Novel Education Modules Addressing the Underrepresentation of Skin of Color in Dermatology Training.

BACKGROUND: Representative images of pathology in patients with skin of color are lacking in most medical education resources. This particularly affects training in dermatology, which relies heavily on the use of images to teach pattern recognition. The presentation of skin pathology can vary greatly among different skin tones, and this lack of representation of dark skin phototypes challenges providers' abilities to provide quality care to patients of color.In Botswana and other countries in sub-Saharan Africa, this challenge is further compounded by limited resources and access to dermatologists. There is a need for improved and accessible educational resources to train medical students and local medical providers in basic skin lesion description and diagnosis. OBJECTIVES: We examined whether online Perceptual and Adaptive Learning Modules (PALMs) composed of representative dark skin images could efficiently train University of Botswana medical students to more accurately describe and diagnose common skin conditions in their community. METHODS: Year 4 and 5 medical students voluntarily completed PALMs that teach skin morphology, configuration, and distribution terminology and diagnosis of the most common dermatologic conditions in their community. Pre-tests, post-tests and delayed-tests assessed knowledge acquisition and retention. RESULTS: PALMs training produced statistically significant (P < .0001) improvements in accuracy and fluency with large effect sizes (1.5, 3.7) and good retention after a 12.5-21-week median delay. Limitations were a self-selected group of students, a single institution, slow internet connections, and high drop-out rates. CONCLUSIONS: Overall, population-specific PALMs are a useful tool for efficient development of pattern recognition in skin disease description and diagnosis.

Accelerating expertise: Perceptual and adaptive learning technology in medical learning.

RATIONALE: Recent advances in the learning sciences offer remarkable potential for improving medical learning and performance. Difficult to teach pattern recognition skills can be systematically accelerated using techniques of perceptual learning (PL). The effectiveness of PL interventions is amplified when they are combined with adaptive learning (AL) technology in perceptual-adaptive learning modules (PALMs). INNOVATION: Specifically, PALMs incorporate the Adaptive Response Time-based Sequencing (ARTS) system, which leverages learner performance (accuracy and speed) in interactive learning episodes to guide the course of factual, perceptual, or procedural learning, optimize spacing, and lead learners to comprehensive mastery. Here we describe elements and scientific foundations of PL and its embodiment in learning technology. We also consider evidence that AL systems utilizing both accuracy and speed enhance learning efficiency and provide a unified account and potential optimization of spacing effects in learning, as well as supporting accuracy, transfer, and fluency as goals of learning. RESULTS: To illustrate this process, we review some results of earlier PALMs and present new data from a PALM designed to accelerate and improve diagnosis in electrocardiography. CONCLUSIONS: Through relatively short training interventions, PALMs produce large and durable improvements in trainees' abilities to accurately and fluently interpret clinical signs and tests, helping to bridge the gap between novice and expert clinicians.

Training pattern recognition of skin lesion morphology, configuration, and distribution.

BACKGROUND: The ability to reliably recognize and classify a range of skin signs and symptoms remains a necessary skill across most clinical disciplines but one that is traditionally mastered via nonsystematic experience over long periods. OBJECTIVE: We investigated whether online Perceptual and Adaptive Learning Modules (PALMs) could efficiently train preclerkship medical students to identify and discriminate primary skin lesion morphologies, configurations, and anatomic distributions. METHODS: Medical students completed an online skin lesion morphology PALM voluntarily in year 1 and by requirement, along with configuration and anatomic distribution PALMs, in year 2. In controlled before-and-after studies, multiple-choice pretests and posttests using previously unused images, assessed PALM-induced learning. In prospective cohort studies, differences in year-2 performance between students who had and had not completed the morphology PALM in year 1 were also assessed. RESULTS: Multiple-choice tests, used to evaluate PALM effectiveness, demonstrated large (effect sizes of 1.1 [±0.1 SE] to 2.2 [±0.1 SE]) and statistically significant (P < .0001) improvements after PALM training, with learning retention when tested after 1 year. LIMITATIONS: Results are from self-selected groups and a single class at 1 institution. CONCLUSION: PALMs are a useful tool for efficient development of the core clinical skills of pattern recognition and classification of skin lesion characteristics.

