To Infinity and Beyond: Expanding the Scope of Basic Sciences in Meeting Accreditation Standards

Abstract

Interprofessional training, social sciences curricula, service-learning, pre-clerkship integration, and self-directed learning are all cornerstones of medical education and closely align with accreditation elements for most accreditation bodies within health professions education. As a sequel to the Winter 2022 series, the Spring 2022 Webcast Audio Seminar (WAS) of the International Association of Medical Science Educators (IAMSE) continued to examine the evolving roles of basic science educators. From March 3 to March 31, 2022, the five-part webinar series was broadcast live to audiences at academic institutions worldwide; recordings are available on the IAMSE website. This series built a framework through which basic scientists can leverage their content to meet various accreditation standards.

Developing Interprofessional Education Utilizing Current Simulation Approaches

Presenter: Brian Mann, Philadelphia College of Osteopathic Medicine (PCOM), Pennsylvania.

Dr. Mann started the first webinar with defining key terms used in medical simulation: (1) objective structured clinical examination (OSCE) assesses clinical and professional competency or performance by employing a standardized patient or using task trainers; (2) simulation (SIM) is a technique that creates a situation or environment that allows a representation of a real event to practice, evaluate, test, or just understand actions and expected and unexpected behaviors, in a safe environment; (3) simulation activity (SIMA) refers to a set of actions including initiation (pre-briefing), simulation, and debriefing, including assessment; (4) a standardized patient (SP) is a trained actor who simulates an actual patient, including personality traits, body language, emotional and mental state levels, anxiety, and giving limited information; they may provide assessment and verbal feedback to students; (5) high-fidelity simulators (HFS) are mannequins that can mimic high-level human body functions such as heart and lung sounds, blood pressure, urinating, bleeding, and swelling; (6) task trainers (TT) are devices to train for specific skills and procedures, such as starting intravenous therapy, performing cardiopulmonary resuscitation (CPR), suturing, and phlebotomy; and (7) simulation rooms (SR) are set up to manage communication and teamwork skills rather than clinical skills. Dr. Mann emphasized the importance of diversity in simulation education including utilizing actors, mannequins, and task trainers of different skin colors, ethnicities, gender, body types, and ages.

Dr. Mann highlighted simulation activities that could provide valuable teaching experiences for foundational sciences such as anatomy and physiology [1–3], especially when using high-fidelity simulators and task trainer models. He stressed the importance of generating goals and objectives that are specific, simple, and appropriate for the students’ level, and using Bloom’s Taxonomy action verbs emphasizing skills rather than knowledge (e.g., analyze, create). He advised using a backward approach to curriculum design, starting from the school’s educational learning objectives, to course objectives, and then to session objectives. Learning objectives should also address interprofessional education (IPE)-specific competencies required for the particular program by their accrediting body, and the four IPE core competencies by the Interprofessional Education Collaborative (IPEC) [4]: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork. Additionally, schools may choose to address international IPE components, for instance, patient/client/family/community-centered care, collaborative leadership, and interprofessional conflict resolution, as required in Canada by the Accreditation of Interprofessional Health Education (AIPHE) [5].

As an example of a learning theory frequently used in medical simulation, Dr. Mann discussed Kolb’s Experiential Learning Theory [6]. This theory includes a concrete experience (the simulation), reflective observation (debriefing), abstract conceptualization (evaluate each task), and active experimentation (repeated simulation activity approximately three weeks later) [7].

In summary, Dr. Mann stressed the value of using simulation to develop IPE activities, stating that any content or topic can be addressed, from clinical situations to psychological and physiological cases, to foundational sciences. Simulation is most effective when integrated into spaced repetition, small amounts of content at a time, and educators introduce foundational knowledge before application. Major challenges are the different schedules of different programs and schools.

The Construction of a Social Medicine Curriculum

Presenter: Timothy Lahey, Larner College of Medicine, the University of Vermont in Burlington.

In the second webinar, Dr. Lahey stated that physicians need more time and better tools to address social medicine in practice. He reviewed the results of two physician surveys. The first survey estimated that only 24% of physician practices screen for the five major social determinates of health (SDH) [8]. The second survey reported that although family medicine physicians are deeply concerned about diversity, inclusivity, and equity, most have too little time and inadequate staffing to address SDH [9]. Social inequity influences health and health care delivery, but simply knowing that inequities exist is insufficient; educators must do more to highlight their negative impact on patient care. Major organizations like the Association of American Medical Colleges (AAMC) call for enhanced social training during medical education to emphasize the importance of SDH.

