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TITLE: Crossing the boundary: a conceptual model for faculty working in teams to support cognitive integration of basic and clinical sciences Fulton TB, Nixon J (co-first authors) English R, Fall L, Harris D, Ngo K, Wilson-Delfosse A, van der Schaaf M, O’Brien B Current aim – Academic Medicine ARTICLE Introduction Since the 1910 Flexner report medical education has been grounded by the belief that basic science has a critical place in medical training.(Educating Physicians, n.d.)(Cooke et al., 2006)(Grande, 2009)(Finnerty et al., 2010) Curriculum and instructional design efforts since then have increasingly focused on the concept of curricular integration of basic science and its clinical applications as a guiding practice.(Brauer & Ferguson, 2015) Curricular integration strategies are thought to support the ability of learners to make deliberate connections between their classroom and workplace learning, a key component in transfer of learning, and a critical goal in medical education.(Bolander Laksov et al., 2008)(K. Kulasegaram et al., 2012)(Norman, 2009) Such curricular integration strategies purposefully place instruction on basic science content in proximity with the clinical applications of that knowledge, thus operationally unifying the presentation and ideally the learning of these disparate pieces of knowledge.(Goldman & Schroth, 2012)(Harden, 2000). Much has been written about curriculum and instructional design approaches that increase proximity of basic science and its clinical applications at the program, course, or session level.(K. M. Kulasegaram et al., 2013) Recently this framework has also been broadened to include strategies specific to integrating basic science within clerkships, including practices and tools to be used at the bedside.(Daniel et al., 2020) It has been suggested that the major struggles in implementation of curriculum integration are rooted in factors associated with individual educators.(Hopkins et al., 2015) Throughout the literature that discusses interventions to support cognitive integration and transfer,(Peters et al., 2017)(Castillo et al., 2018) emphasis is placed on the importance of 1) faculty collaboration across disciplines and 2) faculty learning and teaching in areas outside of their expertise. However, publications in this area uniformly highlight the fact that faculty are reluctant or resistant participate in such activities, which may stem from being unprepared to do so. One critical narrative review of the literature on integration notes the complexity of creating explicit linkages for learners, and adds that “uniformly adopting best practice teaching strategies, coupled with faculty development, may be required.”(K. M. Kulasegaram et al., 2013) In a publication focused on interventions to facilitate curricular integration of basic science into clerkships, authors describe the importance of clinical and basic science faculty partners to develop and deliver content. They note that in-the-moment connection of basic science to patient care “seemed to be what students craved most when they shared their opinions during curriculum planning meetings,” but that “faculty worried effectively teach basic science content that was connected to patient care” on demand.(Daniel et al., 2020) Notably, the perspectives of individual educators and their experiences of teaching in an integrated framework are largely missing from the literature.(Hopkins et al., 2015) Some lessons have been learned from research on interdisciplinary teaching teams. Such work is clearly prone to conflict,(Stalmeijer et al., 2007) and recent qualitative work, framed using team research grounded in management science, describes how personal, interpersonal, and organizational factors can enable or inhibit interdisciplinary teacher teams.(Meeuwissen et al., 2021)

