Tag Archives: medical education

An inventory of meaningful lives of discovery

by Jessica M. Ibarra

I always had this curiosity about life. Since the very beginning, always wanting to understand how animals’ breathe, how they live, how they move. All that was living was very interesting. – Dr. Ibarra

“I always had this curiosity about life and I wanted to become a doctor, but my parent told me it was not a good idea,” Lise Bankir explained in her interview for the Living History Project of the American Physiological Society (APS).  The video interview (video length: 37.14 min.) is part of a rich collection over 100 senior members of the APS who have made outstanding contributions to the science of physiology and the profession. 

The archive gives us great insight into how these scientists chose their fields of study.  As Dr. Bankir, an accomplished renal physiologist, explain how she ended up “studying the consequences of vasopressin on the kidney.”  She describes her work in a 1984 paper realizing “high protein was deleterious for the kidney, because it induces hyperfiltration,” which of course now we accept that high protein accelerates the progression of kidney disease. Later she describes her Aha! moment, linking a high protein diet to urea concentration, while on holiday. 

“It came to my mind that this adverse effect of high protein diet was due to the fact that the kidney not only to excrete urea (which is the end product of proteins), but also to concentrate urea in the urine.  Because the plasma level of urea is already really low and the daily load of urea that humans excrete need that urea be concentrated about 100-fold (in the urine with respect to plasma).” 

Other interviews highlight how far ahead of their time other scientists were.  As is the case when it comes to being way ahead of teaching innovations and active learning in physiology with  Dr. Beverly Bishop.  In her video interview, you can take inspiration from her 50 years of teaching neurophysiology to physical therapy and dental students at SUNY in New York (video length: 1 hr. 06.09 min.).  Learn about how she met her husband, how she started her career, and her time in Scotland.  Dr. Bishop believed students could learn better with experimental laboratory activities and years ahead of YouTube, she developed a series of “Illustrated Lectures in Neurophysiology” available through APS to help faculty worldwide.

She was even way ahead of others in the field of neurophysiology.  Dr. Bishop explains, “everyone knows that they (expiratory muscles) are not very active when you are sitting around breathing quietly, and yet the minute you have to increase ventilation (for whatever reason), the abdominal muscles have to play a part to have active expiration.  So, the question I had to answer was, “How are those muscles smart enough to know enough to turn on?” Her work led to ground breaking work in neural control of the respiratory muscles, neural plasticity, jaw movements, and masticatory muscle activity.

Another interview shed light on a successful career of discovery and their implications to understanding disease, as is the case with the video interview of Dr. Judith S. Bond. She describes the discovery of meprins proteases as her most significant contribution to science (video length: 37.38 min.), “and as you know, both in terms of kidney disease and intestinal disease, we have found very specific functions of the protease.  And uh, one of the functions, in terms of the intestinal disease relates to uh inflammatory bowel disease.  One of the subunits, meprin, alpha subunit, is a candidate gene for IBD and particularly ulcerative colitis. And so that opens up a window to – that might have significance to the treatment of ulcerative colitis.”

Or perhaps you may want to know about the life and research of Dr. Bodil Schmidt-Nielsen, the first woman president of the APS (video length: 1 hr. 18.07 min.) and daughter of August and Marie Krogh.  In her interview, she describes her transition from dentistry to field work to study water balance on desert animals and how she took her family in a van to the Arizona desert and while pregnant developed a desert laboratory and measured water loss in kangaroo rats.  Dr. Schmidt-Nielsen was attracted to the early discoveries she made in desert animals, namely that these animals had specific adaptations to reduce their expenditure of water to an absolute minimum to survive. 

The Living History Project managed to secure video interviews with so many outstanding contributors to physiology including John B. West, Francois Abboud, Charles Tipton,  Barbara Horwitz, Lois Jane Heller, and L. Gabriel Navar to name a few.  For years to come, the archive provides the opportunity to learn from their collective wisdom, discoveries, family influences, career paths, and entries into science. 

As the 15th anniversary of the project approaches, we celebrate the life, contributions, dedication, ingenuity, and passion for science shared by this distinguished group of physiologists.  It is my hope you find inspiration, renewed interest, and feed your curiosity for science by taking the time to watch a few of these video interviews. 

Dr. Jessica M. Ibarra is an Assistant Professor of Physiology at Dell Medical School in the Department of Medical Education of The University of Texas at Austin.  She teaches physiology to first year medical students.  She earned her B.S. in Biology from the University of Texas at San Antonio.  Subsequently, she pursued her Ph.D. studies at the University of Texas Health Science Center in San Antonio where she also completed a postdoctoral fellowship.  Her research studies explored cardiac extracellular matrix remodeling and inflammatory factors involved in chronic diseases such as arthritis and diabetes.  When she is not teaching, she inspires students to be curious about science during Physiology Understanding Week in the hopes of inspiring the next generation of scientists and physicians. Dr. Ibarra is a native of San Antonio and is married to Armando Ibarra.  Together they are the proud parents of three adult children – Ryan, Brianna, and Christian Ibarra.

The Teaching of Basic Science as a Necessity in the Doctor in Physical Therapy Clinical Curriculum

There is an ever increasing need to train evidenced-based clinicians among all the health disciplines. This is particularly true in the relatively young profession of physical therapy, where the educational standards have shifted from entry level bachelor’s degree requirements to clinical doctorate training. The increase in educational standards reflect the growth of the discipline, with an effort to increase the depth of knowledge and level of skill required to be a physical therapist while moving from technician to an independent direct access practitioner. This evolution also marks a shift in standards of evidenced-based practice from clinical observation to an ability to provide mechanistic understanding which includes fundamental scientific insights and transforms clinical practice. The profession also recognizes the need to advance the profession through research that provides a scientific basis validating physical therapy treatment approaches. As a result, there is an expanding, yet underappreciated role, for the basic science researcher / educator in Doctor of Physical Therapy (DPT) programs.

Strategies to integrate and infuse the basic science into practice:

1. Faculty training:

Big Four Bridge in Louisville, KY

How to bridge the gap between basic science and clinical education?  As dual credentialed physical therapist and basic scientist these influence Sonja’s teaching approach, to serve as a “bridge” between foundational science content and clinical application.  Teaching across broad content areas in a DPT curriculum provides opportunities to “make the connection” from what students learn in the sciences, clinical courses, and relate these to patient diagnosis and therapeutic approaches.

While dual training is one approach, these credentials combined with years of ongoing contemporary clinical practice, are rare and impractical to implement in an academic setting. Most often DPT programs rely on PhD trained anatomists, neuroanatomists, and physiologists to teach foundational courses, often borrowed from other departments to fulfill these foundational teaching needs. Thus, Chris’s approach is through crosstalk between scientist/physiologist and clinician to serve as a role model and teach the application of discoveries for identifying best evidence in clinical decision making. By either approach, we have become that key bridge teaching and demonstrating how foundational science, both basic and applied impact clinical decision making.

2. Placement of foundational science courses (physiology, neuroscience, anatomy):

Traditional curricular approaches introduce foundational sciences in anatomy, neuroscience, and physiology in the first year of the DPT curriculum, followed by clinical content with either integrated or end loaded clinical experiences over the course of remaining 2.5-3 years. Our current program established an alternative approach of introducing foundational sciences after the introduction of clinical content and subsequently followed by a full time clinical clerkship/ education. Having taught in both models, early or late introduction of foundational sciences, we recognized either partitioned approaches lead to educational gaps and makes bridging the knowledge to application gap challenging for students.

