In the winter 2019, the authors launched a new course for senior medical students
entitled “Frontiers in Medicine: Behavioral Health and Neuromedicine.” The Frontiers
in Medicine course was launched to provide post-clerkship medical students an opportunity
to return to basic and clinical research topics after completing their clinical clerkships
with a goal of emphasizing the importance of science to medical practice [1, 2]. This
course aims to explore “frontier” areas and emphasize the value in integrating clinical
experience with the study of basic and translational science [3, 4]. The Frontiers
in Medicine course was created as part of the restructuring of the medical school
curriculum that decreased pre-clerkship course work and added several elements to
the fourth year post-clerkship period, consistent with national trends to modernize
medical education [2]. The institution created seven sections of the Frontiers in
Medicine course focused on different specialty topics and required that all senior
medical students complete one section of the course prior to graduation.
The Behavioral Health and Neuromedicine section of the Frontiers in Medicine course
integrates basic and clinical neuroscience and the neuroscience-related medical fields,
focused on neurology and psychiatry and including faculty from neurosurgery, neuropsychology,
and neuroradiology for students in the post-clerkship period. The authors structured
the course by focusing on three major topics using a paradigm of molecules, networks,
and structure: (1) the NMDA receptor in health and disease (molecule); (2) circuits,
seizures, and neurostimulation (network); and (3) trauma and recovery (structure).
The authors chose these topics due to the ability to cover innovative areas in both
psychiatry and neurology (e.g., autoimmune encephalitis in the NMDA receptor section),
areas of emerging research and clinical practice development (“frontiers”; [1]), and
highlight diseases and treatment not emphasized elsewhere in the medical school curriculum.
Each topic also allows for explicit connection between either scientific research
(basic or clinical) and clinical practice [5]. A portion of the course is devoted
to strengthening skills in critical review of the literature and evidence-based practice,
including research methods and design, consistent with the skills necessary for neuroscience
literacy [1], with the goal of fostering life-long learning [2].
In February of 2019 and 2020, the authors ran this course as originally designed,
with all learning sessions held in person. In April 2020, the medical school leadership
approached the course directors to repeat the course in a remote format so that medical
students who were unable to complete clerkship rotations due to restrictions associated
with the COVID-19 pandemic [6] could instead complete this graduation requirement.
Thus, instead of taking the course in the second semester of their fourth year, this
group of students completed the course as third year students, while clerkships were
on hold.
In this report, the authors describe the differential experiences with the course
with two different groups of students in two different formats: (a) in-person teaching
with fourth-year medical students and (b) synchronous distance learning [7] with third-year
medical students. The frame of the course was the same in both formats (course sessions
held for approximately 4 h per day, 4 days per week), and the faculty and topics were
unchanged, except in cases in which a particular member of the faculty was not able
to teach due to other institutional responsibilities. In both versions of the course,
class sessions were a mixture of traditional didactic lecture and active learning
sessions utilizing a flipped classroom model to facilitate learning [4, 8, 9]. The
course was graded as pass/fail as per institutional policy, with class attendance
and completion of group and individual presentations necessary to pass the course.
The data on student evaluation of the course presented here were obtained from the
aggregated, de-identified post-course evaluations completed in the MedHub online evaluation
repository. The institutional Office of Medical Education coordinates survey distribution
and completion for the purpose of program evaluation. Following IRB analyst review,
this project has been determined to be exempt from review by the institutional IRB
as it is consistent with program evaluation and not human subjects research.
Experiences with In-Person Course
There were 38 fourth-year students enrolled in the in-person course in February 2020.
Overall, the in-person course was well received by students, with 24 of 29 (83%) respondents
to the post-course evaluation indicating that they would choose this course again
or recommend it to another student (Table 1). Students had mixed reactions to the
course material: some praised the topics covered, and others expressed concerns that
the material covered in the class had been previously covered in the pre-clerkship
and clerkship curriculum. For example, students noted that the lectures on concussion
and neuropsychiatric evaluations were among their favorite course activities, while
other students specifically noted these were among their least favorite activities.
Interactive sessions were consistently well received, with several students naming
an activity in which they built models of the NMDA receptor using Play-Doh as a favorite
course activity. Students consistently praised the small group discussion sections.
Several students specifically noted that course logistical and infrastructure issues
(e.g., lack of student parking close to the classroom) were their least favorite aspects
of the course.
Table 1
End of course ratings
Evaluation Question
4th year studentsIn person courseAverage (SD)
3rd year studentsRemote course Average (SD)
Number of respondents/Number of students enrolled in course
29/38 (76%)
15/20 (75%)
I feel confident that I can formulate clinical questions relevant to a patient scenario
under most circumstances.
4.21 (0.5)
4.47 (0.5)
I feel confident that I can access literature relevant to answering clinical questions
under most circumstances.
4.24 (0.8)
4.47 (0.5)
I feel confident that I can critically evaluate literature relevant to answering clinical
questions.
