Re-thinking the Integration of Basic and Clinical Sciences in Medical Education

 In this episode our guest, Nicole Woods, PhD joins Kate Mulligan, PhD to discuss how we can re-think the integration of basic and clinical sciences in medical education.  

• Collaborative Advocacy & Partnered Education (CAPE)
• The Wilson Centre
• CLIME Grand Rounds

Transcript

Amanda Garza: Welcome to CLIMEcasts, I'm Amanda Garza the CLIME Program Manager. Our guest today is Dr. Nicole Woods from the University of Toronto. Dr. Woods is the Richard and Elizabeth Currie Chair for Research and Health Professions Education and the Director of the Institute for Education Research at the University Health Network.

She is also a Senior Scientist at the Wilson Center, University of Toronto. Dr. Woods leads an internationally recognized research program that uses methods and principles from cognitive psychology to advance medical education theory and practice. Dr. Woods presented at a CLIME Grand Rounds, which you can now view on our website.

She is here today to continue the conversation with our associate director, Kate Mulligan.

Kate Mulligan: Welcome Dr. Woods. It's so exciting and such a privilege to have you as a guest on this podcast. So, in awe of your work and how prolific you are as a medical education researcher and I know a big chunk of your research of years has been an exploration of the role and the value and impact of integrating basic sciences into clinical training, which is something very near and dear to my heart as a basic scientist.

So welcome and thank you so much for being our guest today!

Nicole Woods: Thank you so much for the invitation and really excited for the conversation and just grateful for the chance to chat about the topic that's near and dear to my heart as well. So thank you!

Kate Mulligan Before we get into the research findings, could you share a little bit of what drew you to this? How did you get to this point in your career and research direction? 

Nicole Woods: Yeah, it's interesting because I don't think very many people would imagine themselves when they're like younger years, they're going to be a medical education researcher, probably because most people don't know that this is a career that someone can have.

I didn't know either, I started my academic career in cognitive psychology. And just by in all honesty, sheer fluke my second year stats prof is one of the most prominent scholars in medical education research. So my second year stats prof was Jeff Norman from McMaster University. And even though he was a stats prof, and so he wasn't really supposed to be teaching about medical education, he used all of his own work in many of his examples.

And I just thought it was kind of neat. It was a neat way to think about psychology work. It was a neat way to do applied research that still felt really meaningful and just fascinating. And so I just became a little bit of a Jeff Norman groupie. I took all of his classes and just he was my thesis supervisor.

And I have to say this topic was the same topic I used for my undergraduate fourth year honors thesis, we started talking about basic science, talking about integration of knowledge. And I continue to do that work to this day, so I had an amazing opportunity to spend my graduate career in the psychology world where we don't study integration of basic science, but we study integration of complex knowledge, and I just continue to evolve in this kind of realm that's specific to health professions. And it's just lucky frankly  that I found a community of people interested in the work and just continue to do it. So it's just very serendipitous, but it's been amazing and I've enjoyed every second of it.

Kate Mulligan: I think you might be, like many humble people, underestimating how much the hard work played a role. I mean, it's easy to say lucky, but I think you're, you work extraordinarily hard and your output shows that. So, so thank you for that. As I said, a big chunk of your work has been an exploration of the role and value and impact of integrating basic sciences into the education of not just medical students, but healthcare professional students.

And it's so helpful to have this research backing up the value of basic science, it seems like post pandemic, especially and in the wake of all the curricular changes that have happened in medical schools, that the time for basic sciences education has diminished and we've brought students into clinical experiences earlier. Another phenomenon that seems to be affecting us now is that the students are very drawn to third party content, commercial basic sciences, if you like, and I feel as basic scientists, we're struggling to articulate exactly what our added value is in the medical education curriculum and sometimes the health professions education curriculum. Could you perhaps summarize your key findings on what our value is for us and talk to us about the role, value and impact of basic science integration?

Nicole Woods: Yeah, absolutely I mean, this is a perennial problem, right? So it feels really contemporary at the moment, as you're saying, because of all the pressures on all of us to think more carefully and deeply about what education means and what's really relevant and important in these kind of post pandemic years, but these questions around what is the value of basic science and why do we really need to include into the curriculum? This is a question we've been struggling with for over 100 years, right? This goes back to Pletzner. This goes back to a lot of conversations with all of us really try to think carefully about a form of knowledge that feels important intuitively, and I often use the example of you, if you had a lay person and you said, I'm going to build a brand new medical school, but I'm not going to teach them any biochemistry. I think even the lay person would be like, well, that doesn't, please don't do that. I don't, I don't want people coming from that medical school.

So intuitively it feels important. And certainly when you're a basic scientist, it feels important, but articulating that value in a way that resonates with clinical teachers that resonates with students can be really difficult. So I think at the crux of it, the argument that we've been making over the last 15 years from my work is that basic science is not only valuable, it's crucial, it's key, it is central.