According to Dr. Lahey, there are several benefits of a medical school offering a social medicine curriculum. A social medicine curriculum better prepares students for the realities of clinical practice, like the risk of illness, access to care, the likelihood of presentation, quality of care, and access to medications. It empowers students to identify and address health inequities, linking system reform and individual care. It appeals to students who enter medical school with aspirations to make a difference. Current challenges include how educators should best access social medicine competencies, the ideal instructional approach to teach social medicine content, and the long-term outcomes of a social medicine curriculum. He pointed out that the National Board of Medical Examiner (NBME) exams do not test students’ knowledge of health inequalities at real-world levels.

Dr. Lahey was involved in a social justice curriculum design at Dartmouth’s Geisel School of Medicine but left before it was implemented [10]. When he joined the University of Vermont, he found a team of faculty and students already working on a similar curriculum (Social Justice Coalition) [11]. Their institutional strategy was fourfold: (1) integration of social medicine material with foundational science content is better than having the material segregated; (2) rich in active learning (discussions, team-based learning); (3) curricular change to include quality improvement training for student leaders; and (4) complement service-learning is an essential part.

Before the intervention, the school’s social justice curriculum included sessions on ethics, public health, global health, and palliative care. However, a needs assessment of patients, students, faculty, and administration revealed that educators had separated these SDH sessions from the foundational sciences curriculum into discrete courses. Furthermore, it was only informally assessed, did not include critical reflection, had no centralized coordination, and provided no direct clinical integration. In response, the Social Justice Coalition team developed high-level curricular objectives, followed by more specific learning objectives that could be mapped to the existing medical school courses and integrated with other learning objectives [11]. They then strategically identified appropriate courses across the curriculum in which educators could incorporate the social medicine content. The team reached out to course directors to initiate and support this integration. In parallel, students on the Social Justice Coalition team developed the Social Medicine Theme of the Week initiative. This initiative contained strategically located sessions across the curriculum (mostly linked to foundational content) addressing social medicine themes and providing infographics and links to reading material. As a result, the school’s curriculum directly integrated core social medicine content throughout the traditional foundational science curriculum without fundamentally changing the courses. In addition, students created weekly SDH themes and offered regular SDH Rounds during their clinical years.

Dr. Lahey discussed the successes and challenges of this intervention. There were numerous curricular points of attachment, yet only a few deeply engaged faculty champions. The theme of the week initiative was led by students. It was compelling but fragile and required durable centralized oversight and linkages to faculty curricular oversight and competencies. The team noted a hidden curriculum, where the topics, although inspiring, were alienating when presented in a way that pays lip service only.

Lastly, Dr. Lahey stressed that circular evaluation, change, and faculty development drive the curriculum. He presented several examples of lessons learned based on surveys of first-year medical students and social medicine faculty [12]. The survey revealed that most students were aware of the social medicine curriculum, thought the curriculum helped address various topics (race, sex and gender, LGBTQ (lesbian, gay, bisexual, and transgender), poverty, global health, structural violence), and valued the pedagogy of storytelling. In contrast, the faculty were less aware and engaged. Specifically, the faculty asked for more guidance and orientation to the curriculum. He summarized that the team is currently using these data to develop a road map for a more solid and integrated SDH curriculum.

Designing Outreach and Service-Learning Programs to Effectively Meet the Needs of the Community, Faculty, and Medical Students

Presenter: Peter Vollbrecht, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan.

