear to me that my students had found a sense of purpose in the course content that was bigger than themselves – they believed that what they were learning would translate to better care for their patients and would ultimately help create healthier societies through movement.

In the qualitative feedback received through a formal student evaluation of teaching (SET) survey, one student wrote “Absolutely exceptional professor.  Please continue to do what you are doing for future cohorts.  You must keep the verbal practical examinations for this class.  Testing one’s ability to verbally explain how the body functions and how it is dysfunctional is the perfect way to assess if true learning has occurred.”  Sharing similar sentiments, another student wrote “I really enjoyed the format of this class. The virtual exams in this class forced us to really understand the content in a way that we can talk about it, rather than learning to answer a MC question. I hope future students are able to learn as much as I did from this class.”

Closing Remarks

When I meet students for the first time during a course, I tell them that even though I am their teacher, I am first a student.  I let them know that in order to teach, I first need to learn the content well myself.  Pandemic pedagogy in the time of COVID-19-related emergency remote education has reinforced my belief that, the best way to learn something is to teach it.  Thanks to my Physiology and Pathophysiology of Human Movement course, I learned more about myself, about teaching and learning, and of course about cellular respiration and genetics.  Do I now consider myself a master of Physiology instruction?  No!  Am I a more confident physiology teacher?  Yes!  Has writing this article made me reflect more on what worked well and what needs to be fine-tuned for the next iteration of my Physiology and Pathophysiology course?  Yes!

REFERENCES:

  1. Williamson B, Eynon R, Potter J. Pandemic politics, pedagogies and practices: digital technologies and distance education during the coronavirus emergency. Learning, Media and Technology. 2020;45(2):107-14.
  2. Bozkurt A, Jung I, Xiao J, Vladimirschi V, Schuwer R, Egorov G, et al. A global outlook to the interruption of education due to COVID-19 pandemic: Navigating in a time of uncertainty and crisis. Asian Journal of Distance Education. 2020;15(1):1-126.
  3. Hodges C, Moore S, Lockee B, Trust T, Bond A. The difference between emergency remote teaching and online learning. Educause review. 2020;27:1-12.
  4. Begam M, Roche R, Hass JJ, Basel CA, Blackmer JM, Konja JT, et al. The effects of concentric and eccentric training in murine models of dysferlin-associated muscular dystrophy. Muscle Nerve. 2020.
  5. Roche JA, Roche R. A hypothesized role for dysregulated bradykinin signaling in COVID-19 respiratory complications. FASEB J. 2020;34(6):7265-9.
  6. Joseph R, Renuka R. AN OPEN LETTER TO THE SCIENTIFIC COMMUNITY ON THE POSSIBLE ROLE OF DYSREGULATED BRADYKININ SIGNALING IN COVID-19 RESPIRATORY COMPLICATIONS2020.
  7. Wikipedia contributors. Shaolin Kung Fu – Wikipedia, The Free Encyclopedia 2021 [Available from: https://en.wikipedia.org/w/index.php?title=Shaolin_Kung_Fu&oldid=1026594946.
  8. Wikipedia contributors. With great power comes great responsibility – Wikipedia, The Free Encyclopedia 2021 [Available from: https://en.wikipedia.org/w/index.php?title=With_great_power_comes_great_responsibility&oldid=1028753868.
  9. American Physical Therapy Association (APTA). Transforming Society – American Physical Therapy Association [Available from: https://www.apta.org/transforming-society.
  10. Yeager DS, Henderson MD, Paunesku D, Walton GM, D’Mello S, Spitzer BJ, et al. Boring but important: a self-transcendent purpose for learning fosters academic self-regulation. Journal of personality and social psychology. 2014;107(4):559.
  11. Fink S. ProfessorFink.com [Available from: https://professorfink.com/.
  12. Eby LT, Allen TD, Evans SC, Ng T, Dubois D. Does Mentoring Matter? A Multidisciplinary Meta-Analysis Comparing Mentored and Non-Mentored Individuals. J Vocat Behav. 2008;72(2):254-67.
  13. Winkelmes M. Transparency in Learning and Teaching: Faculty and students benefit directly from a shared focus on learning and teaching processes. NEA Higher Education Advocate. 2013;30(1):6-9.
  14. Alt D. Teachers’ practices in science learning environments and their use of formative and summative assessment tasks. Learning Environments Research. 2018;21(3):387-406.
Joseph A. Roche, BPT, PhD.  Associate Professor.  Physical Therapy Program.  Eugene Applebaum College of Pharmacy and Health Sciences.  