Regardless, the overall message is clear and suggestive of the need for better integration of foundational/scientific content throughout the curriculum. These challenges are not unique to physical therapy, as this knowledge to clinical translation gap is well documented in medicine and nursing and has been the impetus for ongoing curriculum transformations in these programs. These professions are exploring a variety of approaches on how to best deliver /package courses / and curriculum that foster rapid translation into clinical practice. Arena, R., et al., 2017; Fall, L.H. 2015; Newhouse, R.P. and Spring, B., 2010; Fincher et al., 2009.

Recently, new curricular models have emerged within the doctoral of physical therapy curriculum that complement the academic mission to train competent evidenced based clinicians Bliss et al., 2018, Arena R. et al. 2017. These models leverage the faculty expertise of physiologist/scientist, research, and clinical faculty to create integrative learning experiences for students. These models include integrated models of clinical laboratory learning and/ or classroom-based discussion of case scenarios, that pair the basic scientist and the clinical expert. It is our belief, that teaching our clinical students through these models will lead to enhanced educational experience, application of didactic course work, and the appreciation for high quality research both basic and applied.

3. Appreciation and value of foundational sciences through participation in faculty led research:

Capstone experiences are common curricular elements for the physical therapy profession. This model is believed to 1) prepare future physical therapy generations to provide high-quality clinical care and, 2) provide research needed to guide evidence-based care, and 3) foster the appreciation for evidence and advances in the field. We believe these pipeline experiences could allow for advanced training incorporating strong foundational (science) knowledge that is relevant to the field, which can be applied broadly and adapted to integrate the rapidly growing knowledge base. Such models may assist in integrating the importance of scientific findings (basic and applied) while facilitating the breakdown of barriers (perceived and real) that silo clinical and foundational content (Haramati, A., 2011).

Contributing to the barriers are that relatively few of the basic sciences and translational studies are being conducted by rehabilitation experts. Furthermore, like medicine disciplines, it is unlikely that DPT faculty will be experts as both a clinician and scientist. Rather these emerging models promote teams of scientists and clinical faculty who work together to promote scientific, evidence-based education (Polancich S. et al., 2018; Read and Ward 2017; Fincher et al., 2009). Implementation of these education models requires “buy in” from administration and faculty who must recognize and value a core of outstanding clinician-educators, clinician-scientists, and basic scientists, and reward effective collaboration in education (Fincher 2009).

Although these models are flowering in research intensive universities, the challenges of integrating the basic sciences are greater in programs embedded within smaller liberal arts institutions that lack the infrastructure and administrative support for creating teaching-science-clinical synergies. Often these programs are heavily weighted towards clinical education faculty who emphasize clinical teaching and development of clinical skills, with a less integrated emphasis on the fundamental science in clinical decision making. Our own experience, having taught foundational (physiology and neuroscience) sciences, are that faculty in these programs are more reluctant to embrace and value foundational sciences. A possible explanation may be the limited exposure to and unrecognized value of contributions to the field from such basic and translational approaches. It is frequently implied if it works, it may not be necessary to understand mechanistically how it works. While this might suffice for today’s practice approach, this will not be enough for future clinicians in a rapidly evolving clinical environment. Programs that may not foster scientific curiosity, may be missing the opportunity to instill lifelong learning. We agree with other educators that the integration of basic science is critical for the student progress toward independence and essential competence, and that health science educators should support the teaching of basic science as it aids in the teaching of how to solve complex clinical scenarios even if clinicians may not emphasize the basic science that underlies their reasoning (Pangaro, 2011).

Concluding Thoughts:

Physical therapy departments particularly those within major academic centers housing a mix of research, education, and clinically focused faculty can successfully operate a curriculum able to synergize education, research, and clinical initiatives. Creating synergies early in a curriculum by pairing clinical specialists with science trained faculty will facilitate connections between clinical practice and science (Bliss, et al., 2018). While curricular change can be challenging, programs that implement a collaborative model where faculty with a shared area of expertise (e.g., orthopedics, neurology, cardiopulmonary, pediatrics and geriatrics) and unique complementary skill sets (i.e., research, education, and clinical practice) come together to transform student educational experiences – completing that bridge between basic science and clinical practice.

Stacked Stone Arch

 

References:

Arena, R., Girolami, G., Aruin, A., Keil, A., Sainsbury, J. and Phillips, S.A.,

Integrated approaches to physical Therapy education: a new comprehensive model from the University of Illinois Chicago, Physiotherapy Theory and Practice, 2017, 33:5, 353-360, doi: 10.1080/09593985.2017.1305471.

Bliss, R., Brueilly, K. E., Swiggum, M. S., Morris, G. S., Williamson, E.M., Importance of Terminal Academic Degreed Core Faculty in Physical Therapist Education, Journal of Physical Therapy Education. 2018, 32(2):123-127, doi: 10.1097/JTE.0000000000000054.

Fall, L.H., The Collaborative Construction of the Clinical Mind: Excellence in Patient Care through Cognitive Integration of Basic Sciences Concepts into Routine Clinical Practice, Med.Sci.Educ. 2015, 25(Suppl 1): 5, doi: 10.1007/s40670-015-0192-9.

Fincher, M., Wallach P., and Richardson, W.S.,  Basic Science Right, Not Basic Science Lite: Medical Education at a Crossroad, J Gen Intern Med. 2009, Nov; 24(11): 1255–1258, doi: 10.1007/s11606-009-1109-3

Haramati, A., Fostering Scientific Curiosity and Professional Behaviors in a Basic Science Curriculum, Med.Sci.Educ. 2011, 21(Suppl 3): 254, doi: 10.1007/BF03341720.

Newhouse, R.P. and Spring, B., Interdisciplinary Evidence-based Practice: Moving from Silos to Synergy, Nurs Outlook. 2010, Nov–Dec; 58(6): 309–317, doi: 10.1016/j.outlook.2010.09.001.

Pangaro, L., The Role and Value of the Basic Sciences in Medical Education: The Perspective of Clinical Education -Students’ Progress from Understanding to Action. Medical Science Educator. 2010, Volume 20: No. 3. 307-313.

Polancich, S., Roussel, L., Graves, B.A., O’Neal, P.V., A regional consortium for doctor of nursing practice education: Integrating improvement science into the curriculum. J Prof Nurs. 2017, Nov – Dec;33(6):417-421, doi: 10.1016/j.profnurs.2017.07.013.

Read C.Y., Ward L.D., Misconceptions About Genomics Among Nursing Faculty and Students. Nurse Educ. 2018, Jul/Aug;43(4):196-200, doi: 10.1097/NNE.0000000000000444.

