Exploration of the integration of microbiology and immunology emerging topics into undergraduate medical education (2024)

Associated Data

Data Availability Statement

ABSTRACT

KEYWORDS: Emerging topics, microbiology and immunology, undergraduate medical curriculum, integration of basic science, clerkship readiness

Introduction

Modern preclinical medical curricula are increasingly integrated, as integration is firmly established as being beneficial to learning [1–3]. Horizontal integration in preclinical medical curricula has led to replacement of traditional discipline-based courses by organ system-based courses and other innovative curricula [1]. Accordingly, ‘the preclinical curriculum’ is an intricate puzzle with many pieces, all of which must efficiently work together under severe time and resource constraints to deliver the optimal content for medical students. Medical educators who are part of the preclinical curriculum team of scientists and clinicians that teach medical students are continuously challenged to determine the depth of science medical students need to know. Some scientific disciplines required by medical students, including microbiology and immunology, are constantly changing, for example as infectious organisms emerge or evolve and novel immune-based treatments are approved based upon new scientific knowledge.

With limited curricular time, medical school microbiology and immunology educators may struggle to determine when and how to incorporate new and emerging topics into the curriculum. This is complicated by the fact that many of these topics are taught in courses where they are not the course director or lead. ‘New and emerging’ (and re-emerging) topics were defined for this study as content that has not traditionally been taught or emphasized, but due to scientific/medical advances, increased numbers of patient cases, and/or increased public awareness of the topic, should be considered for addition to the preclinical medical curriculum. Consideration of emerging topics, such as COVID-19 and novel Food and Drug Administration-approved cancer immunotherapeutics, is required of microbiology and immunology educators more than some other basic science disciplines, as the fields of infectious diseases and applied immunotherapies change over time. Determining which emerging topics should be added to the preclinical medical curriculum is a careful balancing act for microbiology and immunology educators. ‘New’ content is particularly relevant and exciting for a medical learner, and all stakeholders want physicians to have the most up-to-date scientific and medical knowledge. However, the rate of acquisition of new medical and scientific knowledge means that including ‘everything’ into the curriculum is impossible, as curricula are already overcrowded [4].

Consensus learning objectives for microbiology and immunology were published in 2009, which were intended to define the minimal content medical students needed for competency [5]. The frequency of medically-relevant changes within the fields of microbiology and immunology since 2009 demonstrates that relying on consensus documents to determine whether a new topic should be added to the curriculum is impractical. Thus, there is no established method by which faculty may determine how to integrate new emerging microbiology or immunology content. The only published article about emerging microbiology topics described the frequency at which applied microbiology content, such as hospital infection control, antimicrobial stewardship, and global health were incorporated into curricula of allopathic medical schools in 2016 [6]. No published studies have investigated emerging topics in immunology in preclinical medical curricula.

The aims of this study were to determine which factors are considered by microbiology and immunology educators in the United States before they incorporate a new and emerging topic into their curriculum, define the microbiology and immunology topics considered new and emerging at a single snapshot in time (2022), and explore best practices of how these topics are being integrated. These results will be useful for educators to consider when incorporating emerging topics in their discipline-specific portions of the premedical curriculum at their respective institutions.

Methods

Exempt status for the research project was granted by the Institutional Review Board of each investigator’s institution (Western Michigan University IRB: WMed-2022–0962, Marian University IRB: IRB S22.172, Indiana University Human Research Protection Program: 17130, Sam Houston State University IRB: IRB-2022-321, Texas Tech University: E23034).

A 17-question anonymous survey (Appendix I) was constructed using Qualtrics (Provo, UT) and emailed to faculty who teach immunology and/or microbiology at allopathic and osteopathic medical schools using the DR-Ed listserv, the American Society for Microbiology (ASM) Connect listserv, and the attendee list of the 2022 Association of Medical School Microbiology and Immunology Chairs (AMSMIC) Education Strategies Workshop. The survey asked participants about experiences, perceptions, and the decision-making process regarding integrating emerging topics into Undergraduate Medical Education (UME). Demographic data on the type and size of medical school was also collected for analysis. A total of 69 participants agreed to respond to the survey, with 40 giving informed consent and completing all questions (not including two open-ended questions). Our analysis was confined to the 40 complete responses from U.S. medical schools.

The survey question types fell into three categories: multiple choice, ranking, and a slider scale. For the ranking questions, respondents ranked a set of choices. In the slider scale question, respondents moved a slider to choose between 1 (lowest) and 5 (highest). For a complete list of survey questions see Appendix I.

