Category Archives: Teaching Strategies

The Olympics, sex, and gender in the physiology classroom

Are there sex based difference in athletic performance before puberty?

In the past few years most state legislatures have considered laws stating that only members of the female sex can participate in girl’s and women’s sports (37 states in 2021 alone), and as of April 20, 2022 fifteen states have adopted such legislation (1). There have also been several well publicized instances of transwomen competing for championships in women’s sports (for example see 2, 3, 4). The International Olympic Committee, the NCAA, and other sports governing bodies have also recently revised their policies regarding the inclusion of transwomen in women’s sports (5, 6).  All of this has resulted in students in my exercise physiology classes commonly asking questions about sex-based differences in sports performance and the inclusion of transwomen in women’s sports.

In a previous PECOP Blog (7) I briefly summarized the sex-based advantages men have in athletic performance in adults, and the research evaluating the effects of testosterone suppression and cross sex hormone use on factors that influence athletic performance. In this PECOP Blog, I will briefly summarize the sex based prepubertal differences in athletic performance and touch on puberty blockers.

A 2012 report from the CDC indicated there were no differences between 6–11-year-old boys and girls in performance on physical fitness tests (8).  Many sports leagues for pre-pubertal children are not separated by sex since the focus is developing basic sports skills rather than competition (9). Furthermore, some scholars have stated that there are no differences in athletic performance between boys and girls prior to the onset of puberty, and that it is only the increased testosterone secretion during puberty that causes males to outperform females in athletic competition (10, 11).

On the other hand, evaluations of fitness testing in children as young as 3 years old shows that boys perform better than girls of the same age on tests of muscular strength, muscular endurance, and aerobic fitness (12-17).  For example, Tomkinson et al. (17) observed that at age 9 boys are running an average of 3.2% faster than girls of the same age during the last stage of a 20 m shuttle run (Figure 1).  In a separate evaluation Tomkinson et al. (16) reported that at age 9 boys have a bent arm hang time that is an average of 48.1% longer than girls of the same age (Figure 2).

Furthermore, youth records from USA Track & Field (18) in the 8-and-under age group and in the 9-10-years-old age group (who can reasonably be assumed to be pre-pubertal) show that boys outperform girls in all events (Table 1).  The smallest difference in track and field records between boys and girls is 0.94% in the 8-and-under 100 m run, with the largest difference being 38.42% in the 8-and-under javelin throw.  We recently analyzed top 10 data for national performance from Athletic.net in 100 m, 200 m, 400 m, 800 m, 1500 m, and 1600 m running events for children in the 7-8 and 9–10 year-old age groups for the years 2019-2021 and found that across all events 7-8-year-old boys were 4.4 ± 1.9% faster than girls, and 9-10-year-old boys were 5.4 ± 1.8% faster than girls (figure 3; not yet published data).  Youth records from USA swimming also show that in 19 out of 23 events the national records for 10 and under boys are faster than girls by an average of 1.72% (19).  It is important to note that in competition the difference between first and second place often comes down to as little as 0.02% difference in speed (Data to be presented at the 2022 ACSM Annual Meeting).

There is no question that the differences in running performance between prepubertal boys and girls is less than the 10-13% difference in running performance observed between post-pubertal boys and girls, and between adult men and women (10, 11, 20).  And there is no question that the large increases in circulating testosterone experienced by boys during puberty is responsible for most of the differences in athletic performance between post-pubertal boys and girls, and between adult men and women (21).  But the existence of differences in athletic performance between prepubertal boys and girls is well demonstrated (12-19).  Juxtaposing the statements of no pre-pubertal athletic differences between boys and girls (8, 10, 11) and the evidence demonstrating that there are pre-pubertal athletic differences between boys and girls (12-19) can facilitate an interesting discussion about data collection, sample size, data analysis, and other factors that may contribute to these contradictory findings.

When explaining the biological causes of the prepubertal athletic advantages in boys, a good starting point is to discuss the differences in growth and development between boys and girls and to explain the processes of sex determination and sex differentiation (22).  Sex determination occurs at conception with the conferral of sex chromosomes.  Six weeks later, sex differentiation begins to become apparent and during the remainder of development the gonads and genitalia acquire male or female characteristics.  During sexual differentiation, the presence of the SRY gene on the Y chromosome along with androgen exposure and anti-Müllerian hormone cause the internal and external genitalia to follow the male developmental pathway. In the absence of the SRY gene on the Y chromosome, lack of androgen exposure, and lack of anti-Müllerian hormone the female developmental pathway occurs. Of course these few brief sentences fail to cover the myriad of complex interactions of genes, primordial stem cells, and hormones that regulate sex development, and the possible differences and disorders that can occur. But it is remarkable that with all of the possible missteps that can happen during sexual differentiation and development, sex can be accurately and easily identified at birth 99.83% of the time (23).

Further substantiating the important role of sex in growth and development are the World Health Organization fetal growth charts (24), which indicate small but meaningful sex-based differences with male fetuses being consistently larger than female fetuses.  Similarly, substantiating the important role of sex in growth and development, the Centers for Disease Control and Prevention have different growth charts for boys and girls from birth through adolescence with boys having consistently higher values for body mass and body height (25).

With an eye towards physical fitness and athletic performance, starting at birth and continuing throughout youth girls have more body fat and less fat-free mass than boys. For example, Davis et al. (26) in an evaluation of 602 infants reported that at birth and age 5 months, infant boys have larger total body mass, body length, and fat-free mass while having lower percent body fat than infant girls. In an evaluation of 20 boys and 20 girls ages 3-8 years old, matched for age, height, and body weight Taylor et al. (27) reported that the boys had less body fat, lower percent body fat, and a higher bone free lean body mass than the girls, such that the girls’ fat mass was 52% higher than the boys, while the bone-free lean tissue mass was 9% lower. In an evaluation of 376 prepubertal [Tanner Stage 1] boys and girls, Taylor et al. (28) observed that the boys had ~22% more lean mass, and ~13% less body fat (when expressed as percent of total body mass) than did the girls. In a review of 22 peer reviewed publications on the topic, Staiano and Katzmarzyk (29) concluded that girls have more total body fat than boys throughout childhood and adolescence.  It is a tenet of exercise science that having more lean body mass provides athletic advantages, so it is reasonable to conclude that having more lean body mass contributes to the prepubertal sex-based male athletic advantages.