 

 

Chris Wingard completed his BA in Biology form Hiram College a MS from University of Akron and PhD from Wayne State University. He has served in physiology departments at University of Virginia, Medical College of Georgia and East Carolina University during his career and has most recently joined the Bellarmine University College of Health Professions as Professor teaching in the Physical Therapy, Accelerated Nursing and Biology Programs.  His interests are in the impacts of environmental exposures on the function of the cardiovascular pulmonary systems.
Sonja Bareiss received a BS in Biology and Master’s in Physical Therapy from Rockhurst University. She completed her PhD in Anatomy and Cell Biology at East Carolina University. Dr. Bareiss was a faculty member at East Carolina University Department of Physical Therapy and Department of Anatomy and Cell Biology before joining the DPT program at Bellarmine University. Her areas of teaching span foundational sciences (neuroscience and anatomy) to clinical content (electrical modalities). Her most recent efforts have been to develop and implement a pain mechanisms and management course into physical therapy curriculum with emphasis on interdisciplinary learning. In addition to her academic experience, Dr. Bareiss has over 8 years of full-time clinical experience where she specialized in treating patients with chronic pain syndromes. Her research and clinical interests have been dedicated to understanding mechanisms of neural plasticity related to the development and treatment of pain and neurodegenerative disease and injury and integrating undergraduate Biology Honors and DPT students into the work.
Teaching for Learning: The Evolution of a Teaching Assistant

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

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

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

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

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

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

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

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

References

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

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

María Alejandra is a last year medical student at the Universidad de Los Andes, School of Medicine in Bogota, Colombia, where she is has been a teaching assistant for the physiology and pharmacology courses for second-year medical students. Her academic interests are in medical education, particularly in biomedical sciences.  She is interested in pursuing a medical residency in Anesthesiology. Outside medical school, she likes running and enjoys literature as well as writing on multiple topics of personal interest.
Medical Physiology for Undergraduate Students: A Galaxy No Longer Far, Far Away

The landscape of medical school basic science education has undergone a significant transformation in the past 15 years.  This transformation continues to grow as medical school basic science faculty are faced with the task of providing “systems based” learning of the fundamental concepts of the Big 3 P’s: Physiology, Pathology & Pharmacology, within the context of clinical medicine and case studies.  Student understanding of conceptual basic science is combined with the growing knowledge base of science that has been doubling exponentially for the past century.  Add macro and microanatomy to the mix and students entering their clinical years of medical education are now being deemed only “moderately prepared” to tackle the complexities of clinical diagnosis and treatment.  This has placed a new and daunting premium on the preparation of students for entry into medical school.  Perhaps medical education is no longer a straightforward task of 4 consecutive years of learning.  I portend that our highest quality students today, are significantly more prepared and in many ways more focused in the fundamentals of mathematics, science and logic than those of even 30 years ago.  However, we are presenting them with a near impossible task of deeply learning and integrating a volume of information that is simply far too vast for a mere 4 semesters of early medical education.

 

To deal with this academic conundrum, I recommend here that the academic community quickly begin to address this complex set of problems in a number of new and different ways.  Our educators have addressed the learning of STEM in recent times by implementing a number of “student centered” pedagogical philosophies and practices that have been proven to be far more effective in the retention of knowledge and the overall understanding of problem solving.  The K-12 revolution of problem-based and student-centered education continues to grow and now these classroom structures have become well placed on many of our college and university campuses.  There is still much to be done in expanding and perfecting student-centered learning, but we are all keenly aware that these kinds of classroom teaching methods also come with a significant price in terms of basic science courses.

 

It is my contention that we must now expand our time frame and begin preparing our future scientists and physicians with robust undergraduate preprofessional education.  Many of our universities have already embarked upon this mission by developing undergraduate physiology majors that have placed them at the forefront of this movement.  Michigan State University, the University of Arizona and the University of Oregon have well established and long standing physiology majors.  Smaller liberal arts focused colleges and universities may not invest in a full majors program, but rather offer robust curricular courses in the basic medical sciences that appropriately prepare their students for professional medical and/or veterinary education.  Other research 1 universities with strong basic medical science programs housed in biology departments of their Colleges of Arts and Sciences may be encouraged to develop discipline focused “tracks” in the basic medical sciences.  These tracks may be focused on disciplines such as physiology, pharmacology, neuroscience, medical genetics & bioinformatics and microbiology & immunology.  These latter programs will allow students to continue learning with more broad degrees of undergraduate education in the arts, humanities and social sciences while gaining an early start on advanced in depth knowledge and understanding of the fundamentals of medical bioscience.  Thus, a true undergraduate “major” in these disciplines would not be a requirement, but rather a basic offering of focused, core biomedical science courses that better prepare the future professional for the rigors of integrated organ-based medical education.

 

In the long term, it is important for leaders in undergraduate biomedical education to develop a common set of curriculum standards that provide a framework from which all institutions can determine how and when they choose to prepare their own students for their post-undergraduate education.  National guidelines for physiology programs should become the standard through which institutions can begin to prepare their students.  Core concepts in physiology are currently being developed.  We must carefully identify how student learning and understanding of basic science transcends future career development, and teach professional skills that improve future employability.  Lastly, we must develop clear and effective mechanisms to assess and evaluate programs to assure that what we believe is successful is supported by data which demonstrates specific program strengths and challenges for the future.  These kinds of challenges in biomedical education are currently being addressed in open forum discussions and meetings fostered by the newly developed Physiology Majors Interest Group (P-MIG) of the APS.  This growing group of interested physiology educators are now meeting each year to discuss, compare and share their thoughts on these and other issues related to the future success of our undergraduate physiology students.  The current year will meet June 28-29 at the University of Arizona, Tucson, AZ.  It is through these forums and discussions that we, as a discipline, will continue to grow and meet the needs and challenges of teaching physiology and other basic science disciplines of the future.

Jeffrey L. Osborn, PhD is a professor of biology at the University of Kentucky where he teaches undergraduate and graduate physiology. He currently serves as APS Education Committee chair and is a former medical physiology educator and K12 magnet school director. His research focuses on hypertension and renal function and scholarship of teaching and learning. This is his first blog.
Thoughts from the Future

 

 

April 23, 2028

 

Dear Dave Harris of 2018,

It has been a long time my friend, in fact 10 years.  I have plenty of good news to share with you, which may be shocking or expected!

First, I am happy to inform you that the past decade has been extremely good for your Philadelphia Eagles!  After winning Super Bowl LII in 2018, they have gone on to win 3 more with Carson Wentz running new “Philly Specials” year after year!  Tom Brady finally retired after he dropped another wide-open pass in Super Bowl LV.  However, the biggest surprise for you may be that the Cleveland Browns won Super Bowl LV!

I am also happy to tell you that the educators survived the Great Medical Education Transformation of the 2020s! I knew that you saw this coming around 2015, but the speed at which the Transformation occurred was mind-blowing for many faculty!  We lost a few good “soldiers” in the process when they failed to adapt their educational views and styles, but as of now, medical education has never been better and there have been substantial improvements in patient safety and outcomes!  I am sharing some of the changes with you to prepare the faculty of the future!

One of the first recognizable changes was the manner in which students approached medical school curricula.  Even during your time, schools saw drastic reductions in class attendance and student engagement with the formal curriculum.  The millennial students were used to obtaining information how they wanted and immediately when they wanted.  Recording of lectures led to students remaining at home so that they could double speed your voice to sound (you have no idea how they describe you!), allowed them to view these lectures at midnight in their pajamas, and gave them the ability to stop and take notes.  Many faculty mistook this as student disengagement and tried to “force” them into class by making mandatory sessions or increasing the frequency of assessments. However, students responded by stating that some sessions were a “waste of time” and “took time away from studying for Step 1”.  They continued to vote with their feet and migrate away from the classroom!