I am an Associate Professor in the Physical Therapy Program at Wayne State University, located in the heart of “Motor City”, Detroit, Michigan.  My research program is focused on developing regenerative and rehabilitative interventions for muscle loss arising from neuromuscular diseases, trauma and aging.  I have a clinical background in Physical Therapy and have received intensive doctoral and postdoctoral research training in muscle physiology/biology.

https://www.researchgate.net/profile/Joseph-Roche-2

https://scholar.google.com/citations?user=-RCFS6oAAAAJ&hl=en
Balancing Coursework, Student Engagement, and Time
Jennifer Rogers, PhD, ACSM EP-C, EIM-2
Associate Professor of Instruction
Director, Human Physiology Undergraduate Curriculum
Department of Health and Human Physiology
University of Iowa

First, a true story. Years ago, when my son was very little, he and his preschool friends invented a game called “What’s In Nick’s Pocket?” Every day before leaving for school my son would select a small treasure to tuck into his pocket.  The other 3- and 4- year olds at school would crowd around and give excited “oooh’s” and “aaah’s” as he presented his offering, which had been carefully selected to delight and amaze his friends.  And so it is with the PECOP blog forum—as each new post arrives in my inbox I wonder with anticipation what educational gem has been mindfully curated by colleagues to share with the PECOP community.

My contribution? Thoughts on the balance between coursework, student engagement, and time.  Student engagement in this context refers to a wide range of activities that exist outside of the traditional classroom that offer valuable opportunities for career exploration and development of professional skills.  Examples include:

  • Internships: either for course credit or independently to gain experience within a particular setting
  • Study Abroad opportunities
  • Participation in a student organization
  • Peer tutor/mentoring programs
  • Research: either as a course-based opportunity or as a lab assistant in a PI’s lab (paid or unpaid)
  • Job experiences: for example, as a certified nursing assistant, medical transcriptionist, emergency medical technician
  • Volunteer and community outreach experiences
  • Job shadowing/clinical observational hours

These are all increasingly popular co-curricular activities that allow students to apply concepts from physiology coursework to real-world scenarios as an important stepping stone to enhance career readiness and often personal development.  At the same time, however, students seem to more frequently communicate that they experience stress, anxiety, and concerns that they “are not at their best,” in part due to balancing coursework demands against time demands for other aspects of their lives.  If you are interested in learning more about the health behaviors and perceptions of college students, one resource is the American College Health Association-National College Health Assessment II (ACHA-NCHA II) Undergraduate Student Reference Group Data Report Fall 2018 (1).  Relevant to this blog, over half of the undergraduates surveyed (57% of 11,107 participants) reported feeling overwhelmed by all they had to do within the past two weeks.

I recently gave an undergraduate physiology education presentation that included this slide.  It was an initial attempt to reconcile how my course, Human Physiology with Lab, (a “time intensive course” I am told), fits within the context of the undergraduate experience.

I was genuinely surprised by the number of undergraduates in the audience who approached me afterward to essentially say “Thank you for recognizing what it feels like to walk in my shoes, it doesn’t seem like [my professors, my PI, my parents] understand the pressure I feel. “

In response, and prior to the changes in higher education following COVID-19, I began to ponder how to balance the necessary disciplinary learning provided by formal physiology coursework and participation in also-valuable experiential opportunities.  The Spring 2020 transition to virtual learning, and planning for academic delivery for Fall 2020 (and beyond), has increased the urgency to revisit these aspects of undergraduate physiology education.  As PECOP bloggers and others have mentioned, this is a significant opportunity to redefine how and what we teach. 