It is worth noting that serum testosterone concentrations in boys are higher for the first 5 months after birth than in girls (30). Testosterone concentrations are then similar between boys and girls until the onset of puberty, when testosterone concentrations increase 10-20-fold in boys.  Given the well know anabolic and androgenic effects of testosterone, the higher testosterone levels in newborn boys likely contributes to the sex related differences in body size and composition in newborns.  It is unknown how much the lingering sex-linked differences in body size, body composition, physical fitness, and athletic performance are due lasting effects of the higher testosterone levels in newborns, and how much the differences are due to Y chromosome or other sex-linked effects.

Strongly suggesting that sex linked differences in physical fitness and athletic performance in children before puberty are due to biological factors, Eiberg et al. (13) measured body composition, VO2max, and physical activity in 366 Danish boys and 332 Danish girls between the ages of 6 and 7 years old.  Their observations indicated that absolute VO2max was 11% higher in boys than girls, while relative to body mass the boys’ VO2max was still 8% higher than the girls.  Accelerometry based measurements of physical activity indicated that when boys and girls regularly participated in the same amount and intensity of physical activity, the boys had higher measured physical fitness than the girls.  When the findings of Eiberg (13) are taken collectively with the findings of large scale school based physical fitness testing in children that also shows pre-pubertal boys outperforming girls in measurements of aerobic fitness, muscular strength, and muscular endurance (12, 14-17), the youth records from USA Track & Field (18) showing that pre-pubertal boys outperform girls in all events, and the 10 and under records from USA Swimming showing that boys outperform girls in 19 out of 23 events (19), there exists strong evidence that there are differences in physical fitness and athletic performance between boys and girls before puberty.

And finally, this discussion arising from laws stating that only members of the female sex can participate in girl’s and women’s sports can lead to questions about the effects of puberty blockers on physical fitness and athletic performance in prepubertal children.  Puberty blockers are correctly known as gonadotropin-releasing hormone agonists (GnRHa), which disrupt the normal pattern of secretion of as gonadotropin-releasing hormone causing the pituitary gland to stop producing follicle-stimulating hormone and luteinizing hormone. Unfortunately, there is minimal research on the effects of puberty blockers on factors that influence physical fitness and athletic performance.

To the best of my knowledge, there is no research on the effects of puberty blockers on muscle strength, running speed, or other measures of athletic performance.  Indeed, Klaver et al. (31) is the only published research that I am aware of that has evaluated the use of puberty blockers on any athletic performance related factor, and this is only on body composition. Klaver et al. (31) demonstrated that the use of puberty blockers in Tanner stage 2-3 teenagers increased body fat and decreased lean body mass in transgirls, but the use of puberty blockers did not eliminate the differences in body composition between transgirls and comparable female teenagers. Roberts and Carswell (32), concluded that there is no published research that sufficiently characterizes the impact of puberty blockers on growth or final adult height.  Thus, the effect of prescribing puberty blockers to a male child before the onset of puberty on the physical components of athletic performance is almost entirely unknown. This becomes a great point in a discussion to remind students of the ever-evolving nature of science.  Any further discussion on this topic becomes speculation or can be removed from the realm of physiology and into metaphysical discussions of what is or is not fair.  Such metaphysical discussions can be fascinating, and also heated, so caution is advisable when proceeding outside of the realm of physiology in a physiology classroom.

In summary, there is strong evidence that even before puberty there are sex-based differences in physical fitness and athletic performance with boys running faster, jumping farther and higher, and demonstrating greater muscle strength than girls of the same age.  These pre-pubertal sex based differences are smaller than the differences in post pubertal teens and adults, but the differences are likely meaningful in terms of competition.  There is currently insufficient evidence to determine what effects puberty blockers have on physical fitness and athletic performance in children.

