Integration of Microbiology, Pharmacology, Immunology, and Infectious Disease Using Active Teaching and Self-Directed Learning

Abstract

In an era of decreasing basic science curriculum at medical schools, we sought to re-imagine how to optimally deliver three core basic science disciplines (microbiology, pharmacology, and immunology) together with infectious disease in a 5-week course. This course, developed as part of a new 1-year pre-clinical basic science curriculum at the recently established Dell Medical School (DMS) at the University of Texas at Austin, featured a fully integrated curriculum in which the majority of the sessions were team-taught. This course, in line with the goals and missions of DMS, presented material using primarily self-directed and active learning approaches. Here, we describe the format and content of the course. We present our strategy and rationale for selecting these particular learning modalities and topics for pre-class and in-class coverage, using educational and cognitive psychology literature as a guide. We also discuss how, based on feedback from both student evaluations and performance data, the course evolved over the first two iterations.

Electronic supplementary material

The online version of this article (10.1007/s40670-018-00689-8) contains supplementary material, which is available to authorized users.

Introduction

Over the past 10 years, there has been a growing imperative for U.S. medical schools to both restructure the delivery of the preclinical curriculum and to find ways to integrate the basic sciences together with clinical medicine [1, 2]. This imperative was codified by Irby and Cook in 2010 with the publication of “Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010” [3]. In addition to increasing integration of the basic sciences with clinical medicine, there are concurrent movements towards condensing coverage time for basic sciences and reducing the use of lectures in lieu of more active teaching approaches. This is partly borne out of the desire to move students into clinical experiences earlier, but is also a consequence of more recent findings from educational psychology showing superior learning with more active, non-didactic lecture-based teaching techniques [4]. A number of recently established medical schools have designed curriculums from the ground up that both condense and integrate basic science and clinical medicine topics.

Medical schools have taken several approaches to restructure their curriculum. Szarek and colleagues described their development of an integrated curriculum at The Commonwealth Medical College (TCMC), which started with its first class in 2009 [5]. Here, they delivered their new basic science curriculum over 2 years using a combination of traditional lecture-based courses in the first year (focused on normal structure and function) and a systems approach in the second year that centers around clinical presentation (focused on abnormal structure and function) similar to what was originally developed at the University of Calgary [6]. They used the “clinical presentation” model to organize the integration of the content to be delivered in their two second-year systems courses which are 17 and 14 weeks respectively. For the actual delivery of the basic science material, they relied on a flipped classroom approach with podcasts for pre-work, partitioned time for self-directed learning, simulation, team-based learning, and student response activities where students are called upon to answer questions in class. They also incorporated small-group learning that centered around clinical cases which integrate basic, clinical, and social/behavioral issues together. Szarek and colleagues integrated microbiology, antimicrobial pharmacology, and immunology into the systems courses, which span the second year, in the context of the organ discussed at that time. This was accomplished by incorporating these disciplines into cases or question and answer sessions. However, it remains unclear, given the small amount of in-class time, how and why certain topics were selected and precisely how they integrated these disciplines together.

The University of Central Florida College of Medicine (UCFCOM), which matriculated its inaugural class in 2009, has a similar integrated, spiral curriculum that blends together the basic sciences in the human body (HB) courses in the first year and clinical medicine with pathology and pharmacology in the systems (S) courses in the second year of the curriculum [7]. The course begins with a week of principles followed by an organ system structure. To facilitate integration and reduce the number of direct lectures, faculty at UCFCOM use a variety of active teaching approaches such as team-based learning (TBL), co-teaching, and small group learning using integrated cases [7–10]. They also developed a variety of self-learning modules to encourage self-directed learning throughout the first and second years of the pre-clinical curriculum [11]. In their HB3 course, entitled “Health and Disease”, they use microbiology as the central unifying element integrated with pharmacology and immunology in cases and temporally coordinated in lectures. For the most part, immunology is taught as a separate block of lectures.

Bauler and colleagues on the other hand, used immunology as the core structure upon which microbiology and infectious disease were scaffolded together with selected topics in pharmacology at the new Western Michigan University Homer Stryker M.D. School of Medicine [12]. Their course “Foundations of Immunology and Infectious Disease” serves as a primer in immunology and infectious disease to support students “understanding of microbial and immunologic diseases encountered in subsequent organ system-based courses”. The authors state that much of the integration between the disciplines of immunology, microbiology, and pharmacology within the course is accomplished using weekly TBL. The authors also note that the integration with microbiology was accomplished by presenting microbiology earlier in the curriculum in the two preceding courses.

