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The Great Diseases Project

A Partnership Between Tufts Medical School and the Boston Public Schools

Jacque, Berri PhD; Malanson, Katherine PhD; Bateman, Kathleen MEd; Akeson, Bob MEd; Cail, Amanda MEd; Doss, Chris MEd; Dugan, Matt MEd; Finegold, Brandon MEd; Gauthier, Aimee MEd; Galego, Mike MEd; Roundtree, Eugene MEd; Spezzano, Lawrence MSc; Meiri, Karina F. PhD

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doi: 10.1097/ACM.0b013e31828b50fb
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As biomedical researchers, we are acutely aware of the serious consequences that follow from the failure to adequately educate citizens about medicine and health. For example, the doubling in the United States of annual deaths from infectious disease since their historic low in 1980 appears due as much to changes in human behavior as to evolution of pathogens,1–3 suggesting that disease prevention depends on an educated, scientifically literate citizenry. Convinced that this education must begin before adulthood,4 we believe that high school students must be exposed to up-to-date, scientifically rigorous, life-relevant information about infectious disease. Unfortunately, in this era of “teaching to the test,” many high schools have sacrificed time they used to spend teaching science and health, focusing instead on “core” subjects such as mathematics and English.5 The available teaching materials do little to counter the imbalance; BSCS Biology: A Human Approach, a first-level biology text used nationwide by many school districts, including Boston’s, covers both the immune system and infectious diseases in only 25 of its 648 pages.6

These shifting priorities and lack of good, up-to-date materials mean that little current biomedical information about infectious disease is disseminated in the high school classroom. As a result, many students (and their teachers) harbor misconceptions that affect the decisions they make about their own health.7–10 It is hard not to be pessimistic about how U.S. students will learn to make educated decisions about their personal health, let alone how they will be able to replenish the scientific workforce that researches and develops new strategies against microbial resistance and emerging pathogens.

The poor performance of U.S. high school students against international benchmarks raises concerns about their science education in general.11–13 One particular challenge that undoubtedly affects their performance is their low level of engagement in science.14–19 Students engage when taught content they value, yet classroom learning rarely mirrors the science of real-world experience.19 When it does, students’ motivation and achievement increase,20–22 suggesting that high school curricula based on topics students find inherently interesting, such as their own physiology and health, can improve both engagement and academic performance.*

High school curricula focused on life-relevant topics like infectious disease, therefore, fulfill two critical needs by improving informed decision making and by fostering interest and engagement in science. The potential benefits, however, are limited by a lack of both teachers who know the science and scientists who can effectively communicate with teachers. Medical schools shoulder significant responsibility for this knowledge gap. They rarely provide incentives for their content experts to interact with the K–12 community. They also suffer consequences of this segregation because they are not exposed to the wide range of pedagogical strategies available to educate students with diverse learning styles.23

The Project

To redress this imbalance, in 2009, with support from the Science and Education Partnership Award Program of the National Center for Research Resources, we established the Great Diseases Project to create an 11th- to 12th-grade science curriculum, made up of discrete modules, for second-level biology students. Best practices in curriculum design identify two essential elements: (1) an equal partnership between content experts and teachers and (2) evaluating outcomes and making improvements in real time.24 To create the partnership, we established a collaborative learning community with members of the Center for Translational Science Education at Tufts Medical School, scientists from Tufts Medical School, and biology teachers from two of the largest high schools in the Boston public school district: Boston Latin (a college preparatory school) and Madison Park (a technical and vocational high school).

The community meets, on average, twice each month. For the first curricular module, on infectious disease, the nine Tufts “content experts” comprised two faculty and seven students (four postdoctoral, two doctoral, and one medical school). (As we move onto other modules, we recruit other content experts relevant to those disciplines.) Our 10 teacher partners, who remain associated with the project of designing the entire curriculum, educate a diverse, inner-city student population (87% minority, 74% free or reduced-cost lunch) of 9th- through 12th graders. Their schools encompass the broadest range of academic achievement in the district. The Boston Public Schools district strongly supports the collaboration because it lacks a pedagogically cohesive second-level biology curriculum. This study and its surveys were approved by the institutional review board of Tufts University School of Medicine.