References

  1. Lavietes M. (April 13, 2022) Kentucky Legislature overrides governor’s veto of transgender sports ban [online]. NBCNews.com  https://www.nbcnews.com/nbc-out/out-politics-and-policy/kentucky-legislature-overrides-governors-veto-transgender-sports-ban-rcna24303 [Accessed April 20, 2022]
  2. Barnes K.  (March 17, 2022)  Amid protests, Penn swimmer Lia Thomas becomes first known transgender athlete to win Division I national championship. [online]. espnW.com. https://www.espn.com/college-sports/story/_/id/33529775/amid-protests-pennsylvania-swimmer-lia-thomas-becomes-first-known-transgender-athlete-win-division-national-championship [Accessed April 20, 2022]
  3. Ellingworth J, Ho S.  (August 2, 2021) Transgender weightlifter Hubbard makes history at Olympics. [online]. APNews.com https://apnews.com/article/2020-tokyo-olympics-sports-weightlifting-laurel-hubbard-e721827cdaf7299f47a9115a09c2a162 [Accessed April 20, 2022]
  4. Morton V.  (June 3, 2019)  CeCe Telfer, Franklin Pierce transgender hurdler, wins NCAA women’s national championship [online]. Washingtontimes.com  https://www.washingtontimes.com/news/2019/jun/3/cece-telfer-franklin-pierce-transgender-hurdler-wi/ [Accessed April 20, 2022]
  5. Yurcaba C.  (January 22, 2022) NCAA’s new trans athlete guidelines sow confusion amid Lia Thomas debate [online]. NBCnews.com https://www.nbcnews.com/nbc-out/out-news/ncaas-new-trans-athlete-guidelines-sow-confusion-lia-thomas-debate-rcna13073 [Accessed April 20, 2022]
  6. Nair A, Nair R, Davis T.  (April 8, 2022) Transgender women unable to compete in British Cycling events as policy suspended [online]. Reuters.com https://www.reuters.com/lifestyle/sports/british-cycling-suspend-transgender-participation-policy-2022-04-08/[Accessed April 20, 2022]
  7. Brown G. (August 18, 2021). The Olympics, sex, and gender in the physiology classroom [online].  PECOP Blog. https://blog.lifescitrc.org/pecop/2021/08/18/the-olympics-sex-and-gender-in-the-physiology-classroom/ [Accessed April 20, 2022]
  8. Ervin RB,  Wang CY, Fryar CD, Miller IM, and Ogden CL. [online] Measures of Muscular Strength in U.S. Children and Adolescents, 2012.  NCHS Data Brief No. 139, December 2013. (https://www.cdc.gov/nchs/products/databriefs/db139.htm; accessed April 6, 2022)
  9. Wells MS, Arthur-Banning SG.  The Logic of Youth Development: Constructing a Logic Model of Youth Development through Sport. J Pakr & Rec Admin.  26: 189-202, 2008
  10. Handelsman DJ. Sex differences in athletic performance emerge coinciding with the onset of male puberty. Clin Endocrinol (Oxf). 87:68-72, 2017
  11. Handelsman DJ, Hirschberg AL, Bermon S. Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance. Endocr Rev. 39:803-829, 2018
  12. Catley MJ, and Tomkinson GR. Normative health-related fitness values for children: analysis of 85347 test results on 9-17-year-old Australians since 1985. Br J Sports Med 47: 98-108, 2013.
  13. Eiberg S, Hasselstrom H, Gronfeldt V, Froberg K, Svensson J, and Andersen LB. Maximum oxygen uptake and objectively measured physical activity in Danish children 6-7 years of age: the Copenhagen school child intervention study. Br J Sports Med 39: 725-730, 2005.
  14. Latorre Roman PA, Moreno Del Castillo R, Lucena Zurita M, Salas Sanchez J, Garcia-Pinillos F, and Mora Lopez D. Physical fitness in preschool children: association with sex, age and weight status. Child Care Health Dev 43: 267-273, 2017.
  15. Tambalis KD, Panagiotakos DB, Psarra G, Daskalakis S, Kavouras SA, Geladas N, Tokmakidis S, and Sidossis LS. Physical fitness normative values for 6-18-year-old Greek boys and girls, using the empirical distribution and the lambda, mu, and sigma statistical method. Eur J Sport Sci 16: 736-746, 2016.
  16. Tomkinson GR, Carver KD, Atkinson F, Daniell ND, Lewis LK, Fitzgerald JS, Lang JJ, and Ortega FB. European normative values for physical fitness in children and adolescents aged 9-17 years: results from 2 779 165 Eurofit performances representing 30 countries. Br J Sports Med 52: 1445-14563, 2018.
  17. Tomkinson GR, Lang JJ, Tremblay MS, Dale M, LeBlanc AG, Belanger K, Ortega FB, and Leger L. International normative 20 m shuttle run values from 1 142 026 children and youth representing 50 countries. Br J Sports Med 51: 1545-1554, 2017.
  18. (December 19, 2018)  American Youth Outdoor Track & Field Records.  [online] USATF http://legacy.usatf.org/statistics/records/view.asp?division=american&location=outdoor%20track%20%26%20field&age=youth&sport=TF  (accessed April 20, 2022)
  19. (2022) National Age Group Records [online]. USA Swimming. https://www.usaswimming.org/times/popular-resources/national-age-group-records (accessed April 20, 2022)
  20. Millard-Stafford M, Swanson AE, Wittbrodt MT. Nature Versus Nurture: Have Performance Gaps Between Men and Women Reached an Asymptote? Int J Sports Physiol Perform. 13:530-535, 2018
  21. Levine BD, Joyner MJ, Keith NR,  Bagish AL, Pedersen BK, Schmidt W, Stachenfeld N, Girard O, Nagatomi R, Foster C, Okazaki K, Stellingwerf T, Jiexiu Z, Robson SJ, Bailey DM, Bosch A, Murphy RM, Qiu J, Lollgen H, Mitchell J, Kearney J, Scott JM, Lundby C, Steinacker J, Trappe S, La Gerche A, Masuki S, Roach R, Schneider S, Millet G, Kohrt WM, Roberts WO, Kraus WE, Benjamin HJ, Koning JJ, Gatterer H, Wehrlin JP, Charkoudian N, Lawley JS, Hopman MTE, Hawley J. The role of testosterone in athletic performance. [online] https://web.law.duke.edu/sites/default/files/centers/sportslaw/Experts_T_Statement_2019.pdf (accessed April 6, 2022).
  22. Rey R, Josso N, Racine C. Sexual Differentiation. 2020 May 27. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, Dungan K, Hershman JM, Hofland J, Kalra S, Kaltsas G, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Morley JE, New M, Purnell J, Sahay R, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Online]. South Dartmouth (MA): MDText.com, Inc.; 2000–. PMID: 25905232. (Accessed April 6, 2022)
  23. Sax L. How common is intersex? a response to Anne Fausto-Sterling. J Sex Res. 39:174-8, 2002
  24. Kiserud T, Piaggio G, Carroli G, Widmer M, Carvalho J, Neerup Jensen L, Giordano D, Cecatti JG, Abdel Aleem H, Talegawkar SA, Benachi A, Diemert A, Tshefu Kitoto A, Thinkhamrop J, Lumbiganon P, Tabor A, Kriplani A, Gonzalez Perez R, Hecher K, Hanson MA, Gülmezoglu AM, Platt LD. The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight. PLoS Med. 14:e1002220, 2017
  25. Centers for Disease Control and Prevention.  Clinical Growth Charts  [online] https://www.cdc.gov/growthcharts/clinical_charts.htm; (Accessed April 6, 2022)
  26. Davis SM, Kaar JL, Ringham BM, Hockett CW, Glueck DH, and Dabelea D. Sex differences in infant body composition emerge in the first 5 months of life. J Pediatr Endocrinol Metab 32: 1235-1239, 2019.
  27. Taylor RW, Gold E, Manning P, and Goulding A. Gender differences in body fat content are present well before puberty. Int J Obes Relat Metab Disord 21: 1082-1084, 1997.
  28. Taylor RW, Grant AM, Williams SM, and Goulding A. Sex differences in regional body fat distribution from pre- to postpuberty. Obesity (Silver Spring) 18: 1410-1416, 2010.
  29. Staiano AE, Katzmarzyk PT. Ethnic and sex differences in body fat and visceral and subcutaneous adiposity in children and adolescents. Int J Obes (Lond). 36:1261-9. (2012).
  30. Senefeld JW, Lambelet Coleman D, Johnson PW, Carter RE, Clayburn AJ, Joyner MJ. Divergence in Timing and Magnitude of Testosterone Levels Between Male and Female Youths. JAMA. 324:99-101, 2020
  31. Klaver M, de Mutsert R, Wiepjes CM, Twisk JWR, den Heijer M, Rotteveel J, Klink DT. Early Hormonal Treatment Affects Body Composition and Body Shape in Young Transgender Adolescents. J Sex Med 15: 251-260, 2018.
  32. Roberts SA, Carswell JM. Growth, growth potential, and influences on adult height in the transgender and gender-diverse population. Andrology. 9:1679-1688, 2021.
Dr. Greg Brown is a Professor of Exercise Science in the Department of Kinesiology and Sport Sciences at the University of Nebraska at Kearney where he has been a faculty member since 2004. He is also the Director of the General Studies program at the University of Nebraska at Kearney. He earned a Bachelor of Science in Physical Education (pre-Physical Therapy emphasis) from Utah State University in 1997, a Master of Science in Exercise and Sport Science (Exercise Physiology Emphasis) from Iowa State University in 1999, and a Doctorate of Philosophy in Health and Human Performance (Biological Basis of Health & Human Performance emphasis) from Iowa State University in 2002. He is a Fellow of the American College of Sports Medicine and an American College of Sports Medicine Certified Exercise Physiologist.
Assessing Students’ Learning — Not Their Googling Skills! — in an Online Physiology Course