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Boundaries, Boundary Crossing, and Boundary Objects One conceptual model for examining basic scientist and clinical educator team work is that of communities of practice.(Wenger, Etienne, 1998) As basic scientist educators and clinical educators come together on interdisciplinary teams, it becomes apparent that although they share responsibilities for teaching medical students and have some shared bodies of knowledge, they also have different depths of knowledge and they apply their knowledge in different ways and in different settings. That is, they have specialized scientific and clinical knowledge, and specialized pedagogic practices specific to the environment in which they have traditionally taught and practiced (ie the classroom and lab vs the clinical setting).(Muller et al., 2008) These discontinuities of depth, application or use of knowledge can be thought of as boundaries between communities of practice (S. F. Akkerman & Bakker, 2011)(Learning in Landscapes of Practice, 2014). The study of boundaries as a sociocultural phenomenon has become more relevant over the last few decades with increasing specialization of knowledge and the need to communicate across boundaries (Konopka 2010 (find this ref)). Scholars in this domain have established the concept of boundary crossing to describe processes that bridge practices of different communities in order to improve integration of knowledge.(S. F. Akkerman & Bakker, 2011) Students cross boundaries when they transition between basic science learning in the classroom and apply their knowledge in the workplace. Faculty cross boundaries between their domains when they co-design learning activities. An emphasis in this literature is on boundaries being spaces of learning potential and transformation, that require specific tools and deliberate practices to overcome discontinuities. As individuals with distinct areas of expertise come together to work on a shared project, such as an integrated curriculum, it may create discomfort and working together may not come easily, thus pointing to a role for Boundary objects - tools that can support boundary crossing by facilitating interactions that might not otherwise come easily.(Star & Griesemer, 1989) An example relevant to the health professions is the medical record, which allows multiple caregivers to both give and receive information about a patient, and importantly allows collaboration. For example, a general surgeon and an internal medicine doctor share many historical aspects in that they both went to medical school and provide care for patients. They also have very distinct areas of expertise that may create discomfort as they cross boundaries to work together to diagnose or recommend treatment for a shared hospitalized patient. The medical record promotes communication and can facilitate shared decision making to provide appropriate care for a patient, and which also allows the patient to access information from all of their physicians in a way that is integrative for them. Boundary objects satisfy requirements of intersecting domains of practice, and can be adapted to local needs, but maintain a common identity across domains. Interactions that take place at the boundary may or may not support boundary crossing.(Learning in Landscapes of Practice, 2014) Akkerman identified several categories of boundary practices in a systematic review of the literature: identification, coordination, reflection, and transformation.(S. Akkerman & Bakker, 2011) While identification involves knowing about different practices in relation to one another, it does not actually involve boundary crossing, as boundaries are constructed (or re-constructed) rather than overcome. A common curricular example is presentation of basic science segregated from its clinical applications. Coordination is a boundary crossing practice that is characterized by exchanges between practices without significant identity reconstruction. The emphasis is on continuity of work, with less effortful movement between practices. A curricular example is co-presentation of basic science and clinical applications, but without generation of interdisciplinary sessions or assessments. Reflection is characterized by interactions that result in or allow for an

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expanded set of perspectives, and thus identity, that informs future practice. Transformation is characterized by development of new practices that stand between the original domains. Reflection and transformation are boundary crossing practices that would be expected in curricula at the “sharing” or higher levels of integration where faculty must adapt their practices to accommodate one another’s objectives and content. Boundaries in Educational Practices In 2013 Aquifer Sciences began work to develop a publicly available curriculum (organized into an open searchable database available at https://www.aquifersciences.org/). The curriculum includes the core basic sciences concepts that must be understood and mastered by health professions learners in order to provide safe, routine patient care, as described by learning objectives focused on clinical decisions. This work, undertaken in conjunction with International Association of Medical Science Educators (IAMSE), brought basic scientists and clinicians together to work on developing the curriculum. This work identified major discontinuities in the interactions of these faculty, which echoed experiences that all had or were having in their own institutions. In producing the curriculum and materials many basic scientists indicated their discomfort with trying to apply concepts in a clinical context as they felt like “frauds”. Clinicians, similarly, often expressed discomfort at trying to apply basic science principles to their clinical context as they felt they could not adequately recall the science underpinning their clinical decisions. Both groups observed that their approaches to problems were different with scientists typically focusing on the underlying “why”, while clinicians focused on the facts one needs for safe and expeditious decision making. As part of a project in which teams from 12 US medical schools developed learning materials that support student cognitive integration, we explored the experiences of basic science and clinical educators working in teams. Our research questions are: What boundary practices do participants describe in their work together? How do these practices facilitate or inhibit development of tools that support cognitive integration? Approach Approval for this study was received from the University of Minnesota Institutional Review Board (study STUDY00007371). From October 2018-March 2019 we worked with teams from twelve US medical schools across the United States. Six teams were assembled to develop Integrated Illness Scripts (Medical Science Educator, accepted with revisions), and six teams were to develop virtual patient cases. Each school formed a team consisting of a basic science lead, a clinical educator lead, and at least 2 medical students. Templates and detailed process descriptions were developed for each type of learning material, which hinged on use of elements of the curriculum database. Schools developed their materials in cycles, using a design thinking and rapid prototyping approach. After a calibration round (all case schools wrote cases from same integrated learning objective, concept, condition; all IIS schools wrote scripts from same condition), schools were given assignments to create 2 cases or scripts at a time in 3 rounds, with multiple planned review cycles. After teams completed work on the materials, we asked them open-ended questions as part of a program evaluation designed to explore the mechanisms at play in boundary crossing as they worked together (Appendix A). Basic scientist and clinical educator team leads (24 total) and faculty contributors (need #) were invited to respond to surveys by email. In an anonymous Qualtrics survey, we asked each lead and contributor to identify whether they had the basic science or clinical role. We asked 17 open-ended questions of

