Teaching pathology more effectively to medical students

A summary of our successful efforts in an international setting

Shivayogi Bhusnurmath, MD, FRCPath, Dean of Basic Sciences and Professor, Department of Pathology, University of Medicine and Health Sciences- UMHS, 

Bharti Bhusnurmath, MBBS, MD Pathology, Emeritus Professor of Pathology, St Georges University School of Medicine, Grenada, West Indies

Shefali Goyal, MBBS, DAB Path, USA, Recent Professor of Pathology,  St Georges University School of Medicine, Grenada, West Indies

1.   How does one make the expectation of what is to be learned clear to the student? 

Learning objectives

The different oversight bodies like the Medical Councils (8), State Education Departments, and Accreditation bodies usually have written documentation of the overall expectations, which is called the curriculum. It generally includes overall learning outcomes under knowledge, skills, and professional behaviors. The knowledge segment includes contents or topics (e.g., cardiovascular system), level of competence at a given stage (year 1, year 2, etc.), and discipline (subject) like Pathology, Physiology, etc. We will revisit this segment shortly. The skills component in the medical education context includes two broad categories- communication skills (how to take a history, interact with medical team members, patient’s relatives, administrations, convey bad news, etc.) and Clinical skills - (how to do a physical examination of the patient, perform certain basic medical procedures). The professional behavior component includes various components like being on time, completing assignments, participating in 3600 evaluations of the program, being courteous, demonstrating empathy, exhibiting cultural competence, avoiding racial gender bias, showing respect, etc.

The discipline of Pathology mainly deals with how and why a person (organ, tissue, cell) falls sick, how it tries to adapt, the consequences of serious injury or death of cells in various organs and tissues, their effect on the patient (symptoms, signs), laboratory evaluation to confirm the diagnosis, assess the degree of damage, monitor for complications and make a judgment on the course of the disease and outcome for the patient.

If we link this scope of the discipline of Pathology, which is essentially under the domain of knowledge (cognitive), to the clinical skills component, one realizes that there is a strong cause-and-effect relationship. A good clinician, while taking a patient’s history - would be asking relevant questions – main symptoms – their details, associations, etc. Then, based on the symptoms, there would be different types of physical examination of the patient based on the suspected diagnosis. All this history-taking and physical examination is based on scientific, logical thinking related to the symptoms and signs. This scientific logical thinking is called clinical reasoning. The various clinical departments like medicine, surgery, and pediatrics teach the student the art of history taking, the skills of physical examination, and the skills (psychomotor) of performing certain procedures like taking blood pressure, drawing a blood sample, collecting ascitic fluid, etc.

However, the clinical reasoning behind all these activities comes from a good learning of the subject of Pathology. Unfortunately, a lot of Pathology teachers regurgitate information from textbooks, which involves the course of disease, morphologic changes in the tissues affected, and how to make a diagnosis on the gross specimen, biopsy slide, or a blood or bone marrow smear.

The main learning of clinical reasoning, which includes how and why this damage produces the symptoms and signs, and how this pathology requires a certain set of lab investigations in the patient, is generally not included in the teaching by many Pathology teachers. This has led to many medical students treating pathology as a necessarily evil subject to be passed on the way to graduating from medical college to become a doctor. However, if the pathology subject is taught and learned as the essential basis of all clinical reasoning (Medicine), it becomes meaningful and exciting. It results in medical graduates who think logically and scientifically to approach any patient to make a diagnosis and prepare an action plan for management. It moves away from the current practice of learning by memorization just to clear the exam. In effect, it will improve the healthcare delivery in the region or the country because the doctors will be scientific and logical. The clinical departments can concentrate more on teaching communication and clinical skills since these clinical reasoning processes will be well learned in the Pathology course. The interactive time with the patient in the wards and OPD is very precious and it is better utilized by the clinical faculty to teach and assess the history taking, physical examination, and procedural skills rather than wasting it on the detailed discussion of differential diagnosis, lab investigations, etc. which are essentially clinical reasoning and can be taught in another setting which does not need the presence of a patient. The pathology teachers should adequately enable the students for this type of clinical reasoning through their teaching sessions.

Does this mean the teaching of entire medicine in clinical reasoning will be the responsibility of the Pathology department and the teachers? Is there enough time in the curriculum to achieve this? How many lectures do we have? How many lab sessions do we have? How can we cover the whole textbook of Pathology and teach medicine too? 

One of the main reasons for the confusion on what to teach and how much to teach is the lack of discussion and guidance (9). We, as teachers, remember how our teachers taught us and try to replicate the same to our students. We do use the prescribed textbook to collect information and most often behave like it is our duty to transfer that chunk of information to the students. Little do we realize that the present generation of students is much smarter than ours in gathering information. Students also figure out what is tested in the exam instead of acquiring the competencies to be a good doctor. Some Pathology teachers teach Pathology to medical students as if they are trying to make pathologists out of them instead of making them learn Pathology as the main basis to explain all effects on the patient. Teaching them to read a slide and tag it to a diagnosis like leukemia makes no sense if the student cannot correlate the altered morphology to explain the symptoms and signs of the patients. 

We realized this when, a few decades ago, a student called us to his computer to show the abilities of his seven-year-old son, who was with him in the teaching lab late in the evening. Every image he flashed on the screen, his son could recall by memory- liver carcinoma, pneumonia, etc. We got into serious thinking that if the son took the practical exam as it was conducted those days, he would have a very high score. Were we doing justice to the process of preparing tomorrow’s doctors through the Pathology course?