Training visual pattern recognition in ophthalmology using a perceptual and adaptive learning module.

OBJECTIVE: To evaluate the efficacy of a perceptual and adaptive learning module (PALM) for teaching the identification of 5 optic nerve findings. METHODS: Second- through fourth-year medical students were randomized to the PALM or a video didactic lecture. The PALM presented the learner with short classification tasks consisting of optic nerve images. Learner accuracy and response time guided the sequencing of successive tasks until mastery was achieved. The lecture was a narrated video designed to simulate a portion of a traditional medical school lecture. Accuracy and fluency on a pretest, post-test, and 1-month delayed test were compared within and between groups. RESULTS: Eighty-three students participated. Accuracy and fluency improved significantly (p < 0.001) from pretest to post-test for both the PALM (accuracy, Cohen's d = 2.94; fluency, d = 3.39) and the lecture (accuracy, d = 2.32; fluency, d = 1.06). For the delayed test, PALM performance remained significantly greater (p < 0.001) than the pretest in both accuracy (d = 0.89) and fluency (d = 1.16), whereas lecture performance remained greater in accuracy only (d = 0.44; p = 0.02). CONCLUSIONS: The PALM facilitated visual pattern recognition for optic nerve diseases among novice learners using a single brief self-guided session. The PALM may be applied alongside traditional didactic lectures to expedite visual pattern recognition in ophthalmology.

Connecting Adaptive Perceptual Learning and Signal Detection Theory in Skin Cancer Screening.

Combining perceptual learning techniques with adaptive learning algorithms has been shown to accelerate the development of expertise in medical and STEM learning domains (Kellman & Massey, 2013; Kellman, Jacoby, Massey & Krasne, 2022). Virtually all adaptive learning systems have relied on simple accuracy data that does not take into account response bias, a problem that may be especially consequential in multi-category perceptual classifications. We investigated whether adaptive perceptual learning in skin cancer screening can be enhanced by incorporating signal detection theory (SDT) methods that separate sensitivity from criterion. SDT-style concepts were used to alter sequencing, and separately to define mastery (category retirement). SDT retirement used a running d' estimate calculated from a recent window of trials based on hit and false alarm rates. Undergraduate participants used a Skin Cancer PALM (perceptual adaptive learning module) to learn classification of 10 cancerous and readily-confused non-cancerous skin lesion types. Four adaptive conditions varied either the type of adaptive sequencing (standard vs. SDT) or retirement criteria (standard vs. SDT). A non-adaptive control condition presented didactic instruction on dermatologic screening in video form, including images, classification schemes, and detailed explanations. All adaptive conditions robustly outperformed the non-adaptive control in both learning efficiency and fluency (large effect sizes). Between adaptive conditions, SDT retirement criteria produced greater learning efficiency than standard, accuracy-based mastery criteria at both immediate and delayed posttests (medium effect sizes). SDT sequencing and standard adaptive sequencing did not differ. SDT enhancements to adaptive perceptual learning procedures have potential to enhance learning efficiency.

Multiple expressions of "expert" abnormality gist in novices following perceptual learning.

With a brief half-second presentation, a medical expert can determine at above chance levels whether a medical scan she sees is abnormal based on a first impression arising from an initial global image process, termed "gist." The nature of gist processing is debated but this debate stems from results in medical experts who have years of perceptual experience. The aim of the present study was to determine if gist processing for medical images occurs in naïve (non-medically trained) participants who received a brief perceptual training and to tease apart the nature of that gist signal. We trained 20 naïve participants on a brief perceptual-adaptive training of histology images. After training, naïve observers were able to obtain abnormality detection and abnormality categorization above chance, from a brief 500 ms masked presentation of a histology image, hence showing "gist." The global signal demonstrated in perceptually trained naïve participants demonstrated multiple dissociable components, with some of these components relating to how rapidly naïve participants learned a normal template during perceptual learning. We suggest that multiple gist signals are present when experts view medical images derived from the tens of thousands of images that they are exposed to throughout their training and careers. We also suggest that a directed learning of a normal template may produce better abnormality detection and identification in radiologists and pathologists.