Dr. Vollbrecht opened the third webinar by comparing “outreach” with “service-learning.” Outreach or community service provides services to any population that might not otherwise have access to those services. Outreach opportunities improve the quality of life for community residents or solve particular problems related to their needs. They complement and reinforce the medical student’s educational program. Service-learning (SL) or community-engaged learning is a form of experiential learning where students apply academic knowledge and critical thinking skills to address genuine community needs. SL combines service activities and educational learning objectives to benefit both the recipient and the provider. SL is defined by the Liaison Committee on Medical Education (LCME) Element 6.6: Educational experiences that involve all of the following components: (1) service to the community in activities that respond to community-identified concerns; (2) student preparation; and (3) student reflection on the relationships between their participation in the activity, their medical school curriculum, and their roles as citizens and medical professionals. Both outreach and SL provide a meaningful impact on communities, the academic institution, faculty, and students. Yet, adapting an outreach activity to an SL activity by integrating the experience into the curriculum makes the activity more impactful. For example, one could convert a “meal delivery” outreach into an SL activity by making it part of a nutrition course that includes studying nutritional values, putting together a meal plan appropriate for the targeted community, and reflection and troubleshooting following the event.

Dr. Vollbrecht went on to describe where educators should start when creating an SL program. He explained that open and frequent communications with all stakeholders are crucial. An SL program must identify the needs of the targeted community and determine if the institution and its faculty and students have the resources, time, and skills to support these needs. His guidance for the following stakeholders are: (1) Community: Ask the community what they need, never assume; present ideas but be open to the response and adjust to requests; not establishing needs correctly upfront is the most common reason for failure. (2) Event Participants: Discuss who participates and why each group participates; establish goals for all participants. (3) Medical Students: Integrate the activity appropriately within the curriculum, considering the students’ skills and time; provide preparation and structured reflection opportunities to help students tie back the experience to the course objectives, clearly state what skills students will learn (e.g., soft skills like communication, empathy, understanding, connection to community, and serving, or hard skills like taking vitals, going through insurance bills); educators must ensure that students receive the appropriate course credit. (4) Institution: Purposeful SL activities increase the institution’s reputation for example through educational outreach that offers formal and informal pathways for diverse students, including for underrepresented minorities in science, technology, engineering, and mathematics (STEM). SL activities, alone or combined with a Social Determinates of Health curriculum, meet LCME accreditation standards. (5) Faculty: Time is the first challenge; the budget is the second; other barriers include lack of designated effort, efforts spent not counted towards promotion, and basic scientists who feel they do not have a service they can provide. (6) Educators: Educators conduct scholarly research and publish data by converting an outreach to an SL experience, thus making it count for professional development that the institution values.

Using backward design and evidence-based practices, Dr. Vollbrecht outlined how to create an SL curricular event: (a) define clear and measurable goals; (b) create experiences that achieve these goals for the community, students, participants, institution, and educator; and (c) design appropriate assessment (important for scholarship). He shared his experiences with the project “Brain Explorers” [13, 14]. Initially, he talked with K-12 students about the brain as a community service project. Hence, over the years, he integrated a defined activity into the medical school curriculum as an SL program. Today, the program focuses on providing neuroscience opportunities for K-12 students with a clear mission statement: “Provide exciting, engaging, accessible, and assessable science engagement for underserved and underrepresented populations.” Crucial to the success of this program was communicating with the participants (students and teachers) to ensure interest and purpose in addressing the mission and that the program reaches the underrepresented population. He published his data on population, demographics, open house participation, school visit participants, and impact on students (quantitative and qualitative responses) [13, 14].

Towards Integrated Medical Education: Getting the Best Out of Interdisciplinary Teacher Teams and Leaders

Presenters: Mirjam oude Egbrink and Stephanie Meeuwissen, Maastricht University Medical Centre, The Netherlands.

Dr. Egbrink started the fourth webinar by summarizing the shifting landscape of healthcare: due to increased medical knowledge, technology, and presentation of patients with multiple chronic diseases, today’s healthcare delivery environment requires a higher level of complexity and an increasing need for collaboration between different healthcare professions. The Maastricht University Faculty of Health Medicine and Life Sciences implemented an interdisciplinary, problem-based curriculum for undergraduate students to address this environmental paradigm shift. In contrast to traditional discipline-specific curricula, educators and leadership organized the integrated curriculum by thematic case-based blocks, each four to ten weeks long. Students engage in small-group sessions to stimulate meaningful and deep learning focusing on relevant real-life healthcare-related problems. Each thematic block includes contributions from a series of disciplines. Since these topics include basic, social, and clinical sciences, the educators who develop and organize these individual blocks must have different backgrounds in different disciplines. Maastricht University calls these groups of teachers Planning Groups. Planning Groups consist of three to five faculty from various departments, including a team leader. This involves a complex organization with over 50 departments and over 300 blocks. Dr. Egbrink and her team studied the following four questions: How do interdisciplinary teacher teams function when working on an integrated curriculum? How does their teamwork influence the quality of education? What are important factors influencing team functioning? How can we promote the successful functioning of interdisciplinary teacher teams?

