101 – Team-Based Learning is an Effective Way to Teach Appropriate Utilization of Hemostasis Laboratory Tests
Vania Zayat and Diane Davis Davey
University of Central Florida College of Medicine

PURPOSE: Team based learning (TBL) exercises are an effective method to promote both individual learning and teamwork. Coagulation is a challenging topic, and the purpose of this was to see whether a TBL involving a complicated bleeding diathesis case would positively impact their learning.  The TBL case requires students to discuss a differential diagnosis, describe rationally the logical order of ordering lab tests and analyzing the results, and treatment.  This allows students to become familiar with common uses for a variety of coagulation and hemostasis test methods, and potentially strengthen their competencies in laboratory medicine.

METHODS: This TBL session occurs in the 4-week Hematology and Oncology module at the end of the first year. Each TBL group has 6-7 students.  Prior to the TBL, they have lectures and online self-learning modules introducing the following topics:  hemostasis and thrombosis, bleeding disorders, both coagulation and vasculature/collagen defects, and platelet disorders. The TBL begins with sequential Individual and Group Readiness Assurance tests (IRAT and GRAT) with the same 10 multiple choice questions (MCQ) for each. The GRAT requires students to agree on the best answer as a team. This TBL group exercise allows students to explore and build the scaffolding required to integrate knowledge acquired previously. The goal is to determine the best, most effective and efficient way to work up and diagnose a patient with acquired Factor VIII deficiency. Each group is given a folder with the clinical case scenario, an image of a hematoma, and a white board with dry-erase markers. Each team has 15 minutes to record a differential diagnosis based on the clinical history alone, and then choose the best 3 initial lab tests from a list of 20 hematology and coagulation assays placed on storyline  (an e-learning authoring tool). They next record their list of differential diagnosis, sequence of next laboratory tests ordered, analysis of results, rationale for final diagnosis, and treatment. There’s a restriction of 11 labs to choose from, but are permitted to explore outside resources. A gallery walk of the completed white boards follows with each team voting on the best presentation; the team with the most votes discusses their findings and clinical approach. Finally, instructors provide additional case discussion, including elaboration about all 20 laboratory tests, common uses, and interpretation.

RESULTS: The IRAT average score was 77% ( rage 30-100%) compared to the GRAT ( 95-100%) group scores of 99.5%. Instructors noticed great enthusiasm for the exercise, and effective teamwork. Institutional program evaluation forms indicated that participants were pleased with the TBL format. Students stated they felt competent in their future approach to a bleeding patient and more familiarity with clinical laboratory hematology laboratory tests orders and result analysis.

CONCLUSIONS: TBL provides a powerful way of teaching students the clinical reasoning approach to a bleeding patient, and the appropriate use of laboratory test ordering and analysis. The format is viewed as enjoyable and interactive and teaches students how to narrow their differential diagnosis by effective laboratory utilization.

102 – Interventions in Pathology Education: A Systematic Review of the Tools Used to Measure Student Performance
Geoffrey Talmon, Sarah McBrien, Daniel Reiff, Andrew Braith, Erika Fennen, Yanwei Liu, Jonathon Ryder, Paige Scholer, and Emily Zurbuchen
University of Nebraska Medical Center

PURPOSE: Pathology education offers unique opportunities for instructional interventions in medical schools (laboratory and simulation activities, team-based learning, problem-based learning, eLearning modules, autopsy experiences). Measuring the effectiveness of these innovations is an integral part of the implementation process and should be done so in a rigorous, evidence-based manner.

Our initial impression of existing pathology education literature is that the tools used to measure an impact of an innovation on student performance often lacks approaches to measuring long-term retention and relies heavily on scales which measure student satisfaction or confidence and on pre- and post-test measures with small sample sizes.

The purpose of this systematic review was to synthesize data from studies conducted in pathology education at the undergraduate medical education level in order to analyze the tools used to measure and report on the effectiveness of instructional interventions.

METHODS: Six hundred fifty-five articles met the search criteria we developed with a medical librarian. Each paper was reviewed by two independent readers, the principal and secondary investigators and a group of medical students. A subset of manuscripts reviewed by students was concurrently reviewed by the principal or secondary investigator to establish reliability of the student investigators’ work.  If dissenting decisions were made about a study’s eligibility, the secondary investigator completed a third review to reach consensus.

RESULTS: For this poster, we intend to only report descriptive statistics related to our review; a full analysis of the interventions and tools used to measure them will be included in a manuscript.

Fifty-five manuscripts met our inclusion criteria: empirical studies of interventions in undergraduate medical pathology education. Data extracted from each manuscript related to sample size, instructional aim, type of intervention, outcome measurement, significance of results, and strength of evidence.