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faculty leads, and 18 of faculty contributors in several areas: team process, engagement with the program, impact of participation in the program, impact of products, and impact on participant’s professional development. Responses received numbered 14 (58%) from leads, X from contributors and X from students. See Appendix A for all questions. We performed a qualitative analysis of these responses utilizing thematic analysis (mixed inductive deductive). Two authors experienced with qualitative analysis (TF and AW) coded responses using the 4 categories of boundary crossing mechanisms as per Akkerman. Codes were first applied independently and reconciled for agreement. We searched for themes related to mechanisms of boundary crossing and facilitators or inhibitors of boundary crossing. Results (DRAFT THOUGHTS ON WHAT WE ARE SEEING SO FAR) Of the faculty lead responses:

We see a range of examples of boundary crossing happening on an individual and on a team level

Universally robust descriptions of the ways that teams coordinated their work (email, Google docs, handoffs, levels of writing and review)

o (CS) “Students did initial work on specific sections in pairs. Faculty reviewed/edited work in their area (basic science versus clinical). Clinical faculty lead then polished final draft.”

o (FS) “Our clinical lead and I would meet either in person or virtually with our team of 2-3 students to initially brainstorm what we thought the patient characteristics should be, and with ideas …. The students would run with an initial draft, usually passing it back and forth before opening it back up to the faculty. We would sometimes reach out to consult with clinical experts. Because of the subject areas we were assigned we wound up not having to consult with other basic scientists outside of our team.”

Some teams indicate elements of coordination that went beyond what other teams described, which suggest transformation – handoffs between individuals and successive editing vs group editing, “read alouds” and synchronous work.

o (FS) “Initial drafts were created independently by each lead member and shared online (Sharepoint). In person meetings were scheduled for subsequent drafts and all team members contributed to editing documents online prior to in person meetings…The final work product included read aloud editing with the team and group edits of both the basic science justification and vignette…Editing rough drafts as a team was very efficient and productive. It was better to let the team analyze a rough draft instead of an individual working extensively on a draft solo.”

Some evidence of inter-team reflection – learning from work of other teams and bringing that to their own team work

o (CS) “- The multiple perspectives were invaluable at every step of the project.- Most of our students were open with their opinions about the content of the scripts and the process itself. - I feel that this collaborative process resulted in a better product, not a compromise product.”

Some evidence of reflection at the individual level – bringing new perspective to their teaching practice moving forward

o (FS) “I'm even more sensitive to and conscientious about asking "why" is it important that students know this? And working hard to make sure I understand the answer. I've learned some really interesting new clinical connections and motivations for teaching basic science.”

Some evidence of transformation at the individual level – change in their teaching practice moving forward

o (FS) “I personally see how valuable it is for students and faculty alike to be able to create integrated illness scripts. As such, I find myself trying to get students more actively engaged in searching the literature and discovering mechanisms for themselves.”

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o (CS) “I am finding more confidence in teaching / integrating the basic science explanations for M1 and M2. (never thought I would be discussing Bernoulli's principle, but I am!)”

Some evidence of transformation at the team level, that led to a change in practice at the participant’s institution

o “[This project impacted how I teach by…] increased awareness of integration and building of curriculum. For example, we developed a co-taught (on-line) session on infectious disease of the cardiovascular system that integrated microbiology and pathology.”

The process we asked teams to engage in prompted struggle/discomfort/discontinuity in all groups, some moved past it, some never did

o (CS) - At some point early on, I think we realized that we were ALL learning from the process (the schools and Aquifer), so that we did not feel as bad for feeling lost at times. - The constant challenge from Aquifer to innovate with constraints was a very helpful framework to build on.

o (CS) “Persistent differences in opinion between basic science and clinical lead re. what material was appropriate/necessary for the cases.”

