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Modified Interteaching Sessions as Application-Based Examinations Reduce Student Exam Stress in an Upper-Level Pathophysiology Class

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Title: Modified Interteaching Sessions as Application-Based Examinations Reduce Student Exam Stress in an Upper-Level Pathophysiology Class
Language: English
Authors: Jesse D. Moreira-Bouchard (ORCID 0000-0002-5644-2540), Lisa M. Roberts
Source: Advances in Physiology Education. 2025 49(1):41-46.
Availability: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
Peer Reviewed: Y
Page Count: 6
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Test Anxiety, Stress Variables, Student Evaluation, Physiology, Advanced Courses, Science Instruction, Communication Skills, Critical Thinking, Student Attitudes, Cooperative Learning, Evaluation Methods, Teaching Methods, Instructional Effectiveness
DOI: 10.1152/advan.00108.2024
ISSN: 1043-4046
1522-1229
Abstract: Testing is a highly important tool, used ubiquitously in academia, to assess student comprehension and understanding of material. Unfortunately, the emphasis placed on test grades has resulted in a modern epidemic of test-related anxiety, which can have adverse health effects on students. Over time, novel testing strategies have been developed to more precisely assess individual skills such as remembering, analyzing, and synthesizing. Yet, there exist few strategies that were also developed to simultaneously reduce stress in the testing environment. We posit here a teaching innovation whereby we modified the classic interteaching session developed in the social sciences to serve as a stress-reduction testing format that also builds student communication and critical thinking skills in an upper-level pathophysiology course. After implementing this novel testing approach, we anonymously surveyed the students in the class to understand how the testing format affected their self-perceived stress levels and their self-perceived learning and to identify their testing preferences. Of 28 students, 12 responded (43%). Our survey data highlight that students largely preferred partnered, open-response, case-based exams to multiple-choice exams. Moreover, students perceived themselves as having lower test-related stress when taking partnered, open-response, case-based exams, as well as a strong overall agreement that partnered, open-response, case-based exams enhanced their learning. We posit this application of modified interteaching can be employed in upper-level physiology or pathophysiology courses as a stress-reduction testing strategy.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1464074
Database: ERIC
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  Value: <anid>AN0183439567;apu01mar.25;2025Mar06.04:31;v2.2.500</anid> <title id="AN0183439567-1">Enhancing student understanding of cardiovascular disease burden in marginalized communities in the physiology classroom </title> <p>Physiology education is at the core of biomedical science and medicine. Physiology unites multiple disciplines to explain the mechanisms whereby a risk factor is associated with disease. Race, ethnicity, sexual orientation, and gender identity are associated with risk of cardiovascular disease (CVD). Minority stress theory attempts to explain the association of identity variables in sex and gender minority (SGM) and Black, Indigenous, and people of color (BIPOC) populations with CVD. However, instruction on how to effectively incorporate the ways that social determinants of health are linked to disease outcomes in marginalized populations, such as the SGM and BIPOC communities, is needed. We investigated the efficacy of teaching minority stress theory concepts in a single lecture in an upper-level cardiovascular pathophysiology course (N = 44 students). To test students' understanding of minority-related disease, we used both subjective and objective measures to evaluate student understanding before and after the lecture. Student self-assessment of understanding of health disparity physiological mechanisms and lifestyle and pharmacological interventions to reduce health disparities in SGM communities increased post intervention. We observed similar results of self-assessment of understanding of health disparity physiological mechanisms and appropriate lifestyle and pharmacological interventions to reduce health disparities regarding the BIPOC community. Our findings suggest that integrating social determinants of health into pathophysiology courses may result in a more inclusive-minded scientific and medical workforce. NEW & NOTEWORTHY: Physiology education has historically lacked the inclusion of the social determinants of health and discussion of medically marginalized communities. Here, we show that discussion of cardiovascular disease and psychosocial stress in marginalized communities improves student understanding of the distribution of and causes of cardiovascular disease in marginalized groups. We conclude that more physiology instructors should include discussions on chronic diseases within multiple communities and programs should incorporate social determinants of health into their curricula.