However, what caught most faculty of your time off guard was the use of external resources outside of your own curricular items.  The emergence of the “hidden curriculum”!  Students were presented with alternative options such as Anki, Sketchy Medical, Osmosis, First Aid, Khan Academy and Pathoma to name a few!  At first faculty were unaware and put up a staunch resistance.  It was even postulated by some that the core curriculum of basic science could be delivered as a shared Medical Curricular Ecosystem (Le and Prober) that would help reduce redundancy in medical schools.  This caused an imbalance in the galaxy and many of the upset faculty tried to prevent this from coming. However, many astute faculty quickly realized that it was already there!!  At that point the faculty rebel forces decided to become proactive instead of reactive!

Town hall meetings, focus groups, and interviewing revealed many weaknesses in the medical school schema to date.  Faculty struggled to realize that the millennial students grew up with the internet and basically a cell phone attached to their hand.  Finding content was not an issue for them and what faculty discovered was that much of the content delivered in lectures was identical to what could be viewed in a video in 8 minutes.  They also discovered that students grew up in a world where everyone was connected through social media and available almost 24 hours a day!  They expected responses from their friends on a chat within seconds!  After all, how many people sleep with their cell phone next to them?  Faculty also discovered in these town halls that the generation valued work/life balance and anything that was deemed inefficient cut into this time that they could be doing something else.  Through these important meetings, faculty also discovered that students were excellent at recalling facts and regurgitating knowledge. However, when asked to apply that knowledge to a problem, the students went back to recalling the facts. Students had mistaken memorizing for learning!  And many faculty had mistaken learning for telling!  Some faculty reflected back and actually admitted that we may have enabled the behaviors with our constant barrage of standardized tests of knowledge!

At least, the good news is that this led to some drastic changes in medical education!  Gross anatomy has been severely trimmed down in an effort to focus on clinically relevant anatomy for undifferentiated medical students. Gross anatomy dissection is reserved for students interested in a surgical career as an elective.  Much of that experience of cutting through muscle layers and isolating each artery, nerve and vein, and picking through layers of fat to get there has been replaced by complex computer programs that help students visualize the anatomy in 3D!  Since ultrasound is currently available to any physician through their phone, more emphasis of anatomy related to ultrasound aspects has been a focus of instruction.  For many of the pathological or anatomical variations, 3D printing has allowed for much cheaper and better alternatives for learning.  Everything is currently related to clinical medicine and focuses on key concepts that are necessary to master as opposed to “knowing” everything!  However, the changes did not stop there!

Much of the basic physiology content knowledge is now presented to the students in alternative ways using directed, short videos or providing references.  The class time has been reserved for higher level threshold concepts where students are placed in situations in which misconceptions and dangerous reasoning can be identified and corrected.  Simulations and standardized patients (robots) have become common place where students have to integrate what they were learning in Doctoring courses with real life physiology.  Students enjoy the safe environment and as faculty discovered the role of affect in cognition, they quickly realized that this was a time efficient pedagogy.  Faculty have discovered that 1 hour of intense, clinically oriented, and high yield threshold concept learning is much more beneficial and time efficient than 4 hours of didactic lecture. And faculty discovered it was fun!

Another aspect under appreciated by faculty of your time is that students enjoy being able to learn in their own environment as opposed to in the classroom.  In your day coffee shops were filled with students studying away, but technology has allowed for large communities of learners to “get together” from their own homes.  Time spent traveling from various hospital sites during the clerkships was saved by developing online communities for learning and using technology to facilitate discussion.  Students felt more at ease critiquing another’s differential with this new design and appreciated the time saved from travel.

As I said my friend, medical education has been transformed in exciting and very positive ways!  Successful faculty have worked with the students to enhance the learning experience as opposed to trying to teach the way we were taught!  Faculty focused more on the learning process as opposed to trying to relay knowledge to the students.  It was discovered that technology could not substitute for poor teaching. Faculty learned to develop activities to get students out of their comfort zones so that true learning could occur.  And lastly, faculty realized that their roles were not eliminated. Rather the role of faculty had to change from the expert sage on the stage to the facilitator of student learning!

Well, I can’t wait to see what the next ten years will bring!  You will be happy to know that your two daughters have grown up to be beautiful, caring people!

 

See you in 10 years and Fly Eagles Fly!!

Dave Harris of 2028

 

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I realize that this letter may be viewed as provocative, crazy, and aspiring!  However, I hope that the conversations in medical education can begin to REALLY improve patient safety and outcomes in the future.  What changes do you think will occur in medical education in the next 10 years?

 

David M. Harris, PhD, is currently an Associate Professor of Physiology at the University of Central Florida College of Medicine in Orlando, Florida.  He received his PhD from Temple University School of Medicine, completed his post-doctoral research at Thomas Jefferson University, and was offered his first faculty position at Drexel University College of Medicine. He moved away from Philly to Orlando in 2011.  He has written several educational research manuscripts, mostly about the use of high fidelity mannequin simulators in medical physiology and currently serves as an Associate Editor for Advances in Physiology Education.  He is also on the Aquifer Sciences (formerly MedU Science) leadership team developing a curriculum that provides tools or how to integrate basic science knowledge with clinical decision making  to prevent harm.

Reference:  Le TT, Prober CG. A Proposal for a Shared Medical School Curricular Ecosystem. Acad Med, March 6, 2018

Surviving Hurricane Maria: A professor’s story (Part 2)

Previously in our story…Hurricane Maria had just ravaged the island nation of Dominica

Flag of Saint Kitts and Nevis

While I waited, my school did what many said could not be done. Our staff and administration arranged for us to be able to complete the fall semester, on the only-lightly damaged island of St. Christopher (usually called St. Kitts), which had been grazed by both Irma and Maria.  They arranged for a large passenger ship which normally ferried cars and people from Italy to Spain and back to sail over to the Caribbean and be modified into a floating campus for our thousand-plus student body for the rest of the year.  They arranged for temporary accommodations for faculty and staff on St. Kitts, where our other sister school, Ross University School of Veterinary Medicine (10), is located.  They revised the schedule to have us resume our semester in October and finish in early January.  And then they set these plans in motion.

In mid-October, I finally got the notice I’d been waiting for, my reporting day to arrive on St. Kitts for my temporary assignment there.  I’d lived on St. Kitts before while working at one of my former schools, so I knew that it wasn’t the same as Dominica.  It was wealthier, far wealthier, with so many cruise ships coming to call during high season that we were almost an afterthought to them.  It had the movie theater and the golf courses and the high-end hotels, and the island infrastructure to handle the mass of tourists who came and went by the planeload and shipload every day.  But on the same token, in Dominica we were a part of the community, we were welcomed by the people, and we were careful to try to be good neighbors.  In St. Kitts, we were mostly treated like tourists, who were perhaps staying a little longer than usual, and on a ship that wasn’t going to sail away with us.  Most of the Kittitians were still the very friendly people you can find everywhere in the Caribbean, of course, but it wasn’t Dominica and I knew it before I arrived.  We faculty were to arrive a few days before the students to get situated and find places to live on the island while the student accommodations/our campus continued its journey across the Atlantic to our new home away from home.