4.10 (0.5)
4.33 (0.6)
I have the tools I need to stay abreast of latest developments in my field of interest
and to integrate new knowledge into clinical practice
4.21 (0.7)
4.33 (0.6)
This course is relevant to my development as a physician.
4.00 (1.0)
4.47 (0.5)
I have a deeper understanding of the foundational science relevant to the clinical
care of patients with brain-based disorders.
4.17 (0.8)
4.67 (0.5)
After taking this class, I am better able to educate patients and their families.
3.93 (1.1)
4.13 (0.5)
The faculty were knowledgeable in the subject material they taught.
4.55 (0.5)
4.67 (0.5)
The course covered an appropriate range of topics at an appropriate depth.
3.83 (1.2)
4.53 (0.5)
Reason that you would or would not recommend the course (selected)
• “I would recommend if they were into neurology, but barely has any behavioral health
aspects in the course”
• “Good exposure to critical thinking, research, clinical applicability”
• “Practicing research review was valuable, neuro and psych diseases are high yield
to almost all fields.”
• “I think [course] did a relatively good job of making the lectures relevant to our
clinical interests and helped re-enforce some important skills. Can’t help but feel
that this course would be much more relevant and helpful significantly earlier in
our education.”
• “Inspiring and learned a lot! If interested in neuroscience or psych, great course
to hear from experts and see the overlap in the two fields”
• “I learned a lot of useful skills in the class such as how to assess a paper while
reading it”
• “Great for looking at basic research and tying it to clinical practice. There is
psych in every specialty, and it is useful for us all to have experience with this.”
• “I found it both interesting and useful, even for someone not going into psychiatry
or neurology”
Response to statements assessed on a 5 point Likert scale, from 1 = strongly disagree
to 5 = strongly agree
Development of Distance Learning
The course directors faced several challenges in rapid creation of a distance learning
course. The first challenge was the rapid time frame: the course directors were first
contacted by the medical school leadership on March 21, 2020 to enquire about the
feasibility of organizing a course to start on April 6, 2020. The course directors
immediately reached out to the faculty who had taught in the course in February 2020,
and almost all were willing and able to teach via distance learning. Two faculty members
were unable to teach, one due to health reasons and one due to clinical responsibilities
caring for patients with COVID-19. Other faculty—both internal and external to the
institution—were able to take the place of the unavailable faculty. The inclusion
of faculty external to the institution was made possible by the distance learning
format, which meant that outside faculty could teach a class session without traveling
to the institution.
The next challenge was that the course directors and faculty had very limited experience
with distance learning. While delivery of a didactic lecture via a videoconference
platform was straightforward, converting the small group activities to remote teaching
posed a greater challenge. The lead course director (AMD) worked closely with the
institutional Office of Medical Education to identify alterations to course activities.
In particular, the course directors utilized the breakout room function of Zoom and
the discussion boards in the learning management system to facilitate small group
discussion. The course directors had not used either of these tools prior to leading
the course.
An additional challenge was inherent to the course design: the medical school curriculum
specifically designated that all Frontiers in Medicine courses were to take place
during the second semester of the fourth year of medical school, after completion
of all clerkships and acting internship rotations. The distance learning course, in
contrast, was to be offered to third year medical students who were unable to complete
clerkships due to institutional and regulatory limitations on medical student involvement
in patient care in the spring of 2020 [6]. The course directors faced the challenge
of deciding which third year students were appropriate for the course. Given that
the course material is designed to build on the material taught in the psychiatry
and neurology clerkships, the course directors limited enrollment to students who
had completed the neurology and psychiatry clerkships earlier in the academic year,
prior to the start of the pandemic. To facilitate classroom management and small group
participation, particularly in the unfamiliar terrain of distance learning, the course
directors limited enrollment to 20 students.
Experiences with the Remote Course
Fifteen of the twenty third-year students enrolled in the distance learning course
completed the post-course evaluation; as in the in-person course, completion of the
post-course evaluation was less than 100% as the institution does not require students
to complete this evaluation. All respondents to the post-course evaluation indicated
that they would choose the course again or recommend it to another student (Table
1). While some students noted difficulty in maintaining attention during lectures
given remotely, other students reported that they felt the course was well balanced
between lectures and interactive sessions carried out utilizing the breakout room
function of Zoom. Of note, the session that required students to build a model of
the NMDA receptor with Play-Doh was not as well received in the remote format, with
one student expressing frustration about the need to purchase Play-Doh for this activity.
Students praised the topics covered in the course as “very interesting” and “relevant
to multiple fields,” with many students reporting that they “learned a lot” from the
course. As with the in-person course, some individual lectures were noted to be the
most favorite part of the course by some students and the least favorite by others.
Logistical issues remained a significant student concern, with several students reporting
that the course website was difficult to navigate and in need of re-organization.
Several faculty provided informal feedback on teaching in the remote format. Faculty
consistently commented on the lack of real-time feedback during a teaching session,
as most students chose to have their video feeds turned off, consistent with guidelines
provided by the medical school for behavior during “large group” remote sessions.
