Digital storytelling for hematology education: Interactive thalassemia module for graduate millennial learners
Authors: Ariela L. Marshall, Susan Mann, Alexandra Wolanskyj‐Spinner
Journal: American Journal of Hematology (2018)

Medical education is rapidly increasing in both complexity and also opportunities for advancement. The changing needs of our learners, restructuring of systems for assessment, improvements in technology and accessibility of information, and advances in learning theory, among others, all contribute to the complexity of medical education and the need to develop new educational methods. The current generation of millennial learners (“Generation Y”), born between 1982 and 2000, has unique tendencies and needs which must be considered as educators develop curricula for learners of all levels. Millennials are highly motivated by achievement, have a desire to belong to peer groups and teams, and welcome personalized learning plans including incorporation of technology.1 There has been significant interest in optimizing medical education development to meet the needs of the millennial generation. However, such novel learning techniques are most often developed for the undergraduate (primarily pre-clinical) learner rather than for learners at the graduate level and above. However, graduate medical learners (residents, fellows, and millennial-generation practicing clinicians) have highly specialized educational needs. Therefore, the opportunity for further educational development across the graduate medical spectrum is broad. As educators in non-malignant hematology, we are faced with the challenge of engaging learners in a highly specialized field often focusing on diseases that learners often do not encounter in clinical practice (yet are a focus of board certification examinations at several levels). Additionally, evidence demonstrates that lack of early exposure (at the resident and fellow level) to patients with non-malignant hematologic conditions is a major barrier to attracting hematology-oncology fellows to pursue a career in non-malignant hematology.2 Educational interventions created to increase knowledge and exposure to such conditions and designed to engage the millennial learner may be of benefit. One particular area of interest for us is thalassemia, the most common hemoglobinopathy but a condition rarely encountered in clinical practice in our geographic area. Our learners, particularly internal medicine residents, had a history of poor performance in this area on in-training examinations (ITE). We therefore wished to create a curriculum for thalassemia in a way that would be interesting and appealing to our millennial learners at the graduate level, as a model for development of similar millennial-focused modules appropriate for learners of all specialties across the graduate educational spectrum. We created an online educational module for internal medicine residents and hematology-oncology fellows rotating on our inpatient hematology services. This module involved a case presentation of a patient with symptomatic anemia related to underlying thalassemia and utilized several sub-modules (history, physical examination, laboratory results, pathogenesis of thalassemia, diagnosis, and management recommendations as well as genetic implications). Learners were given opportunities to interact electronically in the observation of physical examination findings, peripheral blood smear and hemoglobin electrophoresis results, and question-answer components as part of each short teaching submodule, together with an interactive glossary of key abnormal peripheral blood smear findings in consultative hematology. Using a quasi-experimental pre-test/post-test design, learners were required to take a 10-question multiple choice test before accessing the module (pre-test). This test was scored on a 0-100 scale with 10 points given for each correct answer. Regardless of whether their answers were correct or incorrect, learners were then given access to the full set of thalassemia learning module in which relevant educational information about thalassemia along with key references from the literature. They could complete it at a time and duration of their choosing as long as all submodules were viewed prior to the end of the hematology rotation. Following module completion, the learners were asked to (but not required) to retake the 10-question multiple choice question (post-test). Test scores were collected for all learners and entered into an electronic database. Data was analyzed using Microsoft Excel 2010. One hundred and forty-seven learners completed the pretest, including 134 internal medicine residents and 13 hematology-oncology fellows. Of a possible score of 100, the median pre-test score for all learners was 50; median for residents was 50 and for fellows was 60. Of 134 residents who completed the pre-test, 124 residents also completed the post-test. The median resident post-test score was 70. Resident post-test scores were significantly higher than pre-test scores (paired t test P < 0.001). Of the 13 fellows who completed the pre-test, 9 also completed the post-test. The median fellow post-test score was 80. Fellow post-test scores were significantly higher than pre-test scores (paired t test P = 0.001). Previous studies have demonstrated that millennial students in the health professions prefer interactive learning strategies involving a combination of several educational formats rather than a single method of teaching a given topic.3 ,4 Utilizing strategies for curriculum development tailored to the millennial learner, we developed an interactive online educational module to teach principles of thalassemia to graduate-level learners (residents and fellows). A multiple choice test of knowledge was used to assess learner knowledge prior to and after completion of the module, and we found that post-test scores were significantly higher than pre-test scores for learners of all levels. We believe that this is the first reported educational module focusing both on thalassemia as well as using strategies specifically designed to engage millennial learners at the graduate level (residents and fellows). Prior studies have reported outcomes of graduate-level educational interventions for millennial learners, but have focused on general principles of curriculum development (rather than teaching a single topic such as thalassemia which requires coverage but is rarely encountered in clinical practice) and have primarily dealt with learners at a single educational level (residents).5 We believe that our thalassemia module serves as an example of how curriculum development can be tailored to a specific topic pertinent to millennial generation learners of several levels. Careful faculty development and engagement in this process of module creation is essential so that faculty understand the unique needs of the millennial learner.6 One weakness of this study is the pre-test/post-test design, which carries inherent bias due to maturation of learners over time (participation in the hematology rotations itself may increase knowledge and improve test scores) and regression to the mean. We do believe that maturation bias is likely minimal as learners on hematology rotations at our center are rarely exposed to patients with thalassemia on the wards. Additionally, since not all learners completed the post-test, there may be bias on the part of which learners chose to complete the post-test (more motivated learners may have been prompted both to complete the educational module and also the post-test, leading to overestimation of the effect size of the pre-post comparison). Future educational modules could be designed with this in mind, perhaps requiring all learners to complete both pre-test and post-test to receive credit for a given rotation. Moving forward, we hope to expand this type of curricular design to teach learners across the educational spectrum about additional hematologic diseases such as sickle cell anemia. More importantly, this educational structure could be utilized in a variety of other subspecialties to provide additional education on diseases rarely encountered in clinical practice. Knowledge based questions and opportunities for learner engagement with the module could be tailored to the learner level (eg, residents vs fellows) while keeping the base module constant, allowing for broad use of a single module in several populations. Using the principles of curriculum development for the millennial learner, and focusing on an important but rare hematologic condition, we created an interactive module for thalassemia education and demonstrated improvement in learner knowledge after completion of the module. We hope that this serves as an example of using modern medical educational theory and strategies for millennial engagement to create educational interventions suitable to, and engaging for, learners at all levels across the educational spectrum. Nothing to report.