Medical students often struggle to appreciate the clinical relevance of foundational material taught in the preclinical years of the curriculum. Medical educators have recognized that exclusive reliance on didactic lectures, without a connection to their clinical application, may fall short in engaging the learner and fostering long-term retention of knowledge.1 Integrating basic science with its clinical relevance has been identified as an important strategy in transitioning from passive to active learner-centered medical education.1–4
Evidence supports the benefits of early exposure to patient narratives in medical education as one way of integrating basic science with its clinical relevance.5 For example, early exposure to patients has been shown to improve the development of integrated clinical reasoning skills while enhancing student motivation.6 Yet logistical challenges exist, including the recruitment of suitable patients for each medical school at the most appropriate time in their curricula. Potentially detrimental effects on patients’ emotional and physical well-being are also of concern.5 Actors trained to respond as patients (standardized patients) are used successfully in many medical school curricula.5,7 However, standardized patient programs can be expensive and difficult to scale.
Patient-centered teaching videos may offer another option for introducing students to patient narratives early in their medical education. Advances in online learning platforms create the opportunity to broadly distribute video teaching content, fostering the widespread sharing and distribution of curricula. The ability to broadly disseminate digital, medical education could play a critical role in addressing the global shortage of medical educators and health care professionals.8 Innovators in early, nonprofessional education, such as Salman Khan,9 the founder of the Khan Academy, have applied online learning strategies, including the use of teaching videos, in primary and secondary education, with promising results. Such large-scale, digital teaching experiments may offer important lessons for medical educators. The Khan Academy engages and facilitates learning using short, illustrated, online lessons, delivered in a conversational style.9 We believe a similar approach could be effectively used to interweave a patient’s illness script with foundational basic science concepts.
The potential benefits of integrating a patient-centered approach with new, digital teaching technologies has informed recent calls to “reimagine” medical education.3 The inclusion of short, animated videos recounting the course of a patient’s illness could enhance a broad range of teaching activities in medical education, including lectures, problem- or team-based sessions, or flipped classroom experiences, and could play a pivotal role in underscoring the relevance of foundational basic science material taught in the preclinical years.1,3
In collaboration with four other U.S. medical schools (see below), we created 36 content modules relevant to a collaboratively developed preclinical course on microbiology, immunology, and infectious diseases at the Stanford University School of Medicine (SSoM) from January to December 2014 (see Figure 1). Each content module featured a collection of modular, short videos designed to focus on and introduce discrete areas of microbiology and immunology that were believed to be foundational. We designed the content modules in this manner so as to produce a curriculum that could be easily shared with other medical schools, both domestically and internationally.3
We created 36 animated, patient-centered videos (i.e., third-person, narrated accounts of authentic patient cases conveying foundational pathophysiology) from January to December 2014. Dubbed “springboard videos” to signify their anticipated role in helping students dive into new content areas, each animated video was created to optimize engagement in the more didactic material that followed (a playlist featuring all of the springboard videos is available at https://www.youtube.com/playlist?list=PLkdHelTlDZnETkBr6t7XVk0l2jzOxnBS1).
Each springboard video described a compelling clinical case with associated learning objectives and was based on a patient who had been cared for by a faculty member from one of our four collaborating medical schools (see Figure 1). All 36 springboard videos incorporated consistent stylistic and instructional elements. To facilitate this consistency, we created a pathophysiologic framework and used it to support the organization and production of each springboard video. This framework (see Figure 2) integrated the terminology and key concepts (including the relevant microbiology, immunology, and clinical presentation) associated with each infectious disease. The terminology and concepts converged in the springboard video, with the patient, portrayed at the center, providing the context for the interaction of microbes within the human immune system. In the videos, the terminology presented in the framework was consistently highlighted to reinforce connections between microbiology, immunology, and clinical presentation. This consistent approach was intended to provide students with a replicable paradigm for understanding patients encountered in complementary interactive sessions and subsequent clinical rotations.
Springboard video production
After the initial curriculum planning meeting, during which the 36 modules were selected, one of us (M.A.) created and produced each springboard video, in consultation with faculty experts. For each video, this process took approximately 8–10 working days to complete and included the following steps:
- Creating the springboard video script based on the clinical case that would launch students into that specific content module. This process began with a conversation between a faculty content expert (from either the SSoM or a collaborating school) and M.A., during which the relevant teaching points were collaboratively identified and clarified. M.A. then drafted a narrative, starting with an introduction to the patient, including some personal and sociocultural details, followed by relevant symptoms as well as a description of how the patient presented to the physician. After describing the attending physician’s diagnostic approach, the rest of the narrative followed the patient’s story, with integrated explanations of the relevant pathophysiology, basic science, and clinical management. This narrative script was then shared, for quality-control purposes, with faculty experts at the collaborating medical schools, who provided feedback and editorial suggestions. Medical students, acting as advisors to the project, also participated in the narrative drafting process for several videos and provided valuable feedback on the springboard videos at key production milestones.
- Generating a comprehensive storyboard or map outlining the visual components of the teaching schematic. M.A. developed a draft of the visuals that would accompany the narration and determined the sequence in which they would appear on the screen. We used relevant open-source images, including radiographs, CT images, and micrographs as needed. M.A. then reviewed the storyboards with the relevant faculty content experts.
- Recording the video using screen capturing of live illustrations. Using Camtasia Studio 7.0 (TechSmith Corp., Okemos, Michigan) screen-recording software, M.A. recorded the final illustrations according to the approved storyboard, adding annotations to the script where appropriate to help orient video editing support staff during the final phase of editing.