This brings us back to the question: what do we teach, and how do we teach? There have been suggestions to incorporate outcomes based on physician competencies in the curriculum (10). One of the professors in our formative years used to ask questions like – what do you know about amyloidosis? We used to feel that technically if we responded by stating we do not know anything about amyloidosis, we should still get a full score. We should start with a context or topic, for example, pneumonia or gastric ulcer. There could be big textbooks on each topic. What exactly do we expect the students to gain through one lecture session on the topic? That expectation is called the action verb. We could easily think of several action verbs for pneumonia – we expect the students to list the causes of pneumonia, the common age group affected, the common location in the lung, the symptoms, the signs, the x-ray appearances, the complication, list the cause of death. This appears to be a neat set of expectations, and in fact, many textbooks have a similar sequence of information. 

Let us now address two more important questions. If these are the expectations set and this information is available in the textbook or lecture handout we prepare and distribute to the students in advance, why should they come to the lecture at all? They will probably learn it better and faster by themselves at home at their convenient time. One can argue that the textbooks are like reference material and may have far more information than what is needed by the students in our class. We could still synthesize the required information as a summary or lecture handout in a Word document or PowerPoint and disseminate it to the students, which they can learn by themselves without coming to the lecture. We could send it out through email, WhatsApp (11), or a course website. We then need to provide something in the lecture that cannot be disseminated easily like this, the student could see a reason for attending the lecture. One thing that easily comes to mind is showing images or small video clips related to the expectations set. The current state of technology allows us to easily transmit these to the students who can learn them without coming to the lecture.

There are two ways to address the dilemma. One is to set the expectation higher. These students are preparing to become doctors. They are not high school students who can easily memorize and meet expectations. Let us relook the action verbs – they were all list, list, list. If our expectation is for them to list – they can memorize and list. Can we reestablish the expectations to hold them to a higher level of responsibility?

We might make this idea clearer if we visit a kindergarten class. The children first learn to read and write the alphabet. They then learn to associate each alphabet with an item – A for the apple, B for the ball, and C for the cat. They move on to associate the written word apple with a picture of an apple and so on. Next, they learn the spelling of each word and learn to fill in the missing alphabet- app_e (insert l). They then learn to pick out the image apple from a given bunch of images of fruits.

We can extrapolate the same concept in teaching Pathology to medical students. They are older and adult learners. For the topic of pneumonia, our job is to make them competent about the clinical reasoning part of pneumonia, i.e., how and why of common symptoms, signs, lab investigations, complications, and outcomes. It is a subtle but definite shift of action verbs from list to how, why and so what. This pushes the student to think, identify, analyze, distinguish, interpret, and solve problems. Thus, while setting expectations – which are technically called learning objectives – if we push them to this higher level of learning – explain the common symptoms and signs, the basis for laboratory testing, and the monitoring for specific complications, we are not limiting them to memorizations. The students also will realize that learning Pathology in this fashion will help them become scientific, logical doctors. They will learn Pathology as a vitally needed learning essential for becoming good doctors rather than just passing the exam. This is a good example of setting expectations for the students- write higher-level learning objectives  (12). Once the students realize that the exam questions will reflect the learning objectives, they will make efforts to meet those expectations.

An example of a learning objective for renal pathology

Compare and contrast the; 1) relative frequency; 2) etiology and pathogenesis; 3) clinical presentation, course, and prognosis; 4) laboratory findings; and 5) microscopic (light, immunofluorescent, electron microscopic) appearance for the following glomerular diseases:

1. minimal change disease

2. membranous glomerulonephritis

3. focal segmental glomerulonephritis

4. membranoproliferative glomerulonephritis

5. diabetic glomerulosclerosis

6. amyloidosis

7. acute proliferative (post-streptococcal, postinfectious) glomerulonephritis 

8. rapidly progressive glomerulonephritis (e.g. Goodpasture’s syndrome, Wegener’s granulomatosis 

9. Ig A nephropathy (Berger’s disease)

10. Alport’s syndrome

2. What are the methods to help the student learn and the environments where learning takes place?

Lectures, teaching labs, small groups, directed self-study, etc.

Once the philosophy of learning objectives related to clinical reasoning is accepted, the next apprehension in the minds of teachers would be the volume of the material. We have so few lecture slots and so much to cover; how can we achieve all that in the limited time? It is time to remember that this generation of students is much smarter. They are good learners. The tragedy is that we, as teachers, are killing their interest in learning by continuing to practice the age-old traditional teaching.

They are quite capable of learning a lot by themselves once we set clear endpoints or expectations for them and test them in the same way. We can use the lecture hall experience to practice a few of these experiences in an interactive way so that they can practice and learn the rest in their own time. It is, in a way, like cooking rice. When the rice grains are boiling, one only needs to pick up a spoon of the cooking grains to feel the softness and that too on one or two occasions. Based on the sample one can safely assume the bowl of rice to be cooked. We will explore in detail the different ways we can make the lecture experience interactive and provide an exciting platform for the students. We can then move on to planning teaching lab sessions and small group activities.

How to best utilize the lecture experience?