Without that form of knowledge, you're putting students in a position to try to pull together a whole bunch of really complicated clinical concepts without giving them the structure they really need to have it make sense. And that's the rule of basic science. It's supposed to help us make sense of the world, really.

And in this case, it's the medical world, but outside of psychology, we have other similar processes for making sense of the rest of the world. And so I often say that medical diagnosis, clinical reasoning, all of the things we're teaching medicine, they're not special. This is what we do as humans. This is just basic human cognition and our understanding of mechanism, our understanding of, um, what we call conceptual hearing.

That's really important in everyday category and basic science plays those same roles in medical categories. So for me, that's what we've spent the last kind of 15 years trying to, to prove in different ways and using proved in a really liberal way that that's been the crux of the argument is what is the value it's essential for holding together that mental representation of categories.

And if you don't have it, you're making the job a lot harder for students. I appreciate that sometimes there might be more exciting aspects of the curriculum, and I appreciate that there's a lot of pressure to give students more clinical exposure earlier, but I don't think that can be done at the expense of really key basic science content.

Kate Mulligan: Thank you, that was great. You mentioned a couple of terms in there that I'd love you to unpack for me, cognitive integration and cognitive coherence. Can you, can you just help us understand a bit more about what that is? What you mean by those terms and maybe how we go about ensuring that our learners achieve them.

Nicole Woods: Yeah, definitely. So cognitive integration is a construct that we've been working with probably for the last seven or eight years. And it's become really key to my research program. Essentially what we're arguing for when we say cognitive integration is paying really careful attention to what we mean when we say we're integrating basic science into the curriculum.

So it's very easy to do what we call curricular integration, which means you just include content in the curriculum in some shape or form, cognitive integration says, we don't care about how the curriculum is designed. What we care about is whether the content is integrated within the mind of the learner.

So cognitive integration means integrating the clinical and the basic science within the mind of the learner, not necessarily just in the curriculum. And it's a, it sounds like a weird distinction when I say it that way, I say I don't care about the curriculum, but I actually think it's important because we have often make mistakes.

As educators and program designers of assuming that because we've included it in the curriculum, it must be integrated in the mind of the learner and what we're consistently pushing back against is saying no, it's not enough just to include basic science courses or include basic science teachers, or even just include basic science content.

It's really important that you pay attention to how that content is presented and whether it's really possible for the students to tightly integrate it within their own minds. Our goal in doing this is achieving conceptual coherence. So conceptual coherence is what I was talking about previously it's this understanding that you take the clinical content, you hold it together with a network of basic science content in a way that helps it make sense.

The categories should cohere and really, again, it's drawn from, um, basic cognitive psychology and human cognition of other categories. But a, a category where you have a mentally coherent, conceptually coherent, uh. Mental representation is more memorable. It's more durable. And it's a structure that you can build on.

So that's really our goal for basic science education. It's to ensure that we're focused on cognitive integration and developing conceptual coherence. 

Kate Mulligan: Wow thank you. It all makes entire sense the way you're putting it, I wonder what it looks like for boots on the ground. It's kind of like, how, how do we know what's going on in their heads?

And I guess that's what your research is pointing at.

Nicole Woods: That, that's exactly it. It's my favorite thing about doing this type of work and in cognitive psychology, this is all we do. We try to figure out what's going on in people's heads without relying, without relying on them telling us. Right. So this is the tricky piece and it's a nice place to play in a research world and it can be a scary thing to play as a teacher, because how am I going to know this?

Right? So I think building on the idea of cognitive integration, it's actually really freeing for frontline teachers. It's a really freeing free way to think about education because it means that as a frontline teacher, whether I'm a basic science teacher or clinical teacher, I can support and foster cognitive integration.

And because the reason you can do this is because we argue that cognitive integration is best supported by those teaching moments. So it's supported in the moment that the learner makes contact with the material. So forget the program, forget the committee meeting where you discussed how many weeks of basic science you needed.

What matters is that moment when the student makes contact with the learning material. That's the lecture slides, that's the assessment questions, that's the words that come out of the teacher's mouth. And in paying attention to those moments, that's how you drive cognitive integration. So how you achieve this as a faculty member and as a teacher is thinking really carefully about are you explicitly linking basic and clinical sciences in your teaching?

Not in your program, but in your everyday teaching. Are you explicitly connecting it? Are you taking the time to ask students why questions? Are you taking the time to pay attention to whether or not they really are picking up on these tight connections? Again, it's really easy to put something in the curriculum.

The question is whether they're learning it the way you intend it. And so how would you do that? In psychology, we come up with lots of fun ways to run experiments to kind of sort of trick people into telling us within their brain without actually telling us. As an instructor, I'd say you can do this through the way you ask questions.