It has been somewhat challenging to me to consider how to restructure my course, specifically the physiology labs, in the post COVID-19 era when lab activities need to be adaptable to either in-person or virtual completion.  My totally-unscientific process to identify areas for change has been the “3-R’s” test. With regard to physiology lab, there may be many important learning objectives:

  • An ability to apply the scientific method to draw conclusions about physiological function
  • The act of collecting data and best practices associated with collection of high-quality data (identification of control variables, volunteer preparation/preparation of the sample prior to testing, knowledge of how to use equipment)
  • Application of basic statistical analyses or qualitative analysis techniques
  • Critical thought and quantitative reasoning to evaluate data
  • How to work collaboratively with others, that may be transferrable to future occupational settings: patients, clients, colleagues
  • Information literacy and how to read and interpret information coming from multiple resources such as scientific journals, online resources, advertisements, and others, and
  • Science communication/the ability to communicate information about human function, in the form of individual or group presentations, written lab reports, poster presentations, formal papers, infographics, mock patient interactions, etc.

Arguably, these are all important lab objectives.  Really important, in fact.

So, what is the 3 R’s test, and how might it help?  The 3 R’s is simply my way of prioritizing.  In order to triage lab objectives, I ask myself: What is Really Important for students to master throughout the semester versus what is Really, Really Important, or even Really, Really, REALLY Important?  For example, if I can only designate one activity that is Really, Really, REALLY Important, which one would it be?  The answer for my particular course is science communication.  It is obviously a matter of semantics, but I like being able to justify that all course activities are still Really Important, even if it is only my inner dialogue.  Going into the unknowns of the Fall semester, this will help me guide how course activities in physiology lab are transformed. 

Another worthy goal, in light of academic stress and allocation of effort for maximum benefit, is to improve the transparency of expectations for students.  A common question that arose during the spring semester was if students would still learn what they needed to in preparation for future coursework or post-graduation opportunities.  The identification of one or two primary learning outcomes (the Really, Really, REALLY important ones) may attenuate feeling overwhelmed by a long list of lab-related skills to master if there is another abrupt shift to virtual instruction mid-semester; course objectives can still be met even if we discontinue in-person lab sessions. 

To return to the original topic of balancing time demands allocated to formal coursework and valuable experiences, the two broad conclusions I have reached fall under the categories what I can do in my own courses and suggestions for conversations to be had at the program level.

In My Courses: COVID-19 has sped up the time course for revisions I had already been considering implementing in physiology labs.  Aligning course activities with what is Really, Really, REALLY important will help me manage preparation efforts for the coming fall semester (and hopefully keep my stress levels manageable).  Another important goal is to improve the transparency of course goals for students, ideally alleviating at least a portion of their course-induced stress through improved allocation of effort.  Ultimately, I hope the lab redesigns reinforce physiology content knowledge AND provide relevant experiences to promote career readiness.  *It is also necessary to emphasize to students that both will require focused time and effort.

At the Program Level:  Earning a degree in physiology is not based on acquired knowledge and skills in a single course, rather it is an end-product of efforts across a range of courses completed across an academic program.  Here are some ideas for program-wide discussion:

  • Faculty should identify the most important course outcome for their respective courses, and we should all meet to talk about it. Distribute program outcomes throughout the courses across the breadth of the program.  (Yes, this is backward design applied to curriculum mapping.)  From the faculty perspective, perhaps this will reduce feeling the need to teach all aspects of physiology within a particular course and instead keep content to a manageable level.  From the student perspective, clear communication of course objectives, in light of content presented within any particular course, may promote “buy in” of effort.  It may also build an awareness that efforts both inside and outside of the classroom are valuable if the specific body of content knowledge and aptitudes developed across the curriculum, relevant for future occupational goals, is tangibly visible.
  • Review experiential/applied learning opportunities. Are there a sufficient number of opportunities embedded within program coursework?  If not, are there other mechanisms available to students, for example opportunities through a Career Center or other institution-specific entities?  Establishing defined pathways for participation may reduce student stress related to not knowing how to find opportunities.  Another option would be to consider whether or not the program would benefit from a career exploration/professional skills development course.  Alternatively, could modules be developed and incorporated into already existing courses? 
  • Lastly, communicate with students the importance of engaging in co-curricular activities that are meaningful to them; this is more important than the number of activities completed. Time is a fixed quantity and must be balanced between competing demands based on personal priorities. 

As we consider course delivery for Fall 2020, the majority of us are reconsidering how we teach our own courses.  There are also likely ongoing conversations with colleagues about plans to navigate coursework in the upcoming semesters.  If everything is changing anyway, why not take a few minutes to share what is Really, Really, REALLY important in your courses?  The result could be an improved undergraduate experience related to balancing the time and effort allocations required for success in the classroom along with opportunities for participation in meaningful experiences.

