Curriculum Innovations: Enhancing Medical Student Neuroscience Training With a Team-Based Learning Curriculum

Problem Statement

Nonengaging neuroscience teaching with a failure to demonstrate relevance to clinical neurology can result in the development of neurophobia among medical students.¹ In this study, we propose a curricular innovation using clinician-educators and team-based learning (TBL) to enhance poorly rated neuropathology education in a medical school neuroscience course.

The global burden of neurologic disease is growing, and providers across medical specialties will interact with and manage patients with neurologic conditions.^2,3 Given this, it is essential that medical trainees develop competence and confidence in the care of patients with neurologic disease. Unfortunately, medical education today falls short on this imperative. Among US medical graduates, neurology clerkship quality is rated the second lowest across core rotations, and only approximately 2.5% of graduates choose to enter neurology, a number that has remained static over the past 10 years.⁴

Neurophobia is a principal driver of these outcomes and is often caused by poor experiences in the preclinical years with students unable to apply knowledge of basic sciences to their clinical experiences.¹ There is an increasing literature on methods to mitigate neurophobia in preclinical training with clear benefit from shifting to active learning methods; engaging clinicians in neuroscience training; and demonstrating the application of neuroscientific principles to clinical neurology.^5,-,8 With these goals in mind, neurologic educators should strive to establish a continuum of neurologic education with neuroscience learning grounded in clinical neurology and clinical training grounded in neuroscientific principles (Figure 1).

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Figure 1 Framework for the Implementation of a Continuum of Neurologic Education in Undergraduate Medical Education That Focuses on Neuroscience Knowledge Generation Within a Clinical Frame in the Preclinical Years and the Development of Clinical Expertise With a Grounding in Neuroscientific Principles in Clinical Training

TBL is an established didactic method in medical education that uses a constructivist paradigm to facilitate knowledge acquisition and application.^9,10 Learners complete self-directed learning at home, participate in in-class readiness tests, and complete team-based case review in a large group setting to apply the recently acquired knowledge.^9,11 Group learning is overseen by a faculty facilitator, and a single facilitator can lead a group of 100 students or more. Given these features, TBL is an optimal method to facilitate neuroscience learning. The scaffolded approach facilitates low-level knowledge acquisition (remembering and understanding) with the asynchronous material and allows students to use higher-level knowledge attainment skills (applying, analyzing, and evaluating) in active sessions led by a clinician facilitator, where they use the knowledge gained in the prework.^12,13 This facilitates greater retention of knowledge, provides frequent and timely feedback to students, and allows opportunities for informal peer evaluation in the group readiness test and in case reviews.¹⁴ There is some literature on the use of TBL in neuroscience education, though the use of a formal TBL curriculum has primarily been described in premedical or international medical education.^15,-,21

Course Background

The preclinical neuroscience course at the University of Rochester School of Medicine and Dentistry is a 9-week course at the start of the second phase (year) of the 4-year medical school curriculum. The neuropathology curriculum extends over the final 4 weeks of the course, covering 12 topics in neuropathology with 1 hour of lecture and laboratory time each, totaling 24 hours of course time. Before implementation of the novel curriculum, a typical day of neuropathology learning consisted of 2 hours of lecture covering 2 topics, followed by a medium group (approximately 25 students) neuropathology laboratory time (Table 1). A neuropathologist provided 9 of the 12 hours of neuropathology lectures prior to implementation of the new curriculum, with the remaining sessions covered by the course director (2 hours) and an infectious disease specialist (1 hour). Laboratory sessions were run by a neuropathologist or one of the course directors (neurologists) with review of gross and histopathologic slides, as well as neuroimaging on relevant topics via slide presentations. There was substantial redundancy in the material presented in the lecture and laboratory portions of the teaching with the same disease processes, key learning points, and, at times, the same slides used between the 2 sessions. In addition, there was minimal active learning in either the lectures or the laboratory sessions.

Curricular Changes

To reduce redundancy between the lecture and laboratory curricula, we invited neurologists and neurosurgeons from clinical specialties aligned with each neuropathology topic (e.g., a neuroimmunologist was invited to lecture on disorders of myelin) to provide the lectures. The directive for new lecturers was to update the lecture syllabi and to provide an overview of gross and histopathology on the topic with a strong clinical anchor and correlation. Invited faculty were selected based on course leadership knowledge of the faculty member's teaching abilities. A pathologist continued to provide an overview of neuropathology as the first lecture in the series, and 4 new faculty were added to the teaching roster with the remaining lectures given by faculty members who were already involved in other portions of the course. All invited faculty members accepted the invitation.

We converted the laboratory activities to a TBL format. Each TBL session lasted approximately 2 hours and covered 2 topics in neuropathology. TBL is used in other courses in the preclinical curriculum at the University of Rochester, and the session schedule is based on the format used in a formal TBL curriculum^9,22; our session schedule was modeled after this, and a typical breakdown of the time in each session is summarized in Table 1. We elected to split the class of 104 students into 2 groups, with one group led by the course director (C.G.T.) and the other group led by the former course director (R.F.J.). Adult and child neurology chief residents who participate as small group leaders in the course assisted with the facilitation of the sessions.

