Acad Psychiatry (2014) 38:96–99 DOI 10.1007/s40596-013-0015-5
COLUMN: EDUCATIONAL CASE REPORT
Design and Implementation of a Novel Behavioral Sciences Course for First Year Medical Students Marcia L. Verduin
Published online: 16 January 2014 # Academic Psychiatry 2014
Keywords Medical student education . Behavioral sciences . Course design
In 2004, the Institute of Medicine (IOM) issued a call for medical schools to improve behavioral sciences education [1]. Despite ample evidence supporting the importance of behavioral sciences in clinical practice, many institutions struggle with implementation of effective behavioral sciences curricula. One possibility for this is the significant expansion in content covered in a 4-year curriculum. Increasingly, medical schools are reevaluating their curricula to determine what can be eliminated [2]. Unfortunately, behavioral sciences are often afforded a “lower status” by some faculty [1], while others consider them “nice to know” but not integral [3]. Another possibility is that students dismiss the importance of behavioral sciences, and students' lack of interest and engagement limits the effective integration of these topics into the curricula [4] [5]. Behavioral sciences are traditionally taught in preclinical years, concurrent with other basic sciences [1]. Comparatively, behavioral sciences are often perceived by medical students as “soft science” when juxtaposed to other courses such as anatomy, biochemistry, and physiology. Consequently, students often miss the relevance and importance of these concepts [6], and when under the stress surrounding exams, may “triage” material and focus on what they perceive as most relevant. To address these issues, a new approach for teaching behavioral sciences was implemented at the University of Central Florida (UCF) College of Medicine. This paper reviews our experience in the development of the course, focusing on curriculum development, implementation of the pedagogical model, and student outcomes.
M. L. Verduin (*) University of Central Florida College of Medicine, Orlando, FL, USA e-mail: [email protected]
Methods The course director was charged with developing a behavioral sciences course for freshman medical students, delivered concurrently with other basic science courses. The course, “Psychosocial Issues in Healthcare,” was allotted 3 h per week over 11 weeks. Course objectives were geared toward the “undifferentiated medical student,” with the goal of emphasizing core behavioral science content essential to all practicing physicians. A multidisciplinary taskforce was formed to develop curricular materials and ensure the relevance of psychosocial issues across all medical specialties. Taskforce members included physicians specializing in psychiatry, internal medicine, pediatrics, neurology, obstetrics/gynecology, and hematology/oncology, as well as a nutritionist, psychologist, and faculty development director. The taskforce sought an innovative approach that maximizes active learning, emphasizes application, and minimizes passive information exchange in line with recommendations from the Liaison Committee on Medical Education standard ED-5-A, which emphasizes the importance of active learning in undergraduate medical education [7]. Providing protected time to apply and master course objectives became the driving force for curriculum development. The faculty wanted students to come away from the course not simply “knowing” the material, but being able to recognize how these concepts are applied clinically. Thus, Team-Based Learning (TBL) was selected as the sole pedagogy for the course. While TBL has been effectively used as a component of psychiatric education by others [8, 9], to our knowledge, we are the first and only medical school in the USA to deliver an entire course by TBL. While a full description of TBL is beyond the scope of this paper [10], a basic understanding is important in understanding the course design and implementation. In TBL, students are given assignments to complete prior to class. In class, students are tested on their comprehension of the assignment through an Individual Readiness Assurance Test (IRAT). This
Acad Psychiatry (2014) 38:96–99
ensures that all students come to class prepared. Students then retake the IRAT (with identical questions) in assigned teams; this iteration is a Group Readiness Assurance Test (GRAT). The GRAT provides an opportunity for students to teach each other and correct any knowledge gaps, ensuring that all team members master the material. Following the GRAT, teams work on Application Focused Exercises (AFE), comprised of clinical vignettes with challenging questions. All teams work on the same problem and simultaneously reveal their answers by using laminated answer cards indicating their answer choice. The faculty then leads the class in interteam discussion. Students' course grades depend upon individual (IRAT) and team (GRAT, AFE) performance, as well as peer feedback (both quantitative and qualitative).