Our project has its roots in the National Academy of Sciences’ report How Students Learn: Science in the Classroom, which asserts that, for effective learning to occur, “teachers need expertise in both subject matter content and in teaching.”25 Consequently, the project has two parts. The first component is to develop five modules. Each module covers one of the great diseases that pose major threats to global public health, capturing students’ imaginations by presenting cases with a “human face.” The modules, designed to identify the core principles underlying how we understand each disease and to introduce advances in biomedical research, reflect the National Academy of Science’s emphases on both content and pedagogy. The second component of the project is to ensure that the schools faithfully implement the curriculum. The community’s scholarly interactions provide professional development for all participants.


In consultation with the Boston Public Schools Science Department, we chose teacher partners from two large high schools with very distinct needs, so we would be able to design a curriculum to engage the widest range of students possible. We then approached the science teachers directly, and all 10 (5 from each school) accepted our invitation to participate. Again, in consultation with the Boston Public Schools Science Department, we elected to use the “Understanding by Design” model of curriculum design, which begins by identifying core concepts and embeds assessments as an integral part of the learning objectives.26 The teachers were familiar with this methodology and therefore able to focus on the curriculum’s content rather than on the process of its construction.

Table 1 summarizes how the curriculum evolved. In August 2009, realizing that the pathogen- or disease-centric framework familiar to medical students would not resonate with high school students, who needed instead an approach relevant to their own lives, we came to a consensus on the five core concepts. In the remainder of that year, the Tufts team generated a text and intensive seminar series framed around those concepts to introduce teachers to novel content and address their misconceptions about infectious disease. From January to July 2010, the whole group collaborated to create the six-week module, establishing learning objectives for each of its 35 lessons.

Table 1
Table 1:
Stages in the Development and Implementation of the Infectious Disease (ID) Module of the Great Diseases Project, a Partnership Between Tufts Medical School and the Boston Public School System, 2009–2012

We designed classroom activities that would meet the latest national and state education standards that relate to authentic science practices.26–29 These are (1) asking questions, (2) devising testable hypotheses based on modeling, (3) collecting and analyzing data, (4) making claims by applying evidence and reasoning in interpretation, (5) reading and writing about science, and (6) extrapolating scientific knowledge to new situations,29 as well as summarizing, note-taking, and cooperative learning.30 The curriculum’s inquiry-based experiences, reflecting the teachers’ diverse pedagogical approaches, include hands-on activities, student-led teach-backs, intensive reading and writing, lab exercises, case-based learning, and Socratic discussions. The choice of experiences makes the curriculum suitable for schools with few resources or restrictive schedules.


Successful, faithful implementation of a curriculum ultimately depends on the teacher; it is a major challenge even when teachers are familiar with the curriculum’s content.31 When content and lesson materials are both novel and complex, teachers need a system of support to give them enough confidence in their understanding of the subject matter that they can faithfully, and thus effectively, implement the curriculum.31–33 The problem is readily apparent in much of the current infectious disease material targeted for high school classrooms.34–39 High-quality curricular activities themselves cannot ensure successful implementation if the only support the teacher receives is activity-specific, comes out of context without a clear conceptual framework, and assumes a significant amount of background knowledge. For example, the teacher’s manual accompanying the infectious disease curriculum activities produced by the Biological Sciences Curriculum Study for the National Institutes of Health’s Office of Science Education34 states:

Bacteria are frequently divided into two broad classes based on their cell wall structures, which influences their Gram stain reaction. Gram-negative bacteria appear pink after the staining procedure…. Gram-positive bacteria appear purple after the Gram stain procedure.

The manual then neglects to address two concepts embedded in that statement: how cell wall structure influences Gram staining and why this is important to bacterial function and disease. Not understanding these concepts affects how well the material can be implemented in the classroom.

Our goal of providing comprehensive support that avoids embedded concepts required two levels of support, a system we call “modeling for fidelity.” Modeling for fidelity features an intensive mentoring system that shows teachers how to emulate authentic scientific practice while teaching novel content and complex concepts. It relies first of all on the teacher text and a written narrative that accompanies the comprehensive curriculum materials. By familiarizing themselves with the text and following the narrative as they prepare for each lesson, a teacher sees how classroom discussions may evolve. Videos of lessons taught by the teachers who designed them further model how to use the materials.