This “fully-integrated” model of undergraduate medical education was also used at another recently established medical school, Hofstra North Shore-LIJ School of Medicine. They have organized their curriculum around integrative cases delivered via a problem-based/case-based learning program called PEARLS (Patient-Centered Explorations in Active Reasoning, Learning and Synthesis) [13]. In this system, students spend approximately 6 h per week in small groups working on PEARLS cases concurrently with other curricular elements including basic science-based sessions, as well as clinical and social science-based sessions, for a total of approximately 22 h/week of in-class contact time. The remainder of student time in this program is dedicated to self-directed learning.

Integrative and condensed curricular restructuring is not exclusive to new medical schools. Many established institutions are also in the process of redesigning and rethinking their curriculum. For example, Halliday and colleagues recently described how they restructured a 16-week-long anatomy course into a 6-and-a-half-week-long course at the University of Oklahoma College of Medicine [14]. This was accomplished, in part, by using a broader mix of teaching modalities including case-based learning, audience response polling, regular quizzing, and team-based cadaver dissections. Despite the truncated nature of the course, the authors reported that students’ final course grades between the two course versions were roughly equivalent. In addition, they found that USMLE Step 1 anatomy subsection scores actually rose by nearly half a standard deviation with the shortened 6.5-week Human Structure course compared to the 16.5-week Gross Anatomy course. Thus, integrating and condensing did not appear to harm student performance on high-stake exams.

These reports, and others, constitute a growing body of literature in which institutions and faculty are experimenting and innovating in order to more optimally and effectively present basic science information to medical students. Here, we describe our efforts to develop an integrated microbiology, pharmacology, immunology, and infectious disease course in a novel 1-year basic science curriculum using active teaching and self-directed learning approaches. Below, we present our rationale and approach towards managing and integrating three disciplines into a coherent manner using appropriately matched learning techniques and technologies. This is followed by a brief discussion of the pros and cons of our approach and future studies.

Description of School and Course Organization

Dell Medical School Curriculum

The Dell Medical School (DMS) has distilled basic science education into an accelerated, 1-year curriculum to create time for a third-year innovation track where students can do research or get a dual degree. The preclinical MS1 (Medical School 1) year is divided into 5 basic science courses (Fig. 1) which vary between 5 and 16 weeks in length. As illustrated in the standard weekly schedule (Fig. 2), most courses meet for at least 12 contact hours per week (8 am-12 pm on Mondays, Wednesdays, and Fridays) leaving a significant portion of the week available for self-directed study. Two afternoons per week, students attend doctoring (Developing Outstanding Clinical Skills - DOCS) and interprofessional education (IPE) courses. The standard weekly schedule is modified for courses with a lab component. All MS1 basic science courses are delivered through two primary teaching modalities: Small group, self-directed problem-based learning activities (Professionalism, Inquiry, Learning and Leadership through Active Reasoning and Synthesis or PILLARS) and larger instructor-led, active learning sessions (Large Group Interactive or LGI sessions).

Fig. 1.

4-year DMS curriculum overview. The DMS curriculum begins with an integrated pre-clinical year, followed by clinical rotations in the second year, an innovation and discovery year where students can pursue a dual degree, culminating in year 4 which consists of acting internships and electives. Image from Dell Medical School website September 2018

Fig. 2.

First year (MS1) weekly schedule. All MS1 integrated basic science courses at DMS follow a generalized curricular schema. In some courses, a single PILLARS case is replaced with a laboratory session

PILLARS is a case-based, small-group learning modality, which fosters self-directed learning across the first year of the DMS curriculum. Mandatory PILLARS cases, which are modeled after PBL, provide a deep dive into subject areas and are intended to teach the skills of thinking about the science of a disease in a patient-centered case. PILLARS cases relate the story of a patient’s experience with a disease as presented through patient-physician encounters. Initially, these cases are delivered in narrative, paper-based form, and over the course of MS1, they are transitioned to a more clinically-relevant electronic health record format. On Mondays, students, in groups of seven or eight, receive the two cases of the week. During the Monday session, the group reads each case, discusses unclear aspects of the case, and identifies learning objectives regarding the science underlying the patient’s pathophysiology, diagnosis, and treatment. Students then independently research these learning objectives during open study time. On Wednesday and Friday sessions, they regroup to discuss the product of their research. Faculty facilitators are present at all sessions, not as instructors, but as moderators to promote a productive group dynamic. While there is a defined structure to the case delivery and content of PILLARS, the format and pacing of these sessions is determined by group consensus. Students take turns assuming the roles of group leader, scribe, and timekeeper and engage in peer assessment at the conclusion of the session. Both student members and faculty facilitators are rotated frequently throughout MS1 to give students experience with many different group dynamics. After the discussion sessions, students receive the ideal learning objectives for each case. These learning objectives are testable material and are included in both formative and summative assessments.