Implementation of TBL Model After undergoing training in TBL, the taskforce began by determining what students should be able to do by the end of the course and developing objectives to accomplish these tasks. Topics included human development and learning theory; death, dying, and giving bad news; coping styles and personality; patient education, compliance, and change; human sexuality; alcohol use and misuse; abuse, neglect, and partner violence; and difficult patients, transference/ countertransference, and professional boundaries. Cultural issues in health care were integrated in clinical vignettes throughout the course. Readings were selected for each topic from a variety of sources, including a textbook (Behavior and Medicine [11]), primary literature, advanced psychiatry textbooks (e.g., Comprehensive Textbook of Psychiatry [12]), and online resources (e.g., the National Institute on Drug Abuse website). The faculty developed IRAT/GRAT/AFE questions and cases through an iterative process, providing peer review on each with real-time revision. All questions were mapped back to weekly and overall course objectives to ensure appropriate content coverage. IRAT/GRAT questions were written to reflect board-style questions, while AFE questions were, by design, more difficult. A sample AFE case and question are included in the Appendix. Students participated in an “Introduction to TBL” session during orientation, led by the course director, during which teams of five to seven students were formed by the instructor with the goal of distributing resources as evenly as possible across teams and making group formation transparent. Given that these teams would be used for TBL exercises throughout the entire first year curriculum, the student “resources” that were distributed among teams included prior clinical
97
experience (e.g., nursing, paramedic), graduate-level degree in the basic sciences, and undergraduate major. The newly formed teams then completed a TBL exercise on the subject of TBL, culminating in an AFE in which the class determined the relative grade weights for each TBL component under predetermined faculty parameters. The relative grade weights have varied slightly across academic years, but most have approximated the following: IRAT 20 %, GRAT 40 %, AFE 20 %, and peer feedback 20 %. These grade weights were used to calculate the TBL grade, which comprised 85 % of the overall course grade. The final exam made up the remaining 15 %. Students were satisfied with the grading system and quickly realized the power of group learning. All course sessions were held in a large lecture hall. Students completed the graded IRATs and GRATs in a 1-h session early in the week, had time to review any identified deficiencies, and returned to class later in the week for a 2-h session devoted to graded AFEs. The IRAT was completed at individual seats, while the GRAT and AFEs were completed in assigned teams within the large lecture hall. Two faculty instructors circulated throughout the room during periods of team discussion and then led the overall class discussion for each AFE question. The most significant time requirement for the faculty, beyond the 3 h of classroom time per week, was development of the curricular materials. The faculty also spent approximately 1 h per week grading submitted appeals of GRAT and AFE questions. The UCF Institutional Review Board designated this data as not a human subjects research.