Belle Mont Farm Eco-Resort

When I got to St. Kitts, it was…a pleasant surprise.  It wasn’t half as hard to get through customs as I had feared, and the Marriott is a nice hotel.  We stayed there a day or two before the students started to arrive.  To make room for the students, most of the faculty were moved to an eco-resort on the far side of St. Kitts for about a week, which opened in its off-season just for us.  While I appreciated their going above and beyond on our behalf, I only stayed one night before moving into an apartment in town. I just wanted to unpack my suitcases, settle in somewhere, and get back into a routine.

Because I left the eco-resort so early, I was available to help the students come in on their arrival day.  And come in they did, one charter flight at a time to the airport, and one to three buses (they call them cruisers) at a time to the Marriott.  Tired, bleary-eyed, some clearly still suffering the effects of six or more days on Dominica under indescribable conditions ending in evacuation and weeks of uncertainty, the students came.  You couldn’t help but feel for the ordeal they had survived… or admiration for their grit to return anyway, when a small group of others had taken a leave of absence.  On that day and night when the students came in charter flight after charter flight, wave after wave, a dozen volunteers and I helped each group one by one.  We were the friendly faces from home greeting them after their long ordeal.  We smiled and shook their hands and took their bags inside, helped them through check-in, provided them some simple meals, and tried to make each returning student feel special.  It started for me in the afternoon, and then into the evening, and then into the night, with each group of students arriving more and more exhausted.  By 1 a.m. I was feeling pretty exhausted too, but we kept going until the very last group made it in somewhere close to 2 a.m.

I am told that still more planeloads of students flew in the next morning, but I slept in.  That afternoon, students were being transported from the hotel to the port, where our ship had come in.  The lines were long and the sun was hot and the students just wanted to get inside and get to their new berths.  Many of the faculty who were staying at the eco-resort had come into town that morning to help students move in during the morning/afternoon shift.  I showed up for the afternoon/evening shift.  As we had done the previous day, we volunteers did our very best to keep everyone comfortable at the port, as students went through the tedious process of being identified, cleared to come onto the ship, given berth assignments, and other things past my station at the port.  I made a point to smile and joke and most students appreciated it.  By mid-evening the last students had made it past my sorting station at the dock entrance and headed into the ship, so I stumbled home for another exhausted sleep.

There was a lot more involved in starting work at the temporary campus than just showing up, but I and the other faculty made do.  The ship had just one large cafeteria so we sometimes had to wait in meal lines during its designated breakfast-lunch-dinner times.  Many of the prior amenities on the ship (e.g., a movie theater and a pool deck) had been converted into classroom and study areas before we boarded, and other spaces were modified for student use later.  This included the conversion of an entire deck of the ship which is usually a car garage into an air-conditioned suite of temporary study spaces, clinical exam rooms, and simulation labs. Since the ship spent most days at sea, it was rather crowded at first.  We faculty didn’t have offices per se but like the students we each found our place to be during the day.  My place was at the back of the third semester classroom, in a corner with AC, electric hookups, and a view of the harbor.  I usually teach in second semester as do most physiologists, so I absorbed a lot of clinical applications even as I worked on lectures and active learning sessions, module directing, pre-mini-workshop design, and all the other routines of a typical teaching-oriented school.  And in so doing I, like so many other faculty who don’t get to know a lot of students normally, did connect with many of them.  When we had to get up at 3:30 a.m. to catch the 4:15 a.m. bus to get us to the boat before it sailed at 5:00 a.m. to make room for a set of larger cruise ships throughout the day, we shared in the students’ experience of having to make sure they too were up at the same time, early enough to download their most important materials of the day before we sailed, just in case the harbormaster put us far out at sea.  When the days came that other ships left late and we didn’t dock until 7:30 at night, the students shared that with us too.

Photo: St. Kitts in the morning light, mid-November 2017. Photo credit: Bruce Wright

Along the way, we made time for some activities.  Twice I went scuba diving with fellow members of our RUSM (Med School) Scuba Club (11); others went diving even more regularly.  People organized groups for exercise on the outside deck every morning and night.  There were religious services, club meetings, and other miscellaneous activities on the boat.  Off the boat there was at least one school-planned movie outing, an island tour, and a few students even made it to a “beach bash” hosted by the RUSVM (Vet School) Scuba Club.  More informally, the port facilities were nice as one would expect at a regular Caribbean cruise ship stop, with everything that entails. It became a shared experience of life in close quarters, dedicated to a common purpose and with a common spirit that we would make it through, together and with no drop in our commitment to teaching and learning despite it all.

Would I have traded it for a nice quiet semester in Dominica with no Hurricane Maria in the first place?  Well, sure!  But you have to deal with what life gives you and we made the best of it.  And the quality of the teaching did not go down.  We might have been in close quarters but we delivered virtually the same curriculum in the fall as we had in the previous spring and summer.

By mid-November, air service to Dominica was spotty but running, so I booked a trip there for a few days including Thanksgiving Day.  We’d just found out that we were going to be in Knoxville, Tennessee for the January semester but no one knew much more than that.  While some people started actively looking for places to live, I planned my return to Dominica and hoped the school would handle the Knoxville move for me and many others (it did).  I booked a room at the only hotel open in Portsmouth, Dominica, just in case my cottage was uninhabitable, and then I hoped for the best.

Photo: Sunset in Dominica, late November 2017. Photo credit: Bruce Wright

When I flew in, it was afternoon and, well, the island I loved looked different.  This was now two months after Hurricane Maria did its damage and still the island was brown, not green.  The volcanic ridges were sharp and distinct, and the remains of trees were all over them, standing tall and naked.  But if I looked closely, I could see that at the tops of the trees, leaves had started growing again.  Not enough to cover the scars on the land, not yet, but enough for some hope.  I had the taxi driver take me to my cottage before going to the hotel, and amazingly almost everything had survived.  The food and other perishables were gone with a few other items (e.g., my Swiss army knife), but overall I had a lot of things to ship home.  When someone had built the place he or she had cemented the window frames into the concrete wall for extra strength, which isn’t standard practice anywhere but it worked there.  Whoever it was had also put odd-looking vents under the roof which somehow prevented the roofs from flying.  As a result, though my furniture was flooded at floor level, almost everything else was salvageable.  It was a miracle compared to the sheer devastation we’d driven through from the airport to town.  That night I saw my first sunset on Dominica in many months, and it was beautiful.

Photo: Looking north from Portsmouth, Dominica, Thanksgiving Day 2017. Photo credit: Bruce Wright

I spent the next two days getting almost everything from my cottage packed up and sent to the local shipping agent for transport back to the USA.  Since my office had survived intact (another unexpected blessing) I took a couple of textbooks and other important items from there. But I didn’t take everything. I left most things in my office against the day I would return.  I also took a few photographs. I chose to avoid taking pictures of the damaged areas. Instead I shot photos of things I’d never seen before, like the caved-in side of a cliff face on the mountain north of town that to me looked just like a monkey’s hand.  Along the way I saw the determination of the people to recover even as they all hoped we would be back in May, and I hoped the same thing.  But it was not to be.  As I flew out with my bicycle sold, my cottage empty, and my most essential items from home and office in two suitcases, I was pretty sure that Dominica wouldn’t be ready for us by then.  There were still too many without power, too many living under tarps and in barely-repaired dwellings, too many roofs still off and the insurance companies being slow to pay claims.