Since teams are complex and prone to conflicts, Dr. Meeuwissen discussed traits essential to a team’s success. These traits depend on the following factors [15]: (1) how members interact with each other; (2) how members build upon each other’s knowledge and experience; (3) how members share information; (4) how members solve conflicts, as constructive conflict management requires an open and respectful environment that leads to the co-construction of content, and it requires negotiating different experiences, perspectives, and knowledge that result in an agreement; and (5) how the members’ individual (personal), team (interpersonal), and organizational knowledge, skills, and attitudes influence team learning, as high-level team learning increases outcomes and innovation.

Dr. Meeuwissen’s team surveyed the faculty participating in the Planning Groups and identified three different team approaches [16]. The first approach was Fragmented Teams (“Hangout”): Team members shared their discipline but did not work with each other’s experience nor build upon each other’s expertise. The second approach was Framework-Guidance Teams (“Distribution Center”): Team members built on each other’s knowledge and stayed outcome-centered. The team leader was in charge of the different perspectives. The third approach was Integrated Teams (“Melting Pot”): Teams worked well together and incorporated members’ knowledge, skills, and attitudes, and the team leader and members together created student-centered education.

Dr. Meeuwissen’s team surveyed the students’ perception of the quality of their education. The integrated teams scored highest in all aspects (organization, structure, learning effects, and cohesion). In contrast, fragmented teams scored lowest in all aspects. Faculty team members confirmed these results since members of integrated teams were most satisfied with their work. These data show that different team approaches produced varying outcomes with an integrated team approach resulting in the highest team learning levels.

Dr. Meeuwissen’s team further identified several personal characteristics and dynamics that influenced the respective team approach [17]: In fragmented teams, personal alignment was dominant, including members’ attributes, tendencies, and motivation. Members did not align with the educational philosophy of integration but instead emphasized discipline-centered education. In framework-guided teams, team leadership was evident. Team leaders and members had a vision, took responsibility, and regularly reflected on their work. In integrated teams, members incorporated organizational processes like decision-making in addition to the attributes mentioned above.

To further explore these findings, Dr. Meeuwissen’s team observed (in-person interactions and written correspondence) and interviewed select team members over one year. They found that the team leader’s inclusive behavior contributed to the success [18]. Inclusiveness included coordinating, explicating, inviting, connecting, and reflecting. The team leaders were on task, knew precisely what was going on, and were mindful of deadlines. They knew the different backgrounds, personalities, capabilities, and emotional states of all team members, gave clear and explicit directions, and made sure each member was heard and contributed to the work equally. In return, team members participated actively, spoke up, and even mimicked the leader’s inclusiveness. These findings indicated a paradigm shift in what contributes to successful health professions’ education leadership, namely from a hierarchical to an inclusive leadership behavior.

As a result, Dr. Meeuwissen’s team developed a faculty development program on leadership identity formation for interdisciplinary teacher team leaders [19]. Because the leader identity development process is an iterative, collaborative, and continuous process that integrates knowledge, broader views on leadership, application, and reflection, they used the method of design-based research, which anchors on theoretical principles: competence-based learning, workplace learning, learning by doing, small-group learning, and tailor-made learning.

Dr. Meeuwissen concluded that leadership is an important asset that determines the culture and structure of the organization. She stated that a leader identity program can convert teachers’ views on leadership, thoughts on education and leadership are essential to changing behavior, all teams are groups but not all groups are teams, and that soft elements of interdisciplinary teams can have hard consequences for education.

Strategies for Incorporating Self-Directed Learning into Basic Sciences Education

Presenters: Samara Ginzburg and Joanne Willey, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York.