Results Overall, students performed very well in the course (see Table 1). IRAT scores averaged 74.2–77.1 % over the past 3 years that the course has been delivered. GRAT scores (reflecting team performance) were considerably better, with an average of 97.3–98.2 % (data not available for one academic year). AFEs were more variable by design. In TBL, when the majority of teams choose the same answer, discussion is limited, and students are not engaged. To maximize discussion, questions were intentionally difficult, and often more than one response could be successfully argued. If teams disagreed with the “best” answer chosen by the faculty, they could submit a written appeal for additional credit. Teams took advantage of the appeal process, most often submitting appeals for AFE questions, which were, by design, the most challenging. At the end of the course, students took a final examination using a National Board of Medical Examiners (NBME) Blueprint exam. Given the novelty of using TBL as the sole pedagogy, a standardized national exam was necessary to assess
98 Table 1 Student performance data. Reported as average percent correct (range)
Acad Psychiatry (2014) 38:96–99
Academic year
Class size
IRAT
GRAT
Customized NBME examination
2009–2010 2010–2011 2011–2012
41 60 80
74.2 (63.8–87.5) 77.1 (61.3–90.0) 75.6 (43.8–90.0)
98.2 (97.0–98.8) Data unavailable 97.4 (95.6–99.2)
89.8 (82.0–99.0) 90.6 (76.6–97.4) 86.5 (71.0–98.0)
Fig. 1 Student evaluation of the course. Students complete an endof-course evaluation each year. This figure demonstrates the percentage of students indicating “agree” or “strongly agree” with the above statements for each academic year. Comparatively, the percent of students indicating “agree” or “strongly agree” with the above statements for other first year courses ranged from as low as 23 % to as high as 100 %, depending on the particular course and year of administration
Percent of students indicating agree or strongly agree with each statement
content mastery. The NBME Behavioral Sciences shelf exam was not appropriate, given coverage of topics not addressed in this course (e.g., psychopathology and psychopharmacology). Over the past 3 years, the class averages on the Blueprint exam were 89.8 % (range 82.0–99.0 %), 90.6 % (range 76.6–97.4 %), and 86.5 % (range 71.0–98.0 %) (see Table 1). Overall, the majority of students were satisfied with the course, indicated that the course workload was appropriate and that the teaching methods were effective (Fig. 1). Comments from student evaluations indicated that “TBL was very effective and should be included as a teaching method” in other courses. One student noted that the course “encouraged in-depth critical thinking and promoted longterm retention of concepts,” while another commented that, “I grew personally from the class because of the format.” Weaknesses noted by students included “lengthy and lowyield” reading assignments, and that TBL was “very frustrating to get the hang of.” It is notable that both student academic performance and student satisfaction with the course dropped in the most recent academic year. While the original course director continued to teach in the course, promotion to an administrative role required that a new course director be appointed. It was this course director's first experience teaching this subject and using TBL, which may account for the differential student satisfaction data.
Discussion During the first 3 weeks, students were frustrated with the transition to TBL. They needed frequent reassurance that they were actually learning the material without lecture. Students also had initial difficulty tolerating the ambiguity of the AFEs, which were designed to reflect the uncertainty of many clinical decisions. Reviewing their knowledge gains and improved critical thinking skills were essential in managing student perceptions. After a few weeks, students became more comfortable with the process, more confident in their mastery of the material, and more appreciative of an alternative pedagogy. Students were also concerned about their grade depending in part on answering intentionally ambiguous questions. They focused more on getting the “right” answer for full credit than on learning objectives. The faculty modified the grading rubric to allow teams that provided convincing arguments for AFE answers during in-class discussion to receive credit “on the fly.” Teams that were not able to successfully argue their answer choice in class could submit a written appeal, which was graded on concept mastery. In conclusion, TBL was an effective and engaging way for the faculty to teach and students to learn. Students mastered the content and began to develop critical thinking skills necessary for success in clinical practice. However, questions remain. Will
100.00% 90.00% 80.00% 70.00% 60.00% 50.00%
2010
40.00%
2011
30.00%
2012
20.00% 10.00% 0.00% The workload in this I am satisfied with this The teaching methods course was appropriate. course. used in this course were effective.
Acad Psychiatry (2014) 38:96–99
knowledge learned transfer to performance on licensing exams? Will content learned through TBL be more “readily accessible” to students in clerkships? Are these data generalizable to other subjects and/or institutions? We hope to address these questions as we continue to refine the course over the next several years. Acknowledgments The author would like to acknowledge the following individuals for their invaluable support and collaboration in developing this course: Virginia Bagley; Andrea Berry; Lori Boardman, MD; Maria Cannarozzi, MD; Laura Cuty-Ruiz, PhD; Moshe Feldman, PhD; Susan Hewlings, PhD, RD; Nasreen Malik, MD; Rebecca Moroose, MD; Garrett Riggs, PhD, MD; and Shirley Scott, RN, BSN, MS, CT. Conflict of interest The author has no conflicts of interest to disclose.
