Active Learning and Competency Preconditioning Strengthen Osteopathic Medical Student Performance, Physician Attributes, and Competency Assessments

Introduction Lecture-based curricula continue to be largely utilized in medical education around the world. However, with the paradigm shifts in medical education and advancements in information technology, we have been obliged to modify the way we deliver medical education to current generations of students, including millennials and Generation Z1. Historically, medical education has been oriented toward didactic lectures which are predominantly teacher-centered learning. Many scholars believe that this strategy has limited scope for critical thinking and promotes passive learning while encouraging adult students to rely on preexisting knowledge to build more information. Based on Edgar Dale’s “Cone of Learning” model, which incorporates several theories related to instructional design and learning processes, one can conceptualize how people learn and retain knowledge2. With information from this model and empirical data from various articles, research shows that after two weeks most students tend to recollect only ten percent of what they read or heard in comparison to approximately ninety percent of what they are involved in doing3. This is the basis of “experiential


Introduction
Lecture-based curricula continue to be largely utilized in medical education around the world. However, with the paradigm shifts in medical education and advancements in information technology, we have been obliged to modify the way we deliver medical education to current generations of students, including millennials and Generation Z 1 . Historically, medical education has been oriented toward didactic lectures which are predominantly teacher-centered learning. Many scholars believe that this strategy has limited scope for critical thinking and promotes passive learning while encouraging adult students to rely on preexisting knowledge to build more information. Based on Edgar Dale's "Cone of Learning" model, which incorporates several theories related to instructional design and learning processes, one can conceptualize how people learn and retain knowledge 2 . With information from this model and empirical data from various articles, research shows that after two weeks most students tend to recollect only ten percent of what they read or heard in comparison to approximately ninety percent of what they are involved in doing 3 . This is the basis of "experiential learning" or "active learning" 4 . Active learning mostly encompasses a variety of educational methods intended to facilitate student involvement in the learning process in comparison to the lecture-based approach to medical education 5,6 . Many researchers have used various types of innovative teaching and learning methods to promote active learning environments and to obtain feedback regarding curricular content and improvement 7 .
Active learning methods such as problem-based learning, audience response system, and social media usage (podcasting, Twitter, and Facebook) have been shown to improve student participation and attention, increase classroom attendance, reinforce key concepts and content, and become a medium for communication between student and teacher. This in turn improves instruction and enhances learning performance and retention of the presented material 8,9,10 . Many subject-specific curricula remain focused and dedicated to delivering content detail with less importance placed on the development of student competence and confidence in their field of study. Essentially, this overburdens students with factual, dis-integrated knowledge that is compartmentalized, and lacks holistic intellectual relevance which in turn inhibits acceptance by the present generations of students. This does not help students become confident and selfreliant in situations they may encounter later in training or as a physician, thus rendering them less effective 11 . This discord between how information is provided and how information and knowledge are utilized has led to further modification and modernization of approaches utilized for content delivery and outcome assessment. To overcome these deficiencies, educators and leaders worked collaboratively and collectively to identify an effective, innovative approach, which we now know as competencybased medical education.
The competency-based medical education was introduced in North America at the start of the 21 st century, and with this came a shift in how schools conceptualize their curricula and measure learning outcomes. Competencybased education is widely regarded as an outcome-based approach to designing, implementing and evaluating a curriculum using widely accepted competencies. One widely accepted competency framework in medical education is provided by the ACGME Outcomes project. In 2007, the American Association of Colleges of Osteopathic Medicine (AACOM) created a workgroup to look at core competencies for osteopathic medical students 11 . The primary focus of this workgroup was to help osteopathic medical schools define and integrate the osteopathic core competencies into their curriculums. The main idea behind this workgroup was to create a set of performance indicators that would be common to all students studying osteopathic medicine, although schools were also allowed to develop additional performance indicators depending on their mission or focus. AACOM recommends seven core competencies within which are various indicators that address student performance 12 . The seven AACOM core competencies are Osteopathic Principles and Practices, Medical Knowledge, Patient Care, Interpersonal and Communication Skills, Professionalism, Practice-Based Learning, and Improvement and Systems-Based Practice. If these competencies are practiced properly, they ensure the achievement of professional competency and not merely recall of medical information and retention of knowledge 12,13 .
Much research is being conducted on the importance of attaining core competencies and achieving milestones for a curriculum to be deemed successful in every way. Modern-day medical education is now viewed as a curriculum driven by an outcome-based approach to design, implement, assess, and evaluate using an organized framework of competencies and milestones 14 .
Various methods are at the disposal of educators to not only help train competent physicians but also improve outcomes in high-stakes examinations, which include but are not limited to flipped classrooms, gamification, podcasting, Twitter, Facebook, problem-based or casebased learning, and integrated modular curricula 15,16,17 . Therefore, these tools, both in class and on social media (out of class), need to be used creatively and effectively to improve student participation and their academic outcomes.
The main purpose of this current study is to examine different active learning tools and their effect on enhancing and assessing the AACOM core competencies in a biochemistry and genetics course during the first year of medical school. This should ultimately lead to a better academic outcome and will help create a knowledgeable physician who satisfies all the competencies as required by the medical school and the licensure authority 18,19 . The main focus of this study is to ascertain how core osteopathic competencies such as medical knowledge, professionalism, practice-based learning and improvement, and interpersonal and communication skills can be assessed and utilized in basic sciences courses such as biochemistry, which will encourage and motivate faculty and educational department in various schools to include competency assessment in the initial formative years of a medical student 20,21 . This study may also provide a basis for using active learning tools to enhance curriculum based on observation, and medical content management in real time and with efficiency.

