Abstract
Background
Vertically integrating anatomy into pathology curricula is beneficial for student-centered learning. This study investigates the effectiveness of this approach on student learning outcomes.
Activity
Learners received a vertically integrated pathology curriculum; their pre- and post-course test data were collected.
Results and Discussion
Two-hundred thirty-two learners participated in the activity. Upon completing the activity, their average post-course performance was significantly better than that of a control group (P < 0.05), with significantly higher scores on solving pathology case problems (P < 0.05), as well as on retaining anatomy concepts (P < 0.05). Vertically integrating anatomy in pathology instruction is an effective educational approach.
Keywords: Pathology, Anatomy, Medical Sciences, Integration, Teaching, Learning, USA
Introduction
The curricula of medical schools in the USA and many other countries have evolved over the years with continuous assessments and reforms [1–5]. One aspect of this evolution has involved the incorporation of the study of pathological conditions into the teaching of basic anatomy [6–8]. Inasmuch as medical education competency can be considered to hinge upon a solid foundation of basic sciences [9], it is generally the study of pathology in medical school curricula that bridges the basic sciences with clinical courses [10, 11]. We sought to determine the effectiveness of integrating anatomy reviews into the teaching of pathology in a formal medical school program.
The curriculum of the School of Naturopathic Medicine at Bastyr University has been horizontally designed in a series of human body systems, according to the principle of a spiral curriculum [12] and using the definitions of horizontal and vertical education discussed in the Association of Medical Education in Europe (AMEE) Guide No. 96 [13]. Year one courses teach normal structures and functions including anatomy, physiology, and histology. The second-year curriculum focuses on abnormal structures and functions and includes pathology, immunology, and infectious diseases. Biochemistry and pharmacology are also taught in the first 2 years. Upon finishing all pre-clinical courses, students are expected to pass NPLEX 1 (Naturopathic Physicians Licensing Examination), and then move forward to their clinical training. Integrating relevant concepts of normal structure and function in their pathology class in spiral learning opportunities prepares them for success on the basic science board exam as well as in their future clinical courses. The aim of this study is to investigate the impact of this approach on student learning outcomes.
This paper reports the data collected from naturopathic doctoral (ND) students for four academic years, and it suggests that vertically integrating relevant anatomy concepts in pathology instruction is efficient. It appears to improve students’ retention of anatomy concepts and to enhance students’ performance on solving pathology case problems. This approach should be applicable to other pathology education in other medical degree programs.
Materials and Methods
Upon completing their first-year medical school education on basic structures and functions of human body systems, ND students were invited to participate in this study in their pathology class. Pathology is one of their major courses scheduled in their second year’s fall, winter, and spring quarters. We provided systemic reviews on anatomy concepts as online study materials in conjunction with relevant pathology learning materials. In the classroom, relevant key concepts of normal structures and functions were summarized and the related disease processes were subsequently discussed. In addition, these students were also invited to revisit gross anatomy laboratory to cross-check concepts of anatomy and pathology by examining prosected cadavers by systems including cardiovascular, respiratory, digestive, renal, reproductive, and nervous systems. Anatomy faculty members and pathology faculty members worked together on examining the cadavers before the students’ visits, providing discussion questions and supervising the students during their visits. Students actively interacted with both anatomy instructors and pathology instructors during the scheduled visits. The gross anatomy laboratory was accessible to all second-year ND students for their additional cadaver examination activities.
The pre-course test and post-course test performances of sixty-two second-year Bastyr ND students who did not receive the vertically integrated pathology teaching during the academic year 2015–2016 were used as a control. The intervention group included two-hundred thirty-two ND students comprising three cohorts of second-year Bastyr ND students who experienced vertically integrated pathology instruction over three academic years from September 2016 to June 2019, and the performance on their pre-course tests and post-course tests was collected as intervention group data. Comprehensive and integrated case-based multiple-choice questions (MCQs) covering both pathology and anatomy concepts were created for this study. For both control and intervention groups, the pre-course tests were implemented during their first in-class quizzes, and the same MCQ set was affixed to their pathology final examination at the end of their spring quarter when they completed their pathology course. As a small incentive, all students were promised two extra points added to their in-class quiz in the fall quarter and to their pathology final examination in the spring quarter by simply completing the entire set of questions for this study. Test performance data were statistically analyzed using Prism software (Version 9.0.0). Data were expressed as mean ± standard deviation (SD) as previously suggested [14, 15], and test score differences were analyzed using t-test. Significant difference was determined at P < 0.05. Qualitative feedback was obtained through official course evaluations administered at the end of each quarter in an anonymous format.
Results
Pathology Competency Assessment
Pre- and post-course tests on pathology questions were administered to both the control group who did not receive vertically integrated pathology instruction, and to the intervention group who participated in pathology instruction vertically integrated with systemic anatomy reviews.
Control group: The pre-course test score was 48.03 ± 8.02; the post-course test score was 67.57 ± 6.19. Figure 1 shows that post-course test performance on pathology competency was significantly higher than that of the pre-test via paired t-test analysis (P < 0.001).
Vertical integration group: The pre-course test score was 47.56 ± 8.42; the post-course test score was 83.20 ± 9.46. Figure 1 demonstrates that the pathology performance on the post-course test was significantly better than that of the pre-course test based on paired t-test analysis (P < 0.001).
Comparison between the post-course test of the vertical integration group and that of the control cohort. Figure 1 shows that the vertical integration group achieved significantly better performance on pathology competency at the end of the course than that of the control group based on unpaired t-test analysis (P < 0.05).
Fig. 1.