The type of question determined the statistical analysis used for each question. Chi-square tests were used to determine if there was a significant difference between allopathic and osteopathic respondents. For multiple selection multiple choice questions, contingency tables were generated to examine conditional relationships between the choices (i.e., how often one choice occurred in the presence of another choice). A t-test was used to determine if there was a significant difference between the two choices in the slider scale question where participants were asked to grade the importance of public perception and clinical impact in the decision to include an emerging topic in the curriculum. Inter-rater reliability for the ranking questions was measured using Kendall’s W [7] and statistical significance was measured using a follow-up Chi-square test. Data processing, statistical computations, and visualizations were performed with Python 3.11 using the pandas, scipy, and seaborn libraries. Narrative responses (n = 37) from the open-end question ‘how do you define an emerging topic in microbiology and immunology’ were analyzed using constant comparison analysis [8] and classical content analysis [9]. Qualitative statistics were computed using Dedoose 9.0.90.

Results

The 40 respondents of the study were from 31 medical schools across the United States. Among the 31 schools, 19 (61%) were allopathic medical schools and 12 (39%) were osteopathic medical schools. Relatively more osteopathic schools were represented in this study compared to the current U.S. totals of 155 (80%) allopathic and 38 (20%) osteopathic schools. The participating institutions have a variety of different campus environments, with an average incoming class size ranging from 49—550 per campus, the number of campuses ranging from 1—9, and the ratio of microbiology and immunology faculty to campuses ranging from 0.8:1 to 20:1. Among the 40 respondents, 15 (37.5%) report teaching microbiology only, 10 (25%) teach immunology only, and 15 (37.5%) teach both disciplines.

To test for differences in responses to the multiple choice and single-selection questions between faculty at allopathic and faculty at osteopathic medical schools, chi-square tests were conducted, and no significant differences were identified for any of the questions (α=0.05).

Discussion

How and when to incorporate new and emerging topics into undergraduate medical school curricula is a challenge frequently faced by medical school faculty. While the COVID-19 pandemic made microbiology and immunology faculty particularly aware of the need to regularly reevaluate and update their content, there have been many other significant infectious disease outbreaks and immune-based therapeutics that have become important in the past decade. In this study, microbiology and immunology educators from medical schools across the country were surveyed to define these new and emerging topics, evaluate what factors they consider before incorporating a new and emerging topic into their curricula, how this content should be taught and assessed, and what challenges must be overcome.

Efforts to integrate emerging topics in other disciplines have been addressed in previous studies. For example, in 2022, after talking to various stakeholders, Sullivan et al. conducted a comprehensive analysis to determine where and how to insert climate change and health into their curriculum [10]. They devised a 6-step model based on Thomas et al to achieve horizontal and vertical integration of climate change and health into the curriculum [11]. Other groups have conducted multi-institution surveys to determine what emerging topics should be taught.

One study published in 2013 surveyed medical schools in the United Kingdom and Ireland on teaching of biological weapons and bioterrorism [12]. Of the 34 medical schools that answered their survey, only 6 (17.7%) had specific teaching on biological weapons and bioterrorism in the curricula, but most schools did not. From free responses, the reasons for why this topic was not part of the curriculum included that the teaching schedule was too busy, or the topic was not compulsory. In addition, some regarded this field of study as a postgraduate subject that was not appropriate for undergraduates, and it would be very rare for a junior doctor to see these types of cases.

All 40 medical educators that participated in this study have included or considered including emerging topics in their curriculum, demonstrating that faculty recognize the importance of teaching emerging topics. There is some correlation between the prevalence and recency of an infectious disease or immune-based therapy and the percentage of respondents who indicated they had considered the topic for integration. For example, COVID-19 was the most selected topic (n = 37, 92%); given its recent global significance, this result was not surprising. Somewhat less frequently identified was Zika virus (n = 32, 80%), a pathogen whose expanded geographic distribution during the 2014–2015 epidemic revealed a previously unappreciated effect on fetal development [13]. Similarly, mRNA vaccines (n = 30, 72%) were ranked higher than Chimeric Antigen Receptor (CAR)-T cells (n = 27, 68%), as mRNA vaccines were broadly distributed worldwide during the COVID-19 pandemic, while CAR-T cells, FDA-approved in 2017, are an effective cancer therapy targeted for a narrower population [14]. Given that survey respondents were all medical educators, the finding that the 1—5 rating of clinical significance was higher (and statistically significant), than public perception in determining which emerging topics to add to the UME curricula, was unsurprising. However, respondents still ranked public perception or media coverage 2.59 on the 1—5 scale, suggesting that indicators of social impact remain important contributing factors in this decision. For example, some topics of lesser clinical significance may be included to address student interests or concerns arising from non-medical sources of information.