As of March 2020, when the SARS-COV-2 pandemic sent teachers and students home to figure out online instruction and learning, I had been teaching high school biology/AP biology for 27 years and anatomy & physiology at the two local community colleges for 7 years. Since I had been practicing flipped coursework for years, I knew that my biggest challenge would be how to fairly assess my students and their learning. This challenge would be compounded by an at-home virtual testing environment without any proctoring.

As I pondered the best approach to my assessment challenge, I was naturally drawn to the College Board’s 2012-13 redesign of the AP (Advanced Placement) Biology curriculum and examination. In the redesign, the AP curriculum focuses on four “Big Ideas” or broad themes covering a number of subtopics/concepts that are further broken down into learning objectives for students. The examination focuses on measuring student learning and skills using what the College Board (AP Higher Education, 2012-2013) calls an “evidence-centered-design approach that parallels the curriculum’s understanding-by-design approach.” The examination consists of a mix of multiple-choice and short-answer/free-response questions. I know from my many years of grading student AP essays/short answers that, when students turn to Google for their answers, they often fail. Students will frequently regurgitate the rubrics for grading the prompts rather than dissecting and answering the question. Subsequently, the students fail to demonstrate their own learning or understanding of the material. This is unfortunate as it is also a missed opportunity for feedback, correction and/or remediation.

In designing a new accelerated online physiology course, I really wanted the course assessments to mimic the AP Biology style of assessments. I wanted them not only to be aligned with course objectives, but to require students to think about and demonstrate the skills and concepts they were learning. I was skeptical, but hopeful I could also find an approach in which I would not have to rewrite the entire examination from scratch each term. In my search for related pedagogies, I ran across an article in the May 2020 HAPS Educator, “Testing in the Age of Active Learning: Test Question Templates Help to Align Activities and Assessments,” and recognized the name of one of the authors, Dr. Greg Crowther (Everett Community College, Everett, WA) from a previous association. I reached out to Greg and requested some more details about Test Question Templates (TQTs). What I found was a pedagogical gold mine!

The TQTs are based on somewhat general learning objectives, much like the four Big Ideas of the AP Biology exam. Students often ignore these learning objectives because they don’t know what they mean or how they will be assessed, but TQTs are formatted as input-output statements that tell the student exactly what they will be assessed on. Two examples (“Example A” and “Example B”) are provided for the students, followed by a prompt encouraging students to create their own test question following the template format.

The timing of my find was perfect for incorporating TQTs into the design of the new course. Since I am totally online, I took the time to video each TQT. On video, I present the input-output statement for each TQT and present Example A, along with approaches to answering the question or solving the problem. My TQT videos are attached to a weekly discussion board in the course management system, where students are then encouraged to work on solving Example B and creating a third example. I frequently visit the discussion board and provide feedback and guidance as needed throughout the week.

Below is an example of a TQT input-output statement and examples given to students ahead of the examination in the discussion board and used to model the examination question:

TQT 3.1. Given the chemical structure or chemical formula of an ion or molecule (chemical structure or text description), list the most likely mechanism(s) by which it crosses cell membranes.

  • Example A: See structure below left. By which process(es) is this molecule most likely to cross cell membranes? Explain your reasoning. [add chemical structure of a molecule like urea]
  • Example B: See structure below right. By which process(es) is this molecule most likely to cross cell membranes? Explain your reasoning. [add image of a peptide like insulin]
  • Example C: Make up an example (think of an ion or molecule that you’ve heard of) and ask your classmates!

In the previous unit, students had been instructed on chemical structures/formulas and bonding properties. In this unit, students are asked to extend and apply their understanding of chemical structures, bonding properties (polar, nonpolar, ionic) with their new knowledge of cell membrane structure (phospholipid) and cell transport mechanisms (passive or active).

Examinations are carefully aligned with the objectives, formative assessments and exact input-output statements given to students in the TQTs. The examination contains 10-11 short answer questions and approximately 25-30 multiple choice questions. I have added a statement on the examination for students to sign, reminding them not to use any outside resources (people, notes, internet….) along with the consequences for doing so. Students are reminded to use what they are learning in the course to answer and solve exam problems/questions. I explain to students how I will know if they don’t follow the rules.

