using “active learning” methods to teach physiology

Medical Science Educator © IAMSE 2011 Volume 21-1 8

MEDICAL SCIENCE EDUCATOR The Journal of the International Association of Medical Science Educators Med Sci Educ 2011; 1: 8-20

ORIGINAL RESEARCH

Using “Active Learning” Methods to Teach Physiology Gary L. Anderson, John C. Passmore, William B. Wead, Jeff C. Falcone, Richard W. Stremel & Dale A. Schuschke University of Louisville School of Medicine, Louisville, KY, USA Abstract The teaching faculty of the Department of Physiology and Biophysics at the University of Louisville School of Medicine have designed and implemented various “active learning” approaches within three different courses that teach physiology to medical and graduate students. The courses are: 1) medical physiology, 2) advanced physiology, and 3) integrated physiology. The unique aspect incorporated within these courses is that students prepare answers to pre-assigned questions or topics and then “teach” that topic to their peers. This pedagogical exercise encourages students to learn the material at a more comprehensive level and to speak the language of physiology. This paper presents the rationale and design for this type of approach within each course and provides feedback comments from both student and faculty participants. We also provide a list of some of the questions and topics used in two of these courses as a practical guide to readers who may want to implement similar approaches. Introduction Five years ago, we implemented changes within medical and graduate courses in Physiology (PHZB 801 Medical Physiology, PHZB 611 Advanced Physiology, and PHZB 609 Integrative Physiology) that would solve three problems in our curriculum. Problem 1) was that we believed systemic physiology is increasingly important but most of our students’ current research and literature exposure is focused on cellular/molecular problems and mechanisms. Problem 2) was that, because of limited time in the medical curriculum and tightened funding for graduate stipends, we had only one semester to complete medical physiology and only four semesters to complete the entire graduate coursework that we require for graduate students in systemic physiology. After one semester, the medical students move onto other courses in their second year, and our graduate students concentrate solely on the research laboratory and their PhD candidacy. Problem 3) was that both medical and graduate students were unprepared after standard lecture courses (that use faculty

lectures and multiple choice examinations) to perform well in a setting where oral presentation of the subject was required. This deficiency was most obvious when medical students had to participate in discussions during clinical rounds with residents/attending faculty and when graduate students had oral cumulative Qualifying Exams required to advance to PhD candidacy. To address these problems, we instituted “active learning” components that emphasize oral presentations in the medical physiology course and in two graduate courses that occur in the last semester of our graduate course work. By “active learning” we mean “the process of engaging students in some activity (other than lecture) that forces them to reflect upon ideas and how they are using those concepts”. In Medical Physiology (PHZB 801), approximately 20% of the course activities involved an active learning component utilizing small group sessions related to clinical questions, case studies, and computerized operating room simulations. In Advanced Physiology (PHZB 611), about 40% of the course utilized an active learning approach where students were assigned specific topics to present and discuss with the class. In Integrated Physiology (PHZB 609), the active learning component was the

Corresponding author: Gary L. Anderson, Ph.D. Department of Physiology and Biophysics, Health Sciences Center A1115, University of Louisville, Louisville KY 40292 USA, Office Phone: (502) 852-6915, Department Office Phone: (502) 852-5371 FAX: (502) 852-6239, e-mail: [email protected]


main-stay of the course, with roughly 90% of the class activity related to students teaching their peers under faculty supervision and input. All three of these approaches required students to present and discuss answers to specific faculty-generated questions in each of the physiology systems. This activity, in effect, caused students to become peer teachers who were supervised by the same faculty who lectured to and/or tutored them. The major benefits of adding “active learning” approaches were:

1. It enabled students to present complicated concepts, evaluate themselves and their peers, and contribute effectively in small group settings.

2. It involved almost all of the Departmental Faculty so that the teaching faculty as a whole got to know and could evaluate almost all students in the program. This benefit was especially significant for faculty members who did not lecture in the basic first-year courses.

3. It educated mentors outside our Department about our program, its expectations, and the importance of learning systemic physiology.

4. The oral format allowed clear evaluation of a student’s level of understanding of integrated physiology systems while simultaneously giving each student the vision and the confidence to progress toward becoming competent teachers.