Some responses suggest that in some cases boundaries were not crossed, but rather there was identification of different perspectives, approaches, knowledge without there necessarily being a change in perspective or practice; potentially reinforces “othering”

o (FS) “Learning from different perspectives makes everything more fun.” o (CS) “I actually think it demonstrated how challenging it is to closely integrate instruction in the

basic and clinical sciences for students near graduation. We will work towards this in our new curriculum but based on this experience I am concerned that some basic scientists really do not understand what practicing clinicians need to know.”

Facilitators o Clarity in knowing roles o Clear logistics, timeline o Feedback and encouragement from project leadership o Faculty willing to extend themselves beyond their expertise o Students doing work o Students as arbiters of level of detail o Leadership as arbiters of level of detail o Work was FUN

Barriers o Opposite of many things mentioned above o Lack of timely feedback from leadership o Shifting expectations from leadership o Schedule constraints combined with rapid deadlines o No protected time for this work o Differences in opinion on breadth/level of detail needed

Still need to analyze the faculty contributor responses References Akkerman, S., & Bakker, A. (2011). Boundary Crossing and Boundary Objects. Review of Educational Research, 81,

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Appendix A Survey questions

[[FACULTY LEAD – 18 qs including indication of role]] [PAGE ONE] Thank you for your participation in the Aquifer Sciences Initiative Pilot School Project, either on Integrated Illness Scripts or on Virtual Patient Cases. We are grateful for the work you did to lead your school’s team, and for any information you can provide as you reflect on your experience and its impact. This survey consists of 18 questions, which we estimate should take you 20 minutes to complete. [PAGE TWO] Please indicate your role: Science lead Clinical Lead [PAGE THREE] THE PROCESS: Your team was asked to collaborate at your local institution to produce sets of cases/scripts with short turnaround time through sequential rounds of development. As you reflect on your experience, please answer the following questions about 1) local and 2) program-level factors. Local factors: This work required collaborative teamwork amongst basic science and clinical educators and students at your institution.

1. How did you structure your team’s local work to produce drafts and final work products?

2. What do you see as the benefits to working together in this fashion? 3. How did you optimize student engagement? 4. What major local barriers or challenges did your team experience? 5. What helped your team to move successfully beyond these barriers?

[PAGE FOUR] THE PROCESS: Your team was asked to collaborate at your local institution to produce sets of cases/scripts with short turnaround time through sequential rounds of development. As you reflect on your experience, please answer the following questions about 1) local and 2) program-level factors. Program factors: The process of case/illness script development was modeled on rapid prototyping methodologies, in which ‘minimum viable products’ are produced and distributed in short cycles of review and feedback, with best practices from each cycle applied to the next.

1. As you moved through the rounds of development, what worked well for your team? 2. What were the benefits of working within this design? 3. What barriers or challenges did your team experience?

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4. The program provided support in each cycle in the form of group design calls with other pilot schools, leadership consultations, and formal feedback from reviewers. In what ways did these options help you move past challenges?

5. What improvements do you suggest? [PAGE FIVE] IMPACT: As you reflect on your experience, please answer the following questions about 1) impact of your team’s collaboration at your institution, 2) potential impact of the products, and 3) impact of this work on your professional development. Impact of collaboration: A key project goal was to promote curricular integration at participating pilot schools.

1. What impact has your participation and/or your team process had on your existing curriculum or intent to implement curriculum at your school?

2. How has the process impacted how you teach?

[PAGE SIX] IMPACT: As you reflect on your experience, please answer the following questions about 1) impact of your team’s collaboration at your institution, 2) potential impact of the products, and 3) impact of this work on your professional development.

Impact of products: The project aims to develop tools to promote cognitive integration in medical education for the purpose of improving safe and effective clinical decision-making.

1. What impact do you believe the tools developed through this project may have to improve clinical decision making through the integration of basic clinical sciences?

2. Do you intend to use the cases and/or integrated illness scripts at your school? If so, how?

[PAGE SEVEN] IMPACT: As you reflect on your experience, please answer the following questions about 1) impact of your team’s collaboration at your institution, 2) potential impact of the products, and 3) impact of this work on your professional development. Impact on your professional development: An additional project goal was to provide a unique avenue for professional development, and academic scholarship.