It's the way you ask questions in the classroom, the way you ask them on tests when it really matters and it's using those items to explicitly let the students bring their mental representation to a conscious level and to share it out to the world. 

Thank you. There's some encouraging things that you're saying in there and some things that are making me pause.

Kate Mulligan: One of the issues we have, I don't know if it's like this in Canada, but it's actually having students come to class. And while I hear what you're saying about slides and curriculum materials and, and test questions, for me personally, it feels like having a student there that I can talk to is going to be the most effective, really the most effective and efficient way to, to help that happen. I don't know how you feel about that. 

Nicole Woods: Absolutely, So I think and I know this is not a popular opinion these days. I know that we're trying to find more and more ways to make learning efficient and accessible. And I'm certainly in agreement to that. But I do think one of the quickest ways to do this is to really have students in front of you and be able to dynamically ask questions.

So it's the ability to listen to their answer and now adjust the question so that you can build and customize to that. And certainly it's a lot simpler to do that in an in person way. One of my favorite models for clinical teaching that inadvertently integrates the basic science is the micro skills model.

It's one of these one minute preceptor models, the one minute micro skills of clinical teaching was developed out at UCSF and it's a really great way of really quickly walking the students through a clinical case. And if you do it in person and you did it right there on the ward, you could do it in literally a minute.

And so it's an amazing way to get at this. Um, it's clearly trickier in some of our other ways of teaching, but I do think that there are opportunities to carefully design. Remote learning opportunities, remote engagement activities that would still be based on cognitive integration. Again, so paying attention to what's on the slide, even if students are reading it on their own, creating any other type of teaching materials.

Again, paying more attention to whether or not those materials are explicitly integrating mechanistic understanding and clinical manifestations. That's another way to get around it. It takes a little bit more time because you can't be as flexible and dynamic, but it's certainly doable. 

Kate Mulligan: Just going back a little bit, could you give me a sense of how you, what you mentioned assessment as a way of helping with cognitive coherence and cognitive integration?

We here, and I think in many medical schools use multiple choice questions, like step one, that sort of test question. Is there a better way or do we just have to craft super duper, you know, high, high level step one questions to get at this? 

Nicole Woods: Yeah, I get asked this question a lot and I don't think anyone likes my answer, but I'll continue to give it anyway because it's the answer and it's the answer it is.

So, is it possible, people always ask, is it possible to design multiple choice questions that would assess cognitive integration? Um, and my answer would be yes it's totally possible. Take some work and some energy. And so the question is, do you have the energy and desire to take the time to carefully construct mcq questions that we would tap into this knowledge?

Um, I think many schools don't, but I think if it's possible to develop at least that cadre of test writers or item writers. So what we've done at U of T, for example, is we've helped workshops with people who are specifically going to be designing items for our progress test. And I work with them, our Fac dev center works with them so that they understand the concept and then they are responsible for really carefully creating these multiple choice questions.

Having said that, at the University of Toronto, because we're based in Canada, we don't have the pressure preparing our students for some of the standardized tests by the NBME and things like that. So we don't take step one, they don't have to do that. And so we're a bit lucky again, in that sense, that we don't have to prep them for that type of test.

But I do think that those kinds of tests can be thought about differently as well, right? Like I think it's having a better understanding of what those tests are designed to do and whether or not they're designed to pick up on cognitive integration. You know, maybe not. 

Kate Mulligan: I wasn't sure if I was going to put you on the spot and ask you.

Nicole Woods: I don't mind. I'm Canadian. They can be nothing to me. Those paths are not divide to pick up on. 

Kate Mulligan: Thank you for bringing up that point because I realized I didn't have a clue about the Canadian system. Is it generally a 4 year, just as an aside, is it generally a 4 year curriculum for medical. 

Nicole Woods: Yeah, so usually a four year curriculum.We have one or two schools that are a three year curriculum technically on paper. They're three years, but it's really just they have a shortened summer, but it's a four year curriculum and then at that point they would move into residency. And we don't have within the four year curriculum, within the four year undergraduate program across the schools, there's no standardized testing requirements.

So everyone just creates their own tests. There's no expectation that everyone takes the same thing. We also have far fewer medical schools. So we don't, I think that's important to say as much as I like to just say, I don't like standardized tests, blah, blah, blah. We also don't need it as much because we don't have as many schools.

It's just bottom line. So we're lucky in that sense as well. 

Kate Mulligan: I think we've touched on this, but I'm going to ask it anyway, because this is what we're faced with at our university, at least if I'm reading your work correctly, there's some data that show that integration is not specifically tied to a delivery method.

And sometimes it feels like we get tied up with this idea of active learning and I think might be a proxy for what you're talking about, but I'm not 100 percent sure. And I'm wondering if you wanted to elaborate on that a little bit and, and maybe the issue of making students struggle a little in the classroom.