Appendix: Sample AFE Case and Question Dr. Carlson finds herself becoming increasingly attracted to one of her patients, Joe, who she has been seeing more frequently for diabetic care. She has always taken an extra interest in her diabetic patients, as she appreciates their struggle, having observed her brother battle brittle diabetes for years. Dr. Carlson enjoys Joe's flattering remarks about her appearance and intelligence. Joe has asked her out for a cup of coffee, and she has politely declined his offer, explaining that she feels it would be unethical. Dr. Carlson was recently divorced and has occupied herself with long hours of work to distract herself from feelings of loneliness. Dr. Carlson looks forward to Joe's visits and at times regrets turning down his offer as he seems like a nice guy. She recommends that Joe schedule his appointments at the end of the day. This allows her to allot more time to him than her usual follow-up visits. On one occasion, she returned his phone call regarding a medical question in the evening, which turned into a lengthy off-topic conversation. Dr. Carlson also makes sure to freshen her makeup prior to entering the exam room where Joe is waiting. Having maintained the highest professional standards her whole career, she finds herself feeling very vulnerable and confused right now. Which of the following statements best summarizes the above scenario AND the most appropriate intervention? a. A normal relationship which has not breached any physician–patient boundaries and does not require an intervention. b. An unethical relationship which should result in transfer of the patient to another physician. c. An inappropriate boundary violation which should be presented before an ethics committee. d. An inappropriate relationship which can be overlooked due to extenuating circumstances.
99
e. A potentially problematic relationship which would benefit from counseling from a trusted colleague.
Implications for Educators • A novel TBL-only approach to teaching behavioral sciences effectively engaged students while ensuring mastery of core concepts. • Use of a customized NBME examination provided an objective measure of pedagogical integrity through the use of standardized exam questions. • Both the faculty and students identified the development of critical thinking skills and long-term retention of core concepts as strengths of the TBL approach.
References 1. Cuff PA, Vanselow NA, Institute of Medicine (U.S.) Committee on Behavioral and Social Sciences in Medical School Curricula. Improving medical education: enhancing the behavioral and social science content of medical school curricula. Washington: National Academies; 2004. 2. Satterfield JM, Adler SR, Chen HC, Hauer KE, Saba GW, Salazar R. Creating an ideal social and behavioural sciences curriculum for medical students. Med Educ. 2010;44(12):1194–202. 3. Litva A, Peters S. Exploring barriers to teaching behavioural and social sciences in medical education. Med Educ. 2008;42(3):309–14. 4. Benbassat J, Baumal R, Borkan JM, Ber R. Overcoming barriers to teaching the behavioral and social sciences to medical students. Acad Med J Assoc Am Med Coll. 2003;78(4):372–80. 5. Rakoff V. The behavioural sciences and undergraduate education in psychiatry. Can J Psychiatr Rev Can Psychiatr. 1984;29(8): 642–7. 6. Van Egeren L, Fabrega H. Behavioral science and medical education: a biobehavioral perspective. Soc Sci Med. 1976;10(11– 12):535–9. 7. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Chicago: Liaison Committee on Medical Education; 2012. 31. 8. Touchet BK, Coon KA. A pilot use of team-based learning in psychiatry resident psychodynamic psychotherapy education. Acad Psychiatry. 2005;29(3):293–6. The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 9. Ravindranath D, Gay TL, Riba MB. Trainees as teachers in teambased learning. Acad Psychiatry. 2010;34(4):294–7. The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 10. Haidet P, Levine RE, Parmelee DX, Crow S, Kennedy F, Kelly PA, et al. Perspective: guidelines for reporting team-based learning activities in the medical and health sciences education literature. Acad Med J Assoc Am Med Coll. 2012;87(3):292–9. 11. Wedding D, Stuber ML. Behavior and medicine. 5th ed. Cambridge: Hogrefe Publishing; 2010. 12. Sadock BJ, Virginia A, Ruiz P, editors. Comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009.