Large group interactive (LGI) sessions are non-mandatory (but strongly encouraged) classes that leverage multiple large-group learning modalities. These sessions are intended to deliver and reinforce basic science content, in an instructor-led, active learning setting. While the format of these sessions varies across MS1 courses, and with instructors’ individual teaching styles, they generally employ interactive mini-lectures, multimedia learning, and clinical cases that center on the basic science content. Though PILLARS and LGI are presented as separate teaching modalities, the content of these sessions are coordinated throughout each course. Weekly PILLARS subjects align with LGI topics, and conversely LGI sessions often build upon cases covered during PILLARS. However, to ensure that PILLARS is truly a self-directed learning (SDL) exercise, the order of the sessions are carefully timed. Cases are organized so that the LGI subject matter does not cover learning objectives from the PILLARS cases, thereby undermining their educational value. The combined learning objectives from PILLARS and LGI sessions are testable in both formative and summative assessments.

Foundations of Disease—Overview

The fourth course of the MS1 curriculum, Foundations of Disease (FOD), encompasses medical microbiology, anti-microbial pharmacology, immunology, and infectious disease. The course begins with a week of introductions focused on general principles of each discipline (Supplemental Figs. 1 and 2). The purpose of this 1st week, is to provide an overview for students as well as the tools they will need for the subsequent weeks’ cases. The remaining week sessions are fully integrated with the all three basic science disciplines and infectious disease being taught concurrently.

Because the FOD course encompasses an enormous amount of material, from four different disciplines, in a very brief time period, we condensed topics and stratified course content among pre-reading, PILLARS, and LGI sessions with little redundancy. As a consequence, our aim was to create a course that was truly foundational and provided a jumping off point for the rest of the MS1 curriculum. Additionally, as a major goal of DMS is to encourage active learning, during LGIs we principally utilized SDL and active learning in a flipped classroom format. To facilitate SDL, the LGI sessions are split into two parts. The first part, referred to as a “student directed collaborative dialogue”, is designed to address student deficiencies and content roadblocks. Students are given learning objectives and suggested pre-work assignments which cover those learning objectives. Prior to each class session, students are asked to complete a survey and select the most difficult or most unclear pre-work learning objectives. In this way, we seek to reduce the material covered in LGI sessions by focusing on student-identified roadblocks rather than wasting valuable time in class on material students already understand. During the “student directed collaborative dialog”, we employed a team-teaching or co-teaching approach to optimize our ability to cover the topics in our disciplines and to facilitate integration. Previous work on team-teaching has shown to be more effective than independently taught sessions in terms of student performance on summative exams [10]. Therefore, during the “student directed collaborative dialog”, all four faculty representative for microbiology, immunology, pharmacology, and infectious disease were at the front of the classroom to give their perspectives on the roadblock issues raised by the students.

During the 2nd hour of the LGI, we present the students with clinical cases that synthesize the daily topics from the four disciplines. These interdisciplinary cases build upon the learning objectives in the 1st hour’s discussion as well as highlight how the basic science and clinical disciplines intersect (Fig. 3). The cases in the 2nd hour are presented using either PowerPoint or kuraCloud™ as a delivery platform. The PowerPoint format, known as “rapid-fire cases”, are collections of brief clinical cases that progressively reveal the patient’s story to the students together as a group. The rapid-fire cases are interspersed with questions and instructor-led in-class discussion. By comparison, kuraCloud™ cases are more elaborate and narrowly focused allowing students to work independently to dive deeper into a particular disease state (Fig. 3). Taken together, these case formats help students re-activate prior knowledge and allow faculty to test and build upon their pre-class knowledge framework.

Fig. 3.