Nicole Woods: Yeah, no definitely. This is a great question because the work in my lab and not instructional design. And so this is why I say that it's not really about any particular teaching modality. Most of the studies that we've done, and you've read a few of them already, we're trying to uncover the value of the knowledge.

We're trying to understand the mental representation. And all of that, the knowledge can be acquired, the mental representation can be developed with a number of different modalities. So I'm very much modality kind of agnostic. I understand the value and Goal and I can appreciate active learning methods for sure.

And I think that they have a place to play, but they're not all created equal and they still have to be carefully structured and carefully designed. So we spent a lot of time in our work, looking at a very particular model of active learning and a very particular model of discovery learning, which is a guided discovery model called productive struggle.

So it's not just discovery for the sake of discovery. It's not struggle for the sake of struggle. It's productive struggle. So it really means that you're challenging students to solve a problem that they've never solved before. And in trying to solve that problem, they begin to develop that mental representation that we really want them because they're picking through the problem, they're thinking it through, they're failing in many times.

And in doing so, you're creating an opportunity for them to think deeply about the problem. And so it's not something that you would do all the time for every learning scenario, for sure. It takes a lot of time and energy to develop, but it can have a lot of value. So that's one model that we, we really, um, try to argue for, but there are lots of other ways to do this and I'm also not entirely against didactic lectures.

I think there's a time and place for that too. I highlight for everybody that if you look across all of our studies, the model that we use in the lab is actually quite dull. The students are coming in and they're sitting there listening to a And I can get them to do that because it's just an experiment.

They're going to be here for an hour and so they'll do it. Can you have an entire curriculum? Based on just boring didactic lectures. I think we're all learning across the world I'm not anymore. No one, no one is letting you do that. So that that matters right in the real world when we take this, these findings out of the lab into the real world, we have to appreciate all of the other things that come into play in adapting to that context and student engagement is certainly one of them, right?

So if the students aren't reading the lecture, they're not listening to the lecture. Okay. They're not learning. So it doesn't matter if the materials were really well done, if they don't show up to class.

Kate Mulligan: In the U S a lot of universities have moved towards the early introduction of clinical experience and the shortening of the basic sciences, and the promise to the basic scientists who were struggling with that was that we'd bring basic science back into the clerkship years in some way. It's. I think there's been variable success in that or variable efforts, maybe, could you talk about this kind of idea of spiral basic science curricula and revisiting basic science during clerkships?

Maybe even pushing back, I guess it doesn't mean that much to you as a Canadian person, but pushing back step one after the clerkships as opposed to before the clerkship.

Nicole Woods: No, I completely see it. So yeah, again, I have less experience with the step one and when it should be placed and things like that. But I do think it's important to build on some of the promises that were made to many basic scientists and to, I would say to society, frankly, when we make decisions to alter medical curricula. So we make a decision to say we're going to change those early two years. So like, you know, our really old curriculum would have had two full years of basic science training before students moved on to clerkship. And that was supposed to be a rich, robust model, right? What we've decided as a community of educators in North America is we're not going to have that model anymore.

We're going to do our best to integrate across the four years, and we're going to do our best to bring some of that clinical content earlier on into the first two years. There's a really strong argument for why that would be necessary. But then I think we also intended to bring more basic science into the other two years into third and fourth, because that's what integration is integration doesn't mean Truncating basic science.

It means integrating that should be across the curriculum and I absolutely think the best way to do that is a spiral curriculum when concepts recur again and again and again, but they don't just recur in the exact same way you're supposed to be building on them every single time when a student encounters a new repeat concept. This is an opportunity to build on it and grow with it. I think for basic science content, that's key, right? I certainly don't expect students to, and, and, you know, several of my settings have shown this. I don't expect students to spontaneously transfer content. They learned in first year to material that they learned in fourth year without some guidance, right?

I expect those, and so that's what a spiral curriculum should do. You should create an opportunity for them to get guided instruction on how to integrate throughout. I have to say, I have seen very few schools put that much energy. Into high quality integration of basic science into the third and fourth years.

Very few. Um, and I, I think that's unfortunate. I think it is a failure of a promise made, not just to faculty, but to society to really produce the graduates that are best prepared for practice and for future learning. And I think to do that, we have an obligation to better integrate the sciences across all four years, but yeah, I've seen very few schools take up the charge to do that really well, probably because of the difficult, right? So it's easy for me to say from my lab, you know. Hey, you, you're not fulfilling your promise. I appreciate the difficulty, but I do think it's a place where we need to sense an energy collectively.

Kate Mulligan: That's, that's interesting. Of course, here at UW, I don't know if you know much about our WWAMI program, but we're a five state regional medical school and our students rotate across the whole region in their clerkships. And so it's, you know, we're not going to be bringing them back to the classroom once a week or anything like that.