COLUMN: EDUCATIONAL CASE REPORT
Design and Implementation of a Novel Behavioral Sciences Course for First Year Medical Students Marcia L. Verduin
Published online: 16 January 2014 # Academic Psychiatry 2014
Keywords Medical student education . Behavioral sciences . Course design
In 2004, the Institute of Medicine (IOM) issued a call for medical schools to improve behavioral sciences education [1]. Despite ample evidence supporting the importance of behavioral sciences in clinical practice, many institutions struggle with implementation of effective behavioral sciences curricula. One possibility for this is the significant expansion in content covered in a 4-year curriculum. Increasingly, medical schools are reevaluating their curricula to determine what can be eliminated [2]. Unfortunately, behavioral sciences are often afforded a “lower status” by some faculty [1], while others consider them “nice to know” but not integral [3]. Another possibility is that students dismiss the importance of behavioral sciences, and students' lack of interest and engagement limits the effective integration of these topics into the curricula [4] [5]. Behavioral sciences are traditionally taught in preclinical years, concurrent with other basic sciences [1]. Comparatively, behavioral sciences are often perceived by medical students as “soft science” when juxtaposed to other courses such as anatomy, biochemistry, and physiology. Consequently, students often miss the relevance and importance of these concepts [6], and when under the stress surrounding exams, may “triage” material and focus on what they perceive as most relevant. To address these issues, a new approach for teaching behavioral sciences was implemented at the University of Central Florida (UCF) College of Medicine. This paper reviews our experience in the development of the course, focusing on curriculum development, implementation of the pedagogical model, and student outcomes.
M. L. Verduin (*) University of Central Florida College of Medicine, Orlando, FL, USA e-mail: [email protected]
Methods The course director was charged with developing a behavioral sciences course for freshman medical students, delivered concurrently with other basic science courses. The course, “Psychosocial Issues in Healthcare,” was allotted 3 h per week over 11 weeks. Course objectives were geared toward the “undifferentiated medical student,” with the goal of emphasizing core behavioral science content essential to all practicing physicians. A multidisciplinary taskforce was formed to develop curricular materials and ensure the relevance of psychosocial issues across all medical specialties. Taskforce members included physicians specializing in psychiatry, internal medicine, pediatrics, neurology, obstetrics/gynecology, and hematology/oncology, as well as a nutritionist, psychologist, and faculty development director. The taskforce sought an innovative approach that maximizes active learning, emphasizes application, and minimizes passive information exchange in line with recommendations from the Liaison Committee on Medical Education standard ED-5-A, which emphasizes the importance of active learning in undergraduate medical education [7]. Providing protected time to apply and master course objectives became the driving force for curriculum development. The faculty wanted students to come away from the course not simply “knowing” the material, but being able to recognize how these concepts are applied clinically. Thus, Team-Based Learning (TBL) was selected as the sole pedagogy for the course. While TBL has been effectively used as a component of psychiatric education by others [8, 9], to our knowledge, we are the first and only medical school in the USA to deliver an entire course by TBL. While a full description of TBL is beyond the scope of this paper [10], a basic understanding is important in understanding the course design and implementation. In TBL, students are given assignments to complete prior to class. In class, students are tested on their comprehension of the assignment through an Individual Readiness Assurance Test (IRAT). This
Acad Psychiatry (2014) 38:96–99
ensures that all students come to class prepared. Students then retake the IRAT (with identical questions) in assigned teams; this iteration is a Group Readiness Assurance Test (GRAT). The GRAT provides an opportunity for students to teach each other and correct any knowledge gaps, ensuring that all team members master the material. Following the GRAT, teams work on Application Focused Exercises (AFE), comprised of clinical vignettes with challenging questions. All teams work on the same problem and simultaneously reveal their answers by using laminated answer cards indicating their answer choice. The faculty then leads the class in interteam discussion. Students' course grades depend upon individual (IRAT) and team (GRAT, AFE) performance, as well as peer feedback (both quantitative and qualitative).