Examples of PILLARS and LGI case topics for the “Foundations of Disease” course. For a complete listing, please see the Supplemental Material. Asterisk symbol indicates case topics that were added in the 2017–2018 iteration

The organizational schema of FOD, the learning modalities used, and the ration of self-directed learning to faculty-directed learning is summarized in Fig. 4.

Fig. 4.

Instructional design of the “Foundations of Disease” course. Learning activities were specifically developed to foster self-directed learning, knowledge retrieval, and application while minimizing faculty directed “lecturing”

Course Integration and Rationale

The organizational backbone of the Foundations of Disease course are the classes of microorganisms (i.e., Gram-positive bacteria in week 1, Gram-negative bacteria in week 2, viruses in week 3, etc) (Supplemental Figs. 1 and 2). Exemplars for each class of microorganisms were chosen based on how prevalent or serious the infection is in clinical medicine and LGI and PILLARS cases were developed accordingly. The integration of the basic science disciplines occurs within the cases. Indeed, when developing our cases, we carefully selected topics that highlighted medically significant microorganisms, as well as important basic science material from immunology and pharmacology (Supplemental Figs. 1 and 2). Complementary microbiology, pharmacology, and immunology content was aligned as to underscore the connections between these disciplines in a clinical context. However, the PILLARS and LGI cases were not solely limited to infectious disease but also included immunological diseases and pharmacologic complications. For example, we developed PILLARS cases dedicated to drug-drug interactions (ex: interactions between warfarin and antibiotics), idiosyncratic drug reactions (Stevens-Johnson syndrome), hypersensitivity (anaphylaxis), transplantation, and autoimmunity (rheumatoid arthritis) (Fig. 3). In general, pharmacology played a supporting role, but we encouraged students to consider how the administration of antimicrobials could alter the patient’s immune response to the infection and vice versa.

As noted, these cases were presented in a progressively evolving manner with immediate feedback in the form of science-based causal explanations as articulated by Kulasegaram and colleagues [15]. This was done to increase knowledge retention (in tandem with retrieval practice questions embedded in our weekly quizzes, as discussed below). For the in-class LGI cases, all three basic science instructors (and in the 2017–2018 iteration of the course, the infectious disease clinicians) co-led the case presentation to the class. In this way, students were presented with a multidisciplinary view of the disease state couched in a basic science explanation. Beyond curricular considerations, we also carefully mapped the topics of PILLARS and LGI cases against Austin Texas Public Health Critical Health Indicators which highlights the major adverse health conditions affecting residents at both the city and state level. This list includes a number of infectious and immunologic diseases including HIV, TB, diabetes and diabetic complications, Hepatitis C, and immunizations. This approach aimed to prime our students for the clinical reality that they would encounter in their second year as they move into the required clerkships.

A significant amount of time was spent on condensing, integrating, and re-allocating material for each of the four disciplines. Much of the integration in the FOD course was as noted, in our cases. Both PILLARS and LGI cases were intentionally developed to, as seamlessly as possible, weave together the different disciplines. In this way we sought to integrate at the multidisciplinary and interdisciplinary levels along the continuum of integration articulated by Goldman and colleagues. [16]. For example, we developed a group A streptococcal/acute rheumatic fever case to provide an exemplar of a Gram-positive organism, together with cell walls synthesis inhibitors (β-lactams), antibody-mediated autoimmunity, antigen recognition, and antibody cross reactivity. In some cases, integration proved difficult. For example, some immunology topics did not involve infectious or pharmacological content, and these topics were allocated dedicated time to ensure proper coverage. These topics included: autoimmune diseases, immunodeficiencies, hypersensitivity reactions, transplantation, lymphoid malignancies, and tumor immunology.

Formative and Summative Assessment

Formative assessments were conducted on a weekly basis as quizzes using the online platform, Firecracker™. In each weekly quiz, students answered 25–30 USMLE Step 1-style multiple choice questions which were taken from both the PILLARS and LGI learning objectives for that week. These quizzes also incorporated an additional 5–7 retrieval practice questions to enhance learning and long-term retention and integrate material. Indeed, retrieval practice, also known as test-enhanced learning, has been shown to influence students’ self-regulated learning ability following completion of an assessment [17–19]. To this end, multiple choice items that integrate microbiology, antimicrobial pharmacology, and immunology were administered formatively in spaced manner across the FOD course as well as the subsequent course, Mechanisms of Disease (MOD), and the entire second year (during clinical rotations). In MOD, retrieval practice questions covering material first presented in FOD were aligned with specific organs systems (i.e., questions on pneumonia are included on quizzes during the pulmonary block) and with the clinical rotation in the second year (i.e., questions on nosocomial infections are included on quizzes during the surgery rotation). This strategy helped to strengthen students’ retention of the core concepts in microbiology, pharmacology, and immunology as they progress towards the USMLE Step 1 at the end of their clinical rotations (Data not shown).