So some of the other more innovative models of delivering, you know, using apps to deliver them questions. Perhaps in a guided conceptual way would be something, but it feels, it feels like a daunting task, let's put it that way. I wonder if you'd comment on this. I think one of the things that I've felt with our curriculum renewals, where we put clinicians and basic scientists together in the first couple of years of the first year and a half of the curriculum, there's an adjustment period.

And it's almost like a cultural clash. I don't know if there's a better word for that, but I feel like some of us have managed that better than others. And when you can meld those cultures, that's when you get that really strong, strong curriculum. I think where you have the basic scientist and the clinician there, and they're both willing to put themselves into a vulnerable position and listen to the other person and accept the value and realize it, I think that is fantastic.

But I think there may be ways. To make that, to make that process smoother. I don't know if you have any ideas. I mean, when you're talking about bringing basic science back into the clinical years, that's putting basic scientists in a completely foreign environment. And for them to have the vulnerability and the guts to put themselves into that situation.

It seems like a big ask. 

Nicole Woods: It is a huge ask. And I would also say there are many clinical teachers who feel similarly out of sorts when they're brought into the first and second years because it's been so long for them. So I'm going to use the example of a clinical teacher, but it's not just clinical teacher.

Sometimes when you encounter something that you're uncomfortable with, your gut is to go with what you're more comfortable with. So when you're a clinical teacher who's teaching in the first or second year. And you're uncomfortable because I forgot a lot of these things, I just haven't thought about them a long time.

Your overt response is to say it doesn't matter. It's to say it's not relevant, it's to say you don't need to know it. That's kind of where you end up going, right? Even if, and that's not true. It's not that it's not relevant and it's not, not that it doesn't matter. It's that I forgot. And so you have to be in a moment to say, you know what?

I don't remember, but let me, you know, tell my basic science colleague, I don't remember. And let me take a moment to relearn something so that I can be a better teacher. And that does take vulnerability and that does take guts. So I think we can learn from that and support basic science teachers who then have to teach in a clinical space because for them, it might not even be, they don't remember, they might have no idea.

They've never encountered this space before. And we need to think more carefully about how their work applies to it, right? Um, and so they have to resent the inherent. Human reaction, which is to just double down on their in depth basic science knowledge and to say, no, I'm going to try to think more deeply about how it might apply to this clinical scenario and this clinical world and they think.

Part of this is helping people develop these types of relationships in safe ways so that people can do paired teaching, people can do group teaching or even better group. What I like is group development of teaching materials that any one person can then deliver. I like that piece. I think the other piece is helping people not feel ownership over course content.

So I think we do have a tendency to give someone a course and it's their course. So I designed the objectives. I created the materials. This is mine. And that. It's highly problematic. We're trying to move towards shared teaching models, integrated teaching models. So I think helping people move away from ownership of courses.

If you really want it to be super radical, and I've challenged many schools to do this. No one takes me up on it. Consider abandoning course structures. Why do you need a course? Why do you need a course director? Why does someone have to be in charge of this? If you really feel like being radical, I think a lot of the things that we've just become accustomed to.

And a lot of the structures that we created within medical education, we forgot that we created them and we don't have to have them. Maybe we could rethink them. So they're comfortable, but maybe you don't need them. Just maybe. No one has ever abandoned their courses. I would love someone to come back.

I've been to so many schools that just don't have courses and people think it's a great idea and they kind of smile and cheer and then I leave and they don't do it. It's hard. So I get it. These are hard things. 

Kate Mulligan: Interesting. Well, you know, people can't see us cause it's a podcast, but there's vigorous head nodding on my side.

Uh, yeah, that's, Ooh, there's so much there for us to think about. I think what I hear what you're saying, and I think it's really fascinating. I do know that I've had a lot of my clinical colleagues who've come and taught in the basic science classroom be excited. about it and have testified that they feel like it's made them stronger practitioners to revisit that material so many years after they'd, they'd taken it.

And so that's really heartening. I find it a little bit harder to imagine. Basic scientists getting a huge personal benefit from being in the clinic. Although if we're thinking about basic scientists doing research that could eventually be applied, that's probably where the, where the gold is. 

Nicole Woods: Yeah, I agree.

And I think I've heard those stories as well. I've heard many, many clinical teachers say that when they did have an opportunity to work in close connection with basic scientists, for example, to develop teaching materials or assessment, how valuable they found that. Professionally, just for themselves, not as teachers, but in their own practice, they very much.

Often people say, well, I would have loved, why couldn't I go do this backwards? Like, what if I had, um, if I could go back to first and second year, I think I'd make much better use of that learning now that I've been in practice for a bit. Right. So I think that happens a lot. I do think that as we're thinking about spiral curricula, as we're thinking about integrating basic science into the clinical years, it might not be right for every basic science teacher.