I will admit that the new course has gotten off to a rough start. For reasons I can only guess at, more than half my students are procrastinating until the last minute to start assignments (lecture, reading, lab, formative assessments, TQTs…). This approach is not consistent with my suggestions to space out their learning, practice, or repetition of concepts that we know is so important to learning and applying the information to new situations.

Not surprisingly, students who participated during the week and spaced-out lecture segments, formative assessments and TQTs did much better on the examination than those who did not. Those who chose alternative approaches to the course material often googled their way through the examination and failed miserably. Using Google, they could identify a molecule, how it is made, and where it is found, but they couldn’t answer the questions asked.

It has taken several examinations to convince many of the students that physiology is not simply about googling or memorizing facts, but about developing critical thinking skills and a higher-order understanding of the material that will persist beyond the course. More students are now actively preparing, studying and asking more complex questions throughout the week than previously (as evidenced by the course management system analytics and student contact). Many have shown improvement not only on their overall exam scores, but in their demonstrations of reasoning on assignments and exams.

After the initial rough weeks of getting students on board, students are now reaching out via email to report progress in their learning, growth, and ability to connect the material to their work as CNAs and Medical Assistants.  For example, one young man in the course writes, “As we’ve progressed onward to future chapters I feel like my knowledge is increasing gradually and I personally feel that like I CAN do this, it has been a struggle I’m not going to lie and say it was a breeze but, I feel like I’m truly getting a ton of knowledge from these chapters, I’ve found much interest on the systems we’ve been studying especially with the TQT examples and formative questions that you help me with your feedback.” Another young lady states, “I am sorry I am not doing well. I have never been forced to study before and though the TQTs are hard I am finding that I am learning a lot and am really interested in learning more. I am glad I didn’t give up.”

In summary, both the AP Biology redesign assessment questions and the TQTs have allowed me to better assess my students’ knowledge and skills. These approaches have also given me insight into student misconceptions and helped me provide feedback, remediation, and other support as needed. I can easily write (or rewrite) questions based on the TQT input/output statements without having to rewrite entire examinations each term. Students are learning that simply googling will not let them ace the exams; instead, they are learning to more carefully read the questions and answer the questions based on their own understanding.

“ACKNOWLEDGMENTS: The author thanks Greg Crowther for help implementing TQTs and for feedback on this blog post.”

References:

  1. AP Higher Education (2012-2013). AP Course and Exam Redesign. https://aphighered.collegeboard.org/courses-exams/course-exam-redesign
  2. Crowther, G., Wiggins, B., Jenkins, L. HAPS Educator (May 2020). “Testing in the Age of Active Learning: Test Question Templates Help to Align Activities and Assessments.”
    Julie Gallagher, professor of anatomy and physiology, has been teaching at Barstow Community College (Barstow, CA) since 2014 and was a high school AP Biology teacher for 27 years at Serrano HS (Phelan, Ca).  Believing in equity and inclusion, Professor Gallagher has built state-of-the-art online anatomy and physiology courses, focused on helping all students succeed.
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.
Pandemic Adaptations for PECOP and the 2022 ITL!

The American Physiological Society (APS) Physiology Educators Community of Practice (PECOP) and Institute on Teaching and Learning (ITL) were created to build connections among physiology educators and to promote the sharing of evidence-based teaching practices in physiology education. Due to the COVID-19 pandemic, the 2020 ITL and other PECOP activities were shifted to a virtual format. Virtual ITL Week included daily two-hour interactive sessions. Session topics and speakers were selected from the original conference schedule, with emphasis on topics that would assist educators during the pandemic. Registration was free, attracting nearly 500 registrants, a five-fold increase over normal ITL attendance. International educator participation was more than double that of previous ITL meetings. Long-term impacts of this unplanned “experiment” include plans for virtual components at some future ITL meetings, a PECOP webinar series open to the public, and an online professional skills training course for new physiology educators. An editorial describing these outcomes has recently been published in Advances in Physiology Education (https://journals.physiology.org/doi/full/10.1152/advan.00245.2020).  Please join PECOP for free by registering your email at the LifeSciTRC (https://www.lifescitrc.org) and select “PECOP Member” in your user profile.  The 2022 APS Institute on Teaching and Learning will be June 21-24 in Madison, WI (https://www.physiology.org/professional-development/meetings-events/itl-2022?SSO=Y).  The institute will engage educators in interactive sessions on best practices in teaching, learning and assessment.  Whether you are an experienced educator or new to teaching, ITL will challenge you to gain the skills needed to design and implement educational research in your classroom and learn how to share your findings with colleagues.  The institute includes plenary talks, concurrent workshops, poster sessions and time to network and connect with your colleagues.  Please keep checking the website to see when registration is ready!

Barbara E. Goodman, Ph.D., Professor of Physiology

Fellow of the American Physiological Society

Editor-in-Chief, Advances in Physiology Education

Division of Basic Biomedical Sciences

Room 224 Lee Medicine

Sanford School of Medicine of the University of South Dakota

 

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.
Pourquoi? Course Redesign: A Story of How and Why.

This is a story of why and how my courses underwent an all-encompassing course redesign.

Why?

Once upon a time, early during my tenure at Heartland Community College, the nursing faculty invited the A&P instructors to lunch to discuss what was covered in the A&P courses because the nursing students were replying that they “didn’t learn that” in A&P.

The dialog went like this: “Do you teach the autonomic nervous system?”

“Yes, we do!”

“The students say they didn’t learn that.  Do you teach the cranial nerves?”

“Yes, we do!”

“The students say they didn’t learn that.”

Etc.

After that meeting, I had a revelation that rocked my world: I wasn’t teaching, and the students weren’t learning!

Then the question was what to do about it? Retirement or Remediation?  Well, shortly after my revelation the economy tanked so retirement wasn’t an option.  Remediation, on my part, was the only course of action to take. I went back and hit the books.