1. Start the lecture with a clinical story that directly reflects the learning objective. 

All learning objectives will be related to how, why and so what about Pathology on the patient- case-based teaching (13).. Raise questions from that patient's story that need to be answered that, in effect, will reflect on the clinical reasoning. E.g. a lecture on breast pathology- start with this slide-

 A 32-year-old female presents with a lump in her breast. She is worried that it could be cancer. What could be the diagnostic possibilities?

Abnormal physiologic response to hormones

Retained secretions

inflammation

Benign tumor

Malignant tumor

How can they be distinguished?

2.  Make the lecture session interactive. 

Monologues from the teacher become a boring activity. The attention span of a class for a speech does not last more than 7-8 minutes. Try to speak for less than 3-4 minutes at a stretch. 

How do we then make it interactive?

The natural response to attempting to make a lecture session interactive is to ask questions to students. This has some major negative effects. It puts the students in a defensive mode, and they feel very apprehensive about giving wrong answers in front of the whole class. The intimidation makes learning less exciting and, in fact, may hinder learning. Some may even start avoiding attending the classes. The response given by a student may not be representative of the ability of the class. It may make the teacher assume incorrectly whether the class has acquired competence or not. The teacher may waste time explaining a concept that is already well understood by the majority or may skip explaining a topic that is still difficult for the class because the chosen student answered it correctly. There is also the chance that throwing a question open to the class may draw a blank response from the class and the teacher may feel embarrassed and decide to move on with the monologue. Open-ended (free-response) questions may also attract long-winded answers from students, which will waste everyone’s precious time. 

We have found it very useful to use MCQs (multiple choice questions) as an inherent part of the lecture. These are all clinical vignette based, linked to the learning objectives. The first one at the start of the lecture has concepts related to what they have studied in the previous lecture or previous course (viz. anatomy of coronary arteries or physiology of cardiac muscle contraction at the start of lecture on myocardial infection). This is followed by a slide on the patient’s story on myocardial infections, mentioning age, gender, symptoms, signs, and predisposing factors like smoking. The teacher can make comments on how and why about each of thee items. 

The teacher could introduce a new question every few minutes. This could be an add-on to the original patient story asking a little more information on how, why, and so what; or a new patient story asking another aspect of the same Pathology. Each lecture of one hour could have about 12 – 15 such questions. Toward the end of the lecture, there could be one or two questions that test the concepts covered during the class. This will be a good summation and will also encourage students to be alert during the class.

The questions are included as part of the PowerPoint presentation for the lecture. The students respond by clicking on their clickers (14,15).. We have been using the audience response system from turning point technologies. This is similar to TV shows like “Who Wants to Be a Millionaire” They are not expensive, and there are a lot of companies manufacturing them in different countries locally at very reasonable rates. Several primary and secondary schools are also using them. Some institutions use the polling of responses through smartphones of students. This really does not incur any additional cost. The MCQ consists of a patient story, and the last line of the stem asks a question related to morphologic changes, etiology, pathogenesis, symptoms, signs, associations, lab investigations, complications, or course of the illness. These are four to five choices. A, B, C, D, E, out of which one is the correct answer (key), and the rest are called distractors. In human situations, there is hardly a condition of one truly correct and rest totally wrong answers.  The choices are constructed such that the students must quickly assess which of the five has the maximum truth in it, although the other four may have varying degrees of correctness in them. The students press the correct response key on their clickers or cell phones. The software instantaneously collates their responses into a bar diagram showing how many responded to each choice. It will also show them the correct answer. This way the teacher can instantaneously confirm if the class has acquired the learning objective. If the teacher sees from the responses that there is still an element of confusion or misunderstanding, he can immediately address it in the class. This will avoid putting any individual student on the spot by directing the question to him or her. This will also give an idea of the understanding of the class instead of individual students. Many of the software allows the tagging of the responses to individual unique numbers (IDs) for each student. This would help mark the attendance of each student in each lecture without any waste of time. This could also be used as one of the elements of in-course assessment (internal evaluation) and the cumulative percentage of correct responses over a module or course. This will provide documentation to the accrediting agencies about interactive learning and provide feedback to the class. The students will enjoy solving problems instead of passively listening to a monologue.

If the clicker questions are mainly used for attendance and are not constructed to really provide clinical reasoning learning activity, the students may resort to shortcuts to get their attendance by proxy. They may pass their clickers to friends to click for them and absent themselves from the session. They may get bored and click any answer randomly. The whole exercise will lose its purpose. It is imperative that the items created really make the students think, are clinically relevant, related to the learning objectives being taught and cannot be easily answered by memorization. The time allotted for the students should be based on the intensity of the taught process needed. We generally allow 75 seconds each. The teachers should try to immediately respond to provide the reasoning for the correct response and why a wrong choice picked up by a fair percentage of the class is not logical. This clicker interaction has tremendous potential and is only limited by our imagination. We have used it in several ways. We could use a question on a concept we plan to teach next and ask the students to discuss it among themselves for a few minutes before responding. They could refer to the textbook, class notes, or internet search for information during the discussion. We could also ask them to respond immediately but not show the correct answer. Allow them to discuss among themselves for 2-3 minutes and then respond again. Then show the correct answer and the distribution of their responses. This is followed by correcting any misinformation as reflected in their responses.