The majority of the studies focused on interventions in the basic science phase (43).  Eight studies were from the clinical science phase, and four studies included both phases.

The instructional interventions described in these manuscripts focused on medical knowledge (49), clinical skills (5), attitudes and perceptions (17), laboratory skills (4), and patient and family interaction (2). Four manuscripts were categorized elsewhere, and each study could fit into more than one category.

One study was identified as multi-institutional, and none included analysis of learning in a longitudinal fashion. Sample size ranged from 34 students to 1501 students. Five authors did not indicate their sample size. Thirteen of the studies reviewed for this project utilized randomization of subjects.

CONCLUSIONS: The use of satisfaction surveys, pre- and post-tests, and confidence ratings were overwhelmingly used to measure the strength of an intervention. Readers cited difficulty identifying specific design details from the Methods section of manuscripts.

More rigorous inquiry and stronger reporting of methodology and results are needed to strengthen the body of pathology education research.  Specifically, investigators should avoid measuring the effectiveness of an intervention on learning by gathering confidence or satisfactions ratings, turning their attention toward measures of actual learning, especially longitudinal measures.

103 – Teaching Pathology in the Twenty First Century
Shirley Siew
Michigan State University

“Teaching Pathology in the Twenty First Century” is a very timely topic, as everybody wants to keep up with the times. However, it raises the question as to what took place between midnight 1999 and the dawn of 2000 to have had a major impact upon the teaching of Pathology. Has there been a significant change in pathologic processes? What is required in order to teach Pathology? First- the students have to understand and apply Basic Processes, which are intangible-they cannot be seen by the naked eye, nor heard, nor touched, nor smelled. Some modern technologic methods may improve their illustration and make it easier for the beginners to grasp. The students must be taught to apply these basic principles, because knowledge that they do not apply is useless to them. Next they have to be taught to use their eyes in the objective examination of morphological lesions of disease processes, which must lead them to make logical conclusions. This necessitates  study at the microscopic level of morbid histology-Histopathology.  Is virtual microscopy superior in that respect to conventional microscopy? That is probably a matter of personal preference and examination at the Ultrastructural level of Electron Microscopy. Then the study of the lesions at gross level, Morbid Anatomy. However,nothing can replace the examination of Morbid Anatomy, preferably, in the fresh state at autopsy. Far from being a step forward into the future, at the present state of Medicine, this is a step back into the past. But, we must take out of the past that which is good. Above all, the students have to be taught to think  and have to be weaned from educated guessing in the twenty first and every other century.

There have been major strides in technology, but does the use of power point improve our teaching and make it easier for students to grasp and retain the subject matter rather than using a blackboard an colored chalk?

104 – Immune response to bacteria: An integrated learning module to help assemble the big picture towards competency in immunology in a clinical presentation based curriculum
Niti Manglik, Ellen Dudrey, Dolgor Baatar, and Janet Piskurich
Texas Tech University Health Sciences Center El Paso

PURPOSE: We recognized that we needed a resource in our curriculum to facilitate self-learning of complex immunological mechanisms underlying immune response to bacteria and their application into clinical medicine. Students find it hard to understand and retain concepts in immunology.  A step-by-step diagram of these mechanisms along with the relevant histopathology images and clinical context helps them comprehend these concepts more easily. The 2009 Scientific Foundations for Future Physicians Report of the AAMC-HHMI Committee recommends overarching principles and competencies that all medical students should demonstrate.  An associated learning objective for competency M4, most related to immunology, states that students should be able to “Apply knowledge of the mechanisms utilized to defend against intracellular or extracellular microbes to the development of immunological prevention or treatment”.  An overarching principle states that “Modern medicine requires the ability to synthesize information and collaborate across disciplines”.  Medical students express frustration that they cannot assemble a comprehensive big picture of how the immune system responds to a microbe and they find it difficult to integrate the relevant histopathologic and clinical data.

RESULTS: Out of a class of 108 students, 82 (76%) students accessed the module. Some accessed it multiple times.  The response rate for a survey given to assess student perceptions of the module was 55%.  More than 85% of students who participated in the survey felt the module was useful when learning material for the first time and was helpful in reviewing the material.  Over 90% of the students who responded to the survey felt that the module helped them to understand the big picture and to identify areas where they needed further study.