Participants
This study was carried out at the Kentucky College of Osteopathic Medicine, Pikeville, Kentucky, during the Fall {YEAR} term with first-year medical students, when students participate in biochemistry & genetics, gross anatomy, histology, and cell biology, osteopathic patient care, and osteopathic manipulative medicine courses. This study included all first-year students enrolled in the Fall term. There were no exclusion criteria as every student admitted into the osteopathic medical school is part of this observational and analytical study. Class population demographics were acceptably diverse, with approximately 30% of the students from the Kentucky and the rest of the students from 28 other states in the United States. Every student was expected to attend lecture classes and active learning sessions, which were offered in form of team-based cased discussions, formative quizzes, and take-home quizzes. Study Protocol: The students were given access to Canvas, a universitywide learning management system that provides access to online lecture materials, accessory reading resources, and lecture capture videos. This study used used a team-based learning (TBL) module, quizzes, and case discussions. For the sessions, the students were advised to come prepared and all the relevant content and information were made available on Canvas. For active learning sessions, the students were randomly assigned to groups by assigning every student a number and then running these numbers through web-based software to divide them into random groups. Every student was notified of their group number in advance. On the day of the sessions, before the teambased session, the students participated in an individual readiness assessment test (iRAT) and then participated as a team to answer the same questions as part of the team readiness assessment test (tRAT). The students were asked to select one member to act as the group leader and group liaison (to moderate the discussions), one member to act as a scribe (to make notes for references), and one member to act as peer grader (to grade the team members on their participation, communication, respect towards other members and preparation for sessions). A grading rubric was provided to the grader and the faculty observer. The duties for participants based on their roles were specified to all students in advance. There were four sessions in all, and every group contained 10-12 students who rotated roles during different sessions as well as a faculty observer. These sessions were used to assess professionalism, medical knowledge, practicebased learning and improvement, and interpersonal and communication skills. It was the responsibility of the members with specific roles to encourage and involve the other members in their group and to help assess the group members fairly. The students were expected to participate in a small group setting, collaborate with their colleagues, and learn in a self-directed session which was facilitated by the faculty member and the student leader of the group. The students were provided with the objectives for the sessions and were responsible to come prepared for the sessions. Resources at their disposal included textbooks, journal articles, and web-based information. The first active learning session was used to create an overview and path to go forward over the semester. During this session, the students first answered a set of cases individually and then as a team. During the group discussions, students were encouraged to provide evidence for the solution or answers for the cases. Answers chosen and marked by the group were expected to be accepted by everyone based on scientific reasoning and not through guessing.
The main objective of the first session was to analyze and observe the importance of these sessions in the long-term retention of the core concepts learned and their significance in the assessment of the content. The students' participation and involvement were measured using an internally developed assessment form for small group sessions and it was the responsibility of the grader to be fair and honest during this assessment. This form was also compared with the faculty observer's assessment to ensure fairness of grading.
Four of AACOM's Osteopathic Core Competencies were used for the assessment: Medical knowledge, Professionalism, Interpersonal and communication skills, and Practice-based learning and improvement. These four competencies were the focus of assessment during this study. Student participation, preparation for the session, behavior towards colleagues and session, communication with others, involvement, and demeanor during discussions were all used to assess these competencies.
Following the sessions, students were then reassessed on the core concepts addressed in the active learning module during their high-stakes examinations. The students at our medical college take four high-stakes examinations each semester following a four-or five-week period of learning medical concepts and content. The assessment for medical knowledge competency was conducted by asking multiple-choice questions based on the concept addressed in the active learning sessions and tagging these questions for outcome measurement.