Mastering Electrocardiogram Interpretation Skills Through a Perceptual and Adaptive Learning Module.

Although accurate interpretation of the standard 12-lead electrocardiogram (ECG) is fundamental to diagnosing heart disease, several prior studies report low accuracy rates among medical students, residents, and practicing physicians. The objective of this study was to determine if an online ECG Perceptual and Adaptive Learning Module (ECG PALM) is an efficient instrument to teach ECG interpretation. The ECG PALM consists of 415 unique ECG tracings with associated pretest, posttest, and delayed tests, each using 30 additional ECGs to gauge the effectiveness and durability of training. Between 2013 and 2015, a total of 113 third-year and 156 fourth-year medical students and 34 first-year, 41 second-year, and 37 third-year emergency medicine residents completed the PALM and associated tests. We measured two mastery criteria: accuracy, the percentage of correct interpretations, and fluency, the percentage of images interpreted accurately within 15 seconds. The ECG PALM produced statistically significant improvements (0.0001 < p < 0.0045) in student and resident performance for both accuracy (effect size = 0.9 to 3.2) and fluency (effect size = 2.5 to 3.1) following training ranging from 46 ± 24 minutes (R3s) to 88 ± 32 minutes (third-year medical students). Medical students and residents performed significantly better on a test the year following training (delayed test) than those without prior ECG PALM training (pretest). The fluency of R3 residents in classifying the 15 diagnostic categories was less than 60% for nine of the 15 diagnoses and greater than 80% for only one. Following PALM training, fluency was higher than 80% for seven of the 15 categories and less than 60% for only two categories. Accuracy in recognizing ST-elevation myocardial infarctions (STEMIs) was high both before and after PALM training for R3s, but fluency was only 64% for anterior STEMIs on the pretest, increasing to 93% following PALM training. These observations suggest that the ECG PALM is an effective and durable supplemental tool for developing mastery in interpreting common ECG abnormalities.

No content without context: integrating basic, clinical, and social sciences in a pre-clerkship curriculum.

BACKGROUND: The basic science curricula in medical schools ultimately succeed or fail at the bedside when students must draw on their pre-clerkship experiences as they learn to form nuanced clinical decisions. Given this expectation, learning context becomes as decisive as content in determining students' recall and application. AIMS: Using the pre-clerkship medical curriculum at the University of California, Los Angeles, as an example, we illustrate how traditional biomedical sciences can be integrated with clinical sciences in a comprehensive foundational curriculum following curricular design features and teaching methods based on learning principles from cognitive psychology and education. METHODS: Multiple planning teams of faculty and students collaborated in the design of the Human Biology and Disease (HB&D) curriculum. Broad participation, careful selection of course chairs, the assistance of educational consultants, ongoing oversight structures, and faculty development were used to develop and sustain the curriculum. RESULTS: The resulting HB&D curriculum features an interdisciplinary spiral block structure including interactive lecture formats, integrative formative and summative examinations, self- and peer-taught laboratories, and problem-based learning with innovative variations. CONCLUSION: Our fully integrated, spiral, pre-clerkship curriculum built on repeating interdisciplinary blocks and longitudinal threads has yielded encouraging results as well as some specific innovations that other schools or individual teachers may find valuable to adapt for use in their own settings.

Improving medical literature sourcing by first-year medical students in problem-based learning: outcomes of early interventions.