METHODS: A “big picture” integrated audiovisual module, along with a self-assessment quiz and a clinical vignette requiring application of the concepts presented in the module was prepared. The module consisted of a step-by-step explanation of immune mechanisms involved in a bacterial infection with detailed explanation and narration. Relevant pathology and histology images were incorporated. Students were also provided with a self-assessment quiz testing the concepts learned in modules and clinical vignette accompanied with multiple choice questions. This module was made available to first-year students as a recommended learning material during our sore throat clinical presentation week.  Data regarding student usage and perceptions as a useful learning tool were collected.

CONCLUSIONS: Providing a “big picture” diagram facilitated student’s ability to understand defense mechanisms against intracellular and extracellular microbes.  A diagram for extracellular microbes was published in MedEdPORTAL in 2011.  We updated this diagram as an animated, narrated, audiovisual module with inclusion of histopathologic material and a self-assessment quiz with a clinical vignette to provide clinical context.  Its use during the sore throat clinical presentation week provided a relevant clinical context and integration of disciplines. The student survey results were very encouraging and indicated that they considered this module as a valuable learning tool which enhanced their learning experience. This approach could be further extended to facilitate student’s knowledge of immune defense mechanisms against specific microbes, viruses and integrate various disciplines.

105 – Self-Directed Learning Modules: An Active Learning Tool for Stronger Motivation and Higher Achievement
Darshana Shah
Marshall University Joan C Edwards School of Medicine

PURPOSE: In the current era of high-stakes accountability there is considerable pressure to focus on student performance and to minimize the extent to which self-directed learning is taught, experienced, and encouraged. Preclinical years are challenging for most medical students and pre-clinical educators. In order for students to learn and apply their preclinical knowledge, they must be motivated, actively engaged, and personally invested.

METHOD: A session on nutritional disorders was prepared as a self-directed learning module. The material was broken into segments and followed an information-question-answer sequence. Each question-answer slide pair emphasized the material immediately prior and allowed for instant feedback. Questions incorporated fill-in-the-blank, true/false, and multiple-choice formats and ranged in difficulty from simple to challenging. A short survey was offered to receive student feedback and student performance on the cumulative block exam was monitored.

RESULTS: Student feedback reflected this module as a dynamic process in which students self-monitor, self-evaluate, and identify correctives to learn. These are critical skills that enhance student motivation and achievement, documented by their performance on the block exams.

CONCLUSION: Based on preliminary data that self-directed learning may be a meaningful learning tool, medical educators can apply a set of practical steps to facilitate this kind of teaching and reap the benefits. Students who (1) set goals that aid their improved understanding, (2) identify criteria, (3) self-evaluate their progress toward learning, (4) reflect on their learning, and (5) generate strategies for more learning, show improved performance with meaningful motivation. Surely, these five steps accomplish two important goals – improved student self-efficacy and confidence to learn – as well as high scores on accountability tests.

106 – Teaching Pathology in the 21st Century
Ritcha Saxena
All Saints University School of Medicine

PURPOSE: Pathology, the foundation of a successful medical career, bridges the gap between basic sciences and clinical medicine. A proper understanding of the subject is of critical importance. It starts in the second-year of medical education, and the students are encouraged to develop an appreciation of mechanism of disease with clinical correlation, in a short time frame.

The aim of the study was to develop and consider the usefulness of a new mixed method approach, based on active learning of clinical problems along with incorporation of teaching methodology of pathophysiology animations, digital microscopy and virtual pathology museum; to enhance the students’ learning of new concepts of pathology in a quick and effective manner, and to gain knowledge of their application and integration with clinical sciences.

METHODS: A hundred and twenty-two students were observed in two consecutive semesters, both for general and systemic pathology (Pathology I & II courses). Students were randomly divided into two groups; to be taught through conventional methods, the control group, or by the use of the new mixed method approach, the intervention group.

RESULTS: After the implementation of the study, the comparison between the two groups as well as the topics taught using the conventional methods versus the new mixed method approach technique showed that the intervention group performed considerably better. Their final scores were significantly higher as compared to the control group. The intervention group students reported that they experienced less stress and anxiety and felt more actively involved in the learning process.

CONCLUSION: In this era of extraordinary curricular reforms in medical education, it is crucial to revamp the pathology curriculum by incorporating cutting edge techniques in conjunction with active learning. The judicious use of a teaching strategy based on active learning with integration of virtual museum, digital microscopy and pathophysiology animations, offered a practical approach to enhance student enthusiasm in learning and integrating the concepts of pathological processes with clinical medicine.