</p> <p>Keywords: BIPOC; diversity; marginalization; physiology education; SGM</p> <hd id="AN0183439567-2">INTRODUCTION</hd> <p>Cardiovascular diseases (CVDs) disproportionately burden individuals belonging to historically marginalized communities. People who identify with the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and Two-Spirit (LGBTQIA2S+) community have a higher risk of CVDs, such as hypertension and myocardial infarction ([<reflink idref="bib1" id="ref1">1</reflink>]–[<reflink idref="bib4" id="ref2">4</reflink>]). While our terminology has changed in the literature with time to become more equitable, we will collectively refer to those with LGBTQIA2S+ identities and gender-diverse individuals as sex and gender minorities (SGM). Similarly, people from historically marginalized racial and ethnic groups are henceforth referred to as Black, Indigenous, and people of color (BIPOC). BIPOC individuals also experience CVD at higher rates than their White peers ([<reflink idref="bib5" id="ref3">5</reflink>], [<reflink idref="bib6" id="ref4">6</reflink>]).</p> <p>Beyond the data regarding race, and explicitly in LGBTQIA2S+ communities, the mechanisms mediating the disproportionate CVD burden in historically marginalized groups have only recently begun to be investigated and are still understudied. Emerging research suggests that both elevated marginalized identity-dependent psychosocial stress, specifically termed minority stress ([<reflink idref="bib7" id="ref5">7</reflink>]), and inadequate clinician training can result in worse CVD outcomes ([<reflink idref="bib8" id="ref6">8</reflink>]–[<reflink idref="bib14" id="ref7">14</reflink>]). Moreover, research in the biomedical space has historically marginalized and pathologized queerness ([<reflink idref="bib15" id="ref8">15</reflink>]).</p> <p>Much of the scientific and medical workforce is not systematically educated on the health disparities present in the SGM and BIPOC communities. For example, a recent report found that medical schools have increased their number of hours instructing on LGBTQI+ health-related topics but were still failing to achieve the number of instruction hours recommended by the Association of American Medical Colleges ([<reflink idref="bib15" id="ref9">15</reflink>]). The lack of sufficient education, and resultant unchecked implicit bias, leads to exclusionary clinical trials and translational science ([<reflink idref="bib16" id="ref10">16</reflink>]), as well as decreasing availability of and access to inclusive health care providers. As such, it is paramount in premedical and medical curricula to discuss the epidemiology and pathophysiology of CVD in diverse populations.</p> <p>Physiology education is a critical component of training the biomedical workforce, in both clinical and basic sciences. Accordingly, a significant investment of resources in developing standardized curricula for the teaching of physiology, as well as pathophysiology, has been made over the last 50 years ([<reflink idref="bib17" id="ref11">17</reflink>], [<reflink idref="bib18" id="ref12">18</reflink>]). In recent years calls for enhancing the inclusion of students from marginalized backgrounds in science ([<reflink idref="bib19" id="ref13">19</reflink>]–[<reflink idref="bib21" id="ref14">21</reflink>]) and for teaching about the health of historically marginalized groups have begun effectively permeating educational spaces ([<reflink idref="bib22" id="ref15">22</reflink>]). However, standardized approaches for curating and teaching content representative of diverse populations of people in physiology are lacking. Specifically, minimal resources exist to help instructors in framing the discussion of how psychosocial stress affects physiology and causes disease across various marginalized groups, including the SGM community and BIPOC.