Another great utility of the clickers is to use the last lecture session or part of a module or system for an integrated review. A lecture of one hour can easily include 20 plus clicker items and the teacher can help review on the spot any misconceptions about the subject in this review session. It could be used as an internal assessment tool too. It will provide feedback to each student on their areas of weaknesses to provide a framework for catching up or to seek individual guidance from the teacher later.

Many of us as teachers are under the mistaken notion that students learn because we have taught them. Students learn in many ways and not necessarily because we taught them.  It is amazing how much they can learn on their own. Many institutions have in their goals that the graduate will be an independent and lifelong learner. How can we make sure we cover this objective in our teaching program? We can inform the students about the reading assignment and self-directed learning material for an upcoming lecture class in advance. This could include various components like pages or chapters from a textbook, a word or PDF file specially prepared by the teacher for the learning objectives to be covered, PowerPoint slides, videos on the internet selected by the teacher or prepared by the teacher, and reference articles published in a journal. These are provided along with the learning objectives and the date and time for the lecture session when they will be reviewed. 

The actual lecture session would then be used to generate interactive discussions with active participation by the students to address clinical reasoning issues (flipped classroom). 

We have used it in several formats.

1. Run a series of clicker questions with or without provision for the students to discuss before responding after each question is projected.

2. Divide the class arbitrarily into groups of 8-15 based on how they are seated. Provide prepared case scenarios with built-in short answer questions. A different case for each group. The groups get 8-10 minutes to discuss among themselves and come up with answers for each of the 3 or 4 short answer questions. The teacher is moving around the class during this time encouraging groups to think and guide them without providing the answers directly. The students are encouraged to use textbooks, the internet, lecture handouts, etc. if needed. The questions should be framed in such a way that the students cannot directly find the answers from the resources unless they analyze the symptoms, signs, and lab investigation data in the questions to come to a diagnostic possibility and then address the questions. At the end of 8-10 minutes, the teacher is back on the podium. He projects each case with the questions and asks the concerned group to answer each question. The other groups can get a chance to answer later if they have different views. The teacher summarizes the correct responses and may use a few slides with or without images to reinforce the learning. The teacher then moves on to the group with the next case and so on. At the end of the session all the students get copies of all the cases for different groups for their own study later.

We call this modified team-based learning under the banner of flipped classrooms(16). Traditional team-based learning (TBL) is very time-consuming and very intensive on the demands of the time of teachers and students, and it is not practical in many institutions with limited faculty resources. He modified the team-based learning activity we used, encouraged active, self-directed learning, improved our thinking on the feet, developed communication skills, improved team activity, and achieved targets much faster. One may wonder if we will be able to “cover” the entire topic this way. It is not important for us to “cover” everything in the class. In fact, it would be more advantageous if, in these modified sessions, we used case scenarios that were different from the lecture notes, slides, or textbook but related to the learning objectives. It encourages students to learn how to think, which is one of the most difficult things to teach. Once they participate in the discussion of a few cases like this, they can easily go back and apply similar analytical and interpretive skills to other cases included in the learning objectives. The lecture sessions become totally interactive. Students are active all the way through, and the teachers spend time developing these platforms for learning activities. The teacher also gets an opportunity to summarize and reinforce important concepts after each case discussion.

An example of student group modified team-based learning

An example of a case for a student group for modified team-based learning during the session on general pathology of neoplasia- ( the answers in dotted lines are not given to the group. The students in the group have to discuss among themselves, refer to the textbook, lecture notes and find out the answers)

The mother of a 2-year-old child brings him to his pediatrician because she recently noticed a mild squint in his left eye. Examination reveals a white pupillary reflex and mild proptosis of the left eye. MRI reveals left-sided orbital mass. Biopsy confirms the diagnosis of retinoblastoma

What category of genes is responsible for this child's condition? 

……tumor suppressor gene ……

What would the pathologist have seen on histopathology to confirm the diagnosis of retinoblastoma?

……Flexnor-Wintersteiner rosettes ……

List at least two native cell types responsible for the destruction of tumor cells in vivo.

……CD8 cells, NK cells ……

Laboratory sessions and small group training

Laboratory sessions and small groups are the other main sessions used in teaching pathology. They can also be made innovative to better achieve the learning objectives related to clinical reasoning. One of the current ways in which lab sessions are conducted in most institutions is to provide a set of glass slides of biopsies, autopsies, blood smears, and bone marrow aspirates and make the students put a diagnostic label for each. Some even ask the students to draw color diagrams of the slides and label the components. The lab exams are also conducted similarly, essentially making the students put diagnostic labels on slides. The students memorize the slides and more often tag a diagnostic label by not analyzing the morphologic features on microscopy but the external appearances of the slide or the way the container of a specimen looks (they remember these aspects from the lab sessions during the term). The essential exercise has been to attach diagnostic labels by any means. There is hardly any effort to assess the scientific morphologic reasoning for making the diagnostic tag. More importantly, there is virtually no effort to correlate the morphologic features with what they mean for the patient, like- What caused the alterations, how they generate symptoms, how this will correlate with physical signs to look for, how and why we pick and interpret particular lab investigations for this patient, etc.  These ideas will crop up if the teacher treats the slide or image as the representative of the patient it was drawn from, and the lab or small group exercise is meant to discuss issues related to the patient based on the altered structure. The learning activity totally moves to a much higher stratosphere.