Materials and Methods The “Medical Physiology” course (PHZB 801) is scheduled over a 16-week semester during the first of two years of basic science courses in the medical curriculum. This course meets approximately 8 hours per week and includes lectures in systemic physiology and small-group sessions where students evaluate physiological concepts associated with clinical situations. The course is organized according to physiology systems presented in the following order; membranes, body fluids, muscles, heart, circulation, kidney, respiration, acid-base, endocrine, and gastrointestinal physiology. The active-learning component of this course was about 20% of the course design, with the majority of the course being lecture based. Each system that was covered had a small-group activity associated with it that utilized “active learning”. There were three different kinds of small-group activities which were termed: 1) TBL (Team-Based Learning), 2) PBL (Problem-Based Learning), and 3) Sims (computerized simulations). TBL involved giving

students multiple choice questions derived from lecture material. The students were asked to answer these integrative questions by themselves and bring their answers to their small group, which was composed of 7-10 students. The small group discussed and clarified the answers of these questions, and after the discussion, each individual student was required to answer another set of related questions. See Examples 1-4 located later in this section. The School of Medicine conducts an online survey of each first-year course asking students to rate 15-18 different questions (the exact number was slightly different depending on the year 2006-2009). In each year, one question rated small group activities within each course and the results of that rating for Medical Physiology are presented in the results section. In addition, selected comments from medical students about these small group activities are presented in the discussion section. The “Advanced Systemic Physiology” course (PHZB 611) is scheduled over a 15-week semester and meets for a two-hour block twice a week. The first and largest section of the course deals with advanced cardiac physiology and builds upon the cardiac physiology taught to graduate students in their first-year, introductory course. The second section presents an in-depth coverage of molecular cardiology where students are taught topics such as post-infarct size changes, stem cell use in clinical cardiology, environmental cardiology, cardiac heart failure, and changes in heart function during diabetes. The third section covers inflammation and blood hemostasis. The last section covers vascular and cardiac remodeling, and the role of oxygen gradients in the microcirculation. As a component of every section (about 40% of the course activity), each student was assigned a topic to present to the other students. This presentation was the basis for an expanded discussion among all the students and was moderated by the faculty member supervising that section of the course. The “Integrated Physiology” course (PHZB 609) is scheduled over a 15-week semester and meets for a three-hour block each week. The topics are divided into three sections. The first and largest section involves presentation of a different organ system each week, including: membrane & muscle; body fluids; heart and circulation; respiration; autonomic nervous system; kidney; endocrine; and gastrointestinal. The basic systems are structured to allow students to review and learn the material at a level required to explain topics carefully and not just answer multiple choice questions about the material. More than any of the three courses


discussed, the format of this course was primarily focused on using “active learning” as the method of instruction. This format aggressively addresses a concern that Michael (2006) expressed “teachers talk physiology too much and students talk physiology too little”.1 Also, this kind of systemic physiology review is particularly valuable to many of our PhD students who are foreign trained medical doctors (MDs) and thus have not been exposed to our preliminary physiology courses. The second section of this course is designed specifically to integrate systemic physiology and involves the presentation of topics that include: acid/base balance and regulation; systemic response to shock; and systemic response to exercise. In PHZB 609, the format for each week’s presentations starts with the distribution of a set of 10 discussion questions for the upcoming topic (see Questions/Topics Used for Discussion in Integrative Physiology at the end of this section). The students then have a week to prepare their set of answers. During the class period, students meet with 3-4 classmates and also 2-3 faculty facilitators who are particularly well versed in the week’s topic. Students are asked in random order to go to the white board at the front of the room and “teach” their fellow students the physiological concepts related to the selected question. During the presentation, students are required to use graphs and figures and to describe the appropriate mechanisms. After each presentation, their peers are asked to comment and critique the presentation. Then the faculty members are asked to expand the discussion at the end of each presentation. The process continues until all questions or topics have been presented and discussed. During the week when kidney topics were discussed, students are required to prepare a PowerPoint presentation, rather than utilize the white board. The third and last section in this course involves students preparing and presenting the research proposals for their dissertation projects. Emphasis is placed on students discussing the physiological principles and background for their projects. The student’s mentors are asked to attend these presentations and to add to the student’s and attending faculty’s critique and comments. Students are then given a week to incorporate the comments they received and present an improved talk again. At the end of the course, each student was asked to rate the course and make any pertinent comments. The course ratings are presented in the results

section and selected comments are mentioned in the discussion section. Example Questions Used in TBL Exercises in Medical Physiology Example 1 Before: 160 grams of a toxin was ingested by a typical 70-kg man. The toxin had the following physical properties: water soluble, non-penetrating, non-dissociating, with molecular weight = 500. Which of the following is NOT TRUE based on the above data?

A. Interstitial osmolality increased by about 8 mOsm/L

B. About 320 millimoles of an equi-molar antidote are needed to detoxify this toxin?

C. Intracellular volume is now about 24.3 liters

D. Plasma volume increased by about 344 milliliters

E. Plasma colloid osmotic pressure has decreased

After: Plasma osmolality of a 70-Kg man was 300 mOsm/L and then increased to 310 mOsm/L by the addition of a solute called substance X. Substance X has a molecular weight of 200, dissolves in water, and has an i of 2. Which of the following can be correctly concluded about substance X?