The semester ended relatively uneventfully.  The students adjusted to where they were going to be in the spring, and so did I.  Knoxville, Tennessee is a nice southern city with both friendly people and all the movie theaters one could ever want. I even went once!  Most of our students are here with us, though some are still in St. Kitts with some of our faculty.  We’ve learned we’re to be here through the September 2018 semester so we have some sense of permanence.  Though I would love to return to Dominica as soon as possible, having a safe, happy Dominica with functional buildings, power, water, cell service, and the other non-movie theater basics restored is really important too, so I can’t complain.  Here I am, a professor at a medical school in the United States, just like I wanted to be so many years ago.  And whether here or Dominica or anywhere else my fate takes me, I’ll get by.

As I told one of my advisees who was having a bad day last December, in the end a school isn’t buildings at all.  A medical school is its people, medical faculty training students through increasingly difficult tasks until at the end the students have risen up to a higher level, doctors ready to begin their postgraduate medical education journey.  The medical arenas and the classrooms and the simulation labs and the journal collections and the fraternity/sorority homes and even the occasional Italian ship sailing thousands of miles to become a “floating campus” are all just the scaffolding around what is really important.  That one student, his or her classmates, his or her basic science and clinical faculty, and everyone else from the Dean to I.T. to the people washing dishes in the back of the cafeteria who make sure everything else runs…these people are the real school.  They make it possible for that one student to excel.

And that’s something that no hurricane– however powerful– can stop.  Ask LSU if it stopped for either Camille or Katrina.  Ask Hofstra if it stopped for Sandy, Baylor if it stopped for either Rita or Harvey, or Nova Southeastern if it stopped for either Andrew or Irma.  Like those other disasters, Hurricane Maria is part of history now. And just like those other schools went on after their respective storms, we’ll keep going too, training the next generation of physicians, semester after semester.  As we do, I’ll be right there doing my part for my students, my school, and the greater medical education community.  Because in the end, that’s not only what I was trained to do, it’s still my passion today.

Bruce E. Wright graduated with a PhD in Physiology from LSU Health Sciences Center in 1993.  He had postdoctoral fellowships/research faculty positions at the University of Florida and East Carolina University.  He served several years as faculty at a liberal arts college in Georgia.  He worked at three Caribbean medical schools from 2005-2008 before joining the faculty at Ross University School of Medicine in 2008.  He worked for two years at a US-based osteopathic medical school in 2013 and 2014 before returning to Ross University in late 2014.  Dr. Wright is currently Treasurer/Award & Event Coordinator for the American Physiological Society’s Teaching Section.  He has served as a reviewer for Advances in Physiology Education.  He is National Faculty for the National Board of Osteopathic Medical Educators (NBOME), for whom he has written and reviewed items for different exams.  He regularly attends Experimental Biology and was an attendee and presenter for the first Institute for Teaching and Learning meeting in Bar Harbor, Maine in 2014.  He is currently interested in educational research involving teaching methodologies.

Photograph: The author with three RUSM students (from left to right, Armin Hojjat, Harenda Ipalawatte, Bruce Wright, and Eddy Mora) just after a double-tank scuba dive, off St. Kitts, November 2017. Used with permission by Harenda Ipalawatte.

References/links/other:

  1. http://www.dominica.gov.dm/about-dominica/country-profile
  2. https://medical.rossu.edu/about.html
  3. http://www.dominica.gov.dm/tropical-storm-erika
  4. https://weather.com/storms/hurricane/news/tropical-storm-harvey-forecast-texas-louisiana-arkansas
  5. https://weather.com/storms/hurricane/news/hurricane-tropical-storm-irma-recap-2017
  6. https://en.wikipedia.org/wiki/Hurricane_Maria
  7. https://www.youtube.com/watch?v=l-5fHwER-Zc
  8. https://www.caricom.org/media-center/communications/press-releases/dominica-prime-minister-roosevelt-skerrit-addresses-the-un-general-assembly
  9. https://www.wunderground.com/cat6/category-5-hurricane-maria-hits-dominica
  10. https://veterinary.rossu.edu/about.html
Surviving Hurricane Maria: A professor’s story (Part 1)

It’s funny, as I begin to write this blog, that I realize that it’s nearly 25 years now since I received my Ph.D. in Physiology in New Orleans.  Back then, I was sure that my career track would lead me to becoming a full professor at a medical school in the United States one day, though I didn’t know exactly how I would get there.  Not being a world traveler, I certainly never expected to spend a day in the Caribbean, but life is funny sometimes.

Like so many other graduates of my day, the “optimal” career track didn’t pan out for me.  My postdoctoral experience didn’t involve receiving any federal grants, so instead of moving straight into medical school, I became involved in undergraduate education. Several years later while advising students, I learned about Caribbean medical schools. When I studied them in more depth, I discovered one program in particular in which I could teach college seniors advanced A&P part-time while I took medical school courses part-time too.  I took a leap of faith and applied for it. Shortly after they accepted me, I took my first flight over the turquoise-blue of the Caribbean Sea.

 

That was the day my life changed

There was and is something different about the Caribbean, its varied islands and its colorful people, so friendly in some places and so unfriendly in others, but always full of life and adorned in bright colors.  Along the way I picked up medical-level Gross Anatomy and with that extra qualification, moved into full-time faculty positions at a couple of small medical schools in the British and Dutch Caribbean.  On those tiny islands I relearned my discipline as a generalist as few others of my generation have done.  There I was THE physiologist with no backup and neither a travel allowance for attending conferences or taking trips home to see my family, nor support for any research.  Instead I had to not only teach the entire medical physiology course by myself three times per year, I also had to assist the anatomy faculty in cadaver dissection twice per week and occasionally teach in an undergraduate course.  My typical medical school course load was 14-16 hours per week of just contact time in lecture and lab, not counting writing exams every three weeks and having many, many meetings with students.  It was hard but it changed me, and made me a better teacher. With this Caribbean-acquired training as a medical physiology generalist, in 2008 I moved up to a first-tier Caribbean medical school in the Commonwealth of Dominica (not the Dominican Republic!), initially to teach digestive physiology.

 

Flag of the Commonwealth of Dominica

Dominica will always have a special place in my heart.  It is a small volcanic island in the British Caribbean that is shaped like a chrysalis (1).  At its widest it’s only about 18 miles and at its longest 29 miles, but it is almost a mile high. It has no five star resorts, no golf courses, and no movie theaters.  It’s hard to get to by air, and even cruise ships mostly go past it in favor of better-developed ports on the islands north and south of it. When I first arrived the entire population on-island was only about 73,000, mostly hugging the west (Caribbean) coast. But for several years I lived in a house on a hillside 500 feet above the Caribbean Sea watching the sun set over the ocean every night from my front porch. On Saturday I would sometimes go down to the village of Mero below me where there would be a half mile of pure gray sand beach and only a dozen people on it.  On Sunday, I might go down again to where five hundred locals had come to party on the beach, or I might have just sat on my porch and listened to the music from far below, as the stars came out and the Southern Cross hung in the April sky. One time, and only one time, I climbed the 4800 foot mountain in the center of the island where there is no trail up to the cloud-cloaked peak.  One time, I swam, dove, and rappelled down a river through a canyon greener than the Emerald City.  And along the way, I taught at a very special school, with smart, tough, high quality faculty and students alike, Ross University School of Medicine (2).