Implementation of TBL Model After undergoing training in TBL, the taskforce began by determining what students should be able to do by the end of the course and developing objectives to accomplish these tasks. Topics included human development and learning theory; death, dying, and giving bad news; coping styles and personality; patient education, compliance, and change; human sexuality; alcohol use and misuse; abuse, neglect, and partner violence; and difficult patients, transference/ countertransference, and professional boundaries. Cultural issues in health care were integrated in clinical vignettes throughout the course. Readings were selected for each topic from a variety of sources, including a textbook (Behavior and Medicine [11]), primary literature, advanced psychiatry textbooks (e.g., Comprehensive Textbook of Psychiatry [12]), and online resources (e.g., the National Institute on Drug Abuse website). The faculty developed IRAT/GRAT/AFE questions and cases through an iterative process, providing peer review on each with real-time revision. All questions were mapped back to weekly and overall course objectives to ensure appropriate content coverage. IRAT/GRAT questions were written to reflect board-style questions, while AFE questions were, by design, more difficult. A sample AFE case and question are included in the Appendix. Students participated in an “Introduction to TBL” session during orientation, led by the course director, during which teams of five to seven students were formed by the instructor with the goal of distributing resources as evenly as possible across teams and making group formation transparent. Given that these teams would be used for TBL exercises throughout the entire first year curriculum, the student “resources” that were distributed among teams included prior clinical
97
experience (e.g., nursing, paramedic), graduate-level degree in the basic sciences, and undergraduate major. The newly formed teams then completed a TBL exercise on the subject of TBL, culminating in an AFE in which the class determined the relative grade weights for each TBL component under predetermined faculty parameters. The relative grade weights have varied slightly across academic years, but most have approximated the following: IRAT 20 %, GRAT 40 %, AFE 20 %, and peer feedback 20 %. These grade weights were used to calculate the TBL grade, which comprised 85 % of the overall course grade. The final exam made up the remaining 15 %. Students were satisfied with the grading system and quickly realized the power of group learning. All course sessions were held in a large lecture hall. Students completed the graded IRATs and GRATs in a 1-h session early in the week, had time to review any identified deficiencies, and returned to class later in the week for a 2-h session devoted to graded AFEs. The IRAT was completed at individual seats, while the GRAT and AFEs were completed in assigned teams within the large lecture hall. Two faculty instructors circulated throughout the room during periods of team discussion and then led the overall class discussion for each AFE question. The most significant time requirement for the faculty, beyond the 3 h of classroom time per week, was development of the curricular materials. The faculty also spent approximately 1 h per week grading submitted appeals of GRAT and AFE questions. The UCF Institutional Review Board designated this data as not a human subjects research.