A. substance X has an osmotic coefficient of 0.90

B. at least 40 grams of substance X was added

C. less than 20 grams of substance X was added

D. substance X is a non-penetrating solute E. none of the above


Example 2 Before:

Which of the following conditions would cause a shift of the left ventricle pressure-volume loop relationship from curve “A” to curve “B”?

A) High sympathetic input B) High left atrial pressure C) Mitral insufficiency D) Low aortic diastolic pressure E) Aortic valve stenosis

After:

Which of the following conditions would cause a shift of the left ventricle pressure-volume loop relationship from curve “A” to curve “B”?

A) Left ventricular hypertrophy B) Increased contractility C) Sinus Bradycardia D) Decreased left ventricle compliance E) A prolonged QRS complex

Example 3 Before:

Calculate systemic vascular resistance (SVR, dyne-cm-sec-5) from the following data: MAP = 103 mmHg CVP = 3 mmHg ∆P = 100 mmHg Hct = 48% R-R interval = 0.75 seconds P-R interval = 0.2 s SV = 60 milliliters

A. 1106 B. 1267 C. 1333 D. 1504 E. 1665

After:

Given the data below, which value below best represents the cardiac index? Body surface area = 0.65 M2 PWP = 8 mmHg EDV = 50 milliliters Ejection fraction = 66.6% ESV = 15 milliliters Atrial kick = 4 milliliters R-R interval = 0.75 seconds P-R interval = 0.2 s MAP = 105 mmHg CVP = 5 mmHg

A. 1.9 B. 2.4 C. 3.7 D. 4.3 E. 5.4


Example 4 Before:

A 50 year old, insulin dependent diabetic woman was brought to the ER by ambulance. She was semi-comatose and was described as having been ill for several days. Some vomiting was suspected. Current medications include digoxin and a thiazide diuretic for congestive heart failure. Lab results on this patient are:

BMP: Na+ 132 K+ 2.7 Cl- 79 HCO3- 19 Glu 815 Lactate 0.9 Urine Ketones 3+ ABG: pH 7.41 PaCO2 32 HCO3- 19 PaO2 82

What is the acid-base status of this patient?

A. Anion Gap Metabolic Acidosis (AGMA) with a combined Non-Anion Gap Metabolic Acidosis (NAGMA) B. Anion Gap Metabolic Acidosis (AGMA) with an underlying Metabolic Alkalosis C. Non-Anion Gap Metabolic Acidosis (NAGMA) D. Respiratory acidosis with adequate metabolic compensation E. The patient does not have an acid-base problem

After:

A 39 year old man presents in the ER with severe left flank pain and hematuria. The pain is sharp and radiates to the groin. He vomited eight times before arriving. He has a non-obstructing, calcium-oxalate kidney stone at the ureteropelvic junction on the left side. Upon initial evaluation, his BP is 130/90 and HR 110.

BMP: Na+ 141 K+ 4.0 Cl- 100 HCO3- 34 ABG: pH 7.56 PaCO2 36

Which of the following best describes this patient's acid/base status?

A. Metabolic acidosis and respiratory alkalosis B. Metabolic alkalosis C. Metabolic alkalosis and respiratory acidosis D. Metabolic and respiratory alkalosis E. Respiratory Alkalosis

The Questions/Topics Used for Discussion in Integrative Physiology (PHZB 609) Membrane and Muscle

1. Describe the mechanisms by which the cell membrane develops and maintains the resting membrane potential.

2. Describe the transport mechanisms by which substances move across the cell membranes.

3. Discuss the ionic basis of the motor neuron action potential.

4. Describe the conduction of an action potential from an alpha-motor neuron to a skeletal muscle myocyte.

5. Discuss the in vivo excitation-contraction coupling of a skeletal muscle myocyte.

6. Contrast the excitation-contraction process in cardiac and smooth muscle compared to skeletal muscle.

7. Considering that an action potential is an all or none phenomenon, discuss how skeletal, smooth and cardiac muscle responses are graded.

8. Define and illustrate the following terms: spatial and temporal summation, fatigue, accommodation, and adaptation.

9. Describe the cellular mechanisms of hypertrophy in striated muscle. Give specific skeletal and cardiac examples.

10. Compare and contrast the mechanisms of isometric and isotonic contraction. Include the effects of preload and afterload.


Body Fluids 1. Describe the 4 major body fluid

compartments including their boundaries, boundary permeabilities, volumes, compositions, and osmolality.

2. Diagram and Explain the mechanism for CSF production.

3. Describe the practical use of the dilution principle for measuring body fluid compartment volumes. Give one example for each body fluid compartment.