 

Photo: Dominica from my cottage porch, April 2017. Photo credit: Bruce Wright

Through most of my years there, Dominica was spared the worst that Mother Nature could bring to bear.  We liked to say that it was in the perfect place in the Lesser Antilles, too far north for the big Cape Verde hurricanes that would not be turned north as they tracked west through the Central Atlantic to hit, and too far south for those Atlantic storms that did get pulled north as they approached the islands.  Sometimes a tropical storm would come and dump a lot of rain but that just turned the tap water brown or white for a day, no big deal.  The island stayed its radiant green from the tropical rain forests, only browning out for 1-2 months per year in the dry season from January to April.

 

 

In 2015, Tropical Storm Erika formed almost on top of us, and hit the island with the worst rainfall it had experienced in decades.  Dozens of people died and whole towns were cut off for months.  We thought we’d been hit by the Big One, as the estimated damage from Erika’s island-wide flash flooding was about 500 million dollars, or well over half of Dominica’s gross domestic product (3). For two years the island slowly recovered, rebuilding its water treatment facilities, repairing washed-out bridges, and helping rebuild flooded coastal communities.

By August 2017, Dominica was almost completely back.  We too were back.  Our school had had its own water supply even before Erika hit, and the electricity never went out in Portsmouth afterwards. Like the rest of Dominica, my school did lose cell phone service and internet for several days after that storm, which was a serious concern.  Once we were reconnected with the world, we moved to make sure our school would never be caught like that again.  My school installed its own satellite, set up evacuation plans, and built a new student center rated to withstand a Category 5 hurricane. Along the way it continued to matriculate three sets of students per year, semester in and semester out.  Collectively, we thought we’d survived the worst and recovered very well.

No one expected the hurricane onslaught of 2017.  Three major hurricanes, three major disasters, with consequences felt in several parts of the United States, were always theoretically possible but most people didn’t expect more than one to pan out. In the middle of August, I was on vacation at my wife’s home in Georgia as eventual Major Hurricane Harvey formed in the Atlantic and passed south of Dominica as a tropical storm.  Most storms that go that way fizzle out in the eastern Caribbean, but Harvey survived and went on to ravage Houston and the surrounding region of the northwestern Gulf of Mexico like few hurricanes ever had (4). The United States’ people and its government mobilized to help Texas and Louisiana, as it so often does after a major disaster.  I breathed a sigh of relief that Dominica was spared again even as I too donated to help the Gulf coast.

I returned to work before the beginning of the September semester.  Irma was still far out to sea in the Central Atlantic, but it looked like it was going to be trouble almost as soon as it cleared Africa.  I told many first semester students days before Hurricane Irma reached the Lesser Antilles that they should invest in a full set of hurricane supplies as if it would be the worst storm they would ever experience in their lives. Then, when it didn’t hit, they could eat the food, drink the bottled water, and cook with the extra propane all semester long.  Some took this advice to heart and others didn’t.  As Hurricane Irma came closer and closer, it kept heading straight for Dominica, defying days of forecasts that it would turn northwest, and strengthening all the way to one of the strongest Category Five storms of all time.  Only at the last minute seemingly did it turn at last.

Irma was a terrible storm, even by historical standards (5).  It destroyed St. Maarten and several other islands but all we got from it was severe rain and tropical-storm force winds, with only minor damage to our fragile infrastructure.  We grieved for our comrades including our sister school American University of the Caribbean north of us, and then watched as this storm’s heaviest rain bands hit the Miami area, causing even more flooding damage only weeks after Houston’s deluge.  As our University headquarters were there, this had some effect on our operations, but again from Dominica we breathed a sigh of relief.  We had been spared the worst again.

Chugging along some distance behind Irma, another tropical wave came off of the African coast, looking suspicious right from the start.  Maria, as it was to eventually be named, was absolutely the worst case scenario for the island of Dominica and for our basic science campus there (6).  It wasn’t supposed to be a major hurricane when it hit.  The forecasts all said if it hit at all, it was likely to be a strong tropical storm, maybe a Category One.  Nevertheless, in preparing for a business trip to Chicago for the second week of September, I had a group meeting with my mentees a week early, because sometimes even a simple rainstorm over Puerto Rico could delay my return by a day, and I was to return on Monday, September 18th.  I took my work computer with me on the trip on a hunch I might need it before I got back to Dominica.  I had no idea how right I was.

As I worked at my business meeting, I kept following the progress of Maria, joking that it might just prevent me from returning on Monday, but hoping that it would turn like so many storms before it.  This was not to be. By late Saturday even though it was only tropical storm strength, it was apparent that on Sunday the regional airlines were going to evacuate their small aircraft to havens like Aruba and Curacao to the south and Central America to the west.  Since there weren’t going to be any flights, my travel agent arranged for me to go back to my family in Georgia on that Monday to wait out the storm.  We expected I probably wouldn’t get back to Dominica until air service was restored to Puerto Rico, probably four to six days after I’d originally been scheduled to return to Dominica.

September 18th, 2017… Imagine being inside a tornado.

Imagine looking up to see your roof flying away and then the wind and rain coming in on top of your inadequate shelter as you brace your feet against the closet door, hoping it will hold.  Imagine hanging on for hours and hours of storm, enduring howling winds and painful rain and your stuff blowing away around you, hoping you wouldn’t die. If you have trouble imagining it, so do I, because I wasn’t there.  My colleagues who were there said that I was the luckiest person at the school, to be thousands of miles away that fateful day. From my computer screen at home that night I watched the storm give Dominica a direct hit with 160 mile per hour sustained winds, and turning only as the eye was literally over the island such that the entire west coast of the island was struck by the eyewall of Category Five Hurricane Maria.  As I flew home over the United States that day, eighty to ninety percent of the buildings in the country were about to be damaged or destroyed, the hospital, power generators and water reservoirs damaged or destroyed, and the roads and bridges so shakily repaired after Erika destroyed again (6).  The morning after the storm, people went out and saw that not one tree had escaped unscathed on the entire island, and in many places the trees had lost their bark or been snapped in two (7).  Virtually every telephone pole was either in need of repair or down entirely. The airport was knocked out again from both rain and the river beside it washing through the terminal and over the runway. Unlike with Erika, the seaport and its dock and warehouse capacity on the west coast was heavily damaged as well.  And of course, dozens of people were dead and dozens more are still missing to this day. The island was brought to its knees.

A few days after the storm, the prime minister declared in a speech to the United Nations General Assembly that “Eden is broken” (8).

Photo: GOES-16 visible image of Maria just before sunset, at 5:17 pm EDT Monday, September 18, 2017. Image credit: NOAA/RAMMB. (9)

At our campus, that brand new hurricane-proof building delivered.  All of our people were safe, though many of our older buildings were heavily damaged.  The French islands north and south of us weren’t so badly damaged and they were able to get helicopters up to survey the scene of total devastation that Dominica had become.  Our campus became a site for them and other rescuers to base, as it was more functional than any other location on the north side of the island.  With help from many others including the U.S. military, over a thousand students, faculty, staff, and family members were evacuated off the island through seas crowded with entire forests of dead trees and other debris.  Our CEO was there to greet many Ross refugees in Miami as they returned to the US to an uncertain future.  And as before, I watched it all from a distance, not personally devastated as they were but a refugee just the same.  I found out from a colleague who had been my neighbor that my concrete cottage had held up better than most. Like three of the other cottages in the complex it still had both a roof and windows following the storm, but no one could say if anything inside had survived the flooding, or whether the post-storm looters who sadly went through many other places had broken in after they were evacuated.  As soon as I could, I checked in with my school to let them know where I was and that I was safe. I was told to sit tight and wait for instructions, just like everybody else.  So that’s what I did, for several weeks.