Although this approach clarifies how to work with the lesson materials, it does not fully address the challenge of teaching novel content. Excellent teachers can teach misconceptions excellently, so correctly knowing the content is essential. To meet the challenge, we partnered each piloting teacher with a Tufts content expert, who participated in content tutorials either face-to-face or by using virtual formats such as Skype or Google Chat. Each unit required three to four hours of tutorial time, but the flexibility of the virtual format meant that it could occur whenever mutually convenient. Tutorials for labs, initially done in person, are now available as videos. The teachers and mentors also interacted via “just-in-time” consultations, often by text messaging, where teachers could ask questions right up until a lesson began. For example, one teacher, whose students were struggling with how to transfer their knowledge of the central dogma of molecular biology to viral replication, quickly worked with her mentor to put together a review just in time for the next lesson. Teachers and mentors also interacted at formal debriefing sessions.

We had hoped that the pilot teachers would be in touch with their mentors daily, and, thanks to the mutual trust established via initial tutoring interactions, this was indeed the case. Many misconceptions were avoided as a result. Mentors were not in the classroom during the initial infectious disease enactments in January through May 2010, but as the partnership has evolved, the high school teachers and students have welcomed Tufts participants to provide enrichment experiences and career insights and even to team-teach challenging material. These interactions have enormous bridge-building potential with respect to the biomedical pipeline, even though it is currently not a focus of our intervention.

The Impact

Our study’s funder, the National Institutes of Health, required that the project be continually assessed by external evaluators. Rather than applying already-validated instruments to our novel situation, which would have required revalidation and been less specific, we worked with our external evaluators from Davis Square Associates to construct new instruments that asked questions germane to the material under investigation, instruments that measured students’ and teachers’ engagement with the subject matter, their sense of self-efficacy, and their gains in content knowledge and problem-solving abilities. These included online surveys, which were administered online using Survey Monkey, in which both teachers and students participated anonymously and voluntarily; pre- and postmodule tests, which teachers administered to students as part of normal classroom instruction (so participation was not voluntary); and an online focus group questionnaire administered to students who did not participate in the module.

To date, the infectious disease module has been taught four times in three Boston area public high schools (one college preparatory, one general, and one technical and vocational) by four teachers (two of whom were involved in the curriculum’s initial design and two who were not) to 161 students. The curriculum was revised after the first enactment, and the fourth enactment focused on adjusting the curriculum for remedial learners, so we present data from the second and third enactments (Table 2). Also, because of absences, the number of completed, matched pre- and postmodule tests was less than the total number of participating students. We report only results from completed, matched tests. Students were assigned identification numbers, but we did not have access to the identification key. The instruments are reliable (Cronbach alpha range 0.85–0.95) and are in the process of validation, thereby ensuring that our data can advance the field. The average demographics of students whose data are presented here were as follows: 49% women, 59% white, 15% black, 14% Asian, 6% Hispanic, and 1% other or multiracial.

Table 2
Table 2:
Impacts of the Great Diseases Project’s Infectious Disease Module on Teachers and Students, Boston Public School System, 2009–2012

The 10 teachers who originally participated in designing the curriculum all took the online attitudinal and content knowledge surveys twice: after the design phase and again after participating in our “modeling for fidelity” program. The attitudinal surveys comprised 10 six-point Likert scale-type questions on attitude, whereas the content knowledge questions comprised two case studies with content knowledge questions that asked them to critically evaluate research findings related to the H1N1 pandemic. All initially expressed low values of self-efficacy and content knowledge of ID-related material, demonstrated some lack of knowledge about infectious disease, and expressed doubts regarding their ability to teach it, but after participating in the modeling for fidelity program, they demonstrated significant gains in both (Table 2), confirming that increased content and more knowledge correlates with increased confidence in implementation.

On the basis of our underlying rationale that students will engage with material they find inherently interesting, thereby improving their knowledge and problem-solving skills, we designed a survey instrument that used questionnaires to measure attitude and self-efficacy. Each domain was addressed with a total of 10 six-point Likert scale-type questions. The instruments, which use a retrospective pretest model previously shown to be effective at avoiding Type II error,36 will be suitable for evaluating large numbers of students as use of the curriculum expands. (In the 2012–2013 school year, over 300 students from 10 schools nationwide are using the curriculum.) Students showed significant gains on both measures (see Table 2). Hence, involving medical schools in creating curricula focused on biomedical content like infectious disease seems to be a practical and effective method to increase student engagement in learning. Engagement correlated with behavioral changes. After participating in the module, students reported significantly increased discourse about infectious disease with their family, friends, and school peers when compared with the focus group that completed the online questionnaire (P < .05 by paired t test, η = 0.86).