4. Discuss and explain a normal intake-output balance for daily water turnover.

5. Explain osmolality and osmotic pressure. What is the difference between osmotic pressure and osmolality? What is osmosis?

6. Describe osmotic coefficient. Explain how to calculate osmotic coefficient. Explain why the osmotic coefficient for sucrose is > 1?

7. Describe 4 common intravenous solutions and how each one is used. What is the daily requirement for IV fluids for a comatose person?

8. Describe how osmoreceptors and stretch receptors function to control ADH.

9. Explain the control of Aldosterone secretion.

10. Describe the use of volume osmolality diagrams and give examples.

Heart

1. Describe excitation-contraction coupling of cardiac muscle including the role of calcium.

2. Discuss atrioventricular nodal excitation. 3. Discuss at least three different mechanisms

by which a positive inotropic intervention could occur in ventricular muscle.

4. Discuss effects of a premature ventricular contraction of muscular origin on left ventricular performance and contractility.

5. Discuss the physiologic mechanisms of effects of changing afterload on ventricular function.

6. Discuss your choice of an index of left ventricular contractility that is independent of preload and afterload.

7. Discuss the cellular and sub-cellular structure of cardiac muscle.

8. Discuss the role of the nervous system to regulate cardiac muscle contraction.

9. Discuss the electrical activity of the heart as assessed by the electrocardiogram

10. Discuss the factors which regulate cardiac output of the intact heart, including Frank-Starling and inotropic state.

Circulation 1. Explain the relationship between pressure,

flow, and resistance. Describe Poiseuille’s equation and the resultant equation for resistance to flow.

2. What is hematocrit and how do changes in hematocrit affect blood flow and total peripheral resistance (TPR)? Is SVR different from TPR?

3. What are the primary determinants of systolic and diastolic blood pressure? Explain how changes in each determinant affect these blood pressures.

4. Describe Fick’s Law of Diffusion and discuss the factors that affect diffusion related to exchange between the microcirculation and nearby cells.

5. Describe the Starling Fluid Flux concept and equations. Describe the formation of lymph and control of tissue fluid volume.

6. What are the important factors that determine Pmc (mean circulatory pressure)? What happens to Pmc when the heart stops? Why?

7. Describe calcium handling by vascular smooth muscle (VSM). How do norepinephrine and nitric oxide produce contraction and dilation of VSM?

8. Explain the interaction between vascular function and heart function curves in the context of blood volume, heart contractility, and heart failure.

9. What are the important factors that control coronary blood flow and resistance?

Respiration

1. How does an inequality of alveolar ventilation and pulmonary capillary perfusion cause hypoxemia?

2. Humans are normally less sensitive to hypoxemia than hypercarbia or acidemia. Explain.

3. Explain the transport of oxygen and carbon dioxide in the blood with specific reference to hemoglobin.

4. What is meant by diffusion and perfusion limitations to gas exchange? What are the consequences of these limitations in normal physiological circumstances?

5. Discuss the overall neural control of breathing and include the influences of central and peripheral components.

6. Explain the respiratory and cardiovascular consequences of a pneumothorax.

7. Discuss the major factors that regulate pulmonary blood flow and pulmonary vascular resistance.


Nervous System 1. Describe the location of and the

mechanisms related to the temperature regulation center in the hypothalamus.

2. Describe the autonomic nervous system including its location and pathways; distinguish between sympathetic and parasympathetic systems.

3. Describe the release of neurotransmitters released by the sympathetic and parasympathetic pathways and the receptor mechanisms associated with them. Compare and contrast epinephrine, norepinephrine, and acetylcholine.

4. Describe the baroreceptor reflex related to the changes in blood pressure that occur when a person changes from a reclining to a standing position. Include the pressor (SNS) and depressor responses. Mention orthostatic hypotension.

5. Describe the dual mechanisms of sympathetic and parasympathetic control of heart rate and force of contraction. Include transmitter function.

6. Describe the “fight or fright” response that may occur following the sudden appearance of a fierce foe.

7. Describe the role of the hypothalamus in mediating the skeletal muscle blood flow during the fight or flight response.

8. Describe the fainting or “playing dead” response that can occur during a very emotional response by an individual.

9. Describe the enteric portion of the autonomic nervous system including its location and transmitters.

Kidney PowerPoint Presentations (Limit 15-20 minutes) about Kidney

1. Explain the concept of Tm for reabsorption and secretion. Use the Tm for glucose and the Tm for PAH as examples using graphs to compare and contrast each one.

2. Explain the role of the loop of Henle in dilution and concentration of urine. Include the actions of ADH and the roles of vasa-recta capillaries, urea, and renal prostaglandins.