1. How has your participation impacted your career as an educator? 2. Has your team received recognition by your institution's leadership as a result of your

participation in the initiative? If so, what form did this recognition take? 3. If there were opportunities to continue working on case/script development, what

factors would lead you to consider working further on the project?

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FACULTY CONTRIBUTOR [PAGE ONE] Thank you for your participation in the Aquifer Sciences Initiative Pilot School Project, either on Integrated Illness Scripts or on Virtual Patient Cases. We are grateful for the work you did to participate with your school’s team, and for any information you can provide as you reflect on your experience and its impact. We estimate this survey should take you 20 minutes to complete. [PAGE TWO] Please indicate your role: Science contributor Clinical contributor [PAGE THREE] THE PROCESS: Your team was asked to collaborate at your local institution to produce sets of cases/scripts with short turnaround time through sequential rounds of development. As you reflect on your experience, please answer the following questions about 1) local and 2) program-level factors. Local factors: This work required collaborative teamwork amongst basic science and clinical educators and students at your institution. If your role did not include work as indicated below, feel free to answer “N/A”.

1. How were you recruited to the team? 2. How did you contribute to the team’s work, and how was your work structured within

the work of the team to produce drafts and final work products? 3. What do you see as the benefits to working together in this fashion? 4. Did you work with students and if so, how did you optimize student engagement? 5. What major local barriers or challenges did you experience? 6. What helped you to move successfully beyond these barriers?

[PAGE FOUR] THE PROCESS: Your team was asked to collaborate at your local institution to produce sets of cases/scripts with short turnaround time through sequential rounds of development. As you reflect on your experience, please answer the following questions about 1) local and 2) program-level factors. Program factors: The process of case/illness script development was modeled on rapid prototyping methodologies, in which sample products are rapidly generated in cycles, with continuous review, and best practices from each cycle applied to the next. If your role does not include work as indicated below, feel free to answer “N/A”.

Did you participate in work on multiple cases/scripts in sequential rounds? [Yes/no – if yes, include all questions below. If no, skip to next page/section.]

1. As you moved through the rounds of development, what worked well for your team?

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2. What were the benefits of working within this design? 3. What barriers or challenges did your team experience? 4. The program provided support in each cycle in the form of group design calls with other

pilot schools, leadership consultations, and formal feedback from reviewers. In what ways did these options help you move past challenges?

5. What improvements do you suggest? [PAGE FIVE] IMPACT: As you reflect on your experience, please answer the following questions about 1) your expectations regarding the project, 2) potential impact of the products, and 3) impact of this work on your professional development. Expectations: A primary goal of the project was to engage a variety of pilot school faculty to contribute relevant basic science and/or clinical expertise to the collaborative development of integrated teaching and learning tools.

1. What factors led to your decision to contribute, and what expectations did you have for the process and outcome of your work?

2. Did your experience working on the project meet your expectations? Why or why not? [PAGE SIX] IMPACT: As you reflect on your experience, please answer the following questions about 1) impact of your team’s collaboration at your institution, 2) potential impact of the products, and 3) impact of this work on your professional development.

Impact of products: The project aims to develop tools to promote cognitive integration in medical education for the purpose of improving safe and effective clinical decision-making. If your role does not extend to curriculum implementation feel free to answer “I don’t know.”

1. What impact do you believe the tools developed through this project may have to improve clinical decision making through the integration of basic clinical sciences?

2. Do you intend to use the cases and/or integrated illness scripts at your school? If so, how?

[PAGE SEVEN] IMPACT: As you reflect on your experience, please answer the following questions about 1) impact of your team’s collaboration at your institution, 2) potential impact of the products, and 3) impact of this work on your professional development. If your role does not include work as indicated below, feel free to answer “N/A”. Impact on your professional development: An additional project goal was to provide a unique avenue for professional development, and academic scholarship.

1. How has your participation impacted your career as an educator? 2. Have you received recognition as a result of your participation in the initiative? If so,

what form did this recognition take?

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3. If there were opportunities to continue working on case/script development, what factors would lead you to consider working further on the project?