Results Overall, students performed very well in the course (see Table 1). IRAT scores averaged 74.2–77.1 % over the past 3 years that the course has been delivered. GRAT scores (reflecting team performance) were considerably better, with an average of 97.3–98.2 % (data not available for one academic year). AFEs were more variable by design. In TBL, when the majority of teams choose the same answer, discussion is limited, and students are not engaged. To maximize discussion, questions were intentionally difficult, and often more than one response could be successfully argued. If teams disagreed with the “best” answer chosen by the faculty, they could submit a written appeal for additional credit. Teams took advantage of the appeal process, most often submitting appeals for AFE questions, which were, by design, the most challenging. At the end of the course, students took a final examination using a National Board of Medical Examiners (NBME) Blueprint exam. Given the novelty of using TBL as the sole pedagogy, a standardized national exam was necessary to assess
98 Table 1 Student performance data. Reported as average percent correct (range)
Acad Psychiatry (2014) 38:96–99
Academic year
Class size
IRAT
GRAT
Customized NBME examination
2009–2010 2010–2011 2011–2012
41 60 80
74.2 (63.8–87.5) 77.1 (61.3–90.0) 75.6 (43.8–90.0)
98.2 (97.0–98.8) Data unavailable 97.4 (95.6–99.2)
89.8 (82.0–99.0) 90.6 (76.6–97.4) 86.5 (71.0–98.0)
Fig. 1 Student evaluation of the course. Students complete an endof-course evaluation each year. This figure demonstrates the percentage of students indicating “agree” or “strongly agree” with the above statements for each academic year. Comparatively, the percent of students indicating “agree” or “strongly agree” with the above statements for other first year courses ranged from as low as 23 % to as high as 100 %, depending on the particular course and year of administration
Percent of students indicating agree or strongly agree with each statement
content mastery. The NBME Behavioral Sciences shelf exam was not appropriate, given coverage of topics not addressed in this course (e.g., psychopathology and psychopharmacology). Over the past 3 years, the class averages on the Blueprint exam were 89.8 % (range 82.0–99.0 %), 90.6 % (range 76.6–97.4 %), and 86.5 % (range 71.0–98.0 %) (see Table 1). Overall, the majority of students were satisfied with the course, indicated that the course workload was appropriate and that the teaching methods were effective (Fig. 1). Comments from student evaluations indicated that “TBL was very effective and should be included as a teaching method” in other courses. One student noted that the course “encouraged in-depth critical thinking and promoted longterm retention of concepts,” while another commented that, “I grew personally from the class because of the format.” Weaknesses noted by students included “lengthy and lowyield” reading assignments, and that TBL was “very frustrating to get the hang of.” It is notable that both student academic performance and student satisfaction with the course dropped in the most recent academic year. While the original course director continued to teach in the course, promotion to an administrative role required that a new course director be appointed. It was this course director's first experience teaching this subject and using TBL, which may account for the differential student satisfaction data.
Discussion During the first 3 weeks, students were frustrated with the transition to TBL. They needed frequent reassurance that they were actually learning the material without lecture. Students also had initial difficulty tolerating the ambiguity of the AFEs, which were designed to reflect the uncertainty of many clinical decisions. Reviewing their knowledge gains and improved critical thinking skills were essential in managing student perceptions. After a few weeks, students became more comfortable with the process, more confident in their mastery of the material, and more appreciative of an alternative pedagogy. Students were also concerned about their grade depending in part on answering intentionally ambiguous questions. They focused more on getting the “right” answer for full credit than on learning objectives. The faculty modified the grading rubric to allow teams that provided convincing arguments for AFE answers during in-class discussion to receive credit “on the fly.” Teams that were not able to successfully argue their answer choice in class could submit a written appeal, which was graded on concept mastery. In conclusion, TBL was an effective and engaging way for the faculty to teach and students to learn. Students mastered the content and began to develop critical thinking skills necessary for success in clinical practice. However, questions remain. Will
100.00% 90.00% 80.00% 70.00% 60.00% 50.00%
2010
40.00%
2011
30.00%
2012
20.00% 10.00% 0.00% The workload in this I am satisfied with this The teaching methods course was appropriate. course. used in this course were effective.
Acad Psychiatry (2014) 38:96–99
knowledge learned transfer to performance on licensing exams? Will content learned through TBL be more “readily accessible” to students in clerkships? Are these data generalizable to other subjects and/or institutions? We hope to address these questions as we continue to refine the course over the next several years. Acknowledgments The author would like to acknowledge the following individuals for their invaluable support and collaboration in developing this course: Virginia Bagley; Andrea Berry; Lori Boardman, MD; Maria Cannarozzi, MD; Laura Cuty-Ruiz, PhD; Moshe Feldman, PhD; Susan Hewlings, PhD, RD; Nasreen Malik, MD; Rebecca Moroose, MD; Garrett Riggs, PhD, MD; and Shirley Scott, RN, BSN, MS, CT. Conflict of interest The author has no conflicts of interest to disclose.