</p> <p>In this study, we sought to evaluate the baseline understanding of the higher risk of CVD in SGM and BIPOC communities and how the social determinants of health contribute to their elevated risk among advanced undergraduate and early graduate students. We assessed student understanding of the population-specific CVD burden in marginalized communities before and after a targeted curricular intervention, that is, a single lecture added to our course to explicitly teach the aforementioned burgeoning health disparities content. Our intervention consisted of a lecture incorporating the ways that psychosocial stressors can contribute to the higher prevalence of CVD in historically marginalized communities. We hypothesized that our intervention would facilitate inclusive thinking about students' future clinical practice and research study design. We demonstrate a proof of concept of an effective curriculum for the instruction of the specific CVD risks in SGM and BIPOC communities that improves both subjective and objective measures of student understanding. We propose that this intervention could be adopted for implementation in human physiology programs on a wider scale to facilitate more inclusive practices in science and medicine.</p> <hd id="AN0183439567-3">METHODS</hd> <hd1 id="AN0183439567-4">Ethics and IRB Approval</hd1> <p>Institutional Review Board (IRB) exemption was granted by the Boston University Chobanian and Avedisian School of Medicine IRB for this study, as no identifiable information was collected from the student participants. The IRB determined that our students faced no risk of harm by voluntarily completing the two surveys.</p> <hd1 id="AN0183439567-5">Study eligibility.</hd1> <p>All study participants were either juniors or seniors in college or first-year Master of Science students in the Human Physiology program at Boston University. All students enrolled in a cardiovascular pathophysiology were eligible for study participation. All participants provided written informed consent on the survey form.</p> <hd1 id="AN0183439567-6">Survey</hd1> <p>Anonymous pre- and postintervention surveys were designed to capture participant gender identity, sexual orientation, and racial and ethnic backgrounds. Survey questions using Likert-scale agreement statements ranging from 1 to 5 assessed prior experiences of participants with health disparities in SGM and BIPOC communities. Similar Likert-scale questions also evaluated subjective understanding of the presence of health disparities and physiological mechanisms mediating health disparities in SGM and BIPOC communities. Additional questions assessed student confidence in their ability to foster the inclusion of these marginalized groups in current and future research. Additionally, open-ended questions were used to objectively assess participants' ability to identify disparities present in SGM and BIPOC communities and to validate their subjective perception of their knowledge. Open-ended question responses were also ranked by skill level using Bloom's taxonomy ([<reflink idref="bib23" id="ref16">23</reflink>]), including the lower-level skill of knowing/remembering as well as higher-order analysis and synthesis level skills. The entire preintervention and postintervention surveys can be found in Supplemental Tables S1 and S2 (all Supplemental Material is available at https://doi.org/10.6084/m9.figshare.27038077).</p> <hd1 id="AN0183439567-7">Curriculum</hd1> <p>A search of PubMed was conducted with the terms "cardiovascular disease" and one more of "queer," "gay," "lesbian," "bisexual," "transgender," "intersex," "asexual," "2-spirit," "Black," "POC," "Hispanic," "Asian," "Indigenous," "race," and "ethnicity." Research articles and contemporary systematic reviews were used to construct a 1 h and 15 min lecture covering CVD disparities in SGM and BIPOC. The epidemiology of hypertension and myocardial infarction among the marginalized groups was discussed. Although understudied, the proposed pathophysiological mechanisms underlying the higher CVD prevalence among individuals belonging to the SGM or BIPOC populations, including minority stress theory and associated enhanced sympathetic outflow, were discussed as potential mediating factors. We discussed how historically marginalized groups face elevated levels of psychological stress and how elevated activity of stress and anxiety-related brain regions is associated with sympathetically mediated blood pressure variability. We also discussed how excessive sympathetic nervous system activity is implicated in high arterial blood pressure and CVD via the interorgan actions of the vasculature, kidneys, and heart. Finally, health care access inequities and lack of inclusion of SGM and BIPOC populations in human clinical trials and research were discussed. A visual summary schematic of the lecture is presented in Fig. 1.