Thinking outside "The Box": Case-based didactics for medical education and the instructional legacy of Dr John M. Graham, Jr.

The increasing demand for advanced genomic services has finally come to the attention of healthcare systems and stakeholders who are now eager to find creative solutions to increase the pool of genomic literate providers. Training in genetics and dysmorphology has historically been conducted as a self-driven practice in pattern recognition, ideally within a formal or informal apprenticeship supervised by a master diagnostician. In recent times, case-based learning, framed by flipped classroom pedagogy have become the preferred teaching methods for complex medical topics such as genetics and genomics. To illuminate this perspective, our article was written in honor of the teaching style and pedagogy of Dr John M. Graham Jr and his lifelong commitment to medical education and mentoring.

Flattening the Learning Curve: A Case-Based Video Orientation for a Subspeciality Residency Rotation.

OBJECTIVE: To determine whether a clinically focused rotation orientation delivered through e-learning videos would be an effective method to improve residents' clinical knowledge and confidence. METHODS: A pre-post study design evaluated for change in knowledge and confidence between a control and intervention group of residents assigned to outpatient pediatric endocrinology rotations at 2 residency programs from July 2017 to March 2019. The intervention group utilized the first morning of the rotation to complete the video curriculum designed to rapidly orient residents to common clinical management tasks in outpatient pediatric endocrinology. RESULTS: A total of 35 of 41 residents (85%) completed the study (control group: 18/19 [95%]; intervention group: 17/22 [77%]). Score increase from pretest to post-test was significantly higher for intervention group compared to control group (+24.7% ± 12.1 vs +5.8% ± 7.9, P < .0001). Confidence increases were significantly higher in the intervention group compared to control group in 3 of 5 topics. Two themes illustrated residents' perspectives of this e-learning curriculum: 1) increase in foundational clinical knowledge and 2) improvement in efficiency of learning and patient care. CONCLUSIONS: This clinically focused rotation orientation delivered through e-learning videos was an effective method to improve residents' clinical knowledge, without reliance on faculty to deliver this orientation throughout the academic year. Further studies should be pursued in various settings.

The Efficiency of Online "Inked" Videos Versus Recorded PowerPoint Lectures on Teaching Pathophysiology to Medical Students in Pre-Clerkship Years: A Pilot Study.

BACKGROUND: As online learning develops an increasingly important role in medical education, new online teaching modalities are arising all the time. One such teaching modality that is gaining popularity among medical students is the "inked" video, a type of animated video that utilizes a virtual blackboard. Student reviews suggest that the dynamic style of the inked video allows it to teach more efficiently than traditional teaching modalities, but currently there is no quantitative evidence to support or guide the use of this teaching modality. HYPOTHESIS: When compared to the traditional recorded PowerPoint lecture, online inked videos teach the same pathophysiology concepts to pre-clerkship medical students in a shorter amount of time. METHOD: A randomized, crossover-design study was conducted with second-year medical students at the David Geffen School of Medicine at University of California, Los Angeles (n = 22). Students were randomized to 2 groups. Each group received 2 lessons on 2 different pathophysiology topics: one via a shorter inked video and the other via a longer recorded PowerPoint lecture. Two sets of dependent variables were used to test modality effects: immediate post-tests scores and delayed retention post-test scores. A perceptions survey was also administered to assess student preferences between the 2 teaching modalities. RESULTS: Students performed similarly on immediate and delayed post-tests for the shorter inked videos and the longer recorded PowerPoint lectures (P > .05). Students reported greater engagement (P < .05) and greater satisfaction with learning (P < .05) with the inked videos than the recorded PowerPoint lectures. CONCLUSIONS: This study, although limited by its small-scale and single-institution design, provides preliminary evidence that online inked videos may be a more efficient and non-inferior alternative to recorded PowerPoint lectures.

Using Modified Team-Based Learning to Teach Antimicrobial Stewardship to Medical Students: One Institution's Approach.