Pathology-specific outcomes are significantly increased after 1 year of vertically integrated pathology education. For the control cohort of students who were not exposed to systemic anatomy reviews integrated into their pathology instruction, their post-course performance is significantly higher than that of their pre-course test performance via paired t-test analysis (pre-test mean ± SD = 48.03 ± 8.02; post-test mean ± SD = 67.57 ± 6.19). For the “Vertical Integration” group of learners who were exposed to vertically integrated pathology teaching, their post-course test performance is significantly higher than their pre-course test performance via paired t-test analysis (pre-test mean ± SD = 47.56 ± 8.42; post-test mean ± SD = 83.20 ± 9.46). Moreover, the post-course test performance of students who participated in vertical integration is significantly better than that of the control group based on unpaired t-test analysis. *P < 0.05 indicates significant difference. **P < 0.001 indicates highly significant difference
Anatomy Competency Assessment
Pre- and post-course tests on anatomy-specific questions were administered to the control group, who did not receive vertically integrated pathology instruction, as well as to the group who participated in pathology instruction that was vertically integrated with systemic anatomy reviews.
Control group: The pre-course test score was 49.26 ± 14.78; the post-course test score was 50.0 ± 19.48. Figure 2 shows that there was no significant difference between the pre- and the post-course test performance on anatomy competency (P > 0.05).
Vertical integration group: The pre-course test score was 50.96 ± 19.12; the post-course test score was 61.96 ± 18.79. Paired t-test analysis shows (Fig. 2) that the post-course test performance was significantly better than that of the pre-course test (P < 0.001).
Comparison between the post-course test performance of the vertical integration group and that of the control cohort (Fig. 2) demonstrates that the post-test performance on anatomy concepts of the vertical integration group was significantly higher than that of the control group (P < 0.05).
Fig. 2.
Integrating anatomy in pathology teaching significantly improved learners’ retention of anatomy concepts. No significant difference was identified between the pre-course and post-course test performance on anatomy concepts among control group learners who did not receive integrated pathology instruction in their pathology course, using paired t-test analysis (pre-test mean ± SD = 49.26 ± 14.78; post-test mean ± SD = 50.0 ± 19.48). For participating learners who were provided with systemic anatomy reviews along with their pathology learning, the post-course test performance on anatomy questions is significantly higher than that of pre-course test scores based on paired t-test analysis (pre-test mean ± SD = 50.96 ± 19.12; post-test mean ± SD = 61.96 ± 18.79). In addition, the anatomy performance on post-course tests of the vertical integration group was significantly higher than that of the control group who were not exposed to vertical integration based on unpaired t-test. *P < 0.05 indicates significant difference. **P < 0.001 indicates highly significant difference. Not significant (ns)
Discussion
This study suggests that integrating anatomy theory and cadaveric prosections into pathology teaching is an effective approach. Vertically integrating anatomy instruction into a second-year pathology course not only increased student pathology course learning outcomes, but also enhanced their retention of human anatomy [16]. As discussed earlier, it is important to integrate pathology with other biological disciplines [7, 17]. Our student assessment data spanning four academic years demonstrated that vertical integration served to enhance spiral learning opportunities and enrich student medical school learning experiences. Spiral learning is asserted to exist in our curriculum already; therefore, this new addition enhances that aspect of our curriculum over succeeding years. This approach should be recommended for curriculum committees and educators of medical schools.
The improvement of student performance reported here could be in part due to their exposure to cadaveric pathologies [8], as well as to the known educational advantages of retrieval, spaced practice, elaboration, and concrete examples [18]. The students positively regarded their gross anatomy laboratory experiences as reported previously [8]. Our first-year ND students participate in a 9-month cadaveric dissection laboratory that parallels anatomy theory and a clinical skills course. Learners who participated in this study had the opportunity to revisit gross anatomy laboratory in their second year. Subjective assessment of the experience was very positive. Students reported that revisiting the gross anatomy laboratory provided an opportunity to relate what they learned in years one and two to their future as physicians.
Vertically integrated pathology teaching was implemented by a team of multidisciplinary faculty members from September 2016 to June 2019. Almost all students in these pathology classes participated in this study and their learning outcomes were assessed. Their pre-course and end of course integrated test question responses were collected and graded for the purpose of this study only, and were not part of their course grade. In addition, the questions we used for this study were comprehensive case-based questions; therefore, they were more challenging to the students compared with their regular class examination questions. The authors felt that this decreased any unintended bias of the data based on grade performance. For the control group, the authors used the student cohort from the year before we implemented vertical integration to pathology course; the control and intervention groups were not in the same school year. Despite these limitations, we remain confident about the conclusions drawn from this study.
Conclusions
This study is the first report on systemic evaluation of vertically integrating anatomy into pathology teaching in a medical school curriculum as a multi-year spiral learning opportunity. It suggests that this approach is beneficial to medical students, evidenced by the improved comprehension in both pathology and anatomy among learners. Therefore, it is a valuable approach for medical educators to improve student educational outcomes.
Acknowledgements
The authors would like to thank the Faculty Development mini-grant program at Bastyr University. We also thank Dr. Xizhang Sun at the University of Washington for statistical advice.
Abbreviations
- ND
Naturopathic doctor
- NPLEX
Naturopathic Physicians Licensing Examination
- MCQ
Multiple choice questions
- SD
Standard deviation
Declarations
Ethical Approval
Ethics of this study has been reviewed by the chair of Bastyr University Institutional Review Board (IRB 16–1651) and was found to be exempt from IRB review as it meets the exemption criterion listed under 45 CFR 46.101(b)(2).
Informed Consent
Informed consent was sought from all participants.
Conflict of Interest
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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