In the fifth and final webinar, Dr. Willey began by stating that the literature is full of information on student characteristics and their relationship to self-directed learning (SDL). Yet to their knowledge, there are no studies with information on the understanding of SDL by faculty. They conducted a national survey of medical educators designed to assess faculty needs and faculties’ knowledge of SDL [20, 21]. They had two basic research questions: Do faculty value SDL for medical student education, and are faculty familiar with strategies documented to promote SDL? They found that of the 350 undergraduate medical educators who responded, approximately 95% believed that SDL is essential for medical student success. When asked what, in their opinion, are the outcomes of SDL, the team identified three layers: (1) highest layer: life-long learning values, self-reflection, curiosity, motivation, goal setting, and better equipped to meet challenges; (2) middle layer: better prepared for the classroom and clinical responsibilities, peer teaching, team-based skills; and (3) lowest layer: improving academic performance, communication skills.

Continuing the webinar, Dr. Ginzburg defined SDL as “a construct that embodies the process elements associated with self-regulated learning and the characteristics of the learner and the culture of the learning environment” [22]. The concepts include three separate areas that must complement each other: (1) learner characteristics (motivation, curiosity, resilience); (2) the culture of the learning environment (assessment, resources, values, hidden curriculum); and (3) the self-regulated learning cycle. The cycle encompasses planning, learning, assessing the knowledge to identify gaps, and adjusting behaviors to close these gaps. The latter is intrinsic to the entire SDL process, and although this process is innate to some personalities, most faculty need to learn and practice. She then summarized the definition of SDL by the LCME Element 6.3: Educators need to make sure students know how to self-assess their learning, how to independently analyze, identify, and synthesize the relevant information (learning of the cycle), how to appraise the credibility of resources and ensure that students receive feedback on their information-seeking skills. The LCME requires doing these steps as a unified sequence, meaning altogether as part of the same learning activity. This element has driven many changes in curricula across the country to include SDL.

Dr. Willey reviewed her team’s data from their national survey [20, 21], in which the team created questions for medical educators addressing three SDL strategies: (1) cognitive strategies that make the material more accessible; (2) metacognitive strategies that increase the ability to set goals, self-assess, and adjust; and (3) emotional and motivational strategies that address learner attributes and the culture of the learning environment. The data indicated that faculty were overall familiar with the metacognitive, emotional, and motivational strategies to promote SDL but were less comfortable with cognitive strategies despite having the most control over them as they teach.

To highlight the different question types, Dr. Ginzburg discussed the Grow model of staged SDL from the general education literature [23] where a student is considered to pass through different levels of self-direction. A student starts as a dependent, and becomes interested, then involved, and then self-directed. The student functions on different levels depending on the content; they may be on a higher level in one area but on a lower level in another area. This model changes the role of the instructor from being an authority/coach, to a motivator/guide, to a facilitator, to a consultant/delegator. As students progress through these levels, the faculty should also adjust their roles. Ideally, the instructor matches, or near matches, the level of the student, and a mismatch, or severe mismatch, is undesirable. If an instructor works with a group of students, the instructor should find the overall best level, accepting that there might be a severe mismatch with some students and that one-on-one meetings might be required to best help such students. The faculty’s task is to recognize and meet the learners on their level and take learners step by step from one level to the next.

Lastly, Dr. Willey explained that faculty typically use the same question type during teaching instead of moving between question types on purpose, depending on the students’ levels and environment. The type of questioning drives what happens before, during, and after an SDL session. She illustrated how faculty could convert a recall question into an analysis question, then into a synthesis question, based on work from the Stanford Faculty Development Program, Leland Stanford University (1998). Faculty should also encourage students to rephrase their questions from the first level to higher-level questions to generate discussion and practice scaffolding. Recall questions (what?) probe for basic facts and require prior knowledge or experience. Recall questions do not generate much discussion but engage learners in some form before the session. Analysis and synthesis questions (how?) require learners to demonstrate a more profound understanding, create context into which individual pieces of data fit, and apply deductive reasoning and logic to answer questions. Analysis questions generate reasonable discussions in advance, during, and after the SDL session. Application questions are complex and require integrating different materials but generate robust discussions. Application questions require preparation, highly stimulating discussions, and continue to have an impact after the SDL session.

We wish to thank each of our presenters for their contributions to this series!

Declarations

Ethics Approval

N/A

Informed Consent

N/A

Conflict of Interest

The authors declare no competing interests.