</p> <p>PHOTO (COLOR): Figure 1. A schematic representation of the links between marginalized identity and adverse cardiovascular outcomes adapted from Caceres et al. ([<reflink idref="bib24" id="ref17">24</reflink>]) that was used as the framework for the curricular intervention lesson plan. Boxes in green were topics discussed in class, and boxes in blue were topics that were not discussed at length. BIPOC, Black, Indigenous, and people of color; HPA, hypothalamic-pituitary-adrenal; LGBTQIA2S+, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and Two-Spirit.</p> <hd1 id="AN0183439567-8">Statistical Analyses</hd1> <p>We used several Likert-like items and open-response questions in the surveys. Historically, Likert-like items have been used in educational research to derive quantitative meaning from subjective opinions and feelings of study participants ([<reflink idref="bib25" id="ref18">25</reflink>]). Individual Likert-like items are considered categorical data, except in instances when multiple Likert items are used to measure similar concepts that positively correlate with one another, in which case they can be treated as continuous data ([<reflink idref="bib26" id="ref19">26</reflink>]). Our Likert-like items were not designed to measure similar concepts but instead were designed to measure a continuity of different learning outcomes related to the same groups of people (SGM or BIPOC communities). As such, we treated our Likert-item data as categorical, employing nonparametric statistical tests to determine significance between pre- and postintervention survey responses. Notably, as the surveys were anonymous, responses were not linked on the individual level but were instead compared as group medians.</p> <p>Data normality of responses to Likert-like items was assessed by Kolmogorov–Smirnov tests. As all data were not normally distributed, we used nonparametric Mann–Whitney rank <emph>t</emph> tests to evaluate differences in the perceptions of the various measures in the preintervention survey between groups of individuals based on their self-identified sexual orientation, gender, and race. Of note, to enhance participant response rates, responses were kept anonymous, and therefore data are compared between pre- and postintervention groups in aggregate and not as paired individual-level responses. All postintervention survey responses used for analysis were from individuals who affirmed that they also completed the preintervention survey; hence, the effect of the curricular intervention was assessed on participants' subjective perceptions by comparing the response medians from the preintervention to the postintervention survey via paired, nonparametric Wilcoxon rank sign tests for each Likert-like item. Responses to the postintervention survey that stated that the individual had not completed the preintervention survey (<emph>n</emph> = 4) were removed before analysis. <emph>P</emph> values < 0.05 were considered significant. All statistics were performed in GraphPad Prism (v9).</p> <p>Responses to open-ended questions designed to assess objective knowledge of CVD health risks in marginalized communities were classified according to the level of Bloom's taxonomy. The responses were grouped into the following Bloom's taxonomy-based categories: <emph>1</emph>) remember, if the response demonstrated knowledge of factual information presented in the lecture; <emph>2</emph>) analysis, if the answer demonstrated the ability to analyze an issue discussed in class and explore context related to that issue; and <emph>3</emph>) synthesis, if the answer demonstrated ability to take information presented and combine it with original, contextually relevant thoughts that resulted in a novel idea and/or plan for reducing the health risk. No formal thematic analysis was employed, but answers were grouped into response categories for data presentation.</p> <hd id="AN0183439567-9">RESULTS</hd> <hd1 id="AN0183439567-10">Participant Demographics</hd1> <p>Of the 44 preintervention survey respondents, 27% identified as men, 68% identified as women, and 5% identified as nonbinary. Of the participants, 2% identified as transgender and 16% of respondents identified as Latiné/Hispanic. When asked about race, 52% of respondents identified as White, 48% identified as Asian, 5% identified as Middle Eastern, 7% preferred not to disclose, and no participants identified as Black or Indigenous/Native American. When asked about sexual orientation, 73% identified as straight/heterosexual, 11% as gay/lesbian, 14% as bisexual, 2% as asexual, and 9% as queer (Table 1). Of the 44 preintervention responders, 28 (64%) responded to the postintervention survey. All 28 respondents acknowledged completion of the preintervention survey. The postintervention respondent demographics were similar to the preintervention survey respondents, although two fewer students selected "Prefer not to answer" and one additional student self-identified as Black (Table 1).