| Abstract|| |
Context: Teaching methods in pathology for undergraduate medical students are not effective. Aims: To document measures that can be adopted by individual teachers that can excite the interest, participation of the students and help them learn pathology in a clinical reasoning context. Settings and Design: Medical students in a large international medical school with class sizes of 700–900 were taught the pathology course in a period of sixteen weeks for two cohorts of students each year over a period of twenty years. Subjects and Methods: Specific learning objectives were devised to achieve higher levels of cognitive domain including interpretation, analysis and problem solving of clinical data of patients related to the objectives. The teaching sessions were modified to provide for maximum active participation by students with effective feedback at multiple points. Additional learning tools like concept maps, clickers, modified essay questions, flipped classrooms, clinicopathological conferences, directed self-learning activities were included. Learning objectives and assessment tools for professional behavior and communication skills were included. Results: The students actively participated in all the learning activities with enthusiasm and achieved the objectives as reflected in the performance in the in-house examinations and the USMLE step one examination which tests clinical vignette-based problem-solving principles of which around 70% are related to pathology. Conclusions: The teaching sessions in pathology were useful and effective with adaptation to interactive, clinical reasoning platforms for teaching and assessment.
Keywords: Clinical reasoning, clinicopathological conference, concept maps, curriculum, flipped classroom, learning objectives, medical education, modified essay questions, personal response system, teaching methods
|How to cite this article:|
Bhusnurmath SR, Bhusnurmath BS, Goyal SB. Helping medical students to learn pathology more effectively. Indian J Pathol Microbiol 2021;64:746-51
| Introduction|| |
A pathology teacher in a medical college can create a lot of interest in the subject in the minds of the medical student based on the approach to the teaching methods. This article documents several strategies the authors have evolved to make the learning of pathology more effective.
| Subjects and Methods|| |
We defined detailed learning objectives for each lecture and small group session. This included not just the topic (content) but an action verb that pushed the student to attain a higher level of learning required for clinical reasoning such as, analyze, interpret, distinguish, compare, and contrast. We included clinical correlations in the objectives as far as possible. All the learning objectives were linked to the outcome objectives of the medical school program.
Teaching sessions included lectures and small groups. The lectures started with question that helped students recapitulate an important objective from the previous lecture or from one of the earlier courses like anatomy, biochemistry, or physiology. This was followed by a slide having a clinical vignette related to the main disease to be covered along with a list of questions that needed to be answered. The subsequent slides explained these questions. We interspersed eight to ten clinical vignette-based multiple-choice questions (MCQ) amidst the lecture slides. The students responded by clicking the responses using the Turning point technologies app. The results were instantly displayed on the screen as a Venn diagram or a bar diagram. The lecturer clarified any misconceptions of the class on the topic instantly. The learning objectives and the lecture power points were made available to the students in advance. The lecture recording was also made available immediately after the lecture.
Some of the lectures were converted into a flipped classroom session. The lecture material was provided in advance to the students. They were instructed to come prepared to discuss the topic in the subsequent session. We arbitrarily divided the students in groups of 10–15 and gave a unique case scenario to each group. The groups got about ten minutes to discuss the case scenario given to their group. At the end of 10 min the lecturer projected the case for the first group with the questions to the whole class. Someone from the group volunteered to answer the questions. When the group response was concluded, the lecturer asked the rest of the class for any comments. Other cases followed similarly. We called these as modified team-based learning sessions in the flipped lecture setting.
At the end of each module or system, the last lecture included a review session that included about 20 clinical vignette-based MCQs that comprehensively reviewed the main learning objectives These sessions were called IMCQ sessions—integrated multiple-choice questions session.
Some of the topics meant for lectures were provided to the students to study on their own—directed learning activity (DLA).
The small group activity consisted of students working on previously unseen images related to the learning objectives. The digital images included gross pathology specimens, a few histopathology images, imaging studies, clinical photographs, blood and bone marrow smears, laboratory data of a patient with clinical features mentioned or concept maps that had gaps which the students were expected to discuss and complete. The students were provided a rubric to complete individually for each image [Table 1] and share with the group. The images were provided a few days prior to each session online. During the session, the students discussed their rubric in the presence of a preceptor who was a clinical tutor.
The rubric allowed them to synthesize the pathology information into a total patient story, recapitulate the related anatomy, physiology, and biochemistry (pathologic basis of clinical medicine).