- Recording the script and integrating audio and video files to generate the final teaching video. M.A. recorded the patient-centered, third-person narration separately from the video, then transferred the audio and video files to editing support staff who synchronized the audio and video components.
For this process, we found it useful that the creator of the springboard videos (M.A.) had a medical background as well as basic skills in illustration, screen capture technology, and oral presentation. A similar final product could potentially have been accomplished by a team consisting of a content area expert with strong oral presentation skills, a medical illustrator, and educational technology support staff.
Characteristics of the springboard videos
The final springboard videos were each under 10 minutes in length, based on previously published recommendations suggesting that 10-minute videos are sensitive to the average peak learning period for adult learners.3 Students could rewind and replay challenging concepts as needed, and because the videos were relatively short and modular, they could also be used for review purposes or revisited during subsequent patient encounters.3 Additionally, the final image of each video could be printed and used as an anchor for the module’s content.
To underscore the clinical relevance of the foundational concepts covered in each video, patient “avatars” were embedded in the pathophysiologic framework. These avatars represented a broad spectrum of ages and socioeconomic and ethnic backgrounds to reflect a diverse patient population and facilitate international use. We also included medical student avatars in some of the videos to support professional identity formation, a highlighted priority for medical education reform.1,4
The decision to include some of the social challenges faced by patient avatars, as well as their management, was based on recommendations that medical students should be exposed to a more holistic view of the patient experience and the broader civic and advocacy roles of physicians.1,4 Additionally, in consideration of research on the factors that enhance sustainability of knowledge acquisition, many of the patient stories incorporated elements of the unexpected as well as a plot designed to elicit emotion in the viewer.2,10
Considering the potential for these videos to be used by a global learning community, we chose to report body temperatures in both Celsius and Fahrenheit and laboratory results in general terms (e.g., using phrases such as “elevated serum glucose”), rather than providing specific numeric values with associated units which might have limited international applicability.
The final components of each of the 36 content modules, for which we created the springboard videos, included:
- The patient-centered springboard video, used to facilitate early engagement in the module;
- Voice-over PowerPoint videos presenting more didactic content;
- An in-class interactive session facilitated by faculty at each of the participating medical schools; and
- Assessments emphasizing problem solving and critical-thinking skills, devised by faculty content experts.
Beginning in January 2015, the content modules were deployed at the SSoM and collaborating medical schools: the University of Washington School of Medicine (UW); University of California, San Francisco School of Medicine (UCSF); and Duke University School of Medicine (DUSM). (Because of previously scheduled curriculum changes, the University of Michigan Medical School opted for a role as an observing collaborator only.) All of the video content, including all of the springboard videos, was piloted at the SSoM, UW, and DUSM using a flipped classroom pedagogical approach from January 2015 to June 2016; because of curricular constraints, UCSF piloted only a small subset of the springboard videos. We summarize data on springboard video deployment at the SSoM and UW below (data from DUSM were not yet available for inclusion in this report).
This study was approved as an exempt protocol by the Stanford University Institutional Review Board and was exempt from review by the University of Washington Institutional Review Board.
To assess the impact of the springboard videos, we analyzed student feedback from course evaluations and focus groups, using a mixed-methods approach from January 2015 to June 2016 (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A423). Feedback from course evaluations included students’ qualitative comments along with responses on 1–5 (where 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent) and 1–6 (where 1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good, 6 = excellent) Likert-type scale items from the SSoM (n = 78) and UW (n = 110), respectively. Sixty-eight (87%) SSoM and 79 (72%) UW students rated the videos either good, very good, or excellent (see Figure 3).
A total of 48 (26%) students from both the SSoM and UW provided written comments referencing the springboard videos in their course evaluations (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A424). Of these, 29 (61%) described the springboard videos as adding value to the learning experience, whereas 14 (29%) comments attributed no added value to these videos. Two (< 1%) comments described technical difficulties in accessing or viewing the videos, and 3 (< 1%) comments indicated that students had chosen not to watch the springboard videos. Of the 29 positive student comments, 4 (14%) specifically noted enhanced engagement, and 6 (21%) referenced enhanced learning and retention.
We also conducted four focus groups (total of 24 volunteer students, with an average of 6 students per group) using a semistructured format with guiding questions from December 2015 to April 2016. Feedback from these focus groups, analyzed informally by program evaluators, was predominantly positive, mirroring the qualitative comments collected via the course evaluations. During the focus groups, students expressed different usage patterns for the springboard videos, with some preferring to watch the videos at the beginning of each module to help put new concepts into context, while others felt that watching the videos at the end of each module was helpful for review purposes.
Patient-centered springboard videos could serve as compelling entry points to new content areas for medical students across all foundational preclinical areas and could serve to support students’ review of content already taught. To further explore this, we will continue to gather and analyze data from medical schools using the springboard videos as part of their core preclinical curriculum. Simultaneously, we plan to produce similar videos for use in other foundational areas of undergraduate medical education. Because of the modular nature of the video content, springboard videos also lend themselves to open sharing domestically and abroad. To this end, educators and instructional technology support staff at the SSoM are in the process of building an open-access medical education portal to facilitate broad distribution of this and similar content. Patient-centered springboard videos, developed for medical students, could also be repurposed for use in continuing medical education, graduate medical education, and patient education. As access to technology spreads both nationally and internationally, short, animated teaching videos have the potential to be powerful resources for both medical and public health education.
Acknowledgments: Collaborating schools included the Stanford University School of Medicine; University of Washington School of Medicine; University of California, San Francisco School of Medicine; Duke University School of Medicine; and University of Michigan Medical School.
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