By: Joseph Miller, PhD | Aquifer Curriculum Integration Specialist

“There is only one way to eat an elephant: a bite at a time.” (Desmond Tutu)

Making a small change in the way you teach can have a significant impact on student learning and it doesn’t require a heavy lift.  In this blog, I will describe six simple activities that you can implement immediately with Aquifer’s Integrated Illness Scripts that will lead to improved student learning and, over time, better and safer patient care.

Integrated Illness Scripts (IIS) are a more effective way for students to learn the basic science causal mechanisms of common diseases.  Aquifer’s IIS organize common clinical features and basic science causal mechanisms together in a blended description, which is an approach that has been shown to improve transfer from one learning context (basic science) to a new context (clinical scenarios) (Baghdady et. al. 2013). Integrated Illness Scripts present an opportunity to change the way we teach students about causes of disease.  However, getting started with new teaching and learning tools is inherently difficult and, for time-strapped health professions educators, overcoming the contextual barriers can seem impossible.  What follows is a selection of six activities from Aquifer’s IIS Activity Cards that are available to Aquifer Curricular Partners (subscribers to all five Aquifer courses) in the Educator Resources section of your Aquifer account.  These activities are short (as little as five minutes), require almost no preparation, and leverage strategies shown by cognitive science to improve learning. 

Clinical Communication

(5-10 Minutes)

Clinical Communication is an activity where the students are expected to use what they have learned from studying the Integrate Illness Script for a common condition to explain why that condition happens to their patient.  For example, during the pediatric clerkship prior to newborn nursery exposure, assign the three IIS related to neonatal jaundice ( ABO Hemolytic Disease of the Newborn, Breastfeeding Jaundice, and Physiologic Jaundice). Have the students explain to a parent (or a colleague role-playing a parent) why their infant developed jaundice. Provide feedback on the clarity of communication, level of language used, and accuracy of the information.

100% (n=10) of the Student Advisory Group session participants said that they would recommend faculty use the Clinical Communication activity with clerkship-level students.

In this scenario, the students would be expected to draw on information in the IIS and effectively communicate the basic science reasons for jaundice. When explaining complex processes learners will often look for examples to describe what is happening. Identifying concrete examples of a complex concept increases the understanding and probability of remembering it (Pavio et. al. 1994). Students appear to favor this activity in the clerkship year because it has practical value, but it is also a simple and effective way to encourage understanding of basic sciences.

Minute Paper

(5-10 Minutes)

One surprisingly effective strategy for helping students learn and remember the basic science causal mechanisms of illness is to have them write a Minute Paper (Lang 2021). One way to use the Minute Paper is prior to a required didactic on the diagnosis and management of diabetes, assign students to study three scripts (e.g., Diabetes Type 1, Diabetes Type 2, DKA). In the first 10 minutes of the didactic, ask each student to complete a Minute Paper (write for three minutes on one of the conditions) and then turn to a fellow student in the class and discuss for five minutes.  The Minute Paper activity leverages retrieval practice to improve memory of the important elements of the disease process.  Just the act of remembering is a powerful strategy for improving student learning. Having the students pair with a colleague and share what they know is an active learning approach linked to improved outcomes. You can also collect these short papers and review for gaps in student knowledge and tailor future didactics to address misconceptions and important content.  The IIS Activity Cards include three different versions of the Minute Paper with different writing prompts. 

Elaborative Interrogation

(10-20 Minutes)

Elaboration is an oft-identified strategy for improving learning by connecting new content to existing knowledge. Elaborative Interrogation is a specific approach to using elaboration by asking questions about how and why things work and then coming up with answers (McDaniel and Donnelly 1996). The IIS Activity Card Elaborative Interrogation encourages a more active learning environment by putting students in pairs and having the students interview each other using a series of what, why, and how questions about Integrated Illness Scripts that they have studied prior to class. The suggested questions for interrogation include: 

• How do the specific Clinical Features happen?  
• What is the most important basic science Core Concept for me to understand with this illness and why?
• What is the underlying pathological insult?
• What Core Concepts do you think are difficult for students to understand in this illness and why?

Elaborative Interrogation is an effective approach to making learning more active.  For example, prior to a physiology class, faculty could assign students to study the three IIS related to Shock (Cardiogenic, Hypovolemic, Septic). During class, assign pairs of students two of the IIS related to Shock to discuss. Have the students complete Elaborative Interrogation interviews, switching after five minutes. Following the interviews, ask the pairs to report out on one pearl from the discussion to share with the class (or small group).

What are the Clinical Features?