There is also another way for the teachers to outsource the learning activity to the students without minilectures or monologues in these sessions. The less the teacher speaks and the more the students speak, the better the active learning process. We created groups of eight students each even for the lab sessions. The students take ownership of the discussions. We provide the learning objectives and the slides, images, specimens, etc., a day to a week in advance. We provide a rubric to the students, and they must study on their own before the actual lab session and come prepared with the write-up. If the teacher has the facility to allow them to upload their write-ups on a group site electronically, it could augment the efforts, but this is not a strict need. The rubric we follow is (or the slides, images, specimens): (4).

1. Identify (I) the organ or tissue giving reasons (self-recapitulation of anatomy and histology – vertical integration). If there is not enough material in the slide to identify the structure, the teacher provides the information- specifically for histopathology. For example, this is from the liver.

2. Describe the morphologic (M) alterations. One of the skills of a good doctor is describing a lesion or an observation. We encourage the students to describe in such a way that a person not looking at the slide or a blind person can vividly imagine what it looks like. If it is a gross specimen, the student indicates what would the histology of the lesion look like. If it is a histopathology slide, the student indicates what would the gross appearance of the lesion be like. 

3. Diagnosis (D) – The students use information from the textbook, lecture notes, etc., to reach a diagnosis based on the altered morphology and list the points that favor the diagnosis. Once the diagnosis is made, the subsequent steps move on to the patient from whom this slide was obtained and clinical reasoning.

4. Etiology (E) – What is the cause – bacteria, virus, ischemia, mutation (for the pathology) – is it itis (inflammation), emia (ischemia), oma (tumor)?

5. Pathogenesis (P) – what is the mechanism by which the etiologic agent damaged the tissues (direct toxicity, hypersensitivity, immune-mediated, etc.) – (recapitulation from microbiology course where relevant).

6. Symptoms (S) – what would be the altered functions of the damaged tissue, and what symptoms would they lead to, for example – cough, blood in the sputum, difficulty breathing, and pneumonia? Each symptom listed should be accompanied by an explanation based on altered morphology and physiology (neuroscience)- vertical integration. At the present level, when the student is studying pathology and has not completed training in clinical disciplines like medicine, surgery, pediatrics, etc., we encourage students to limit their write-ups to about three of the most common and easily explained symptoms.

7. Physical signs (S) – the student must extrapolate the morphologic changes in the slide to explain at least three important physical findings when one examines the patient.

8. Investigation (I) – based on the altered morphology the student must review the related biochemistry and physiology (vertical integration) to come up with at least three important lab investigations, justifying the basis on which these would be abnormal. The students are also encouraged to indicate which of them is done to confirm etiology, diagnosis, serenity of the disease, etc. ( this will also encourage them as future doctors to desist from requesting a whole lot of unnecessary lab investigations which increases the health care expenses and also can produce more damage to the patient if the doctor has a tendency to treat abnormal lab results than the patient himself)

9. Course of the disease (C) – based on the lecture notes and the textbook, the student should indicate which course the patient is likely to take – spontaneous recovery, complete recovery with the appropriate therapy, downhill progress, spontaneous relapses and recovery, etc. They are also encouraged to mention if there are any important associated lesions in the patient.

10. Complications (C) – what are the possible complications, what is their timeframe for development, and how does one monitor the patient for such complications?

11. Clinical vignette – (V) Write a clinical story of the patient, including possible age, gender, symptoms, signs, investigations, associations, and complications. This would be a summary of the above observations put as a clinical story.

12. Multiple choice question (Q) - Write a multiple choice question (MCQ )based on the above clinical vignette. The last line would ask for etiology or pathogenesis or explanations for signs, symptoms, lab investigations, complications, etc. This would give them practice in quickly analyzing a given clinical vignette in the future because they have learned how to create one and how questions can be created from the same.

The rubric of IMDEPSSICC (Identity, Morphologic description, Diagnosis, Etiology, Pathogenesis, Symptoms, Signs, Investigations, Course of the disease, and Complication) is a good learning tool for laboratory sessions. Not all of these may be relevant for a given slide but going through the checklist makes them doctors who will think logically and scientifically.

Finally, the V (writing a vignette) and Q (question) allow them to synthesize the pathology information into a total patient story (pathologic basis of clinical medicine) and allow them to think of different elements from such a patient story that can be tested in an exam (17). Our students, on average, develop 400 such IMDEPSSICS and VXCS in a period of 16 weeks in which the entire pathology course is taught.

How does one choose the slides for the lab sessions? 

They must be related to the learning objectives for that period. It would be better if they were not the same as the ones used by the teacher in the lecture sessions. If they are the same, the students tend to copy-paste and not go through the active learning process. It is also not necessary to include all possible slides in the sessions. Only a few representative slides will do. It is important for them to spend quality time with the slides and once they have figured out how to analyze, they can do so on their own for the remaining slides or any other related slide.

What really happens in the lab sessions? 

The students provide what they have prepared (rubric) to the other seven students in their group of eight. They decide on a team leader to conduct the session. The team leader then requests one by one to present their rubric. Each student presents a different slide. Once the student has presented, the other students can ask questions to clarify confusing issues, identify any errors or omissions, and add constructively to the rubric. The students are free to divide the slides for each session among themselves. All of them review each slide well before the session, but each student is assigned by their group a slide or two to prepare the rubric for presentation to the group.