Students’ grades in FOD were determined by their performance in PILLARS and their score on a single summative, 100 multiple choice-item exam. PILLARS performance was evaluated on a three-scale subjective assessment conducted by their PILLARS facilitator. The summative exam questions were drawn in equal fashion from each of the participating disciplines based on learning objectives for pre-class activities, in-class activities, and PILLARS cases. Most of the exam was comprised of integrated clinical vignette style items designed to simulate conditions on the USMLE Step 1 exam. As the course is pass/fail, students needed to score at least a 70% on the exam together with a passing score on their summative PILLARS assessment to pass the course.

Course Evolution over the First 2 Years

2016–2017

For the inaugural 2016–2017 cohort, FOD ran for a total of 6 weeks: 5 weeks and 1 day of instruction and a 4-day study period in advance of the summative exam (Supplemental Fig. 1). Week 1 LGIs were devoted to three independent introductory sessions for microbiology, pharmacology, and immunology. For example, in the “Intro to Pharmacology” session, topics such as minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC), concentration-independent and -dependent killing, and general adverse effects are introduced. For immunology, the introductory sessions give an overview of the immune system including immune cell development and function, comparison of the innate and adaptive branches of immunity, and inflammation. For microbiology, the focus in the first week is on basic microbial taxonomy, Gram staining, structural components of bacteria, bacterial genetics, and classification of viruses, endotoxins, and exotoxins. As described below, for LGI session in weeks 2–4, the three basic science disciplines were completely integrated. PILLARS cases in the first week covered cellulitis and a patient with a diabetic foot ulcer.

Week 2 LGI sessions focused on Gram-positive and Gram-negative bacteria, bacteria with unusual cell envelopes, cell wall/protein/DNA synthesis inhibitors, antigen recognition by B/T cells, antigen presentation by MHC, and immunoassays. Integrated cases during LGI sessions included group A Streptococcus infection and post-streptococcal acute rheumatic fever, Neisseria gonorrhoeae and Chlamydia trachomatis co-infection, Mycoplasma pneumoniae, and Mycobacterium tuberculosis cases. PILLARS cases in the second week included Pneumococcal pneumonia and Clostridium difficile infection.

Week 3 LGI session covered acute and chronic viral infections, antiviral drugs, pathogenic fungi and antifungal drugs, adaptive immunity, immunoprophylaxis, B and T cell development, antibody and TCR diversity, tolerance, and immunodeficiency. Integrated LGI cases covered influenza, hepatitis C infection, Coccidioides immitis infection, X-linked agammaglobulinemia, and opportunistic Candida infection in a patient with APECED. PILLARS cases included hepatitis B infection in a liver transplant patient and anaphylaxis.

Week 4 LGI sessions were devoted to helminths and protozoan infections, antihelmintics and antiprotozoal drugs, immune response to parasites, immunoregulation, cancer immunotherapy, tumor immunology, lymphoid malignancies, immunosuppressants and NSAIDS, hypersensitivity reactions, transplantation, and GVHD. Integrated LGI cases included malaria, Hodgkin’s lymphoma, tumor immunology and immunotherapies, rheumatoid arthritis, kidney transplantation, blood typing, transfusion reactions, and hemolytic disease of the newborn. PILLARS cases for the fourth week covered drug-drug interactions and Stephens-Johnson syndrome.

Week 5 was entirely devoted to clinical infectious disease. LGI session topics included vector-borne infections, zoonoses, endemic and opportunistic mycoses, neutropenic fever, travel-related infections, skin and soft tissue infections, osteomyelitis, HHV infections, sepsis, mycobacterial infections, urinary tract infections, sexually transmitted infections, and CNS infections. LGI mini cases covered opportunistic mycoses, neutropenic fever, Rocky Mountain spotted fever, Lyme disease, babesiosis, sepsis, HSV-2 infection, ecthyma gangrenosum, shingles, osteomyelitis, CMV retinitis, TB, urinary tract infection, syphilis, and bacterial and viral meningitis. Fifth week PILLARS cases included endocarditis and HIV/syphilis co-infection. A single LGI session in week 6, which covered the coagulation cascade and anticoagulants, served as a transition to the subsequent course, Mechanisms of Disease. There were no PILLARS cases in week 6, as it was largely a study week leading up to the summative exam.