Results
All 145 students enrolled in the biochemistry class were osteopathic medical students. The students were evenly divided by sex, with 51% being females and 49% being males ( Table 1). The age of the learner group ranged from 20 to 40 years, and all had a similar educational background and GPA close to the mean GPA for the class upon entering the school. No exclusions weremade while performing the tasks or during the analysis of the results of the study.
In all, 40 cases were used for this study. The cases were developed by the faculty with certain concepts horizontally integrated with other subjects taught in Fall semester for the active learning module. These were grouped into six broad categories based on general concepts addressed in the didactic lectures: general biochemistry, synthetic and degradative metabolism, nutritional biochemistry, disorders, biotechnology, and genetics. The concepts which were assessed during the active learning were then reassessed during the block examinations in the form of clinical vignettes and tagged with the competencies to be assessed and analyzed following the examinations. The statistics for the study were compiled at the end of the academic year and analyzed for any significance according to Pearson's correlation using SPSS data analysis software. This method was utilized to assess the impact of using the modified TBL technique on students' acquisition and retention of medical knowledge and then to measure the outcome based on their performance in the highstakes examinations. This method was used to address the competency domain involving medical knowledge. Typically, students take four high-stakes examinations in a semester. For this research, the concepts delivered through the active learning method were embedded into the examinations and those questions were monitored for their performance. Every examination had approximately seven to eight questions from the core concepts and objectives addressed during the TBL session. Other competencies such as professionalism, communication and interpersonal skills, and practice-based learning and improvement were assessed during the active learning sessions. As described earlier, the scribe from the group was given the task of assessing the students for their participation, involvement, communication skills, and professionalism.
The results of the study correlated well with the hypothesis of the study and the desired outcome. Student performance on the high-stakes examinations after the active learning session on the content and concepts had a statistically higher average percent point in the second, third and fourth examinations. The average discrimination index for the questions which were tagged to the medical knowledge competency (tagged questions) was Diff (p) as 0.75 with a weak positive correlation (r=0.390) for their final grades in the biochemistry course. The results of the analysis after the first session were better; the average Diff (p) for the second, third, and fourth examination to the questions being considered for the study were (Diff (p)= 0.84, 0.83, and 0.92) with a positive moderate correlation for the second examination (r= 0.535) and strong positive correlations for third and fourth examinations ( r=0.745 and r=0.856) with their final biochemistry grades ( Table  2). The statistical analysis of the student performance in various assessment sessions correlated well with their final grades in biochemistry (r=0.844).
The mean average discrimination indices for all other questions (untagged questions) on the respective examinations were comparable to those of the questions being considered for assessing the competency. The Diff (p) for the rest of the questions in the various examinations was 0.794, 0.780, 0.813, and 0.867, respectively ( Table 3).
The outcomes of the other competencies during the active learning session were all satisfactory. The professional competency assessed by their presence and participation during the session had an average of 100%.
The domain involving interpersonal and communication skills had a mean average of 78% (Diff (p)= 0.78) and the practice-based learning and improvement domain had a mean average of 81% (Diff (p)=0.81). Both values are in the satisfactory range.

Discussion
This article reports on the study performed to assess the utilization of ACGME competencies in the first year of osteopathic medical students in a biochemistry course. In general, competencies are assessed during the clerkship or clinical years but are seldom assessed in basic sciences courses. During the active learning sessions, the students were completely engaged in the task at hand, discussed different challenges, and arrived at their conclusions after a thorough debate. Medical students tend to be competitive, but this activity fostered group relationships. The results of this study indicate that the active learning sessions have a favorable effect on students' academic outcomes. There was a clear indication that this method improved academic outcomes for certain concepts and along the way helped foster an important competency domain, medical knowledge. Though the results showed positive outcomes for knowledge acquired through active learning sessions, these results were not drastically different from knowledge acquired through conventional learning and teaching methods. One reason for similar results obtained by two different methods of learning may  be explained by different methods of learning on the part of the learner group or differences in strategies used for learning. However, the analysis of other determinants in the competency domain was favorable based on the participation and assessment by facilitators and group scribe.
To discuss the study further, one aspect must be kept in mind if a college intends to use the competency assessment through active learning sessions in a traditional curriculum: it is vital to have designated and reserved times for these active learning sessions. These sessions can be used to facilitate the required competency development. It must be acknowledged that these sessions are extremely effective in low-participating and shy learners' gain in the necessary confidence and platform to channel and put forth their opinion in a collegial and open environment 20,21 . The earlier the students are exposed to such sessions, the better. In the medical curriculum, knowledge plays an integral role in expertise development. Based on the data, we found no negative impact of utilizing active learning sessions in the acquisition of medical knowledge. It is expected that students who participated in these active learning sessions may be better prepared in clinical practice due to early exposure and assessment of different competency domains 22,23 .
Another aspect of utilizing active learning sessions was to expose students to other competency domains on which they will eventually be assessed, such as professionalism, interpersonal and communication skills, and practice-based learning and improvement during their pre-clerkship and clinical years. However, with the changes in curricula and basic science courses following a more clinical approach, it is also a positive indicator to use the various assessment domains in medical biochemistry courses.

Conclusion
To conclude, this study indicates that active learning methods are a useful way to deliver curriculum for a competency-based education system, and some positive and significant data have emerged which support the use of these active learning methods in providing and assessing most of the competencies, although perhaps not all of them. Further study is indicated to see how such a student learner cohort performs on the assessed competency domains during the clinical years in medical school.

Ethical approval
This study is exempt from IRB ethical committee approval.