Appendix: Sample AFE Case and Question Dr. Carlson finds herself becoming increasingly attracted to one of her patients, Joe, who she has been seeing more frequently for diabetic care. She has always taken an extra interest in her diabetic patients, as she appreciates their struggle, having observed her brother battle brittle diabetes for years. Dr. Carlson enjoys Joe's flattering remarks about her appearance and intelligence. Joe has asked her out for a cup of coffee, and she has politely declined his offer, explaining that she feels it would be unethical. Dr. Carlson was recently divorced and has occupied herself with long hours of work to distract herself from feelings of loneliness. Dr. Carlson looks forward to Joe's visits and at times regrets turning down his offer as he seems like a nice guy. She recommends that Joe schedule his appointments at the end of the day. This allows her to allot more time to him than her usual follow-up visits. On one occasion, she returned his phone call regarding a medical question in the evening, which turned into a lengthy off-topic conversation. Dr. Carlson also makes sure to freshen her makeup prior to entering the exam room where Joe is waiting. Having maintained the highest professional standards her whole career, she finds herself feeling very vulnerable and confused right now. Which of the following statements best summarizes the above scenario AND the most appropriate intervention? a. A normal relationship which has not breached any physician–patient boundaries and does not require an intervention. b. An unethical relationship which should result in transfer of the patient to another physician. c. An inappropriate boundary violation which should be presented before an ethics committee. d. An inappropriate relationship which can be overlooked due to extenuating circumstances.
99
e. A potentially problematic relationship which would benefit from counseling from a trusted colleague.
Implications for Educators • A novel TBL-only approach to teaching behavioral sciences effectively engaged students while ensuring mastery of core concepts. • Use of a customized NBME examination provided an objective measure of pedagogical integrity through the use of standardized exam questions. • Both the faculty and students identified the development of critical thinking skills and long-term retention of core concepts as strengths of the TBL approach.
References 1. Cuff PA, Vanselow NA, Institute of Medicine (U.S.) Committee on Behavioral and Social Sciences in Medical School Curricula. Improving medical education: enhancing the behavioral and social science content of medical school curricula. Washington: National Academies; 2004. 2. Satterfield JM, Adler SR, Chen HC, Hauer KE, Saba GW, Salazar R. Creating an ideal social and behavioural sciences curriculum for medical students. Med Educ. 2010;44(12):1194–202. 3. Litva A, Peters S. Exploring barriers to teaching behavioural and social sciences in medical education. Med Educ. 2008;42(3):309–14. 4. Benbassat J, Baumal R, Borkan JM, Ber R. Overcoming barriers to teaching the behavioral and social sciences to medical students. Acad Med J Assoc Am Med Coll. 2003;78(4):372–80. 5. Rakoff V. The behavioural sciences and undergraduate education in psychiatry. Can J Psychiatr Rev Can Psychiatr. 1984;29(8): 642–7. 6. Van Egeren L, Fabrega H. Behavioral science and medical education: a biobehavioral perspective. Soc Sci Med. 1976;10(11– 12):535–9. 7. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Chicago: Liaison Committee on Medical Education; 2012. 31. 8. Touchet BK, Coon KA. A pilot use of team-based learning in psychiatry resident psychodynamic psychotherapy education. Acad Psychiatry. 2005;29(3):293–6. The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 9. Ravindranath D, Gay TL, Riba MB. Trainees as teachers in teambased learning. Acad Psychiatry. 2010;34(4):294–7. The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 10. Haidet P, Levine RE, Parmelee DX, Crow S, Kennedy F, Kelly PA, et al. Perspective: guidelines for reporting team-based learning activities in the medical and health sciences education literature. Acad Med J Assoc Am Med Coll. 2012;87(3):292–9. 11. Wedding D, Stuber ML. Behavior and medicine. 5th ed. Cambridge: Hogrefe Publishing; 2010. 12. Sadock BJ, Virginia A, Ruiz P, editors. Comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009.