Who moderates the session? 

It is important that there is proper monitoring of the sessions. If not, the learning opportunity is wasted, the students may lose interest and may not put in the proper effort required and, more importantly, may end the session with the wrong information or incomplete information. In our department, we have created a system where we recruit many clinical tutors who are recent medical graduates waiting to do exams like USMLE, PLAB, etc., to move on to postgraduate residency programs in the US and UK. We are just two pathology-trained full-time professors and a part-time professor (18). We do get some visiting professors occasionally. We prepare the teaching material. We also train the clinical tutors for the lab sessions every day. The clinical tutors also attend the Pathology lectures prior to the lab sessions on those topics. They then act like preceptors for the lab sessions for groups of eight students (two sessions each day of two hours each, a total of 16 students). 

The professors move around during the lab sessions in case there is any issue in any group that cannot be addressed satisfactorily by the clinical tutors. The tutors are trained on what rubric to expect from students for each slide as well as the possible conceptually difficult issues that students can face in each slide and how to address them. They are trained not to give direct answers to the questions from students. The students tend to memorize the answers without understanding the reasoning. Each question is like the tip of an iceberg. There is a deeper foundation of understanding that is incomplete. It is important for the student to figure out the foundation and come to the right answer by self-effort. The tutors guide them towards the correct answer by asking smaller simple questions that clarify the basis for the larger question. They also encourage students to refer to the textbook and lecture notes in the lab session itself to find the answers to their questions. The tutors also redirect the question to the other students in the group, and most often, someone else in the group comes up with the right answer. All this leads to active learning of the pathology by the students in a clinical context. The lab session groups also present a unique opportunity to teach and assess learning objectives related to professional behavior. These may not be in the strict realm of the discipline of pathology but nevertheless are important building steps in preparing the doctors for tomorrow. If we consider ourselves as architects of tomorrow’s doctors instead of creators of future pathologists, then concepts become clear. All the students are going to become doctors whereas very small numbers may become pathologists. There are opportunities for that small number to train in pathology later in the postgraduate residency programs. What are the professional behavior learning objectives that can be taught and assessed in pathology small groups? We have identified these and allotted specific scores for the same independent of their knowledge of Pathology. They include behaviors like-

Being on time, taking responsibility, showing respect to fellow students and teachers, rotating leadership, not dominating the discussion, allowing others to participate, active listening, being sincere, expressing disagreements without being disagreeable, being empathetic to a team member who needs help, professionally dressed for the session, appropriate body language, maintaining eye contact with the person who is speaking, sharing an interest in the discussions, etc.

All these are made clear to the students in writing in advance along with how they will be scored. The students get a point for each lab session when they demonstrate these behaviors. They lose a point if they fail to meet the requirements in any session, along with personal feedback from the tutor on how to do better in the future. Students who fail to respond to multiple feedback like this are reported to the dean’s office or further disciplinary process. The lab group that is voted as the best in each term and the student who is voted as the best by the tutors get a certificate from the department, and their photos are displayed in the lab as a recognition for future students to notice. The small group can thus reinforce positive behaviors in the students to make them better doctors. 

Clinical Tutors

Many departments of Pathology may not have a budget to employ such clinical tutors. They may also have a much smaller number of full-time faculty. Who will supervise the small groups then? The postgraduate residents in pathology would be ideal stand-ins for the role played by clinical tutors in our department. It is an opportunity for them to revisit the clinical reasoning component of education while they are otherwise occupied in learning to tag slides with diagnostic labels as residents. They will become better pathologists. Their main knowledge base and reasoning skills will improve when trying to discuss with students in the lab. Their own professional behaviors will undergo a positive transformation as they become role models for students and are trying to evaluate these in the students. The department will not need additional human or financial resources.

Our students do not perform any laboratory procedures in our course. We do realize that they are an inherent component of the course in other countries. It will be worthwhile taking each procedure and breaking it down into the sequence of steps to be performed. They can then be taught and tested in a standardized fashion. There will also be an opportunity to incorporate professional behavior learning objectives related to their handling microscope, lab equipment, etc., which can be taught and tested. It is important to reconsider what lab procedures are being conducted in real practice now and incorporate them into the lab teaching sessions. It is frustrating to see the teaching and testing of lab procedures that have become extinct decades ago, still now in medical schools because no one has bothered to review their current context. The lab sessions, which include results of hematology and clinical chemistry, provide better mileage to students if these are given as data in a clinical context and students sit in groups discussing the how, why, and so what of the test results. It is much more useful in the training of doctors than making them perform the procedures themselves. This could be done by individual institutions to decide what is more relevant.

Concept Maps

We have been practicing another method of learning called concept maps for almost two decades (19,20,21). The emphasis is to move students towards deeper learning by concepts and associations rather than surface learning by memorization. Rote memorization would have helped most students in earlier courses in medical school where they could score high with that study technique. When the students reach the pathology course, they are suddenly threatened by the vast scope – integrating with material from previous courses like anatomy, histology, biochemistry, physiology, etc. for every disease entity they come across and in addition connect the knowledge of pathology to baby steps of clinical medicine like symptoms, signs, lab investigations, etc. The entire spectrum cannot be taught by the pathology professor in the lecture class. The vast scope of the material precludes the student from memorizing all the information. The type of questions asked preclude the student from straightforward regurgitation of information in the exam. Many students who used to score high in previous courses by memorization start finding the going tough in the pathology course.