2017–2018

Several changes were made to the second iteration of FOD (2017–2018) based on course evaluations, feedback from our student focus group, PILLARS facilitators, and kuraCloud™ performance. First, the course was extended to 7 weeks in length: 6 weeks and 1 day of instruction with a 4-day study period in advance of the summative exam (Supplemental Fig. 2). This allowed for a decompression of course material (for example, Gram-positive bacteria were covered in a single day in 2016–2017, while they were given an entire week in 2017–2018). Second, infectious disease topics were no longer contained within a stand-alone week, but were interspersed throughout the entire course. Infectious disease content was introduced in the first week of the course by an infectious disease physician. This session introduced concepts including causal reasons behind infectious disease, the value and interpretation of epidemiological data, modes of infectious transmission, vectors, reservoirs, incubation, virulence, and infectivity. This reorganization not only resulted in the full integration of all four disciplines throughout the FOD course, but also eliminated some content redundancies, thereby making room for new content, as described below. While the majority of the FOD content was unchanged from the 2016–2017 to 2017–2018 iterations, there was a reorganization of both the LGI session topics and PILLARS cases (Supplemental Figs. 1 and 2). These two modifications substantially decompressed course content and reduced student’s overall cognitive load.

Following the completion of the first iteration, we identified content areas that were overlooked and topics were added to remedy these oversights. First, to increase the presence of pediatric and rheumatologic content within the course, two additional PILLARS cases were added: childhood viral infections/Kawasaki disease and rheumatoid arthritis. Additionally, with the 2017–2018 cohort, several overarching curricular themes were initiated which are carried throughout the MS1 curriculum. This involved the addition of two additional LGI cases. The first is a Longitudinal Diabetes Case, which follows a family of Austin residents and their experiences with diabetes and its complications across the entire MS1 curriculum. The FOD component of this longitudinal case focused on osteomyelitis in a patient with latent autoimmune diabetes of adults. The second was a Multidisciplinary Case, which highlighted the transdisciplinary nature of patient care with certain chronic illnesses. The FOD Multidisciplinary Case presented the role of primary care physicians, neurologists, and physical therapists in the care of patients with multiple sclerosis. Both the Longitudinal Diabetes Case and the Multidisciplinary Case continued the integrated and interdisciplinary nature of the FOD course as all were co-presented by the FOD basic science and clinical instructors, visiting physicians, and patients. These cases further enriched the content of FOD and the MS1 curriculum as a whole by providing additional opportunities for integration between basic science and clinicians.

Discussion

We have integrated microbiology, antimicrobial pharmacology, immunology, and infectious disease in a 6-week course for first-year medical students at the recently established Dell Medical School. The structure and teaching modalities used in this course were chosen to address unique curricular challenges. The first and most daunting curricular challenge is the accelerated nature of the first-year program. Teaching a traditional medical microbiology, pharmacology, immunology, and infectious disease curriculum in 6 weeks with 12 h per week of instruction time is impossible; therefore, our aim was to provide a solid foundation on which later coursework and clinical rotations could build upon. To achieve this goal, and illustrate key concepts and classes of microbes and infectious diseases, exemplars were carefully chosen which showcased clinically relevant, high-yield topics (Supplemental Figs. 1 and 2).

The second curricular challenge was the lack of subject matter experience among our students. Although students enter the FOD course with a strong basic science background having completed first semester coursework in cellular and molecular biology, genetics, population health, medical neuroscience, anatomy, and physiology, most students have extremely limited prior knowledge of FOD course content. Indeed, only 39.2% of DMS students (42.0% 2016–2017, 36.2% 2017–2018) have taken a microbiology and/or immunology course prior to matriculating. With the large cognitive load generated by the condensed FOD course, having a background in at least one of the disciplines covered in the course would alleviate some stress for the students.