107 – Demystifying Transfusion Medicine for Internal Medicine residents
Carla Caruso, Joseph Merlo, Elizabeth Frauenhoffer, and Melissa George
Penn State Health Milton S. Hershey Medical Center

PURPOSE: Transfusion medicine should not simply be viewed as an isolated branch of medicine. In this discipline, specialists in internal medicine, surgery and anesthesiology, interact with the blood bank staff (technicians, trainees, clinical pathology attendings and nurses). The main goal of this relationship is to coordinate the delivery of optimal patient care, often for a complex and critically ill patient population. Based on our experience and the review of the literature, we recognized a deficit in some basic knowledge concepts of transfusion medicine among internal medicine residents rotating in our blood bank. These deficiencies can lead to improper use of blood products and miscommunication between blood bank staff and clinical teams. Additionally, can cause delays in urgent patient care, and could potentially result in serious patient harm. Our long term goal for this project is to include targeted transfusion medicine education modules in orientation for internal medicine, surgery and anesthesiology residency programs. This will foster a better understanding of appropriate utilization of blood products, basic immunohematology, and recognition of transfusion reactions, with a secondary goal of improving communications between clinical teams and blood bank staff.

METHODS: Thirty two internal medicine residents from 1st and 2nd year of the Internal Medicine Program of Penn State Hershey Medical Center agreed to participate in this study. Third year internal medicine residents did not participate in the lectures and therefore were excluded from the assessment. Four educational modules focusing on blood products, identification of red blood cell antibodies, ABO/Rh compatibility and transfusion reactions were specially developed for internal medicine residents. The 30-minute modules were presented during noon conference on 2 consecutive days. An anonymous online-based survey (SurveyMonkey) with multiple choice questions was sent 3 days prior and 15 days after the lectures. Chi-squared distribution analysis was utilized to estimate the statistical significance of the results.

RESULTS: All the residents (32/32) answered the pre and post-lecture assessments. The results showed a statistically significant improvement in the knowledge of blood products and their use (p=0.023), red cell antibody identification (p=0.024), and ABO/Rh compatibility (p=0.004). There was a trend towards adequate knowledge of transfusion reactions. Anecdotally, participants in the educational intervention note improved utilization of blood products in their clinical practice.

CONCLUSIONS: Our data suggests that training incoming residents with brief modules targeting specific blood bank and blood transfusion principles results in significant improvement in medical knowledge.  The participants note increased confidence in blood utilization and smoother communication with the blood bank. Future studies are necessary to determine the outcome on improving patient care, reducing unnecessary blood product utilization and wastage.

108 – The Early Bird Catches the Applicant: Attracting More US Medical Students to Careers in Pathology
Nicole Williams and Elizabeth Frauenhoffer
Penn State College of Medicine

PURPOSE: Graduates of US medical schools are entering the field of pathology at a declining rate. Residency programs compete for the same excellent students and many fail to fill all available positions through the National Resident Matching Program (NRMP). According to NRMP data for 2016, there were 0.45 senior US trained medical students per available pathology residency position. We hypothesize that lack of early exposure to pathology during pre-clinical years is a major contributor of this trend.

METHODS: A retrospective review of exit survey data from third and fourth year medical students completing elective pathology rotations at Penn State Hershey Medical Center over a three year period from August 2013- August 2016 was performed. Nineteen third year and eighteen fourth year medical students responded to the survey (n=37). The students’ impression of pathology after a two to four week elective was evaluated.

RESULTS: The open comment section of the survey was the focus of this study. Only 22 of the 37 students completed this section; however there were common themes among student responses. All students stated they would recommend the pathology elective to other classmates and eight students specifically stated it would benefit all students. Another common theme was perceived lack of previous exposure to pathology. Students also stated they wished they had this exposure prior to making specialty choice decision during oral feedback sessions with faculty.

CONCLUSIONS: Many US medical schools have adopted integrated curricula that seamlessly blend courses to the point pathology is often unrecognizable to students. This lack of early contact during the pre-clinical years is hypothesized to be a cause of less US trained applicants entering into field of pathology. Our retrospective analysis was limited by low response rate of students to exit surveys after elective pathology rotations.  It was further limited by incomplete responses.

The results show that once students have intense exposure to pathology they thought everyone should have this exposure prior to third year when career decisions begin to solidify. A multifaceted strategy to increase exposure to pathology from the first day of medical school has been our charge this academic year based on the results of this data and oral feedback from students. A pathology student interest group was organized in 2013 for first and second year medical students; however activities were increased to include more resident and faculty interaction. More student exposure to pathologists has been built into the curriculum with increasing pathology content, lecture and laboratory time. Additionally a pathology laboratory workshop was designed for all third year medical students entering their required surgery clerkship. This multifaceted approach will insure that all medical students at Penn State College of Medicine are exposed to pathology early and often to reverse the current trends of medical student applicants.