We conduct a session on drawing concept maps at the very beginning of the course in an interactive session. They pick up any topic which they have just been taught in the course. One of the important topics they learn in the first week is cell injury and cell death. In the training session on concept maps, we go around each lab group asking them to say anything important they remember from the topic. The responses are jotted down by the professor on an overhead projector in a grouped fashion. The points will be definitions, types of necrosis, morphologic features of necrosis, and common organs for each of the types of necrosis. Then, we ask them to think about patients with necrosis, such as coagulation necrosis of the myocardium. What would be the morphology, etiology, symptoms, signs, lab investigations, complications, etc., similarly fat necrosis of pancreas, liquefaction necrosis of brains, etc?  We try through their discussions to show the associations, correlations, etc., between morphology, clinical features, recapitulate anatomy, histology, physiology, biochemistry, etc. They also mention where else similar morphology clinical features can be seen and how to distinguish them. This makes them think outside of silos for each pathologic lesion and its effects on the patient. 

We emphasize that concept maps are drawn to show the thinking process, and the higher the number of associations and correlations depicted will reflect the higher sense of conceptual learning. The concept maps do not necessarily include all the information available. They are also unique to the individual student and for that level of learning. The concept map on myocardial cell necrosis in the first weeks of general pathology would be quite different from the concept map drawn by the same student during the later part of the course dealing with systemic pathology. These are great tools for a great revision of the topic for the student. We mandate each student to draw at least one concept map each week on a topic they studied during the week and submit it to the preceptor of the small group on the Monday lab session of the following week. We train the preceptors to critique the concept maps submitted to look for associations and correlations and give feedback to individual students on any improvements needed. The students then resubmit the concept map after revision. 

Drawing such maps repeatedly converts superficial learners toward deep or conceptual learning. For example, a superficial learner can memorize everything about individual conditions like pneumonia, bronchiectasis, pulmonary tuberculosis, and lung abscess. They can answer any question on the topics once we ask them - with the pathology or diagnosis mentioned. 

For example, in a patient with a lung abscess, what would be the symptoms, signs, lab investigations, etc? However, the superficial learner finds it difficult to analyze a question in which the diagnosis is not mentioned, for example, a patient with fever, chest pain, cough, and hemoptysis – they need to look at associated features to distinguish between the entities mentioned above. If they had been drawing concept maps, they would have depicted -each symptom in a patient with lung abscess, the other conditions where it can also be seen, and what features help to distinguish one from the other. These features may include morphology, age, gender, signs, lab investigations, associations, etc. This really helps them to learn clinical reasoning and differential diagnosis based on each feature and mimic real-life clinical experiences. No patient presents with a label – I have bronchiectasis, now find this or answer this. The patients present as a puzzle with chief complaints and the student must learn how to proceed from there.

Concept maps are also great tools for teaching and assessment. 

An entire lecture can be prepared as a concept map. The teacher initially projects the entire map to show the different components.  Then he focuses on each component to provide explanations and clinical correlations. Toward the end of the lecture, the teacher again shows the entire map to recapitulate the correlations and associations between the various components.

We have used concept maps with missing elements in lab sessions. The student group sits and discusses the various possible answers to fill in the blank slots and justify the choice. We have also found the quality of concept maps drawn by a student as graded by the number of associates and correlations identified in the map strongly correlates with their exam scores (all our exam items are clinical vignette-based analytical and interpretive type MCQ of the USMLE Step 1 type). There is, however, a little bit of irony about the concept maps. The students who would benefit most from it are the linear or superficial learners (who like memorization). They are the ones who find drawing concept maps boring and difficult. Students who are natural conceptual or deep learners do not really need to practice drawing concept maps, but they really enjoy drawing many concept maps. Thus, concept maps can be used for teaching, learning, lectures, lab group sessions, and assessment. They are important tools to help the learner to consolidate clinical reasoning skills. We have seen that many students adapt to concept maps as a regular way to study other course material, too, following the pathology course. Ultimately, in clinical practice, this is how a clinician’s mind works, and we are happy that the pathology course is preparing the students well for that.

Modified Essay Questions

Another tool that is very useful in lab groups or small group sessions is modified essay questions (MEQs). Essay-type questions essentially mean that the question expects a student to respond with an answer in his own language, expressions, and sequence of thoughts. The usual essay question is a one or two-sentence long item. The answer expected could be a paragraph, page, or several pages based on the scope of the question. The quality of the response is dependent not only on the subject knowledge of the student but also on the language skills, handwriting skills, and, in some ways, the ability to fill in pages with nonconsequential information to make up the volume of the answer. It makes the scoring of the exam also very subjective. Multiple choice questions generally have a much longer stem, the responses are already included, and the student has to just tick the correct answer. These directly test the knowledge and there is no subjectivity in scoring based on language, handwriting, or the length or volume of the answer. However, if the MCQ is constructed to test just memorization of facts, it loses the purpose of testing clinical reasoning.