I think you're probably right. That someone with a research background, someone who's interested in kind of the application. of basic science knowledge might be in a better space to engage in the clinical space. It actually goes back to what I was talking about, about how I got into this field. So I'm a cognitive psychologist.

Not every cognitive psychologist would want to work in education and would want to work in health professions education. If you're someone who really wants to get a rich understanding of a really basic phenomena. I'm going to use an example of negative priming from Cog Psych because it was one of my things from undergrad that, you know, I had faculty members who spent their life trying to understand negative priming.

They don't want to help me design a medical school curriculum. They can't, they get zero interest, no value. They don't want to do that. And so maybe that's not exactly the right teacher to include in, in some of the later years, but I think that's okay because I think that the whole point is again with a spiral curriculum.

is that you're building as concepts grow. So maybe early students get one conversation with one basic scientist. Hopefully that conversation will recur in fourth year with a different scientist and they get a different perspective. And I think that's totally fine. It's actually better. That's that

that's ideal education, if you can put it that way 

Kate Mulligan: I like that, going back to the eliminate the course structure I'm going to give you just a couple of minutes to help me understand and help me fantasize about a different way of doing things. Do you want to, have you given that a lot of thought? 

Nicole Woods: Yeah, I played with this lots of different ways when I designed my imaginary medical school that no one will ever fund or allow me to build.

I think that the challenge with courses, the way we have them now is they tend to silo knowledge in so many ways. So, you know, from an exam standpoint, you have one course, you have all the content in that course, and then you have an exam on that content, and then you move on to another course. And that's just not how anyone uses knowledge in the real world.

That's not how knowledge is used. So it's a very strange way. I think from a cog psych perspective, it's a strange way to design knowledge, to design a school that's intended to help students develop knowledge that they're going to use is you're setting it up in this compartmentalized way. Some schools kind of do this a little bit in the earlier years where they have their courses, at least designed around like life cycle.

Or they have like I think those types of approaches that allow people to blend knowledge across disciplines and encounter knowledge from different sources in one moment. I think that's really powerful. So I like the idea of course that I mean, it's not that it's not an anti courses because I get from an administrative standpoint.

It can be helpful, but I'm anti siloing of knowledge. It just makes no sense. So any structure that will allow students to more flexibly encounter material and to encounter the more integrated way is better. So, even if you had a structure where yes, you had a, we do this in undergrads. We have like a. Week one, week two, week three, that's it.

That's all students need to know. This is week one. Does it matter? I don't think it helps anyone if you say, this is the cardiac week. Why? Why, why does this have to be the cardiac week? That's ridiculous. I just don't understand that kind of approach. Right? So I think we can combine kind of an administrative structure that allows us to not have chaos, right?

But with, you know, some flexibility about the type of knowledge that students encounter. I've seen this done a little bit, and I'm even hesitant to mention it because I don't think it's perfect, but we have seen some of the longitudinal integrated clerkships where students are following patients. And where the, the structure is designed around patient care, I think, and, and the opportunities are that students might be on a clinical rotation in surgery in the morning, and then they might go to an, um, obstetrics clinic in the afternoon, and they kind of try to mix up the clinical experiences.

I can see some value to doing something like that. I'll add, I'm hesitant to say it just because I know from an administrative standpoint, it is very difficult to do. So we had a longitudinal integrated clerkship at University of Toronto. We no longer have it. We just couldn't maintain it. We have a very large medical school.

We didn't have it. And the way our health system is, it's difficult to do that. But I just think that's one example of an opportunity for breaking down silos of different forms of knowledge. 

Kate Mulligan: Well, thank you. Thank you for the inspiration. Yeah I feel like there's a lot of investment in those silos. Yeah, there is.

Professional, reputational, whatever. 

Nicole Woods: So that's the issue, right? Like, and I think this is why doing this type of work, I like doing it in the lab and that's great. And I'm not envious of people who have to do it in the curriculum, because I do think that we have a vested interest in a lot of these structures because we've had them for so long.

And I'm not going to pretend that the structures don't. At value in many other ways, so I think there is again some efficiencies that are afforded to us when you have a really strong course director when you have developed a program that kind of we already have things established to support it. We have learning objectives.

We have a department structure. We have a lot of reasons to maintain some of these. Ways of thinking and ways of doing things. So I think it's just on us as we're, we're all doing curriculum renewal every what, like five years. Sometimes it feels like every other year you're doing it. We spend a lot of time in those moments, sometimes thinking about content and never really questioning.

Some of those basic structures and do we really need them and can we reconsider them? And those might be moments to just try something new. 

Kate Mulligan: Wow thanks for that inspiration. One of the other concepts that I think I got from some of your work was this idea that maybe, especially the basic sciences, but integrating knowledge from a lot of different domains is really important for our learners to help prepare them for future learning. Could you help me understand what that means to you and what it looks like on the ground and in the classroom? 