Respondents to our study suggested lectures (n = 18, 45%), case-based learning, and discussions (n = 12, 30%) as the best methods for teaching emerging topics. It was interesting that TBL/PBL were chosen less frequently. This may be because educators find it easier to add a slide or case to an existing lecture than create an entirely new TBL/PBL. Additionally, because these are new and emerging topics, there may be insufficient verified clinically relevant information to create a new TBL/PBL. With the trend of UME moving toward integrative models and the adaptation of virtual learning due to the recent pandemic, some additional ideas for integrating emerging topics include introducing them through asynchronous learning modules, small case studies, or TBL activities in system-based courses. Several studies have reported innovative ways to teach individual emerging topics. Chiu et al. share their experience in developing and implementing a student-led virtual COVID-19 course, while Kemp et al. describe a collaborative self-directed learning COVID-19 elective [15,16]. In another study, Kabelitz et al. report on the formation of an Education Committee of the International Union of Immunological Societies (IUIS). This committee administers three to four one-week courses per year, that focus on the most relevant topics and health issues facing specific countries or regions around the world [17]. The optimal curriculum design and teaching methods for emerging topics likely vary based on the impact of the disease or immunotherapeutic and the depth of the scientific literature on the topic. For example, for COVID-19 it is reasonable to explore the opportunity in the curriculum to have multiple, focused active learning sessions, as well as develop the connection between various concepts and disciplines, such as public health and ethics. Some other emerging topics, such as immune checkpoint inhibitors, may merit simply replacing a small fraction of an existing lecture on cancer immunotherapies due to a reduced worldwide impact.

Although a new or emerging topic may be important and exciting to scientists, and faculty may desire to devote hours of teaching to the topic, it is not feasible for every program to identify space in the curriculum to offer an independent session or course for emerging topics. As UME curricula prepare future physicians for lifelong learning and promote the culture of self-identification, including in the curriculum all content that might be relevant to physicians in future decades should not be the goal of medical educators. In fact, based on the survey, the biggest challenge for incorporating emerging topics in UME is making room in an already full course and curriculum. The concerns of curriculum overload for UME has lasted over a century [4,18–20]. Several solutions have been proposed to address the issue and a few studies report the successful implementation of a less comprehensive curriculum, which usually involves a huge multidisciplinary team effort [21–23]. When deliberate curriculum planning cannot take place, purposeful and creative integration of new/emerging topics in curriculum may require removing older, ‘classic’ topics with less medical relevance from the curriculum entirely. Content experts and course directors are the major decision makers regarding what and how to incorporate new topics in the curriculum, per our survey data. In the future, faculty development and encouragement of scholarly design and dissemination of education materials and/or modules for these new topics will be very beneficial for the medical education community and may alleviate the burden of content development.

This study was subject to several limitations. First, there were strong selection effects as the survey was not distributed randomly. A medical education conference attendee list and two education-focused listservs were used to distribute the survey. While there was diversity in the sample, methods to correct selection effects, such as post-stratification, were not used due to a limited sample size. Also, faculty who attend educational conferences and subscribe to medical education-focused email list servs likely have distinct viewpoints compared to faculty who do not. In addition, several respondents came from the same institution, and respondents may teach only microbiology, only immunology, or both. There are also limitations for the rank-based questions. Differences between ranks are subjective for each respondent, making absolute comparisons between ranked items impossible. For instance, a respondent may rank their first choice nearly equal to their second choice, or they could consider their first choice far above their second; a ranking question cannot distinguish between these two possibilities. Due to these limitations, this study was not designed to test a specific hypothesis, but instead its purpose was to describe how education-focused faculty incorporate and teach emerging topics in microbiology and immunology.

Another limitation is this study defined the ‘new and emerging’ microbiology and immunology topics at a specific moment in time, Fall 2022. Accordingly, COVID-19 was the most-frequently selected topic. While the study also identified Mpox as a highly-relevant new topic, barring a recurrence of an Mpox outbreak five years from now, Mpox would likely not be included in the curriculum of 75% of respondents in 2027. This limitation also demonstrates the importance of faculty defining the process of how and when new and emerging topics are added to (or removed from) the curriculum, because the medically-relevant microbiology and immunology topics are regularly changing.

The core curriculum of the UME should ensure the competency of medical graduates to deal with the common or important clinical problems that they are likely to encounter in future clinical practice [24]. As we reflect on the COVID-19 pandemic that has deeply impacted all aspects of medical school education, we conclude that it is important to include emerging topics in the medical school curriculum to prepare students for changes in clinical practice and the needs of future doctors.

Acknowledgments

We would like to thank our institutional librarians, Christopher Bishop (Marian University, Hackelmeier Memorial Library) and Cecelia J. Vetter (Ruth Lilly Medical Library, Indiana University), for their help with literature reviews. We would also like to thank our colleagues who provided input on an early draft of the survey.

Appendix I. Survey Questionnaire

• (1) Please answer the following demographic questions regarding the school you are affiliated with.