Some of the small group sessions included analysis of clinical and laboratory data of patients or incomplete concept maps that the group had to complete after discussion.
Other small group sessions included discussions on modified essay questions (MEQ). These were clinical vignettes just like the MCQs with laboratory data included. The student had to come up with an accurate answer in his or her own word or words. For e.g., the data would have information that leads one to conclude that this is a diabetic patient in coma. The student would be asked the cause of coma. He or she had to answer in only one word—hypoglycemic, hyperglycemic non-ketotic, or ketotic.
Patient interviews in the small group sessions: Occasionally patients with chronic diseases relevant to the learning objectives for the week were invited to the session based on their availability. The students would volunteer to take the history. The students would then justify the questions based on their knowledge of pathology.
Concept maps—The students were taught in the second week of the course how to draw a good concept map. Each student had to draw at least once concept map every week and submit to the clinical tutor in the first session the following week. The tutors were trained to critique the concept map and give a feed back to the student.
The students were encouraged to submit the MCQs they had developed on their own to the department and the department would use the good ones with proper edits in the examinations.
Clinicopathological conferences: The students were provided tutored paper cases that included complicated clinical data. The students were directed to individually write up the analysis including various diagnostic possibilities, points in favor or against each of them, how the laboratory tests helped move towards or away from each of them, which results could not be explained, what additional tests would have helped and how and the final diagnostic possibilities in order of preference. These were discussed in small groups.
The small group sessions also had a list of learning objectives related to professional behavior and communication skills. They included items such as, arriving on time, completing assignments on time, showing respect to peers and faculty, being courteous during the discussions, rotating leadership, practicing active listening, disagreeing without being disagreeable, dressing professionally, not monopolizing the discussion, encouraging all the members to participate, helping others to address their difficulties in the topic. The tutor gave a feedback on these objectives at the end of each session.
Clinical tutors: We recruit recent medical graduates from across the globe who are planning to exams like USMLE and PLAB to move on to postgraduate residency programs in the United States or United Kingdom to work with us as preceptors (International clinical tutor teaching fellowship program) for small groups in the teaching lab. They are trained by the department to function as preceptors for small group sessions.
Guidance for students who needed additional help to keep pace with the learning: The professors had designated office hours when students could seek appointments to discuss study strategies. Clinical tutors by rotation were made available in the evenings and weekends in the designated teaching spaces for students to get one on one help in clarifying difficult concepts.
Sample questions: Sample questions were posted weekly based on the learning objectives for the week for the students to study by themselves. They had explanations on why a given choice was correct or incorrect.
Assessment consisted of clinical vignette-based multiple-choice questions linked to the learning objectives. The students had to make a diagnosis based on the clinical data provided and respond to concepts on etiopathogenesis, clinical features, laboratory data, complications, associations, course of the disease, etc. These were used from the item bank we had generated over the years with performance data and exams could be blue printed to expect a mean score of 80%. The passing score was 70%.
The students appeared for two midterm and one final exam which consist of clinical vignette-based MCQs. About 10–12% of the final grade included points for professional behavior in the small groups, concept maps, and participation in the clinicopathological conferences.
| Results|| |
The students performed very well in the clinical problem-solving exam questions with the failure rate being less than 2% over several years. The mean score tended to be around 80%. Students were happy with the interactive pattern of learning which they found relevant to their eventual role as doctors. All the students had to take the USMLE step 1 exam and pass before they could move on to the final 2 years of clinical training in the United States and United Kingdom. The step 1 exam consists of mostly clinical vignette-based problem solving MCQs out of which about 70% are related to pathology. Our pass rate has been varying between 94 and 98% over the years. Most of the students in our school were those who had not succeeded in gaining admission in the United States and Canadian medical colleges because of lower-than-expected scores in the qualifying exams for the medical school entry. Thus, the high pass rate in USMLE is significant.