3. Explain renal clearance of inulin and PAH. Also explain relative renal clearance. Describe the use of the relative inulin U/P ratio and the number line.

4. Explain renal handling of calcium. Include all actions of PTH in the kidneys.

Other Questions about Kidney 1. Explain glomerular filtration. Include

Filtration barriers, balance of Starling forces, PCOP, and afferent/efferent arteriole control effects on GFR.

2. Explain the mechanism of proximal tubule reabsorption of Na+, Cl- and water.

3. Describe potassium handling by the kidney. Include the difference between proximal and distal tubule mechanisms.

4. Describe the many hormones affecting Na+ reabsorption in the kidney.

5. Explain control of renin secretion and the actions of aldosterone in the kidney.

Endocrine

1. Compare the relationship between the hypothalamus and the anterior pituitary to that of the hypothalamus and posterior pituitary.

2. Explain the mechanism of action and effects of insulin and contrast the differences between Type 1 and Type 2 diabetes mellitus.

3. Discuss the fight or flight response. Describe hormone origin, production, release and the metabolic and physiological effects.

4. Diagram and discuss the regulation of ADH secretion.

5. Describe at least four conditions related to either hyper- or hypothyroidism that could lead to the formation of a goiter.

6. Explain in detail the mechanisms (two direct and one indirect) by which PTH causes an elevation in plasma ionized calcium levels.

7. Draw a diagram of a typical menstrual cycle with changes in anterior pituitary, and ovarian hormone levels along with development of the follicle and changes in the uterus.

8. Discuss the secretions of the adrenal cortex with emphasis on the actions of cortisol and aldosterone.

9. Contrast the mechanism of action of protein hormones, steroid hormones and thyroid hormone. Also explain the second messenger concept.

10. Describe the regulation of secretion of growth hormone and describe both the growth promoting and metabolic effects of this hormone.


Gastrointestinal 1. Describe the forces and sequential

contraction of muscles of deglutition. Discuss the effect of autonomic denervation of the upper and lower esophagus.

2. Describe the Parasympathetic and Sympathetic autonomic control systems/mechanisms in the stomach and/or intestine.

3. Describe how acid is secreted by the stomach including potentiating factors and how buffering, H2 blockers and proton inhibitors function. Be prepared to discuss the ramifications on other aspects of the GI tract to chronic increased or decreased acid production.

4. Describe both the function and regulation of the GI endocrine control mechanisms (including but not restricted to: Gastrin, Secretin and Cholecyctokinin (CCK)).

5. Discuss the exocrine secretions of the pancreas. How do humans control pancreatic, liver and intestinal secretions?

6. Discuss the formation, storage, secretion and digestive mechanisms involving bile. Conclude this discussion with how fats and lipids are digested and absorbed.

7. Describe the types of motility and their control in moving the digested foods through the GI tract.

8. Define the process by which carbohydrates are digested and absorbed.

9. Describe how proteins are digested and absorbed.

10. Describe vomiting and defecation and the control mechanisms involved.

Acid-Base

1. Why is the bicarbonate buffering system the most important in the body? Be sure to include the concept of buffering power.

2. Give an example of how metabolic acidosis with partial respiratory compensation might occur.

3. Describe the phosphate buffering system. Explain where it has its major effects and why. Include the concept of buffering power.

4. Can the use of diuretics affect acid/base balance? Explain your answer.

5. Derive the Henderson-Hasselbach equation and explain what it means.

6. Describe how COPD can influence acid-base balance.

7. Which is more likely (common) and why: respiratory acidosis or respiratory alkalosis?

8. How does aldosterone stimulate H+ secretion and where does this occur along the nephron? What is diffusion trapping?

9. Describe how diabetes mellitus alters acid-base balance?

Shock

1. Describe and illustrate the compensatory mechanisms that occur in mammals that act to provide a sustained cardiac output and a sustained peripheral blood flow following loss of blood (hemorrhage).

2. Describe and illustrate the loss of compensatory mechanisms and the development of circulatory decompensation, progressive failure, and irreversibility that can occur in late hemorrhagic shock.

3. Describe myocardial depression in the later phases of hemorrhagic shock. Do positive feedback mechanisms related to the progression of circulatory shock.

4. Describe and illustrate the changes in renal blood flow that occur as a result of hemorrhage. Include a discussion of acute renal failure.

5. Describe shock as it may occur as a result of sepsis. Compare and contrast septic shock with hemorrhagic shock.

6. Compare and contrast cardiogenic shock with hemorrhagic shock.

7. Compare and contrast anaphylactic shock with hemorrhagic shock.

8. Describe shock as it occurs following large burns.

9. Describe and illustrate Multiple Systems Organ Failure; describe and illustrate the organ damage concepts. Mention survival statistics etc.

