INTRODUCTION

Embracing systems-based approaches has propelled general medicine to the vanguard of efforts to improve quality, safety, and value of care. This focus on how we care for patients has also informed how generalists teach, prioritizing healthcare systems and processes1 and tacitly drawing attention away from foundational physiologic and pathophysiologic principles. This dichotomy is curious, as the integration of basic science into clinical problem solving can improve diagnostic accuracy2,3,4,5 and enhance value-based care by providing a framework for physicians to work through uncertain clinical scenarios.6 Bringing science to the bedside through research and education has been the bedrock of inpatient general medicine for decades, yet few in the nascent hospital medicine field pursue research and basic science investigation.7,8,9

Applying physiology-based principles to patient care reinforces the mission of general medicine to provide high-quality, safe, and cost-effective care.3,10 Studying basic science may allow clinicians and learners to adopt new approaches as scientific understanding continues to advance rapidly. Mechanistic thinking helps clinicians ask the right questions11 and get to the underlying causes of a patient’s illness. Finally, the scientific method not only strengthens the ability of clinicians to rigorously test hypotheses about individual patients, but also to read the literature critically, and apply it to the patients they care for. Strategies employed by medical schools to ready physicians to practice high-quality care, however, have focused primarily on health systems science,12 with increasing reliance on clinical rotations for acquisition of basic science knowledge.

The restructuring of medical schools to start clinical training earlier13,14 and the vertical integration of basic science education13 implicitly values clinical work over science. The shift in clinical training is exacerbated by a lack of generalists conducting research (including basic science).9 Insufficient teaching of physiology in the context of patient care, and few clinician investigators, implicitly widens the erroneous gap between basic science and clinical medicine, and undermines the design of an integrated medical school curriculum. It is no wonder that fewer trainees are interested in basic science research.15 We believe that fewer residents interested in physiology results in fewer attendings facile with physiologic principles and the cycle spirals. To date little has been done within the field of general medicine to break this cycle.

These concerns prompted us to consider new ways to promote interest in physiology among general medicine clinical faculty. We created a novel faculty development course that merges basic science with clinical decision-making, aiming to stimulate general internists to incorporate more physiology-based teaching into their clinical practice.

SETTING AND PARTICIPANTS

We educated 67 faculty participants (59 hospital medicine physicians, 4 primary care, 4 other specialties) from 24 medical centers across 17 states in annual courses between 2015 and 2019. Courses all took place at the Mount Desert Island Biological Laboratory (MDIBL), an independent, nonprofit, biological research institution located in Bar Harbor, Maine.

PROGRAM DESCRIPTION

We launched “Teaching Physiology On-The-Fly,” a faculty development course for clinical teachers, in 2015 as a collaboration between the Department of Medicine at Beth Israel Deaconess Medical Center (BIDMC) and MDIBL. We chose MDIBL because of its rich history pursuing comparative physiology research and interest in educational programming.16 We used our own experience and an existing BIDMC residency course (Comparative Physiology)10 as a blueprint to interface hands-on basic physiology experiments, and clinical decision-making. Though we did not pursue a formal needs assessment, the impetus for the course was based on course directors’ experience that a lack of comfort and insufficient training were limitations to generalists teaching physiologic principles at the bedside.

The course was structured around 2 main components: Re-learning basic physiology principles and developing teaching skills. We used physiology primers, delivered by specialists, to review basic physiology concepts and then solidified concepts through hands-on basic science experimentation. Each primer was partnered with teaching skill development through reflection and debriefing to unpack the skills employed by the facilitator. Each experiment was paired with a clinical conundrum which was solved through the hands-on investigation. Consider the following example:

A 56-year-old man presents with fevers, chills, and purulent drainage from a diabetic foot ulcer. His vitals reveal fever, hypotension, and tachycardia. Exam is notable for petechiae. Laboratory analysis demonstrates marked thrombocytopenia, lactic acidosis, coagulopathy, and an erythrocyte sedimentation rate (ESR) of 10 mm/h (normal: <25mm/h). Why is the ESR normal? Through a series of experiments, the participants discover that fibrinogen is the single most important factor influencing the ESR, and that the ESR is normal in this case because of low fibrinogen levels in the setting of disseminated intravascular coagulation.

Participants engaged in two of the following physiology modules: hematology, secretory, cardiology, and salt and water homeostasis. To ensure a hands-on experience for all, each module accommodated 3–5 participants and included one to three unique experiments running simultaneously. The four modules ran concurrently, and participants rotated through two modules during the 5 days of the course, spending 2 days on each module and working in teams (Table 1). Each module was structured in the following manner: the first day consisted of exploring clinical dilemmas, forming hypotheses, and conducting experiments, while the second day focused on synthesizing learned information into presentation form, and ultimately into teaching scripts for future use. For example:

Table 1 Sample schedule of the Teaching Physiology on the Fly Course
Full size table

The cardiac physiology group ponders how malignant hypertension results in pulmonary edema. Their hypothesis is that hypertension increases afterload which reduces cardiac output. In their experimental model, the learners explant a bullfrog heart and connect it to a bypass circuit. After collecting baseline stroke volume measurements, the investigators then increase afterload by raising the height of the overflow reservoir. Through this experiment, the learners discover that raising the afterload increases cardiac wall-stress and reduces stroke volume, thereby increasing left ventricular end diastolic pressure, and ultimately manifesting in pulmonary edema. The group then synthesizes their findings into a presentation for other course participants

The cardiac physiology group ponders how malignant hypertension results in pulmonary edema. Their hypothesis is that hypertension increases afterload which reduces cardiac output. In their experimental model, the learners explant a bullfrog heart and connect it to a bypass circuit. After collecting baseline stroke volume measurements, the investigators then increase afterload by raising the height of the overflow reservoir. Through this experiment, the learners discover that raising the afterload increases cardiac wall-stress and reduces stroke volume, thereby increasing left ventricular end diastolic pressure, and ultimately manifesting in pulmonary edema. The group then synthesizes their findings into a presentation for other course participants

The course ended with each participant developing a teaching script based on the physiology explored during the week. These are meant to be used for “on-the-fly” teaching of future learners. Each participant led a teaching session in a small group, observed by course faculty who debriefed the teaching. Other experimental questions incorporated into teaching scripts included:

How the stool osmotic gap can help diagnose the cause of diarrhea.