Stay tuned for next week’s exciting conclusion…

 

Bruce E. Wright graduated with a PhD in Physiology from LSU Health Sciences Center in 1993.  He had postdoctoral fellowships/research faculty positions at the University of Florida and East Carolina University.  He served several years as faculty at a liberal arts college in Georgia.  He worked at three Caribbean medical schools from 2005-2008 before joining the faculty at Ross University School of Medicine in 2008.  He worked for two years at a US-based osteopathic medical school in 2013 and 2014 before returning to Ross University in late 2014.  Dr. Wright is currently Treasurer/Award & Event Coordinator for the American Physiological Society’s Teaching Section.  He has served as a reviewer for Advances in Physiology Education.  He is National Faculty for the National Board of Osteopathic Medical Educators (NBOME), for whom he has written and reviewed items for different exams.  He regularly attends Experimental Biology and was an attendee and presenter for the first Institute for Teaching and Learning meeting in Bar Harbor, Maine in 2014.  He is currently interested in educational research involving teaching methodologies.

References/links/other:

        1. http://www.dominica.gov.dm/about-dominica/country-profile
        2. https://medical.rossu.edu/about.html
        3. http://www.dominica.gov.dm/tropical-storm-erika
        4. https://weather.com/storms/hurricane/news/tropical-storm-harvey-forecast-texas-louisiana-arkansas
        5. https://weather.com/storms/hurricane/news/hurricane-tropical-storm-irma-recap-2017
        6. https://en.wikipedia.org/wiki/Hurricane_Maria
        7. https://www.youtube.com/watch?v=l-5fHwER-Zc
        8. https://www.caricom.org/media-center/communications/press-releases/dominica-prime-minister-roosevelt-skerrit-addresses-the-un-general-assembly
        9. https://www.wunderground.com/cat6/category-5-hurricane-maria-hits-dominica
        10. https://veterinary.rossu.edu/about.html 
Stress and adaptation to curricular changes

 

 

 

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

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

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

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

Advantages and challenges of active learning

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

Some of the biggest challenges for teachers are the following:

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

Some of the challenges for students include:

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

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

Intermediate disturbance hypothesis and stress in education

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

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

 

 

 

 

 

 

 

 

 

Figure 1. Intermediate disturbance hypothesis in education.

 

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

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

 

 

 

 

 

 

 

 

 

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

 

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

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

References

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

He enjoys spending time with his kids. Outside the office he likes running and riding his bicycle in the Colombian mountains.
Who’s Teaching Tomorrow’s Teachers?

Have you ever had a colleague say to you:

 “They want me to teach in this new integrated physiology course, but no one has ever taught me how to be an effective teacher!  I’ll be so nervous and probably make embarrassing mistakes, like saying the “love hormone”, oxytocin, is synthesized from cholesterol in the adrenal medulla.”

Being asked to teach first year medical students can certainly be intimidating, but that assignment is not actually akin to being thrown to the wolves. It is true that medical students are often over-achievers, but it’s been my experience over many years that these students are respectful and anxious to learn.

 

Maybe I can offer you a few tips that will help you avoid or prevent these first time  ‘teaching jitters’:

  • Know your subject and relevant scientific facts inside and out
  • Take advantage of teaching skills, workshops, and faculty development programs at your institution or through professional organizations
  • Ask your colleagues for constructive criticism of your first presentations
  • Remember that practice makes perfect, at least most of the time
  • Remember that a good sense of humor goes a long way, but bad jokes rarely help the situation
  • Don’t be afraid that you will make a couple of mistakes- we all make them but not all of us learn from them
  • Work to create effective visuals which may include human interest stories, physiology in the news, and even masterpieces by your favorite artist

Another more proactive approach is to offer programs that will encourage students to pursue their interests in teaching and help them develop the communication skills and understanding of different learning styles and pedagogies that are so essential to becoming an enthusiastic and dedicated educator. Many medical students want to ultimately incorporate teaching into their future careers as clinicians, either by formally teaching in an academic medical center or more informally through their communication with patients and with the community at large.

Here at the Carver College of Medicine at The University of Iowa we encourage our students to pursue one of our specific distinction tracks, which include research, teaching, global health, service, humanities and healthcare delivery science and management, while they are pursuing their medical degree. Although the whole concept of “teaching medical students to teach” is certainly not unique to my institution (ref 1), I do believe that our Teaching Distinction track is unique and has succeeded in terms of achieving the desired outcomes.  I’ve been very fortunate, not to mention honored, to serve as the faculty mentor for several of our previous and current students who have selected to pursue their MD with a Distinction in Teaching. It has been very exciting for me to have the opportunity to impact a student’s learning, not only in the classroom, but also in terms of their own experiences and development as educators. It has also been very gratifying when a former mentee tells me that they learned so much from me- not just endocrinology and cell biology, but also how to convey passion and enthusiasm as a teacher.  Certainly this has been a win-win experience because I’ve learned so much from these students!  Maybe Henry Adams was right when he concluded that “A teacher affects eternity; he/she can never tell where his/her influence stops.”

In order to graduate with a Distinction in Teaching our students must meet a number of requirements that include a minimum of 60 hours of relevant teaching experiences that may include: tutoring and didactic teaching; creating new educational materials; serving as a small-group facilitator; and participation on medical education committees (ref 2).  These students are also required to develop a teaching portfolio and to successfully complete a 4-week teaching elective with a capstone project (ref 2).  Since this distinction track was fully implemented in 2010, approximately 60 students, or 7-8% of all graduates, have graduated with a Distinction in Teaching.  We’ve also heard anecdotally that some students have decided to attend medical school here at the University of Iowa because they specifically wanted to pursue this track, and that having this distinction track on their resume gave them a competitive advantage during their interviews for residency positions.

Great teachers are not always born with that potential, but frequently discover their passion at some point in their careers.   I hope that through this Teaching Distinction track we’ve trained and inspired some excellent teachers who will have major impacts on all of their future students.

References

  1. Soriano RP, Blatt B, Coplit L, CichoskiKelly E, Kosowicz L, Newman L, Pasquale SJ, Pretorius R, Rosen JM, Saks NS and Greenberg L. Teaching medical students to teach: a national survey of students-as-teachers programs in U.S. medical schools. Acad Med. 2010;85:1725-31.
  2. Schmidt TJ, Ferguson KJ, Hansen HB and Pettit JE. Teaching distinction track for future medical educators. Med. Sci. Educ. 2015;25:303-06.
Thomas Schmidt is a Professor in the Department of Molecular Physiology and Biophysics at the Carver College of Medicine, The University of Iowa. He is a Fellow of the American Physiological Society and has served on the Education Committee and the Career Opportunities in Physiology Committee.  He has been the recipient of numerous teaching awards including: The President and Provost Award for Teaching Excellence (The University of Iowa); Master Teacher Award (International Association of Medical Science Educators); and most recently the Arthur C. Guyton Educator of the Year Award (American Physiological Society).  He has served as a mentor for a number of medical students who have graduated with a Teaching Distinction.