Eric Schmidt, M.D.'18, answers questions from Class of 2021 medical students during an active learning session he developed and taught

A bold pledge – to go 100 percent lecture-free – catapulted the Larner College of Medicine at the University of Vermont into the medical education spotlight. Thanks to a September 2016 Associated Press article, more than 150 media outlets, including the Washington Post, National Public Radio and the New York Times, covered the College’s push to transform its entire curriculum to an active learning approach, garnering the attention of medical schools and educators around the country.

Innovation was not a new concept at the Larner College of Medicine, however. The Vermont Integrated Curriculum had won wide acclaim and the school had been incorporating active learning methods since well before it opened its first active learning classroom in 2014. In fall 2016, the College was at about 50 percent active learning; since then, that number has grown to 67 percent, thanks to the tireless work of dedicated faculty and support of a newly created Office of Active Learning. But faculty aren’t the only ones helping move the transition forward; medical students are playing a critical role in creating active learning curriculum as well.

Student-faculty collaboration and input is key to the success of the transition, says UVM Professor of Pathology and Laboratory Medicine Rebecca Wilcox, M.D., course director for Nutrition, Metabolism, and Gastrointestinal Systems (NMGI). “We think of active learning as the best thing for this generation [and] we really need to have people in this generation designing it,” says Wilcox. “As a course director, I know what objectives I want [to achieve] and what is important for them to learn during the course, but the students help me ‘get it’ at the student level.”

One of those students is Liz Carson ‘19, who first became involved as a representative for the Student Education Group (SEG). SEG student representatives act as liaisons with faculty to “provide a unified point of view, and to appropriately bring pertinent education issues to the attention of faculty and course directors.” More recently, Carson took on an even more hands-on role in helping with the active learning switch, incorporating it into the research portion of her year-long pathology fellowship. Medical students accepted into the pathology fellowship defer graduation for a year for the opportunity to do four months of surgical pathology, two months of autopsy, several month-long elective rotations, and one month of research. An experienced outdoor guide and wilderness medicine teacher, Carson immediately knew she wanted to focus on medical education for her research project. She approached Wilcox, former chair of the College’s Active Learning Task Force, whom she says is a “real educational innovator,” to be her mentor and help her develop a project that would combine her two passions – pathology and medical education. 

Carson’s project had two main objectives – first, take a class that’s still lecture-based and turn it into an active learning module; second, present the module using two different active learning classroom methods to determine which works best for students and faculty.

To start, Carson worked with Wilcox to identify areas in the first-year curriculum that students struggle with and create an approach that would help reduce the difficulty with which they learn and apply the concepts and information. “We had a few different ones to choose from and we settled on [metabolic liver disease] because Dr. Wilcox is really good at identifying what students struggle with,” Carson says. “[That’s] really advanced,” she adds. “You have to be really good at teaching to be able to pick up on…aspects of these diseases that year after year students struggle with.”

Metabolic liver disease is covered in a series of lectures taught by Steven Lidofsky, M.D., Ph.D., a UVM hepatologist and professor of medicine. Lidofsky had already laid the groundwork for transitioning his lectures into an active learning session by condensing approximately 2.5 hours of lecture into four pre-learning video modules totaling 36 minutes in length. In active learning, students use self-paced pre-learning modules to gain foundational knowledge prior to their in-classroom session.

Carson reviewed Lidofsky’s videos as if she was a first-year student, then picked out teaching points she felt were the most salient based on her recent experience in clinical clerkships and taking the first two out of three United States Medical Licensing exams. Then, she, Lidofsky, and Wilcox collaboratively developed a clinical scenario and patient profile for the classroom-based learning that would follow the videos they’d watched the previous night.

Clinical scenario and patient profile in hand, Carson created a module that can be used in a versatile way – a non-linear Powerpoint that can act as an interactive application to deepen the students’ conceptual understanding of the information presented in Lidofsky’s videos. “I wanted to create a patient assessment ‘video game’,” she says. “[It’s] a great way to apply learning to a clinical context – to virtually walk through seeing a patient, asking them questions, ordering lab tests, interpreting the lab tests, and coming up with the assessment and plan.” 

Her inspiration came, in part, from an extremely versatile pharmacology module she used in an optional session during her first-year Neural Science course. The module allowed students to learn in a group format or independently.

Carson’s module features a clinical vignette featuring a 19-year old female UVM student presenting at a health center with vague, non-specific symptoms. Students are asked to use the knowledge gleaned from Lidofsky’s videos to make choices, such as what diagnostic tests they should order for the woman, which will lead them down different paths within the application. Still, regardless of which path they choose, all students will be presented with the same key takeaway points – information they’ll most likely face during USMLE and more importantly, in the practice of caring for patients.