(10-20 Minutes)

When students are asked to think about too much information their brains can be overloaded making learning difficult. Educators often think about how to effectively reduce cognitive load so that learning is more efficient. What are the Clinical Features is an activity intentionally designed to reduce cognitive load and maximize learning. This activity asks students to write in the clinical features on a writable handout version of the Mechanism of Disease (MOD) Map.

80% of the participants in the Student Advisory Group discussion on the IIS Activity Cards said they would recommend this activity during the clerkship years. 

For example, during either emergency medicine, family medicine, or internal medicine rotation, faculty could assign students to study the scripts for Pneumonia, Pneumothorax, and Pulmonary Embolism. At the beginning of a lecture on common pulmonary problems or at the beginning of a clinical session, provide the students with the writable MOD map of each of the three conditions (available for download from your Aquifer account). Ask the students to independently fill in the missing Clinical Features and turn them in. After the students have turned in their assignment, share the completed MOD map and review it with the students. The process of reviewing the MOD map with some (not all) information missing facilitates the retrieval practice of key information.

Illness Analogy

(20-30 Minutes)

Analogies create associations between the known and unknown (or lesser-known), which serves to strengthen understanding, and students that have used a teaching and learning approach dependent on analogies reported that it improved their learning and enhanced communication skills (Kanthan and Mills 2006). An Illness Analogy is an activity where students work together (pairs or small groups) to develop an analogy (visual or verbal) that explains a disease’s Core Concepts and how they cause particular Clinical Features. To create effective analogies, students should be reminded that they are short and simple, easy to visualize, and use a common concept that people understand to explain the more complex concept. The Illness Analogy would be an effective activity to deepen understanding of the basic science related to inflammatory bowel disease.  During pathology or a gastroenterology basic science course, assign students to study the two IIS related to inflammatory bowel disease (Ulcerative Colitis and Crohn disease) and to develop one or two ideas about an illness analogy. During class, create groups of 3-4 students and give them 20 minutes to finalize one analogy about either Crohn disease or Ulcerative Colitis. At the end of the class, collect the analogies. (Optional: All analogies are shared at the end of the class through a medium of your choice (e.g., poster, handout, slideshow).)

Simple Compare and Contrast

(20-30 Minutes)

Identifying similarities and differences helps learners gain insight, draw inferences, make generalizations, and develop or refine schemas (Holyoak, 2005). When presented with appropriately arranged contrasts, students are likely to notice new features they hadn’t noticed before and learn which of those features are relevant to a particular concept (Bransford, Brown, & Cocking, 2000). The Simple Compare and Contrast is intentionally designed to challenge students to compare and contrast how Core Concepts lead to Clinical Features in two different common conditions.  On the surface, some cases and symptoms may seem the same but have different causal mechanisms. In this activity, students are asked to review a group of sibling IIS prior to class.  During class, students use the Simple Compare and Contrast handout (on Aqueduct) to describe how the Core Concepts differ in each illness.  After completing the handout, students can check their work with a colleague or be encouraged to check their answers with the IIS after class. Comparing and contrasting disease processes and checking their work promotes metacognitive and self-directed learning.  

Integrated Illness Scripts are a new teaching and learning tool that have the potential to improve student learning and increase the safety and effectiveness of patient care. Starting small, trying one of the activities described in this blog post (or by selecting a different activity from the full set in the Educator Resources) will make a big difference in student learning. The IIS Activity Cards are quick and so simple that they will fit in almost any context.

References

Baghdady, M. T., Carnahan, H., Lam, E. W., & Woods, N. N. (2013). Integration of basic sciences and clinical sciences in oral radiology education for dental students. Journal of dental education, 77(6), 757-763.

Bransford, J. D., Brown, A. L., & Cocking, R. R. (2000). How people learn (Vol. 11). Washington, DC: National academy press.

Holyoak, K. J. (2005). Analogy. In Keith J. Holyoak and Robert G. Morrison (Eds.), The Cambridge handbook of thinking and reasoning (pp. 117-142). Cambridge, MA: Cambridge University Press.

Kanthan, R., & Mills, S. (2006). Using metaphors, analogies and similes as aids in teaching pathology to medical students. The Journal of the International Association of Medical Science Educators, 16(1), 19-26.

Lang, J. M. (2021). Small teaching: Everyday lessons from the science of learning. John Wiley & Sons.

McDaniel, M. A., & Donnelly, C. M. (1996). Learning with analogy and elaborative interrogation. Journal of Educational Psychology, 88(3), 508.

Paivio, A., Walsh, M., & Bons, T. (1994). Concreteness effects on memory: When and why?.  Journal of Experimental Psychology: Learning, Memory, and Cognition, 20(5), 1196.