Exercise and Temperature Regulation

1. Discuss the factors involved (potentially involved) in the increase in maximal oxygen uptake that is found with exercise training.

2. Differentiate between the factors involved with the hyperthermia found with exercise and the hyperthermia that often accompanies illness.

3. Discuss and contrast the fatigue that occurs with short-term intense exercise (a few minutes) and the fatigue that occurs with long-term sustained exercise (hours).

4. Discuss blood flow distribution (skin, muscles, internal organs) and temperature regulation during exercise in different environments (e.g. desert, tropics, polar).


5. A person is performing long-term exercise in a hot environment. He/she is sweating profusely and then rather suddenly the sweating decreases/stops. Why has this happened? What are the mechanisms? Is this helpful/harmful?

6. Why does ventilation increase during moderate intensity exercise?

7. Explain the physiological consequences of the Anaerobic Threshold.

8. What are the consequences of moderate exercise on systemic arterial blood pressure?

9. How are cardiac output and ventilation related to metabolic rate changes? What are the regulated mechanisms?

10. What are the consequences of exercise training to heart rate at rest and during exercise?

Results This year there were 156 medical students in the medical physiology course (PHZB 801), 6 graduate students in the Advanced Physiology course (PHZB 611), and 8 graduate students in the Integrated Physiology course (PHZB 609). The ratings and comments from medical students about the small-group activities that used “active learning” were derived from the online survey done at the end of the first year of medical school where all the first-year, basic-science courses were surveyed together. In 2009, the small-group, active-learning component of medical physiology was rated 4.47 ± 0.73 (mean ± SD, n = 123 respondents) on a Likert scale from 1-5 with 5 being best. This score compared with other components of the course that were rated from 4.2 to 4.6 in 2009. In a comparison of years 2006 through 2009 (see Table 1 below), it is apparent that the active learning component was rated higher after the first year it was introduced (2006) and may have had an impact to raise the overall course rating as well. However,

the scores are not statistically different from one year to the next and because other curriculum changes were made during those same years, the trend in the results cannot be attributed solely to the use of active learning. Of the fourteen graduate students surveyed, six were typical graduate students seeking a 4-5 year PhD degree after coming from a four-year undergraduate program. Eight were MDs seeking a PhD while in medical residency at the University of Louisville. Each student had a faculty mentor, nine of which were associate faculty mentors outside our Department. Representative comments from two typical graduate students and two mentors involved with these courses summarize the outcome. These comments reinforce that the courses which focused on active learning methods are viewed as very demanding but at the same time very beneficial to the students and their mentors. The student ratings ranged from 3.45 - 5.00 on a scale from 1-5 with 5 being best, averaging 4.56 ± 0.56 (mean ± SD, n = 7). Discussion There are many opinions, albeit biased, about what is most important to teach in the life sciences. Vander promotes that a particularly large emphasis should be placed on integrative physiology.2 Hansen and Roberts state that “whole body physiology is at the center of both medical science and clinical medicine”.3 Rosenberg et al. point out that “the extrapolation of findings at the cellular level is not always meaningful, because the whole is inevitably not the sum of its parts”; they state that physiology “should emphasize the study of organ systems and especially that of the intact body”.4 Claude Bernard ended a discussion on the place of physiology among other sciences by declaring: “But I repeat, in all of this, it is life which is the object and the other sciences are only means of investigation. It is therefore necessary above all to be a physiologist”.5

The preceding references address the “what should Table 1. Medical student ratings of the active learning components of Medical Physiology. The values are mean ± Standard Deviation, n = number of respondents. Year Respondents/class size Active learning component rating* Overall course rating* 2006 130/146 4.10 ± 0.87 4.22 ± 0.81 2007 109/150 4.43 ± 0.61 4.43 ± 0.63 2008 122/153 4.44 ± 0.74 4.48 ± 0.75 2009 123/156 4.47 ± 0.72 4.45 ± 0.73 * ratings are based on a Likert scale of 1 to 5 with 5 being the best score


be taught” component of medical and graduate physiology, namely systemic physiology, but do not explain the “how it should be taught” approach. “Passive learning” in the form of didactic lectures, passive note taking, and multiple choice testing has been a common method of teaching the discipline of physiology. Richardson suggests that a well organized lecture is still an effective way to present information on complex topics, which are often encountered in the teaching of physiology.6