What is the physiologic response to a salt or water load?

Why do thiazide diuretics lead to hyponatremia more often than loop diuretics?

Is the hematocrit always 3 times the hemoglobin level?

PROGRAM EVALUATION

We surveyed all participants before and after the course to gauge their confidence, satisfaction, and self-reported skill teaching pathophysiologic concepts. Of the 52 participants who responded to the survey (78% response rate), only 41% of participants were comfortable teaching pathophysiology on the wards before the course, compared to 97% following the course. Similarly, 93% of post-course respondents agreed that understanding pathophysiology was important for patient care, and 100% agreed that the course enhanced their understanding of the mechanisms of disease. We also observed improvements in overall teaching, 58% of participants rated their teaching ability highly based on “above average” (55%) and “high” (3%) responses before the course, compared to 82% (70% above average and 12% “high”) following the course. In terms of course satisfaction, 96% reported the course was a “community building experience,” 94% felt their “goals were met,” and 94% reported they would “recommend the course to a colleague.”

The course cost $4000 per participant to cover operating expenses such as laboratory materials, acquiring and handling aquatic species, faculty expenses, and participants’ housing and meals for the week.

DISCUSSION

We established a novel faculty development course to reintroduce core physiology principles and inspire general medicine faculty to incorporate teaching mechanisms of disease into clinical practice. We found high levels of satisfaction among course participants who overwhelmingly would recommend the course to a colleague. We also found significant improvements in participant’s self-reported teaching ability, specifically incorporation of physiology into clinical teaching, and understanding of mechanism of disease.

One reason we found improvements in confidence teaching physiology may be the integration of teaching skill development with physiology primers. Peer feedback also helped to ensure that teaching scripts were tailored to clinical practice. Another key may be the hands-on experimentation. For example, measuring the cardiac output of an explanted shark heart and plotting a Frank-Starling curve following administration of norepinephrine, dobutamine, or metoprolol allows the learner to connect basic cardiac myocyte physiology with clinical care, offering tangible evidence to otherwise abstract principles.

We believe generalists want to incorporate teaching physiology in clinical practice but often lack the skills and confidence to do so. Consistent with this view, clinicians entered our course with low confidence in their basic physiology knowledge and ability to teach it. It is possible the lack of confidence stems from a general trend in medical training towards systems-based approaches compounded by a faculty recruitment process that does not emphasize research.17 The changing landscape of medical training and lack of incentives to pursue basic science research may create a pipeline of new generalist faculty with a gap in basic science knowledge that belies its importance to their work. Our course was predicated on the idea that one way to combat this cycle is to offer faculty development.

Several publications have described programs to promote basic science interest among physicians and trainees, and found similar results to our experience. Spencer et al. found that integrating basic science into clinical practice stimulated interest in the sciences among undergraduate medical students, and that students were better able to recognize the relevance of pathophysiology to patient care.18 A similar course for internal medicine residents found that residents developed an appreciation for physiology and an interest teaching physiology in clinical practice.10 In contrast to these and other programs, our focus was on faculty already in practice and consequently further separated from the basic science curriculum of medical school.

While we found improved interest and confidence teaching physiology, we are not sure how durable these findings are. Although a single experience of relatively short duration may seem unlikely to have a lasting impact, one of our goals in the course was to promote a way of thinking, rather than just provision of discrete facts; in this respect, it is possible that the durability of the impact could be greater than predicted from the brief nature of the exposure. Due to the geographic distribution of participants and small sample size, we were also limited in our ability to explore higher level outcomes such as impact on learners or integration of physiology teaching with clinical care.

The design of the course and unique location offer numerous advantages, but may be too resource intensive in cost and staffing for other programs to replicate. Ready access to a research lab for animal procurement and handling may also be a barrier to program scaling. While other strategies such as asynchronous physiology teaching and simulated experiments are likely cheaper and more readily accessible, we believe much would be lost by eliminating the hands-on experimentation and community building aspects inherent in this program.

We believe that generalists are uniquely positioned to incorporate physiology principles into clinical practice. The close monitoring of inpatients allows generalists to observe physiologic changes in real time. For example, witnessing a patient’s cognition improve with rate control of supraventricular tachycardia, or watching the creatinine improve with diuresis in the setting of heart failure. The clinical laboratory of inpatient medicine allows for easy integration of teaching physiology in clinical practice. Moreover, incorporating mechanistic thinking and teaching physiology only serves to promote system-based practice efforts and improve patient safety, both of which are central to the ethos of a generalist. In fact, cognitive errors are considered the most common cause of diagnostic error19 and most adverse events that result in malpractice suits are actually errors in thinking rather than knowledge.20

One potential strategy to promote interest among generalists to both learn and teach basic science is through immersive faculty development and to directly connect abstract concepts with clinical care. Through use of experiments and mechanistic thinking to solve clinical questions, we were able to demonstrate relevance of basic science to patient care and reinvigorate enthusiasm for pathophysiology among general medicine faculty. We believe our experience offers one approach to bridging the widening gap between basic science and general medicine.