Course faculty created syllabi for each TBL topic to serve as the presession material that students reviewed prior to TBL. Among the 12 topics, the course director (C.G.T.) created 8 new syllabi, repurposing content from the prior neuropathology laboratories and other prior course materials; lecturing faculty members provided new syllabi for 3 additional topics; the final prereading was created using excepts from the textbook, Escourolle and Poirier's Manual of Basic Neuropathology,²³ which was available for free to students through the medical center library. A sample of one of the presession syllabi is included in eMethods 1 (links.lww.com/NE9/A10). The time required to review each syllabus was estimated to be approximately 30 minutes per topic.

Each TBL session starts with a 10-minute individual 8-question quiz (4 questions per topic) termed the individual readiness assessment test (IRAT), which is based on the presession materials (eMethods 1, links.lww.com/NE9/A10). The course director (C.G.T.) created the quiz questions, and the prior course director (R.F.J.) and neurology chief residents reviewed the questions for content. Questions were generally 5-option multiple choice questions, with each question framed in a clinical vignette; questions included a combination of gross and histopathologic images, as well as neuroimaging. Quiz implementation was completed and scored on the Blackboard Learn platform (Reston, VA), which houses all course materials. After the IRAT, students complete the same 8-question quiz termed the group readiness assessment test (GRAT) with their team of 5–6 students that remains static over the course; group responses are submitted by 1 member of each group via Blackboard. After the GRAT, the group facilitator reviews the 8 questions with each team lifting a placard corresponding with their answer. The time spent on review of each question is modified based on the unanimity of responses, with more time spent reviewing items where questions arise or disagreement is apparent.

Students spend the next 45 minutes completing 4 application exercises (2 per topic). Application exercises are 3- to 4-question extended clinical vignettes with intermixed multiple choice questions; application exercises also included a combination of gross and histopathologic images, as well as neuroimaging (eMethods 1, links.lww.com/NE9/A10). The course director created all application exercises, and the former course director, lecture faculty, and neurology chief residents reviewed the application exercises for content. After completing the application exercises, the group facilitator reviews each of the application exercise questions with each team lifting a placard corresponding to their response with a similar format to the IRAT/GRAT review.

Outcomes and Analysis

Outcomes were assessed using Kirkpatrick model of training evaluation with a focus on reaction, learning, and results.²⁴ Lecture quality was assessed based on end-of-course feedback. A random selection of 25% of the class was invited to review each lecture, with rating from 1 (poor) to 5 (excellent); students can additionally provide narrative comments on lecturers. We compared the mean rating for lecturing faculty in the implementation year to the mean lecture quality rating for the neuropathology lecture faculty in the prior academic year using a 2-sample t test. Because 2 neuropathology faculty lecturers provide a number of other lectures in the course, we conducted the analysis with and without their inclusion.

We assessed student opinions of TBL in multiple ways. First, we evaluated both quantitative and qualitative end-of-course feedback evaluations; session quality is rated on a 1 (needs much improvement) to 5 (excellent) scale, and students have the option to provide narrative feedback as well. In addition, we created a novel survey to assess student opinions of each component of the TBL session (prereading, IRAT/GRAT, application exercises, and review portions), facilitator quality, and overall impression via narrative comment. The survey was reviewed by faculty experts for content and pretested by 2 third year medical students with minimal changes made to improve question clarity.

The survey was administered via Research Electronic Data Capture, a secure web application that provides a toolset for effective data collection and management.²⁵ Students were invited to participate via email. On clicking the survey link, students were presented with an information sheet prior to survey completion. Survey completion was anonymous. However, at the end of the survey, students had the option to agree to participate in an interview to discuss their opinion of the TBL sessions. If the student agreed to participate, they were redirected to another form where they could provide their contact information. This was not linked to their survey responses. There was no incentive offered for completing the survey or participating in an interview.

Interviews were scheduled and conducted by the course director, who followed a semistructured format with prewritten questions (eMethods 2, links.lww.com/NE9/A11); all interviews were recorded and lasted 30–45 minutes. We aimed to conduct approximately 10 interviews (∼10% class participation). All narrative feedback and qualitative interview responses were reviewed for common themes. We did not follow a coding or formal qualitative review process because the goal of the review was for session improvement, rather than a sociological assessment of student opinion.

We assessed the impact of the updates to the neuropathology curriculum on student outcomes in the course. Course assessments include 3 in-house multiple choice examinations (total 300 questions), and a 140-question National Board of Medical Examiners (NBME) subject test in neuroscience with questions selected by the course director. We compared final student course grades and NBME subject test performance between the preimplementation phase (2020–2021 academic year) and postimplementation phase (2021–2022 academic year) using a 2-sample t test, treating the pre-implementation cohort as a historic control. We additionally compared student performance on the neuropathology subcomponent of the NBME subject test. Given the high student performance in the course prior to implementation and the numerous confounding factors that influence student examination performance beyond the neuropathology curriculum, we hypothesized that course outcomes would not change significantly between the preimplementation and postimplementation phases.

Standard Protocol Approvals, Registrations, and Patient Consents

Administration of the novel survey and conduct of the interviews were reviewed and approved by the local institutional review board; all other course outcomes used in assessing the curricular changes were included as part of typical course conduct.

Data Availability

Data will be made available through request directed to the corresponding author.