Nicole Woods: Yeah, so I think this is a piece that we've been talking about in the last couple of years, and it's become a way of thinking about basic science integration that I wish I'd thought of sooner because it's so powerful, right?

Cause I think thinking of ourselves as preparing learners for the future fits really nicely with everything we've been saying about basic science about conceptual coherence about cognitive integration. So the idea is that, yes, basic science is valuable and it helps you develop a coherent mental representation.

But why does that matter? Why does it matter if we have a coherent representation? When we first started doing this work, I was like, well, it matters because coherence is more memorable. I was a memory researcher, so I was focused on memory. So yes, coherent categories are more memorable, great. The other thing coherent categories do is they set a basic structure, a basic foundation on which you can build more knowledge. So the idea here is that if you're doing a really good job of cognitive integration and you give students that really tightly coherent, mentally coherent mental representation, you're setting the stage for them to continue learning. They can add to that mental representation as they continue to encounter new concepts, as they encounter new programs, right?

Literally you can map it all out and watch that mental representation grow as students add new content to it. That's the definition of learning from a psychology standpoint. That's just straight up what it means to learn. Um, but I think it's a really powerful way to think about education, right?

Undergraduate education is never going to prepare students for every single thing they need to know for practice. It's not, it's not even going to prepare students for everything they need to know for residency. So the only thing we can do is prepare them to continue learning. That's it. That's all you can do at any stage of education is prepare people to keep learning for the future because you cannot give them everything they need to know in four years, in eight years.

It's not possible. So I really like that way of thinking about it. So I think of it from a cognitive psychology standpoint, which is just we give them a basic mental representation and one that in Best position to help them grow that mental representation. If you don't have basic science, let's say somebody else comes and they build this medical school with no basic science, what they're doing is limiting the ability to continue to learn afterwards. You would have to provide all of the content right now. 

Kate Mulligan: I can't process as fast as you can talk. Let me just think about that for a minute. There were two things that came to mind, when you're helping students build a mental representation or coherent concepts, I wonder what the role of flexibility is in that.

Because I feel like sometimes you have to blow something up and rethink it, and the example I'm thinking about a little bit is The incorporation of theme, what we call theme material here, which is the social determinants of health and much bigger contextualizing of health that wasn't present when I started teaching.

Uh, and there are aspects to that seem to challenge some of the coherence of the supposed coherence that we have. Can you, can you maybe speak to that? 

Nicole Woods: Yeah, you know what it's funny This is again, one of those topics that seems to be coming up more now, and it didn't come up earlier, and it might be exactly what you're discussing earlier in my career, and it might be for the exact reason you're discussing, I think right now, we're seeing more challenges around what we need to include in the curriculum, and what we really think of as core to medicine, right?

As we, as we change the forms of knowledge that we think of as core to medicine, and we change what we think it means. Thank you. To be a physician and to support health, we have to think carefully about what kinds of knowledge you have to bring in. And it seems like we keep having to bring in more and more, right?

There's always more content and so I don't think that this is really a challenge at all to conceptual coherence. I'll tell you kind of why the, the model of conceptual coherence that we've been working with is built on a principle from cognitive psychology called semantic networks. It's basically understanding how, um, knowledge is organized in the mind.

The key piece of a semantic network is it's supposed to be dynamic. It's supposed to change it's supposed to grow. It's not static at all. It's supposed to change. And sometimes you build pieces of the network and it turns out that was all wrong. You have to blow it up and start again, and that's okay.

Then it's not supposed to be a static thing. So I think that this way of thinking about basic science education is also really freeing because it means sometimes you have to change, you have to change what you think of as a basic science. Sometimes you might have to be satisfied with answers to basic science questions that change over time as new knowledge develops, right?

So I think the whole idea is that, yes, we're building conceptual coherence, but we're building very flexible mental representation. And we want to prepare students to be able to build their knowledge flexibly when they lead. Encountering new models, new ways of thinking, new methods. Treatment, the medical world that they have today isn't the one that they're going to be practicing it, right?

It's just going to be different and we have to prepare them for that flexibility. 

Kate Mulligan: Right yeah, there seems to be a part of that that might be related to being excited about uncertainty as opposed to completely threatened by it. It's a lot of our students seem to be and faculty. 

Nicole Woods: Yeah, absolutely. And I think That's key to curriculum design, right?

One of my fears when we focus too much on what goes into the curriculum, we think about, okay, we have to make sure that the students are exposed to this type of work and this type of work and this type of practice setting and this type of clinic, and they need rural experiences. We seem to have decided that they need to see everything now, as opposed to saying, you know what, I don't know what you're going to see.

And that's exciting. And I'm going to make sure that you're prepared to deal with uncertainty. And ambiguity and novelty, all of those things, because that's what's inherent in the world. So I think that designing a curriculum around preparation for future learning, it's designing curriculum that embraces uncertainty and embraces ambiguity and embraces novelty. 