| Discussion|| |
The teaching of pathology offers a unique opportunity for vertical integration of various basic sciences like anatomy, physiology, biochemistry, microbiology, and apply them to baby steps in clinical medicine using the concepts of pathological changes. One needs to provide a learning platform considered favorable by the students who see the activity as fully relevant to their goal of becoming good doctors. The design of learning platforms and the efforts to reinforce behaviors during the learning process and finally assessing the degree to which targeted outcomes were achieved need careful consideration as described in the Kirkpatrick model. Kern's six-step approach to curriculum development details six main steps including identification of the problem, targeted needs assessment, defining goals and objectives, related knowledge skills and attributes, developing strategies for teaching, implementing the planned strategies an finally evaluation of the process and feed back to refine the curriculum. It has been emphasized that medical education should not be just a check list of learning objectives but concentrate on developing competences—competency-based medical education.,,,, Competence is defined as the characteristics and abilities of doctors to do well. Outcome-based education is of far greater relevance than the one based on learning objectives.,,,,,, Defining incremental steps of achievements called milestones and assessing for their achievement by the students has been considered important in the training of postgraduates in medicine., Competence has indeed been considered of greater value than performance. It was suggested that narratives are more important than check lists. Entrustable professional attributes—EPAs were developed to better define outcomes. Each competence would include several goals and learning objectives. The medical competency-based curriculum that is expected to produce good doctors emphasized seven main competences- being a professional, communicator, collaborator, leader, health advocate, scholar, and a medical expert. The pathology teaching has been identified to include three main competences all of which are related to knowledge component. They include disease mechanisms and processes, organ system pathology, and diagnostic medicine and therapeutic pathology., It has been stressed that case-based designs teaching is important to achieve competencies.,
A US status report in 2016 based on a large survey of 98 medical schools indicated that although 84% had a course in laboratory medicine and 78% required it, the time allotted was insignificant and the students and faculty showed a significant lack of interest in it. This competence is neglected in many institutions.,
The Medical council of India in 2018 outlined 5 competences in its publication on competency-based undergraduate curriculum for the Indian medical graduate. The graduate should possess requisite knowledge, skills, attitudes, values, and responsiveness so that he or she may function appropriately and effectively as a physician of first contact of the community while being globally relevant. The competences listed in the document include- clinician, communicator, team leader and team member, lifelong learner and professional committed to excellence. The teaching methods listed include lectures, small groups, and laboratory practicals. There is no description on how to develop these platforms to achieve the goals and objectives. It is left to the individual institutions and teachers to develop the teaching platforms to achieve these objectives. The pathology competences are listed in detail in the later part of the document. This has a comprehensive list of content or topics but the action verbs in the objectives again mostly include identify, describe, enumerate, discuss. These can be achieved by students without coming to the teaching sessions by studying books or reference material. Most of the students tend to treat pathology as a boring subject that needs to be passed on the way to becoming a doctor. The current teaching practices may not offer anything exciting in the teaching session for the student to participate actively and learn the basis of clinical medicine. They attend to satisfy the attendance requirements. What efforts can an individual teacher undertake to provide a better experience for the students in lectures, small groups and practicals that it makes it attractive for them to participate? There has been documentation on the use of case-based learning and social media platforms like WhatsApp., Some have documented that blended learning within class activities, tend to give better results. Others have tried online testable concept maps, digital games, and peer-assisted learning to generate better learning platforms in lectures and small groups. There is also a suggestion that students playing the role of diagnostic pathologists helps them achieve the objectives better. Another publication suggested the usefulness of students writing multiple choice questions gives them a better learning experience to understand pathology. Flipped classrooms have been proven to be effective but have limitations and shortcomings. There is also documentation that using virtual microscopy gives better value than the students studying with slides under a regular microscope. The images for small group sessions can be provided in a digital format rather than making them study slides under the microscope. Virtual microscopy is a great tool for training postgraduate in pathology but may be not needed for medical students as there is very little in the learning objectives to be gained by it.
We have been able to incorporate many components in providing active learning formats in our teaching sessions. These included, creating learning objectives at higher levels of cognitive domain to emphasize clinical analysis and reasoning, interactive learning platforms in lecture setting including structuring of lectures to make them clinical problem solving, multiple clicker questions in each lecture which require students to think and respond and providing effective feedback, flipped class rooms with modified team based learning, concept maps, modified essay questions (the USMLE has only recently started exploring the possibility of using such test items and calls them free response test items), analysis of previously unseen pathology and clinical images to correlate with patients symptoms, signs and lab investigations, clinicopathological conferences, interviewing actual patients in the lab and providing many sample questions as study guides. Directed learning assignments for relatively easier topics helped us spend more time to deal with more difficult concepts in the actual lecture sessions. The pathology departments in India could use the postgraduate residents in the role of preceptors for small group sessions. It would benefit the residents too to gain additional competences. The assessment tools were created to reflect the higher level of learning for clinical reasoning and the quality of the assessment was maintained using blue printing, item banking, and experimental questions in each offering. The pattern was like the items in USMLE exams which helped the students to do well in those standardized external exams. Modified essay questions can easily be very effectively used to test critical clinical reasoning in case the regulations of the institution do not permit extensive use of MCQs.