Thus, faculty were not able to see facial expressions and make adjustments in their
teaching in real time. The lack of real-time feedback was also notable in small group
sessions. In traditional, in-person teaching, it is straightforward for faculty facilitators
to walk between small groups and listen to ongoing student discussions to identify
likely topics for larger group discussion. This is possible, though much more difficult,
in the virtual teaching format utilizing Zoom breakout rooms, as it requires a course
director or other meeting host to move the faculty in and out of the virtual breakout
rooms where students are engaged in discussion. Additionally, in the virtual format,
facilitators are not able to use the ambient noise level or observation of student
behavior as cues for ending small group discussion time.
Synthesis
An encouraging take-away from the course directors’ experiences is that a course with
active and interactive learning sessions can be successfully adapted for distance
learning without harm to the learning experience [7, 10], as has been previously demonstrated
for different medical education settings, including didactic lectures among urology
residents [11] and facilitation of family medicine clerkship problem-based learning
small group sessions [12]. One previous report has suggested that certain students
may learn more in the distance learning environment [13]. The mechanism for enhanced
learning in the distance environment is not well understood, though it may be related
to the comfort and convenience of learning at home. For example, the student concerns
regarding the difficulty of finding parking close to the classroom for the in-person
course was moot for the remote course. The authors also speculate that the remote
course was more convenient for students with significant family care-giving responsibilities
and potentially less anxiety-inducing for all students. The students who took the
distance learning course gave the course similar, though numerically higher, ratings
overall compared with the students who took the in-person course, both in terms of
overall course acceptability (measured by percent of students who would recommend
the course) and at the end of course rating of confidence in skills and knowledge
consistent with the course objectives (Table 1). These ratings are consistent with
the written comments provided by the students, in which the third year students more
consistently described the class as beneficial to their education. These data were
not statistically compared and must be interpreted cautiously due to the context in
which the distance learning course occurred—third year students had been removed from
clerkships, and many were anxious to complete any course available in order to progress
in their medical education. Thus, any comparison of the course is not truly a comparison
of in-person versus distance learning; instead, these metrics demonstrate the feasibility
and acceptability of virtual learning in the context of a systemic upheaval due to
a viral pandemic. The authors’ experience with both course formats demonstrates the
feasibility of integrating cross-disciplinary neuroscience education in the latter
half of medical school education, in keeping with previously reported incorporation
of neuroscience education in the psychiatry clerkship [14] and consistent calls for
enhanced integration of neuroscience into clinical disciplines [1, 4, 5].
Several factors likely contributed to successful implementation of distance learning.
At the outset of the viral pandemic and transition to remote teaching, the authors’
institution created and made available to all faculty a series of webinars and guides
on remote teaching, similar to initiatives described at other institutions [15]. These
sessions served as high-level introductions to the principles of and tools for remote
teaching available through the institution, including the breakout room and polling
features of Zoom that the course directors utilized throughout the course. The course
directors also utilized individual guidance provided by faculty in the Office of Medical
Education on which of the available tools were best suited to adapt each aspect of
the course. The discussion boards on the course website, which had not been utilized
during the in-person course, were essential to facilitating discussion in the remote
course. Additionally, use of the Zoom platform, which allows for audience polls and
break out rooms for small group discussion, was essential for creating remote active
learning sessions. The course director’s open attitude and willingness to try multiple
new techniques to determine which were best suited for course activity was also important
for course success.
The question of whether students should be encouraged (or required) to maintain their
video feeds on during remote learning sessions remains highly discussed among the
faculty. Guidance for remote learning provided by the medical school to all students
stated “you are expected to be on camera for the entire time of the session” and noted
that “it is acceptable to turn video off when not speaking” in large group sessions.
The latter statement was in bold font, and no definition of “large group session”
was provided, which may explain the authors’ observation that students typically had
video feeds off. Given the course directors’ lack of experience with remote teaching,
the course directors did not state an expectation regarding video feeds at the course
outset. Based on the course directors’ experience, students typically had cameras
turned off during didactic lectures, which was acceptable to some but not all faculty.
The ability to have the video feed turned off also made it possible for students to
sign in for sessions but then not remain present for session; this is a larger concern
for lectures than for small group discussion sessions. In the future, the course directors
will set clear expectations that students will be expected to maintain video feeds
on during any live course activity, including didactic lectures. However, the course
directors remain aware of growing concerns that attempting to require video feeds
to be on does not respect medical student equity (e.g., financial expense of high
bandwidth needed to maintain video feed may not be possible for some students) or
privacy and will continue to work with the students and faculty to balance these needs.
Future Directions
The course directors are currently working to determine the format of the course for
the next time it will be taught, February 2021. The course directors recognize the
possibility that the COVID-19 pandemic will again require the course to be taught
exclusively in a distance learning format. The course directors are hopeful, however,
that in-person teaching and learning will be possible, which will allow for a blended
course utilizing techniques of both in person and remote learning to enhance our goal
of sharing excitement and engagement with the clinical neurosciences [16].