I found and used many excellent resources and used parts of all, but it wasn’t until I was searching for how to assess conceptual understanding that I found methods that were used for the major redesign of my courses.

How?

When I hit the books, I read that third graders could learn to do physics.  So, I thought there should be no reason that the method developed by a physics professor/research scientist at Harvard, couldn’t be used for A&P courses at Heartland. Therefore, I chose to redesign my courses using a combination of Just-in-Time Teaching (JiTT), Peer Instruction (PI), and Concept Questions (CQs) that are assessed with clickers, in a manner described by Eric Mazur.

It is very important to make expectations known. In the first week of class, students are asked to complete an anonymous, on-line introductory questionnaire (Mazur, 1997).  This helps to make sure that the student’s expectations conform to what will be taking place in class.  The results of this questionnaire are compiled into a handout and discussed in class.  This questionnaire is followed up with another questionnaire (Mazur, 1997) during the fourth week of the semester to identify is there is anything I can do to improve the in-class experience to help their learning and to address any expectations that are contrary to what we are doing in class.  The result of using these questionnaires is an improved sense of cooperation.

The first week of the semester is also used expressly to help students get acclimated with the flow of the course and the technology used in class with several non-graded assignments and assessments completed just for practice.   Students must become familiar with the Learning Management System (LMS) and the classroom response system (CRS).

Basically, how it works is students are given pre-class reading assignments and are required to take a pre-quiz following the completion of the reading assignment which are posted in the LMS.    In one way, the quizzes are used to check for reading comprehension.  In another way, the pre-quizzes allow the students to identify and verbalize areas of confusion.  This emphasizes that knowledge acquisition occurs outside of the classroom so that in class, based upon their input, the focus is placed on what students are having difficulty with.

The last question of the pre-quizzes is the JiTT part of the pre-quiz.  “Please tell me briefly what single point of the reading that you found most difficult or confusing.  If you did not find any part of it difficult or confusing, please tell me what you found most interesting.” (Mazur, 1997) Many times students tell me something they found interesting when they didn’t answer any of the questions correctly.  So, they indirectly tell me they don’t know what they don’t know.  In either case, their feedback determines the topics for discussion the next day.

Generally, there are about three topics that are identified from the pre-quizzes.  CQs to be used in class are written for those topics.  The following flow-chart demonstrates how it works in class.  This process forces students to think through the arguments being developed and provides a way to assess their understanding of the concept.

Questions can be written to begin easy and progress to more conceptual content such as application and prediction questions, etc.  This allows for scaffolding of knowledge to occur.  It is important to monitor discussions to keep students on task, find out how students are thinking, and to identify possible sources of confusion.

The CQs are assessed with the classroom response system.  Sometimes technologies fail so it is good to have a back-up plan.  I have letter cards available in such situations.  The CQs and are graded upon completion, not on correctness.  Doing so encourages cooperation among students.  Students must be continually reminded that it is okay to get questions wrong and by just committing to an answer will help produce more durable learning.

Tangible benefits from the redesign include:

For most of the CQs asked throughout a semester the percentage of correct responses after PI were greater than before PI.  Students were able to convince their classmates what the correct answer was.  Occasionally, the percent of correct responses following PI was lower than before PI.  This was usually due to a poorly worded or ambiguous question, or a discussion between a student who was confidently wrong and one who was correct but not confident.

Persistence after the redesign was greater than before the redesign.  Before the redesign 18% of students ended up dropping the course; after the redesign only 12% of the students ended up dropping.

Students liked using the classroom response system and student discussions. Students responded to open ended questions on anonymous, end of the semester surveys: “Discuss your thoughts on the use of clickers in the classroom”; “Please discuss your thoughts on the ‘convince your neighbor’ portion of the course.”  Numerical value to their responses were assigned on this Likert scale: 4 = really liked; 3 = liked; 2 = disliked; 1 = really disliked.  The mode/median for the responses regarding using clickers was 4; and 3 for responses regarding the ‘convince your neighbor’ portion of the course.  In their responses, students also raised some concerns: “my partner never did the readings, so he wasn’t a lot of help; but it did help me to try to explain things to him;” “convincing your neighbor never really helped me mainly because my neighbor was never sure.”

Intangible benefits of the redesign include:

Students are conversing using the language of the discipline and are provided with an opportunity to identify and verbalize what they don’t know.  Answering the CQs is a form of forced retrieval which leads to more durable learning. Students must formulate arguments to support their position when “convincing their neighbors.” And lastly, by listening to student discussions instructors can identify confusing questions, misconceptions, students with clear answers, students with faulty logic/reasoning or who are confidently wrong, etc.

The following are recommendations to address issues of concern identified by students and the instructor.

Recommendations:

  1. To reinforce the importance of pre-class reading assignments, in addition to the reading assignments posted to the LMS along with the pre-quizzes, give the students a hardcopy of all the reading assignments in the first week of the semester and post it to an informational page in the LMS.
  2. Explicitly tell the students that work outside of class is expected. The following chart is provided to the students so that they can visualize the general layout of the course.
  3. To reduce knowledge voids and the influence of confidently wrong students, encourage students to seek advice from classmates all around them rather than those sitting next to them. If you use Learning Catalytics (LC) as a classroom response system, it can be set to run the class automatically which will tell each student who they should consult with.  The instructor sets up the parameters (i.e., three students, with different answers, within a certain number of seats or if it is in a small class – anywhere in the room) but LC uses a sophisticated program to reduce the influence of confidently wrong students.  Having diverse permanent/fixed teams and having students discuss the CQs with their teammates also addresses this issue.
  4. To alleviate some anxiety from this non-traditional format students are given lecture notes. Traditional lectures aren’t given, but students are given the next best thing – the lecture notes.
  5. To help motivate the students and to reinforce the importance of meaningful learning and moving away from rote memorization exams should have 50% conceptual questions.

So, there you have it – the why and how I completely redesigned my courses.  Is that the end of the story, you ask?  Of course not.  Teaching is an iterative process and with anonymous, end of the semester input from students, self-reflection, and professional development, the changes have been continual.  Perhaps, in a future blog, I will write the tale of why and how this course redesign evolved and changed overtime.