In addition to creating the interactive module, Carson worked with Wilcox and UVM Associate Professor of Pathology and Laboratory Medicine Ronald Bryant, M.D., to compare the effectiveness of different active learning methods. “There’s a lot in the literature that supports active learning in general,” notes Carson, “but there are not many papers that compare different active learning methods and recommend which ones you should use for which types of information.”

For instance, a small-group session approach, which requires a class of 120 students to break into groups of 10-12 students per faculty member, provides students with an intimate environment and extended facetime with clinical faculty. However, small-group sessions are resource intensive and expensive to run – at least 8 faculty members (who are also busy clinicians) need to be free on the same day, at the same time. Additionally, Carson notes that student evaluations show these sessions can breed stress and anxiety among students who feel that their peers, who are being taught by a different faculty member, may be getting different or more information than they are.   

In the large-group format, the entire class of 120 meets in the same room with one to two faculty members and one to two teaching assistants (TAs) as proctors. During the classroom session, students can work through problems and cases at their own pace either as a group or on their own, asking faculty and TAs questions as needed. With less faculty needed to facilitate, it’s less expensive and easier to schedule. But is it as effective as a small-group session? That’s what Carson set out to determine.

To compare the two formats, Carson had half of the first-year students attend the class in a small-group format and the other half in a large-group format. Students were then asked to fill out a LimeSurvey Carson created with the help of the University of Vermont Teaching Academy through which Carson would gain insight about the effectiveness of each session based on four parameters: student preparedness for the session; student perceptions of the session’s learning effectiveness; learner knowledge assessment upon completion of the session; and short-term (ten days) knowledge retention.

Through the survey and working with UVM Statistician, Alan Howard, to comb through the results, Carson learned that in terms of student preparedness, there was no significant difference between the two formats. The same rang true with the students’ perception of learning effectiveness – students in both groups felt the sessions met the stated objectives and most had no difficulty completing the activity during the in-class session. This trend continued for the remaining parameters – statistically, Carson saw no significant difference between the two formats.

Regardless of the results, she remains interested in researching the comparative effectiveness of different active learning methods and is hopeful that not only will faculty use her interactive application as a template for creating other case-based sessions, but that her application will continue to be used for the NMGI course in the years to come. Wilcox believes it can and will. Essentially, says Wilcox, anyone – teaching assistant or clinical faculty, it doesn’t matter if they’re a liver expert or not – could use Carson’s tool to facilitate an active learning classroom session.

Fortunately for the College, Carson is one of many medical students who have contributed to changes in medical education and active learning.

Eric Schmidt, M.D.’18 was one of those students. In 2014, he and his classmates were the first to access the newly-renovated Larner Classroom. Most of their active learning classes followed a “team-based learning” approach, which sparked Schmidt’s interest in the role of academic clinicians in medical education and active learning methodologies.

When Schmidt was determining the focus of his fourth-year scholarly project, he reached out to Wilcox, the director of his favorite first-year course, for guidance and ideas.

His timing was perfect. Wilcox and her NMGI faculty were in the process of transitioning the few remaining lecture-based classes to active learning, so she suggested that Schmidt, like Carson, take on a session taught by Lidofsky, who had already created a series of seven-minute videos that condensed his old hour-long lecture into short, condensed chunks of the most important information and key points students needed to know before class. Schmidt’s objective was to build upon Lidofsky’s work to create a flipped-classroom session featuring clinical cases, and then deliver that to first-year medical students.

During the session, Schmidt advanced through a Powerpoint that presented students with clinical scenarios he had created. The students were then prompted to discuss the information available to them and analyze it based on what they’d learned from the videos the night before, in order to reach a conclusion about what the patient’s diagnosis was or what their next step might be – for example, to order an additional lab test. After group discussions about each slide’s scenario, Schmidt requested students present their conclusions and takeaways to the class. The ensuing conversations shed light on which concepts students were still struggling with, which Schmidt then addressed.

The session was a success due to the close student-faculty collaboration between Schmidt, Lidofsky, and Wilcox and Schmidt’s “near peer” insight – first-hand knowledge that he’d retained and understood material better when he and his classmates could apply what they were learning to clinical case studies. And as a peer teacher, he was more credible, because he had “recently taken the NMGI exams and tests, such as [USMLE] Step 1 and Step 2.” The students recognized that the content they were learning was “high yield,” says Schmidt.

As the College steadily works toward its goal of a 100 percent active learning based curriculum by 2019, it will continue to look toward both faculty and students like Schmidt and Carson to continue the push ahead.

“[Our students] come [to medical school] with a wealth of ideas about how to improve medical education, and we invite their energy and enthusiasm into the process,” says Senior Associate Dean for Medical Education, William Jeffries, Ph.D. “Not only do they propose ideas, they work with faculty to implement them, and then rigorously evaluate the results. Resulting scholarly projects inform the national conversation.”