Most of these modifications can be implemented by individual teachers with hardly any new resources needed. The only expense incurred was on the equipment for clicker questions. This is now very commonly used even in high schools and should not really be a major burden. One could easily substitute it with almost free apps that can be used on smart phones. Every student has a smart phone now and the free apps could be a great boon for students to respond to questions in the lecture. The small group sessions provided a great opportunity to incorporate learning objectives related to professional behavior and communication skills with positive and negative consequences to make them count. This would be a great contribution towards the overall competencies required of a graduate to function as a community doctor and pushes the pathology platform beyond acquisition of just clinical reasoning.
We do hope that these ideas will provide a nidus for the interested individual pathology educators to modify the learning experiences they are providing to their medical students without requiring any major funding for resources [Table 1].
- Identify (I) the organ or tissue giving reasons (self-recapitulation of anatomy and histology—vertical integration). If there is not enough material in the slide to identify the structure, the teacher provided the information, specifically for histopathology. For example, this is from the liver.
- Describe the morphologic (M) alterations. We encouraged the students to describe in such a way that a person not looking at the slide or a blind person can vividly imagine what it looks like. If it is a gross specimen, the student also indicated what would the histology of the lesion look like. If it is a histopathology slide, the student indicated what would the gross appearance of the lesion be like.
- Diagnosis (D): The students used information from the textbook, lecture notes etc., to reach a diagnosis based on the altered morphology and list the points that favor the diagnosis. Once the diagnosis was made, the subsequent steps moved on to the patient from whom this slide was obtained and towards clinical reasoning.
- Etiology—What is the cause—bacteria, virus, ischemia, mutation (for the pathology) —is it itis (inflammation), emia (ischemia), oma (tumor).
- Pathogenesis (P)—What is the mechanism by which the etiologic agent damaged the tissues (direct toxicity, hypersensitivity, immune mediated etc.)—(recapitulation from microbiology course where relevant).
- Symptoms (S)—what would be the altered functions of the damaged tissue and what symptoms would they lead to, for example, cough, blood in the sputum, difficulty breathing in pneumonia. Each symptom listed should be accompanied by an explanation based on altered morphology and physiology (neuroscience)—vertical integration. We encourage students to limit their write ups to about three of the most common and easily explained symptoms.
- Physical signs (S)—the student must extrapolate the morphologic changes in the slide to explain at least three important physical findings when one examines the patient.
- Investigation (I)—based on the altered morphology the student must review the related biochemistry and physiology (vertical integration) to come up with at least three important lab investigations, justifying the basis on which these would be abnormal. The students were also encouraged to indicate which of tests is done to confirm etiology, diagnosis, severity of the disease, etc.
- Course of the disease (C)—based on the lecture notes and the textbook, the student should indicate which course the patient is likely to take—spontaneous recovery, complete recovery with the appropriate therapy, downhill progress, spontaneous relapses, and recovery, etc. They were also encouraged to mention if there are any important associated lesions in the patient.
- Complications (C)—What were the possible complications, what was their timeframe for development, how does one monitor the patient for such complications.
- Clinical vignette—(V) write a clinical story of the patient including possible age, gender, symptoms, signs, investigations, associations, and complications. This would be a summary from the above observations put as a clinical story.
- Multiple choice question (Q)—Write an MCQ based on the above clinical vignette. The last line would be asking for etiology or pathogenesis or explanations for signs, symptoms, lab investigations, complications, etc.
Note: All the elements of the rubric of IMDEPSSICCVQ (identify, morphologic description, diagnosis, aetiology, pathogenesis, symptoms, signs, investigations, course of the disease, complication) may not be relevant for a given slide but going through the checklist provided a standard method to study the images.
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Shivayogi R Bhusnurmath
Department of Pathology, St George's University School of Medicine, West Indies
Source of Support: None, Conflict of Interest: None