References for Redesign and Remediation:

Bransford, J.D., Brown, A.L., Cocking, R.R., eds. (2000). How people learn: Brain, mind, experience, and school. Washington, DC: National Academy Press.

Broida, J. (2007). Classroom use of a classroom response system: What clickers can do for your students. Upper Saddle River, NJ: Prentice Hall.

Bruff, D. (2009) Teaching with classroom response systems: Creating active learning environments. San Francisco, CA: Jossey-Bass.

Bybee, R.W. (ed.) (2002).   Learning science and the science of learning. Arlington, VA: NSTA Press.

Duncan, D. (2005). Clickers in the classroom: How to enhance science teaching using classroom response system. San Francisco, CA: Pearson Addison Wesley Benjamin Cummings.

Ellis, A. B., Landis, C.R., & Meeker, K. Classroom assessment techniques: ConcepTests. http://www.flaguide.org/cat/contests/contests2.php

Fink, L. D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco, CA: Jossey-Bass.

Finkel, D.L. (2000). Teaching with your mouth shut. Portsmouth, NH: Boynton/Cook.

Herreid, C.F, ed. (2007). Start with a story: The case study method of teaching college science. Arlington, VA: NSTA Press.

Mazur, E. (1997). Peer instruction: A user’s manual. Upper Saddle River, NJ: Prentice Hall.

Michael, J. A. & Modell, H. I.  (2003) Active learning in secondary and college classrooms: A working model for helping the learner to learn. Mahwah, NJ: Lawrence Erlbaum Associates.

Novak, G. M., Patterson, E. T., Gavin, A. D., & Christian, W., (1999). Just-in-Time Teaching: Blending active learning with web technology. Upper Saddle River, NJ: Prentice Hall.

Sullivan, W.M. & Rosin, M.S. (2008).  A new agenda for higher education: Shaping a life of the mind for practice. San Francisco, CA: Jossey-Bass.

Woditsch, G.A. & Schmittroth, J. (1991). The thoughtful teachers guide to thinking skills. Hillsdale, NJ: Lawrence Erlbaum Associates.

After a post-doctoral fellowship at Washington University School of Medicine, Jane began her academic teaching career at Benedictine University in the graduate programs in exercise physiology.  After that Jane taught in the Physician Assistant Programs at Rosalind Franklin University and the University of Kentucky. For the past 18 years Jane taught Anatomy and Physiology at Heartland Community College in Normal, IL, where innovative, student-centered instruction is encouraged. For the last decade, Jane employed Just-in-Time Teaching with Peer Instruction and concept questions assessed with a classroom response system.  Recently, permanent, fixed teams were used in her classes, along with team-based summative assessments, as well as with in-class and post-class forced retrieval activities. Jane is a Professor Emeritus of Biology and had served the Anatomy and Physiology course coordinator.

Jane received her B.S. from Eastern Illinois University, her M.S. from Illinois State University, and her Ph.D. from Marquette University.

 

Looking back and moving forward. The importance of reflective assessment in physiology education.

At the end of the 1986 movie Platoon, the protagonist (Chris Taylor, played by Charlie Sheen) provides a very moving monologue that starts “I think now, looking back, we did not fight the enemy, we fought ourselves. The enemy was in us. The war is over for me now, but it will always be there, the rest of my days.”

When Platoon was first released in theaters I was in high school.  I was enthralled with Platoon, and it has held a very special place in my memories ever since.  The ending monologue has echoed through my mind at the end of almost every semester that I have been a faculty member (albeit with a few changes. No insult or mocking of the movie is intended, this is simply my effort to take a powerful cinematic scene and apply it to my personal situation).  My end of semester monologue goes something like this “I think now, looking, back, I did not teach the students but I taught myself. The student was within me.  The semester is over for me now, but it will always be there, the rest of my days.”  And with that, I begin reflective assessment of my teaching.

For many educators, assessment is a dirty word and a necessary evil.  Hall and Hord (1) reported that faulty experience anxiety about assessment because of a lack of understanding of the process or importance of assessment.  Faculty may also disdain participating in assessment due to concerns about accountability, or due to concerns about accreditation negatively impacting their careers (2). Often, faculty also view assessment reports as things that need to be prepared and submitted to meet requirements imposed on faculty from an administrative office within their institution, or some outside accrediting agency, but think that assessment reports are not really pertinent to the day-to-day work of education (3).  To help overcome hesitancy to fully engage in the assessment process Bahous and Nabhani (4) recommend that institutions hire a full-time assessment officer to work one-on-one with faculty.  All of these are relevant to the formal process of assessment and submitting data and reports to meet institutional or organizational requirements.  When done the right way, these assessment reports can be valuable tools in education.  But what I want to discuss in this blog post is a more informal form of assessment that I think all educators should do, and probably already do, which is reflective assessment.

Students and faculty alike perceive Physiology as a very challenging academic subject (5, 6).  The concepts are difficult, and there is a lot of terminology.  Our understanding of physiology is continually expanding, but yet students often still need to have a firm concept of the basic fundamentals before moving on to more complex and in-depth information.  Physiology is often taught in a system by system approach, yet the systems do not operate independently of one another so at times it may feel like the cart is put before the horse in regards to helping students to understand physiological processes. All of these issues with the difficulty of teaching physiology make reflective assessment an important part of teaching.

Quite simply, no matter how well we taught a class or a concept, as educators we may be able to teach better the next time (7, 8).  Perhaps we can tweak an assignment to make it better fit our needs.  Or perhaps we can provide a new resource to our students, like an appropriate instructional video or a scholarly article. Or maybe it’s time to select a new textbook.  Or maybe we have seen something in Advances in Physiology Education or on the PECOP Blog that we would like to incorporate into our teaching practice.  Whatever the reason, reflective assessment provides an opportunity for us to ask ourselves two very simple, but very important questions about our teaching:

  1. What went well in this class, and what didn’t go as well as planned?
  2. What improvements are we willing to make to this course to improve student learning?