However, another useful and complimentary approach is to utilize “active learning” which is defined as “the process of having students engage in some activity that forces them to reflect upon ideas and how they are using those ideas”.7 Even with an active learning approach, physiology is hard to learn. Michael reports a faculty survey that defines three categories of possible factors contributing to physiology being hard to learn.1 Those categories are: 1) the nature of the discipline, 2) the way it is taught, and 3) what students bring to the task of learning physiology. Characteristics of the discipline are that it requires causal reasoning, use of graphs and mathematics, and is highly integrative. Some characteristics of students which complicate their learning of physiology are: they believe learning and memorizing are the same thing, they compartmentalize, and they cannot or will not attempt to integrate. There are many factors in a cooperative learning environment, regardless of its specific format, that contribute to the achieved success. One of these factors is the requirement that participants talk to one another, articulate their understanding of the subject matter, and ask and answer questions. These behaviors facilitate learning in all disciplines. Meaningful learning is facilitated by articulating explanations, whether to one’s self, peers, or teachers. A central part of learning any discipline is learning the language of that discipline.8 Learning a language requires practice using that language, and thus, it is important that students have the opportunity to hear, read, speak, and write the language of the discipline being learned. There is an even more specific benefit to encouraging students to explicitly articulate their understanding of a topic. A large body of research, much of it by Chi, demonstrates that articulating self-explanations and using self-explanation improves learning.9 Rivard and Straw report that both talking about and writing about important concepts improve meaningful learning and retention. 10 Deciding the best method or combination of methods to teach medical and graduate students

about physiology is an ongoing process at many schools. Michael and Modell review our current understanding of the learning process and discuss key ideas about learning that apply to active learning in the science classroom. 11 Individuals are likely to learn more when they learn with others than when they learn alone.12 Students generate better solutions to problems when they work cooperatively rather than when they work alone.13 And the idea of peer instruction, described by Mazur, increases student mastery of conceptual reasoning and quantitative problem solving.14,15 Given that peer instruction improves conceptual reasoning, there is still the matter of just how to apply any peer approach specifically to the perceived difficulties in learning physiology. Those difficulties include the following list presented by Michael1:

1. Students believe that “learning” is the same thing as “memorizing”.

2. Students compartmentalize (pigeon-hole) everything, failing to look for, or see, commonalities across organ systems or phenomena.

3. Students fail to appreciate the integrative nature of physiological mechanisms; they don’t want to think about respiration now (while learning acid/base balance) because they studied respiratory physiology months ago and have already passed the test on that subject.

4. Students assume that ALL physiological responses must benefit the organism.

5. Students tend to ignore graphs, tables, and figures, and when they attempt to use them, they don’t understand the meaning.

6. Teachers talk (physiology) too much and students talk (physiology) too little.

To address the need for more active learning and apply it in ways to address Michael’s perceived difficulties in learning physiology, the format of our course design stressed peer-instruction of integrated systems. It is increasingly clear that the challenge of learning facts about a physiological mechanism is quite different from the challenge of learning to solve problems with those facts. So, if you expect students to use knowledge to solve any kind of problem, you must provide them with opportunities to practice the needed skills required to discuss and explain the problem and receive feedback about their performance. “There is a great difference between teaching and learning. In fact, there is too much teaching and not enough learning”.2,16 Teaching is not simply telling students what we know, but it is instead, showing students


how we learn.17 Like Lujan and DiCarlo suggest, we needed to avoid the pitfall of providing too much teaching and not causing enough learning.18 Modell notes that if it is the student’s job to learn, it is the instructor’s job to help the learner to learn.19 First and foremost, teaching is not about the teacher at all! It is much more about the learner! It means that the teacher should not ask, “How should I present this?” Instead, the teacher should ask, “What does the learner need to learn, and how can I help the learner accomplish this goal? What we decided that the present-day student needs is to learn how to present important systemic physiology concepts in a spontaneous, but organized and clear manner. The evidence that “active learning” is an effective pedagogy in teaching physiology recently was reviewed by Michael.12 He concluded that “There is evidence that active learning, student-centered approaches to teaching physiology work, and they work better than more passive approaches. There is no single definitive experiment to prove this, nor can there be given the nature of the phenomena at work, but the very multiplicity of sources of evidence makes the argument compelling.” Our long-term experience also has been that physiology is hard to learn. But, during the last five years, when we consciously incorporated various active learning approaches (particularly peer-teaching) into our courses, the students became better at articulating and communicating that they had learned physiology. Michael’s 2007 survey showed that there are several sources for difficulty in learning physiology.1 They include that “the language of physiology is mixed with scientific meaning sometimes being different than their common meanings”. Physiology is a discipline where fluency in the language of the science is important. That importance is stressed in our oral presentation format. Faculty and student peers make comments during and at the end of the student’s presentations. Comments may include how the material may have been presented differently, and whether there was any important information omitted or inappropriate information included. This feedback ensures that even though only one student answers the question, all students must be prepared to discuss each question or topic. The faculty facilitators often use leading questions during the presentation to encourage a student to discuss important subject matter that has been omitted or incorrectly presented. During this process, students realize very quickly that memorizing material for a multiple choice test and learning the same material in order to make a coherent presentation are two very different things, and the latter requires a much better understanding. In addition, students learn