Reference:

1. American College Health Association. American College Health Association-National College Health Assessment II: Undergraduate Student Reference Group Data Report Fall 2018. Silver Spring, MD: American College Health Association; 2018.

Jennifer Rogers completed her PhD and post-doctoral training at The University of Iowa (Exercise Science).  She has taught at numerous institutions ranging across the community college, 4-year college, and university- level higher education spectrum.  Jennifer’s courses have ranged from small, medium, and large (300+ students) lecture courses, also online, blended, and one-course-at-a-time course delivery formats.  She routinely incorporates web-based learning activities, lecture recordings, and other in-class interactive activities into class structure.  Jennifer’s primary teaching interests center around student readiness for learning, qualitative and quantitative evaluation of teaching strategies, and assessing student perceptions of the learning process.

Building a Conceptual Framework to Promote Future Understanding
Diane H. Munzenmaier, PhD
Program Director
Milwaukee School of Engineering

For most of my career, I taught physiology and genetics to medical students and graduate students.  My experiences with many students who had difficulty succeeding in these courses led me to the realization that the way high school and college students learn the biological sciences does not translate to effective physiology learning and understanding at the graduate level.

Medical students, by virtue of their admission to medical school, have, by definition, been successful academically prior to matriculation and have scored well on standardized exams.  They are among the best and brightest that our education system has to offer.  Yet, I have always been amazed at how many medical students truly struggle with physiology.  It is considered by many students to be the most difficult discipline of the basic medical sciences.  Most students come into medical school as expert memorizers but few have the capacity or motivation to learn a discipline that requires integration, pattern recognition, and understanding of complex mechanisms.  My overall conclusion is that high school and college level biological science education does not prepare students to succeed in learning physiology at the graduate level.  Furthermore, I believe if students were prepared to better appreciate and excel in basic physiology at earlier grade levels, the pipeline for graduate education in the physiological sciences would be significantly increased.

Over the past 5 years, it has become a passion of mine to promote a new way of teaching biology and physiology: one that helps students make connections and that lays a conceptual framework that can be enhanced and enriched throughout their educational careers, rather than one that promotes memorization of random facts that are never connected nor retained.  I recently joined the Center for Biomolecular Modeling at the Milwaukee School of Engineering (MSOE CBM) in order to focus on developing materials and activities to promote that type of learning and to provide professional development for K-16 teachers to help them incorporate this type of learning into their classrooms.

One of my first projects was to develop resources to allow students to study the structure-function relationships of a specific protein important in physiology and use that understanding to relate it to relevant physiology/pathophysiology concepts.  The program is called “Modeling A Protein Story” (MAPS) and, so far, I have developed resources for 3 different project themes: aquaporins, globins, and insulin.

The overall concept is for the students to build their understanding slowly and incrementally over time, usually as part of an extracurricular club.  They start by understanding water and its unique properties.  Then they learn about proteins and how they are synthesized and fold into specific 3D conformations in an aqueous environment based largely on their constituent amino acids and how they interact with water.  Eventually they progress to learning about the unique structure of their protein of interest and how it is related to its function.  Once they have developed a solid understanding of that protein, they work in teams to choose a specific protein story that they will develop and model.  This includes finding a structure in the Protein Data Bank, reading the associated research paper to determine what was learned from the structure, designing a model of the structure in Jmol, an online 3D visualization software, and 3D printing a physical model of the protein that helps them tell their story.  Stories can be anything related to the theme that the students find in their research and consider interesting.  For example, student-developed aquaporin stories have ranged from AQP2 in the kidney to AQP4 in the brain to the use of AQP proteins to develop biomimetic membranes for water purification in developing countries.  By choosing projects that students are interested in, they more readily accept the challenge of reading primary research literature and trying to piece together a confusing puzzle into an understandable “story”. 

In the past year, I have used the insulin theme resources and piloted an active learning project-based curriculum at the undergraduate, high school, and middle school levels on insulin structure-function, glucose homeostasis, and diabetes mellitus.  The type of learning environment in which this curriculum was introduced has varied.  Middle school level children participated in the active learning environment as part of a 2-week summer camp.  High school students from an innovative charter school in downtown Milwaukee were introduced to the project-based curriculum as a 9-week seminar course, and the activity was taught to freshman biomolecular engineering students at the Milwaukee School of Engineering as a team project in their first quarter introductory course.