The first question is important for identifying strengths and weaknesses in our courses.  We can ponder what went well, and ask why it went well.  Has it gone well each semester? Or did it go well because of changes we made in our teaching?  Or did it go well because of other changes, such as a change in prerequisite courses?

As we ponder what didn’t go as planned, we can also contemplate why things didn’t go as planned.  I think anyone who has taught through the COVID pandemic can identify lots of unforeseen and unusual disruptions to our courses.  But we can also use reflective assessment to identify ongoing problems that deserve some attention.  Or we can identify problems that have previously not been problems, and make a note to monitor these issues in future courses.

The second question, about what changes are we willing to make, is also extremely important.  Sometimes a problem may be outside of our control such as course scheduling, who teaches the prerequisite course, or other issues.  But if the identified problem is something we can control, such as the timing of the exams, or the exam format, or laboratory exercises, then we need to decide if the problem arises from something we are willing to change and then decide how and what to change.  Can the problem be addressed through the acquisition of new instrumentation?  Can the problem be addressed by changing textbooks?  Some of the problems may be easy to solve, while others might be more difficult.  Some problems might require funding, and so funding sources will need to be identified.  But this is where reflective assessment can really help us to prioritize changes to our teaching.

I ask myself these questions throughout the semester as I grade tests and assignments, but in the midst of a semester there is often not time to really ponder and make changes to my classes.  During the semester I keep a teaching diary to make note of the thoughts that come to me throughout the semester. Then, after final grades are submitted and before the next semester begins there is more time to read through the teaching diary and to reflect and ponder about my teaching.  Often, in this less pressured time between semesters, by reviewing my teaching diary I can take a step back to reflect on problems during the semester and determine if this has been an ongoing issue in my classes or an isolated issue limited to only this one semester.  I often find that what seemed like a problem in the middle of the semester has resolved itself by the end of the semester.

Of course there are many other questions that can be asked as part of reflective assessment (7, 8), and any question can lead to numerous follow up questions.  But I think these two questions (1. What went well in this class, and what didn’t go as well as planned? 2.  What improvements are we willing to make to this course to improve student learning?) form the cornerstone of reflective assessment.  And reflective assessment can then lead to a career long endeavor to engage in action research to improve our teaching skills.

  1. Hall G, Hord S. Implementing change: Patterns, principles, and potholes (5th ed). New York: Pearson, 2019.
  2. Haviland D, Turley S, Shin SH. Changes over time in faculty attitudes, confidence, and understanding as related to program assessment. Iss Teacher Educ. 2: 69-84, 2011.
  3. Welsh JF, Metcalf J. Faculty and administrative support for institutional effectiveness activities. J Higher Educ. 74: 445-68, 2003.
  4. Bahous R, Nabhani M. Faculty Views on Developing and Assessing Learning Outcomes at the Tertiary Level. J General Educ. 64: 294-309, 2015.
  5. Slominski T, Grindberg S, Momsen J. Physiology is hard: a replication study of students’ perceived learning difficulties. Adv Physiol Educ. 43:121-127, 2019.
  6. Colthorpe KL, Abe H, Ainscough L. How do students deal with difficult physiological knowledge? Adv Physiol Educ. 42:555-564, 2018.
  7. Pennington SE. Inquiry into Teaching: Using Reflective Teaching to Improve My Practice. Networks, An Online Journal for Teacher Research 17, 2015. https://doi.org/10.4148/2470-6353.1036
  8. Reflective Teaching Practices. Int J Instruc. 10: 165-184, 2017. NM, Artini LP, Padmadewi NN. Incorporating Self and Peer Assessment in Reflective Teaching Practices. Int J Instruc. 10: 165-184, 2017.
    Dr. Greg Brown is a Professor of Exercise Science in the Department of Kinesiology and Sport Sciences at the University of Nebraska at Kearney where he has been a faculty member since 2004. He is also the Director of the General Studies program at the University of Nebraska at Kearney. He earned a Bachelor of Science in Physical Education (pre-Physical Therapy emphasis) from Utah State University in 1997, a Master of Science in Exercise and Sport Science (Exercise Physiology Emphasis) from Iowa State University in 1999, and a Doctorate of Philosophy in Health and Human Performance (Biological Basis of Health & Human Performance emphasis) from Iowa State University in 2002. He is a Fellow of the American College of Sports Medicine and

     

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

 

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

 

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

 

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

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

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

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

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

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

Class (“lecture”) revisions

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

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

Lessons learned:

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

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

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

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

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

Lab revisions

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

Lessons learned:

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

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

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

Summary

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

Table 1:  Class schedule

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

·       Homeostasis

·       Endocrine system

·       Osteoporosis case part 1

·       Study plan

Day 2 ·       Cellular signaling

·       Microscopic structure of bone

·       Bone remodeling mechanisms

·       Bone remodeling regulation

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

·       Passive membrane transport

·       Active membrane transport

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

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

·       Bone growth disorders activity

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

·       Graded potentials

·       Neuron functional anatomy worksheet

·       Graded potentials worksheet

Mini-exam 3
Day 7 ·       Action potentials

·       Action potential propagation

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

·       Synapses and synaptic integration

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

·       CNS protection

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

·       Pain

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

·       Autonomic nervous system

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

·       Functional skeletal muscle anatomy

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

·       Muscle functional anatomy worksheet

Day 14 ·       Sliding filament theory

·       Neuromuscular junction

·       Excitation contraction coupling

·       Neuromuscular junction worksheet

·       Malignant hyperthermia case study

Mini-exam 6
Day 15 ·       Graded contractions

·       Muscle metabolism and fiber types

·       Motor recruitment worksheet

·       Muscle training worksheet

Exam 2

 

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

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

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

Jennifer E. Schaefer

Associate Professor of Biology

College of Saint Benedict and Saint John’s University

Physiology as an Interpretive Lens for the Clinician’s Dilemma

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

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

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

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

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

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

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

The clinician is working with many competing hypotheses, and is “faced with all sources of variation at the same time and must deal constantly with the full burden of the complex system.”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.