The essay-type questions can be modified to make them fit into testing clinical reasoning, and the subjectivity can be greatly reduced. They can then be used for both teaching and assessment. There is no formal limit to the length of the question stem in the essay questions. We have expanded it to a long paragraph or half a page to describe a clinical scenario just like the stem of MCQ. The last line of the question asks for a very brief response of one word or two words which can only be arrived at by careful consideration of all the data in the stem. The student must write that one word or two words on his own. There are no preselected answers he has to choose from. If he writes more than one or two words as directed, he gets a zero score. It still qualifies as an essay question because the student is writing his response in his own language and words. It is just modified so the question stem is very elaborate, and the response is very brief and to the point.

Modified essay questions are one of the best ways to teach and test clinical reasoning. One practical example will clarify the concept. The question stem describes the age, gender, symptoms, signs, and blood chemistry of a patient. The analysis and interpretation of the data lead to a conclusion of diabetic patients in coma, although these terms are not included in the stem of the question. The last sentence of the question will state – The coma in this patient is related to (answer in one or two words, writing more than one possibility will lead to a zero score). The possible answers could be hypoglycemia, hyperglycemia, or ketoacidosis. Based on the data, there could only be one of these correct. The student must think and write the response in his own words and does not have the option to choose from any responses provided. We have provided these modified essay questions in lab sessions and small groups and encouraged the students in the groups to discuss the possibilities, pros, and cons for each possibility and then make a choice. The preceptor guides them to think more if they are missing an important clue or going in the wrong direction. This activity naturally is thus a great tool for active learning in clinical reasoning.

Artificial Intelligence- ChatGPT

A recent addition to the tools available for enhancing teaching medical students is the Artificial Intelligence- ChatGPT (22)

We have just started using it to create multiple case scenarios and USMLE type test items with varying degrees of difficulty to use in the teaching of a topic in pathology. One has to be careful in carefully scrutinizing the content generated by the Chat GPT to make sure that there are no factual errors before using it; the test items generated can also be very useful for running quizzes. However, we prefer to generate our own test items and use them from our test bank for the actual examinations.

3. How does one measure if the student has acquired what was to be learned (assessment)?

There are some limitations set by the individual institutions or the accreditation agencies on the number and format of questions for examinations in each course. Those cannot be overruled. However, there may not be strict restrictions on the length of the stem of an essay-type question. One can compose a strong clinical vignette linked to the learning objectives and direct the students to address specific issues related to the etiology, morphology, clinical features, laboratory investigations, associations, complications, etc. It will still be an essay question because the student responds in his own language and sentences. However, we are restricting the scope of his response so he cannot get a free license to fly a kite in any direction he wants. For example, instead of a question like – write about myocardial infarction, one can provide a clinical vignette of a 55-year-old male who complains of sudden onset chest pain radiating to the left arm accompanied by profuse sweating. EKG showed ST elevation and T wave inversion. Pulse was rapid and thready. The pain has lasted for the past eight hours. Then add directions for his response like – why did the pain radiate to the left arm? Which coronary artery is most likely to be affected? What is the type of pathology in the coronary artery? Why was the pulse weak and rapid? What biochemical tests at this stage will provide the best diagnostic help? What would be the histological changes in the myocardium in the damaged segment?

The student then must respond with a brief response for each of these directives.  It is difficult to answer without thinking. The answers cannot be copied from a book or any other resource. The answers cannot be memorized and regurgitated because they are unique for the clinical problem that needs to be first resolved by the students before responding to the directives. The scoring will become more objective. Thus, without breaking any of the stipulations of the institution, the pathology teachers can modify the essay-type questions to make them objective and really assess the clinical reasoning skills linked to the learning objectives.

Multiple Choice Questions could be used in formative and summative evaluations if permitted by the institutional guidelines. Care has to be taken to ensure that they are clinical vignette-based and are testing higher cognitive skills like analysis, interpretation, compare and contrast, and problem-solving. 

To conclude, a pathology teacher can make the learning very effective for the students (5,6), make it interesting and attractive, and eventually assist the institution in producing better quality scientific and logical doctors who can improve the health care delivery to the community. Most of the innovations we have used and are recommending do not need additional resources, and some may need just the internet and smartphones, which most medical students already have access to. What is needed is for the teachers to think out of the box and reinvent their role as helpers for learning rather than knowledge fund holders who must disseminate it to the students. To move away from spending time repeating what is a set of information in the textbooks to conducting interactive teaching sessions where the applications of that information in a clinical context come alive. To provide participation opportunities for the students in their learning process.

If the teacher loses the prestige of being the storehouse and distributor of knowledge and further makes the lectures and lab sessions interactive with maximum contributions from students, then what is the reinvented role of the teacher? The teacher now should spend time designing better learning objectives that set the expectations clear to the student, and these expectations are at a high level of analysis, interpretation, and problem-solving related to clinical reasoning. The teacher puts in continuous efforts to create better learning platforms during lectures and lab sessions with clicker questions, modified essay questions, concept maps, and modified team-based learning. Creates new and more meaningful test items, including essays and MCQs, that objectively assess the achievement of the learning objectives by the student. Finally, if the teacher offers open office hours for the students to meet and seek clarifications on concepts that they find difficult to understand, it will help the students to be at par with the rest of the class in acquiring the skills and competencies required.

Conclusion

We do hope that these ideas will provide a nidus for interested pathology educators to modify the learning experiences they are providing to their medical students without requiring any major funding for resources or additional faculty.

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Acknowledgements:

We gratefully thank The Pathologist magazine for permission to use images published in their on line article Pathology in the East and West published in the January 29 2021 edition.