that they cannot compartmentalize information about a single organ system. Instead, they learn that the nature of physiological mechanisms is integrative across organ systems. Michael’s 2007 survey also suggested that students tend to ignore graphs, tables, and figures. 1 Thus, the use of graphs, tables, and figures, with their proper labeling in accepted physiological terminology, were points of emphasis for our courses. The design of the courses entitled “Medical Physiology, “Advanced Systemic Physiology”, and “Integrated Systemic Physiology” as part of the medical and graduate curriculum in the Department of Physiology and Biophysics at the University of Louisville School of Medicine incorporates many ideas which came out of Michael’s survey.1 In our “Peer Teaching” approach, which utilized student’s oral presentations to specific assigned questions or topics related to the various organ systems (see Materials and Methods), we specifically addressed each of the following points highlighted in the survey. Our process has students engage in an activity that forces them to reflect upon ideas, and how they use those ideas. It requires students to assess their own degree of understanding and skill at handling and presenting concepts or problems in a particular discipline. The role of instructors is to provide students with opportunities to learn independently, to learn from one another, and to develop the effective oral presentation skills they need to work effectively with their peers. This approach is thus a student-centered rather than teacher-centered form of instruction. The medical students were enthusiastic about the “active learning” approach and the kind of learning that was obtained, which is reflected in many comments received from the medical students as part of the online survey already described:

“The PBLs were very useful in strengthening our knowledge of the material … I wish there were more of them.”

“Although the TBLs were stressful, they helped get us ready for the block exams.”

“I loved the TBLs and the PBLs. The TBLs provided a great way to really understand the material in depth.”

“I really liked the PBLs. It was a good way to review old material and apply it to a clinical setting.”

“I like the TBLs because it helps me keep up with the material in the course.”

“TBLs were an excellent way to challenge us and ensure we stayed up on the material.”


“The Sims and PBLs are great integration of material.”

“Although the TBLs were frustrating, they really did force us to learn the material, so overall they were beneficial.”

“There was novel integration of multiple learning formats (PBLs, TBLs, SIM center exercises).”

“TBLs really help keep students current and actively assessing how well they know the material.”

“The PBLs were great as far as helping us to apply what was taught in class to clinical situations.”

“The TBLs also helped with motivating me to stay caught up with the material.”

Our approach to use “peer teaching” with medical resident physicians seeking a PhD in physiology also provided telling comments like those received from the following two students:

“As a PhD student, I have learned a lot of career key points, including: 1) Ability to summarize important physiological findings in the most integrated way possible, 2) Improved presentation skills with ability to elaborate on key points, 3) The ability to interconnect all the physiology sections in each session; thus, adding a sense of understanding and comprehension to the whole picture, and 4) As a clinician, this course helped me in illustrating sensible explanations for a lot of key clinical pathologies. Eventually, these lessons improve patient care at the bedside and add more understanding and perception that, as a student in medical school years, we did not have enough time to develop.” “With regards to the 609 course, I am a big supporter of the interactive teaching method employed which expects and allows students themselves to explain a concept or topic and then be questioned on it. The reason I say this, is it forces the student to learn, but also and more importantly, understand the material. It eliminates the down-side of exams, "unluckiness and misfortune", traditionally bad performers on standardized testing, etc. Finally, it allows the students to be pushed to their limits and thus differentiates between different calibers of students. This ability to differentiate between students is important because most exams can only go so far to

push students and really find out who really has developed a strong grasp of the material. If I am ever in a position to design an educational source, all assessment and learning will be in the 609 format, perhaps preceded by several weeks of lectures. I cannot tell you how much my grasp of physiology has improved because of that course. I hope my words have partly reflected that above.”

The final result is that these courses seemed to accomplish what we set out to do. One way to summarize the result is to say “the students learned and could explain physiology” rather than “the faculty taught physiology”. Notes on Contributors GARY L. ANDERSON PhD, JOHN C. PASSMORE PhD, WILLIAM B. WEAD PhD, JEFF C. FALCONE PhD, RICHARD W. STREMEL PhD, and DALE A. SCHUSCHKE PhD All authors are affiliated with: Department of Physiology and Biophysics University of Louisville School of Medicine Louisville, KY 40292 Keywords Active learning, teaching causes learning, oral format


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