A key component of the FOD course design is the intentional division of basic science content into two parts: that which students learn on their own (PILLARS, pre-reading, videos, podcasts, interactive worksheets) and that which students discuss with others (faculty and other students) in-class. Indeed, the abbreviated nature of the course schedule also posed a significant issue with pre-work. While there are many excellent resources available to DMS students, even the pithiest are often too long for a course of this length. Concise texts that not only target the precise course content and appropriate depth of knowledge, but also meet DMS’s goal of providing the students with freely available online resources, do not exist commercially. Therefore, to address this need, we devoted an extensive amount of time and effort developing podcasts, online learning modules, videos, and tailored pre-reading to decrease extraneous cognitive load that can be encountered with exhaustive text-books. Furthermore, students independently sought out test prep resources, such as Sketchy Micro™, during their studies. These types of test prep tools are met with skepticism by faculty due to the fact that they have not undergone peer review or extensive vetting by medical school faculty. Nevertheless, students purchase a large number of 3rd party USLME Step 1 resources for use in class, long before they actually sit for the Step 1. Ultimately, it is the assessment and the types of items used that appears to dictate what resources students use and how they use them. Successful performance on summative exams, with vignette style questions that ask students to synthesize and connect multiple disciplines with disease pathology and treatment, is likely driven by exposure to material from multiple resources rather than one “high-yield” resource. Resources like “Sketchy™” appear to be fine review tools but their long-term utility as primary learning resources remains to be determined and further, carefully controlled study is needed.

Because of limited in-class time, we developed strategies to pinpoint what material needed to be covered in class. Rather than guessing or having faculty predict what students should be taught in class, we asked students to tell us what pre-class learning objectives were the most difficult or most unclear by means of a pre-class survey. Thus, we dedicated a significant component of our course to self-directed learning (SDL) [20, 21]. A variety of methods have been developed and reported to facilitate SDL including the use of pre-class “self-learning modules” (SLMs) [11]. Here they looked at both student performance and student perceptions of SLMs which are defined as “self-contained instructional tools that guide the learner through a step-by-step process in achieving educational objectives”. Khalil and colleagues found that SLMs improved both student performance on high-stake exams, and they were received favorably by students who felt that SLMs gave them more control over their own learning. Of key importance is the notion that SLMs or other multimedia teaching modalities may help lower students cognitive load [22]. Indeed, Khalil and others note that “strategies that give learners control while interacting with dynamic visualization help decrease extraneous cognitive load and increase germane cognitive load”, which is thought to be critical to promote optimal long-term memory retention and information retrieval [11, 22, 23]. Assessment tools that incorporate retrieval practice have also been reported to facilitate learner independence by focusing their self-regulated learning on multiple choice items where their performance and self-monitoring were mis-aligned [17]. Thus, in line with published literature, we incorporated a number of SDL activities, as noted above, including videos, podcasts, pre-class kuraCloud™ modules, and embedded retrieval practice items on weekly formative quizzes. Interestingly, a recent meta-analysis revealed that SDL only leads to minimal increases in knowledge [20].

What has emerged from our experiences, and our course and faculty evaluations, is that there is a high level of stress around large amounts of self-directed learning. Students frequently have a hard time parsing what they need to know and do not need to know (and how deep to go into the material). Although the pre-class survey appeared to address this issue early on in the course, many students fell behind in their pre-class work and participation in the pre-class survey waned. To address this issue, in subsequent iterations of the course, we will be incorporating more faculty-directed LGI sessions. As noted, we have also increased the length of the course from the first iteration of 6 weeks to the current iteration of 7 weeks. This has allowed us to decompress the microbiology and immunology and better integrate the infectious disease faculty (who were previously confined to the last week of the course).

Integrating multiple basic science disciplines in an abbreviated time period is an emerging trend at medical schools across the country. Effectively integrating disciplines in a short-time span requires a careful examination of content and development of clear goals and endpoints. Now that data is beginning to emerge for specific teaching and assessment modalities, more informed judgments can be made on how to best leverage these techniques both inside and outside the classroom. For example, a technique such as the flipped classroom approach (which has been shown to be at least as effective as non-flipped teaching modalities) as well as active classroom activities, optimizes time spent in the classroom applying information rather than hearing it for the first time in a lecture [24]. Using new technologies can also help save time and improve efficiency. As noted, we used kuraCloud™ in the classroom to deliver cases and for pre-work instead of exhaustive amounts of pre-reading. Future studies aimed at assessing the impact of the different teaching modalities (i.e., PILLARS PBL, flipped classroom, rapid-fire cases) and technologies on students’ knowledge retention, knowledge recall, and performance on licensing exams is of paramount importance.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

N.A.

Informed Consent

N.A.