Kate Mulligan: And that prepares them for just regular life as well. 

Nicole Woods: Just regular life, it turns out. 

Kate Mulligan: Thank you so much for all of that, Nikki. I know that you've been, or at least from your recently published work, it seems like you might be taking some bold steps in slightly new directions, maybe embracing more fully interprofessional education.

Would you like to share with us your excitement about that? 

Nicole Woods: Yeah, I absolutely would. Cause this has been so much fun for me. I have the luxury of working in a multidisciplinary research institute. So at the Wilson Center and at the Institute for Education Research, we have scientists who come from so many different backgrounds.

And as I have been doing this basic science work for many years, I've been able to collaborate with a lot of them in different ways. So I've been collaborating for years with Maria Milopoulos on our work on cognitive integration and adaptive expertise. And more recently, I've been collaborating with Stella Ng on work related to interprofessional education.

And the basis of all of this, to be honest, it's still back to my basic science work. So don't tell Stella, but I don't actually see it as that bold. To me, I think we've been talking about a lot of the same things, but it's allowing me to play in a new space. So I've always been, again, a proponent of basic science education.

And the last little bit. I've been thinking about what, what are the sciences that are core to medicine and really thinking about knowledge from social sciences, knowledge from behavioral sciences, knowledge from humanities, and how they can be better included in the curriculum as basic sciences. So I really do think that there are concepts from those disciplines.

That are basic to medicine and they should be considered as foundational to medicine and should be considered basic sciences. And so in doing that work and extending our definition of basic science, it's also prompted me to think more carefully about. Who creates knowledge and who should be benefiting from knowledge and recognizing that it's all well and good to spend a lot of time thinking about education for positions, um, and education, even for nurses, but there are a lot of folks who make a healthcare system work a lot of people who are experts in their own right.

Um, and how can we create. As, as we're building in curriculum that bring in all these forms of knowledge, how can we do that in the interprofessional space and how can we provide high quality education, high profile, quality, interprofessional education on some of these concepts? I think this is a good opportunistic time because the whole world is talking about integrating these new forms of knowledge and I just think we should be doing that together.

I don't want to see now medical schools developing their own social science curriculum and the nurses have their own and then, you know, social work can have them. I think as long as we're in this new world, we should be building these things together. And so we've been working collectively with myself and Stella to create some high quality educational programs that are designed actually around personal support workers.

And I think you must have a similar role in the States. They might not be called that, but it's designed around personal support workers. We spotlight Personal support like workers, all of the programs are built on concepts like cognitive integration, critical reflection, or critical reflexivity.

Everything is co designed. And even though we spotlight the personal support worker, the curriculum is always designed to really be supportive of development of knowledge across the health professions. So we, um, allow and, and, and present a lot of work with social workers, with, with physicians, with community health workers, with nursing, with personal support workers, all working together.

So it's been really just fun. It's been really fun work. I've enjoyed every minute of it. I've had a chance to play with some new, um, methodologies in the lab to actually see. Study this work, but also have a direct translation and knowledge mobilization arm so that we can actually build programs myself.

I was never doing that before. I used to say, don't ask me. I'm not building your materials, not a, an educator, but this in this work, I've actually gotten to play that role. So it's helped my research and taught me how difficult this is. I mean, I was just sitting up at the, at the, in the lab saying, Hey, they're basic scientists.

Change all your materials. And then now I had to design my own materials. I'm like, this is really hard. So it's been, it's been really fun doing this work. 

Kate Mulligan: Thank you, I think that's pretty bold. I mean, it seems obvious when you extract yourself from everyday activities, that there are so many affordances to bringing people together who have a common goal, which is the health of the population. Even things like anatomy we've got the nursing anatomy and the pharmacy anatomy and the medical student anatomy. It's like, wait, you know, there's a basic core material that we could have them all together in. And anyway, I'll stop. Thank you so much.

And integration is the, is the key word, right? So thank you so much. We'll put some links to, I noticed that you sent me a link for the CAPE program. 

Nicole Woods: Yeah, learning is our knowledge mobilization arm and all of the content is completely free. Anyone in the world can log on, make an account and take one of these cognitively integrated courses.

So yeah, definitely. I'm happy to share that with everyone. 

Kate Mulligan: Thank you. And so we'll, we'll put some links in the show notes and thank you again so much. Do you have any last words? that you'd like to share.

Nicole Woods: Just cognitive integration, I guess. I don't know if I've said it this time. But yeah. Thank you so much.

Thanks very much, Dr. Woods. 

Amanda Garza: Thank you again to Dr. Woods for taking the time to talk with us about her work and rethinking the integration of basic sciences and clinical sciences and medical education. CLIMEcast on the streaming app of your choice to get updated when new episodes are released. Thanks.