PURPOSE: To describe and report outcomes of interventions implemented in the preclerkship curriculum at the David Geffen School of Medicine at UCLA to guide students toward use of high-quality information sources and build a foundation for developing fluency in applying primary medical literature to answer clinical questions. METHOD: The authors introduced three phases of change to instruction in literature searching and sourcing for beginning medical students writing learning issue essays: in phase 1 (2003-2006), students were introduced to online resources during orientation week and received a lecture on high-yield literature searching midway through their first curricular block; in phase 2 (2007-2008), the high-yield lecture shifted to orientation week, and a resource matrix and librarian-guided workshop on locating authoritative sources were added; and in phase 3 (2009), peer evaluation and collaboration were implemented. To track changes in sourcing skills, the authors analyzed 3,199 references from 665 essays written by 465 first-year students for two problem-based learning (PBL) cases during the first block of one representative year per phase (2006, 2008, 2009). RESULTS: Over the study period, the authors found significantly increased citations to peer-reviewed journal articles and guidelines and decreased citations to general public Web sites and highly abstracted resources. Peer feedback and collaboration in phase 3 were associated with maintenance of these gains. CONCLUSIONS: Early introduction of instruction on medical literature searching and sourcing, a librarian-guided workshop, and peer collaboration and feedback improved the quality of references cited by students in PBL essays during their first curricular block.

Applying perceptual and adaptive learning techniques for teaching introductory histopathology.

BACKGROUND: Medical students are expected to master the ability to interpret histopathologic images, a difficult and time-consuming process. A major problem is the issue of transferring information learned from one example of a particular pathology to a new example. Recent advances in cognitive science have identified new approaches to address this problem. METHODS: We adapted a new approach for enhancing pattern recognition of basic pathologic processes in skin histopathology images that utilizes perceptual learning techniques, allowing learners to see relevant structure in novel cases along with adaptive learning algorithms that space and sequence different categories (e.g. diagnoses) that appear during a learning session based on each learner's accuracy and response time (RT). We developed a perceptual and adaptive learning module (PALM) that utilized 261 unique images of cell injury, inflammation, neoplasia, or normal histology at low and high magnification. Accuracy and RT were tracked and integrated into a "Score" that reflected students rapid recognition of the pathologies and pre- and post-tests were given to assess the effectiveness. RESULTS: Accuracy, RT and Scores significantly improved from the pre- to post-test with Scores showing much greater improvement than accuracy alone. Delayed post-tests with previously unseen cases, given after 6-7 weeks, showed a decline in accuracy relative to the post-test for 1(st)-year students, but not significantly so for 2(nd)-year students. However, the delayed post-test scores maintained a significant and large improvement relative to those of the pre-test for both 1(st) and 2(nd) year students suggesting good retention of pattern recognition. Student evaluations were very favorable. CONCLUSION: A web-based learning module based on the principles of cognitive science showed an evidence for improved recognition of histopathology patterns by medical students.

Differential effects of two types of formative assessment in predicting performance of first-year medical students.

Formative assessments are systematically designed instructional interventions to assess and provide feedback on students' strengths and weaknesses in the course of teaching and learning. Despite their known benefits to student attitudes and learning, medical school curricula have been slow to integrate such assessments into the curriculum. This study investigates how performance on two different modes of formative assessment relate to each other and to performance on summative assessments in an integrated, medical-school environment. Two types of formative assessment were administered to 146 first-year medical students each week over 8 weeks: a timed, closed-book component to assess factual recall and image recognition, and an un-timed, open-book component to assess higher order reasoning including the ability to identify and access appropriate resources and to integrate and apply knowledge. Analogous summative assessments were administered in the ninth week. Models relating formative and summative assessment performance were tested using Structural Equation Modeling. Two latent variables underlying achievement on formative and summative assessments could be identified; a "formative-assessment factor" and a "summative-assessment factor," with the former predicting the latter. A latent variable underlying achievement on open-book formative assessments was highly predictive of achievement on both open- and closed-book summative assessments, whereas a latent variable underlying closed-book assessments only predicted performance on the closed-book summative assessment. Formative assessments can be used as effective predictive tools of summative performance in medical school. Open-book, un-timed assessments of higher order processes appeared to be better predictors of overall summative performance than closed-book, timed assessments of factual recall and image recognition.