Some of the activities utilized materials that we have developed at the MSOE CBM and were subsequently produced for distribution by our sister company, 3D Molecular Designs.  Others utilize resources that are readily available online such as those available at the Protein Data Bank at their educational site, PDB-101.  Finally, still other resources have been developed by us specifically for this curriculum in order to help the students move between foundational concepts in an attempt to help them make important connections and to assist them in developing their conceptual framework. 

One of the activities that helps them try to make sense of the connection between glucose and insulin is this “cellular landscape” painting by Dr. David Goodsell at Scripps Research Institute and available at PDB-101.

They learn the basic concept that when blood glucose increases after a meal, insulin is released from the pancreas and allows glucose to be taken up and stored by the cells.  But how?  When they are given this landscape and minimal instructions, they must look closely, connect it to what they already know and try to make sense of it.  They work together in a small group and are encouraged to ask questions.  Is this a cell?  If so, where is the plasma membrane and the extracellular/intracellular spaces?  What types of shapes do they see in those spaces?  What is in the membrane?  What are those white dots?  Why is one dot in one of the shapes in the membrane?  Why are there yellow blobs on the outside of the cell but not on the inside?  Eventually they piece together the puzzle of insulin binding to its receptor, leading to trafficking of vesicles contain glucose transporter proteins to the plasma membrane, thereby allowing the influx of glucose into the cell.  By struggling to make detailed observations and connections, a story has been constructed by the students as a logical mechanism they can visualize which is retained much more effectively than if it had been merely memorized.

In other activities they learn how insulin in synthesized, processed, folded, stored, and released by the pancreatic beta cells in response to elevated blood glucose.  They use a kit developed by MSOE CBM that helps them model the process using plastic “toobers” to develop an understanding of how insulin structure is related to its function in regards to the shape and flexibility required for receptor binding but also related to its compact storage in the pancreas as hexamers and the importance of disulfide bonds in stabilizing monomers during secretion and circulation in the blood.  

As the students build their understanding and progress to developing their own “story”, the depth of that story depends on grade level and the amount of time devoted to the project.  Undergraduate students and high school students who have weeks and months to research and develop their story tend to gravitate to current research into protein engineering of insulin analogs that are either rapid-acting or slow-release, developed as type 1 and type 2 diabetes medications, respectively.  The basic concepts behind most of these analogs are based on the structure-function relationships of hexamer formation.  Rapid-acting medications usually include amino acid modifications that disrupt dimer and hexamer formation.  Slow-release medications tend to promote hexamer stability.  Middle school students or high school students with limited time to spend on the project may only focus on the basic properties of insulin itself.  The curriculum is driven by the students, so it is extremely flexible based on their capabilities, time, and motivation.  Students ultimately use their understanding of insulin structure-function to design and 3D-print a physical model that they highlight to show relevant amino acid modifications and other details that will help them to present the story they have developed based on their learning progression and research. 

In conclusion, we have found that this type of open-ended project-based active learning increases learning, retention, and motivation at every educational level  with which we have worked.  Students are initially frustrated in the process because they are not given “the answer” but they eventually learn to be more present, make observations, ask questions, and make connections.  Our hope is that introduction of this type of inquiry-based instruction in K-16 biological sciences education will eventually make the transition to graduate level physiology learning more successful.

Diane Munzenmaier received her PhD in Physiology studying the role of the renin-angiotensin system on skeletal muscle angiogenesis. This was followed by postdoctoral study of the role of astrocytes in stroke-induced cerebral angiogenesis. She joined the faculty of the Department of Physiology at the Medical College of Wisconsin in 1999 and the Human and Molecular Genetics Center in 2008. As Director of Education in the HMGC, Dr. Munzenmaier lectured and developed curriculum for medical and graduate school physiology and genetics courses. She developed an ACGME-accredited medical residency curriculum and Continuing Medical Education (CME) courses for physician education. She also enjoyed performing educational outreach to K-12 classrooms and the lay public. She is passionate about education and career mentoring for students of all levels. Her specific interests in biomedical science education are finding engaging ways to help clarify the link between structure and (dys)function in health and disease.

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

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

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

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

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

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

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

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

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