  • a. Name of the school

  • b. Average incoming class size/year

  • c. Number of Campuses

  • d. Number of faculty who primarily teach microbiology/immunology content (all campuses combined)

• (2) Do you primarily teach Microbiology, Immunology, or both?

  1. Microbiology

  2. Immunology

  3. Both

• (3) How is the pre-clerkship microbiology and immunology taught? (Select all that apply)

  1. Stand-alone microbiology course or stand-alone immunology course

  2. Combined microbiology and immunology course

  3. Part of foundational sciences course

  4. Combined with other disciplines (e.g., Hematology, etc.)

  5. Integrated into organ systems course

  6. Part of fully integrated curriculum (no separate micro/immuno course)

• (4) What major modalities are used to teach the pre-clerkship microbiology/immunology content? (Select all that apply)

  1. Lectures (including active learning components as part of an overall lecture)

  2. Asynchronous modules

  3. Team-based learning (TBL)

  4. Problem-based learning (PBL)

  5. Other active learning – Case-based learning, discussions, etc

  • (5) How do you define an emerging topic in microbiology and immunology? [open response]

  • (6) Please identify emerging topics you added to your curriculum or considered adding to your curriculum in the last 10 years. (Select all that apply)

  1. COVID-19

  2. Monkeypox

  3. Zika

  4. Ebola

  5. Re-emergence of vaccine-preventable diseases (measles, polio, etc)

  6. mRNA vaccines

  7. CAR-T cells

  8. Checkpoint inhibitors

  9. Fecal microbiota transplant

  10. Siderophores to treat cancer

  11. Others [open response]

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• (7) Who is involved in the decision to incorporate an emerging topic into the curriculum? (Select all that apply)

  1. Content expert

  2. Course director

  3. Department chair

  4. Curriculum Committee

  5. Associate Dean of Education or similar administrative entity

  6. Others [open response]

• (8) What levels of clinical impact or important triggers suggest an emerging topic warrants inclusion in the curriculum? (Please rank order)

  1. Newly-approved treatment

  2. Newly-changed management guidelines

  3. Significant number of cases/deaths worldwide

  4. Significant number of cases/deaths seen in region/local community

  5. Others [open response]

• (9) What level of public perception or popular media coverage suggests an emerging topic warrants inclusion in the curriculum? (Please rank order)

  1. See regular social media posts

  2. It’s on the national news nightly

  3. Family members ask you about it

  4. Local news stations are covering the topic

  5. See commercials for new treatment or vaccine

  6. Others [open response]

• (10) On a sliding scale, please indicate your opinion of the relative importance of public opinion vs clinical impact in the decision to include an emerging topic into your curriculum. (5-likert scale, 1-least important, 5-most important)

  1. Clinical impact

  2. Public perception or popular media coverage

• (11) What is the major modality that you think would be best to teach these emerging topics?

  1. Lectures (including active learning components as part of an overall lecture)

  2. Asynchronous modules

  3. Team-based learning (TBL)

  4. Problem-based learning (PBL)

  5. Other active learning – Case-based learning, discussions, etc

  6. Other [open response]

• (12) What is the best way to assess these newly emerging topics?

  1. No assessment

  2. Formative only

  3. Low-stakes summative (quizzes)

  4. Summative examinations

  5. Others [open response]

• (13) If you add a major emerging topic into the curriculum, does something else have to be removed? If yes, who is involved in the decision of what topic to remove? [select all that apply]

  1. Content expert

  2. Course director

  3. Department chair

  4. Curriculum Committee

  5. Associate Dean of Education or similar administrative entity

  6. Others [open response]

  7. Nothing needs to be removed

• (14) Rank the reasons for incorporating emerging topics into the curriculum.

  1. Demonstrate the importance of basic science

  2. Allows more basic science to be taught

  3. Integrate basic science into other disciplines (like ethics of cost of treatment, vaccine hesitancy, public health, etc)

  4. Satisfy student interest in the topic

  5. Prepare students for seeing cases in the clinic

  6. Prepare students for standardized/board exams

  7. Others [open response]

• (15) Rank the obstacles/challenges that work against adding emerging topics into the curriculum.

  1. Making room in an already full course or curriculum

  2. Curriculum committee has to approve all such changes

  3. Time constraints for faculty

  4. Content not covered yet on board exams

  5. Content overload for students

  6. Other: Please specify

• (16) What are the resources you use to develop the session with emerging topics? (Select all that apply)

  1. Textbook

  2. Journal articles

  3. CDC guidelines

  4. UptoDate or similar resources

  5. Others: Please specify

• (17) Is there anything else you want to tell us about integrating emerging microbiology and immunology topics into medical curricula, pre-clerkship or clerkship?

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Complete survey data used/analyzed in this study are available from the corresponding author on request.

References