We measured changes in students’ content knowledge and problem-solving abilities using pre- and postmodule tests. The test comprised nine multiple-choice and three short-answer questions to evaluate gains in content knowledge, together with a six-question case study to evaluate infectious-disease-related problem-solving abilities. Table 2 shows that pre–post gains in content knowledge and problem-solving abilities were also significantly different for each iteration measured. Significantly, the magnitude of individual gains did not correlate with pretest scores, gender, or ethnicity, suggesting that the material was widely accessible to the different types of learners in the school populations. Hence, curricula focused on complex biomedical topics like infectious disease can be effectively implemented in diverse high school classrooms.

The Partnership

The teachers and content experts who participated in the Great Diseases Project, in an anonymous online survey available completing the module, felt that the bidirectional dialogue during the curriculum’s design phase benefited all parties. One participant valued the project because he or she had

not been previously a part of a group that has successfully bridged the inherent communication gap that exists between people who are differently educated (in this case, to do research vs to teach high school students).

When the Tufts content experts delivered their seminars to the teachers, they realized that, to effectively communicate complex ideas to an audience with far less specialized knowledge, they had to learn pedagogical methods not traditionally used in graduate-level scientific teaching. They were exposed to an even wider range of pedagogical approaches when they had to translate infectious disease information into lessons accessible to diverse high school students. As a consequence, they reported an increased appreciation for teaching and communication skills, which they expect will be useful as they advance their carriers as scientists and clinicians.

I feel that I have further improved my teaching abilities. While I have always enjoyed teaching, it was new to cater a talk to people who were not premed students or in graduate school. Getting more people engaged during a didactic session has improved my teaching to peers, and even medical residents immensely.

They also felt that their experiences challenged their views about the importance of communicating biomedical information to the public.

It is amazing the misconceptions people can have about science. Proper communication is key to rectifying these misunderstandings so that science and society can move forward.

More specifically, three of the original content experts (two graduate students on graduation, and one postdoc) have since joined the Great Disease Project as full-time staff, reflecting their commitment to the notion that biomedical scientists must become actively involved in K–12 science education.

In turn, the Tufts content experts altered teachers’ perspectives by pushing them to design lessons that reflect authentic scientific practice. In addition, teachers reported that students’ responses to the curriculum exceeded their expectations.

I was originally skeptical, but I was so impressed with how effective it was that I am very eager to use this approach in my biology class.

A Successful Collaborative Approach

Given the twin importance of educating citizens to manage their health and consolidating the biomedical pipeline, teaching life-relevant biomedical content in the high school classroom should be prioritized. However, segregating keepers of the latest content knowledge from teachers in classrooms creates a knowledge gap that impedes creation and effective implementation of these curricula. We have described a successful collaborative approach to creating and implementing biomedical curricula. The collaboration has not only resulted in robust gains for both teachers and students in biomedical content knowledge and critical thinking skills but has also benefited all partners in the learning community. Participating doctoral and medical students and postdoctoral fellows increased their pedagogical knowledge as well as their appreciation for how important it is to transfer their knowledge effectively to the general public. Our future goals are to leverage the success of the Great Diseases Project by facilitating other effective partnerships between medical schools and the K–12 community.

Acknowledgments: The authors wish to thank Pam Pelletier, director of science of the Boston Public Schools, for her invaluable advice and continued support. They would also like to thank Drs. Russ Faux and Brian Gavel for their expert assistance with evaluation, and Jenna Reece and Jane Newbold for excellent assistance.

Funding/Support: This study reported in this article was funded by the National Center for Research Resources and the Division of Program Coordination, Planning, and Strategic Initiatives of the National Institutes of Health through grant numbers R25OD010953-04 and 5R25RR026012-03.

Other disclosures: None.

Ethical approval: The study reported in this article and the surveys given were approved by the institutional review board of Tufts University School of Medicine.

* We established students' inherent interest in infectious disease by anonymously surveying a focus group of 124 11th–12th grade students who had not elected to take part in the curriculum discussed in this article to rate the study of disease in general and infectious disease in particular. Even these students, who had chosen not to take an advanced biology class, gave both topics scores of 5 (SD = 1) on a 6-point Likert-type scale with 1 = low and 6 = high.
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