Educational interventions are a critical feature of antimicrobial stewardship programs. Most of these interventions target practicing physicians whose prescribing habits are usually difficult to influence. Consequently, there has been increasing interest in familiarizing early learners with the principles of antimicrobial stewardship. However, there is limited data regarding the utility of active learning interventions, such as team-based learning (TBL), for this purpose. In this article, we report the results of a post-course survey eliciting the opinions of the 168 second year medical students who completed the first implementation of a modified TBL course on antimicrobial stewardship. The course consisted of two 120-min modules, each of which guided participant students through most of the characteristic stages of TBL. The post-course survey was analyzed using qualitative and quantitative methodologies. In general, students found the readiness assurance testing, application activity, and team dynamics of TBL effective and the webcasts, used for pre-class preparation, ineffective. This study offers a first glimpse into the attitudes of pre-clinical medical students toward TBL as a strategy for introducing antimicrobial stewardship. It can serve as a roadmap for educators contemplating the implementation of a similar program at their institution and as a launching pad for research on the effects of this type of intervention on physician prescribing habits.

Implementation of a flipped classroom approach to promote active learning in the third-year surgery clerkship.

BACKGROUND: Constructivist student-centered instructional models such as the flipped classroom (FC) have been shown to improve learning. METHODS: A FC approach was implemented for the surgery clerkship. Data was collected in phase 1 to evaluate student learning and attitudes. Based on these results, questions for the phase 2 open-ended survey were developed to improve understanding of learner attitudes, and ascertain how well the FC aligns with constructivist principles. RESULTS: There was no significant difference in shelf exam performance between the control and intervention groups. A majority of students agreed that they preferred the FC over lectures, and that their learning improved. Open-ended survey analysis demonstrated that the FC fostered self-directed, active learning, and that the in-class sessions facilitated application of concepts and deeper learning. Areas identified for improvement included better alignment with learning preferences through greater variety of pre-class learning options, improvement of podcast technical quality, and utilization of smaller in-class discussion groups. CONCLUSIONS: Students had a positive perception of the FC. The FC supports self-directed and more active and deeper in-class learning.

Morbidity and mortality as a televideoconference: a randomized prospective evaluation of learning and perceptions.

BACKGROUND: Central morbidity and mortality conferences ensure uniform content and more participants but consume work hours in commuting for programs with multiple teaching hospitals. Internet-based televideoconferencing (TVC) technology has the potential to eliminate commuting and expand participation and retain quality of instruction. STUDY DESIGN: A prospective, randomized pilot study compared a control (home, n = 43) group in a live morbidity and mortality conference with an experimental (remote, n = 35) group exposed to TVC. After the conference, 78 participants (11 faculty, 38 residents, and 29 medical students) completed a survey assessing learning (6 questions) and conference effectiveness and appeal (7 questions). RESULTS: Comparison of pooled scores on the 6 test items showed no difference by home versus remote group (4.9 versus 4.4; p = 0.47) or among faculty, residents, and students (4.5 versus 4.7 versus 4.7; p = 0.89), indicating that learning was not compromised by TVC. Overall perceptions of TVC were similar for home and remote sites (25.5 versus 23.4; p = 0.13); TVC was perceived as slightly less effective as attending a conference in person, but preferable to commuting. Perceptions of TVC grew proportionately more favorable as commuting distances increased. Students had a more positive perception of TVC than did residents, and faculty had the least positive perception (p = 0.048). Participants were comfortable giving a presentation via TVC, but less comfortable asking questions or participating in a discussion. CONCLUSIONS: This is the first study using televideoconferencing for morbidity and mortality. TVC did not hinder overall learning and was preferable to commuting between facilities. TVC can help maximize educational efficiency and opportunities in programs with multiple training sites.

Information-gathering patterns associated with higher rates of diagnostic error.

Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the percentage of incorrect diagnoses in each cluster. A total of 141 2nd year medical students completed a computer case simulation. Each student's information-gathering pattern included the sequence of history, physical examination, and ancillary testing items chosen from a predefined list. We analyzed the patterns using an artificial neural network and compared percentages of incorrect diagnoses among clusters of information-gathering patterns. We input patterns into a 35 x 35 self organizing map. The network trained for 10,000 epochs. The number of students at each neuron formed a surface that was statistically smoothed into clusters. Each student was assigned to one cluster, the cluster that contributed the largest value to the smoothed function at the student's location in the grid. Seven clusters were identified. Percentage of incorrect diagnoses differed significantly among clusters (Range 0-42%, Chi (2) = 13.62, P = .034). Distance of each cluster from the worst performing cluster was used to rank clusters. This rank was compared to rank determined by percentage incorrect. We found a high positive correlation (Spearman Correlation = .893, P = .007). Clusters closest to the worst performing cluster had the highest percentages of incorrect diagnoses. Patterns of information-gathering were distinct and had different rates of diagnostic error.

Demystifying "learning" in clinical rotations: do immersive patient encounters predict achievement on the clinical performance examination (CPX)?

BACKGROUND: Although the Liaison Committee on Medical Education required U.S. medical schools to quantify students' clinical encounters, optimum patient exposure needed to predict performance has been elusive. This study explored the relationship between comprehensive patient encounters logged on personal digital assistants (PDAs) during three medicine clerkships, to performance on a clinical performance examination (CPX). METHOD: PDA log data for 166 medical students were used to identify educationally "rich" patient encounters, where students were assigned full responsibility for patient care. RESULTS: Univariate regression analyses predicting the effect of immersive patient encounters on CPX case scores did not show statistical significance. CONCLUSIONS: Amount of patient exposure defined by the richness of student-patient interaction did not reflect on the CPX performance for six selected cases. Further research should examine qualitatively different learning experiences occurring with patient encounters and a higher volume of exposure to predict outcomes.

Increasing the pool of educational leaders for UCLA.

The dual goals of the faculty Fellowship in Medical Education (MEF) program at the David Geffen School of Medicine at UCLA, established in 1992, are to prepare excellent teachers to serve as clerkship chairs, course chairs, or residency program directors while strengthening their dossiers for promotion based on a scholarly approach to curriculum development, implementation, and evaluation. Fellows are nominated from their departments and must demonstrate a strong interest in assuming educational leadership in their respective specialties. A total of eight fellows are accommodated each year based on interviews with the MEF faculty. The two-year program consists of two seminars and two projects focused on four objectives: to critique teaching and testing practices in medical education in light of current theories of learning; to develop and implement curricula that reflect these theories; to improve personal teaching skills through reflection and feedback; and to design and conduct an educational research or program evaluation study. An analysis of the curricula vitae of faculty members who have completed the fellowship suggest that this program continues to provide educational leaders for the school as originally intended. Of the 71 medical school faculty members who completed the MEF between 1993 and 2004 and have remained at the university, 43 (61%) have assumed new leadership roles in medical education. The evaluation data strongly suggest that the MEF has had a major role since its inception in creating a pool of faculty members with the confidence to manage the tasks of educational planning and implementation.

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.

Self-instructional "virtual pathology" laboratories using web-based technology enhance medical school teaching of pathology.

Second-year medical students have traditionally been taught pulmonary pathophysiology at the University of California-Los Angeles (UCLA) School of Medicine using lectures, discussion groups, and laboratory sessions. Since 1998, the laboratory sessions have been replaced by 4 interactive, self-instructional sessions using web-based technology and case-based instruction. This article addresses nature of transformation that occurred from within the course in response to the infusion of new technologies. The vast majority of the course content has been digitized and incorporated into the website of the Pathophysiology of Disease course. The teaching histological slides have been photographed digitally and organized into "cases" with clinical information, digital images and text, and audio descriptions. The students study the materials from these cases at their own pace in 2 "virtual pathology" laboratory, with a few instructors supervising the on-site sessions. The students discuss additional cases available on the website in 2 other laboratory sessions supervised by a pulmonologist and a pathologist. Marked improvement in student participation and satisfaction was seen with the use of web-based instruction. Attendance at laboratory sessions, where the students had previously been required to bring their own microscopes to study histological slides at their own pace, increased from approximately 30% to 40% of the class in previous years to almost 100%. Satisfaction surveys showed progressive improvement over the past 4 years, as various suggestions were implemented. The value of web-based instruction of pathology at the UCLA School of Medicine is discussed.