</p> <p>Table 1. Demographics of individuals who completed the preintervention survey</p> <p> <ephtml> <table><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1" /><th align="center" rowspan="1" colspan="1">Preintervention Survey (<italic>N</italic> = 44), data <italic>N</italic> (%)</th><th align="center" rowspan="1" colspan="1">Postintervention Survey (<italic>N</italic> = 28), data <italic>N</italic> (%)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Self-identified gender</td><td colspan="2" rowspan="1" /></tr><tr><td align="left" rowspan="1" colspan="1"> Man</td><td align="char" char="(" rowspan="1" colspan="1">12 (27)</td><td align="char" char="(" rowspan="1" colspan="1">6 (21)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Woman</td><td align="char" char="(" rowspan="1" colspan="1">30 (68)</td><td align="char" char="(" rowspan="1" colspan="1">20 (71)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Nonbinary</td><td align="char" char="(" rowspan="1" colspan="1">2 (5)</td><td align="char" char="(" rowspan="1" colspan="1">1 (4)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Genderqueer</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td><td align="char" char="(" rowspan="1" colspan="1">1 (4)</td></tr><tr><td align="left" rowspan="1" colspan="1">Self-identified as transgender</td><td colspan="2" rowspan="1" /></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="char" char="(" rowspan="1" colspan="1">1 (2)</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="char" char="(" rowspan="1" colspan="1">43 (98)</td><td align="char" char="(" rowspan="1" colspan="1">28 (100)</td></tr><tr><td align="left" rowspan="1" colspan="1">Self-identified race</td><td colspan="2" rowspan="1" /></tr><tr><td align="left" rowspan="1" colspan="1"> Asian</td><td align="char" char="(" rowspan="1" colspan="1">21 (48)</td><td align="char" char="(" rowspan="1" colspan="1">14 (50)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Black</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td><td align="char" char="(" rowspan="1" colspan="1">1 (4)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Indigenous/Native American</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Middle Eastern</td><td align="char" char="(" rowspan="1" colspan="1">2 (5)</td><td align="char" char="(" rowspan="1" colspan="1">2 (7)</td></tr><tr><td align="left" rowspan="1" colspan="1"> White</td><td align="char" char="(" rowspan="1" colspan="1">23 (52)</td><td align="char" char="(" rowspan="1" colspan="1">14 (50)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Prefer not to answer</td><td align="char" char="(" rowspan="1" colspan="1">3 (7)</td><td align="char" char="(" rowspan="1" colspan="1">1 (4)</td></tr><tr><td align="left" rowspan="1" colspan="1">Self-identified as Latiné/Hispanic</td><td colspan="2" rowspan="1" /></tr><tr><td align="left" rowspan="1" colspan="1"> Yes</td><td align="char" char="(" rowspan="1" colspan="1">7 (16)</td><td align="char" char="(" rowspan="1" colspan="1">2 (7)</td></tr><tr><td align="left" rowspan="1" colspan="1"> No</td><td align="char" char="(" rowspan="1" colspan="1">37 (84)</td><td align="char" char="(" rowspan="1" colspan="1">26 (93)</td></tr><tr><td align="left" rowspan="1" colspan="1">Self-identified sexual orientation</td><td colspan="2" rowspan="1" /></tr><tr><td align="left" rowspan="1" colspan="1"> Asexual</td><td align="char" char="(" rowspan="1" colspan="1">1 (2)</td><td align="char" char="(" rowspan="1" colspan="1">1 (4)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Bisexual</td><td align="char" char="(" rowspan="1" colspan="1">6 (14)</td><td align="char" char="(" rowspan="1" colspan="1">2 (7)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Gay/lesbian</td><td align="char" char="(" rowspan="1" colspan="1">5 (11)</td><td align="char" char="(" rowspan="1" colspan="1">2 (7)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Queer</td><td align="char" char="(" rowspan="1" colspan="1">4 (9)</td><td align="char" char="(" rowspan="1" colspan="1">3 (11)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Straight/heterosexual</td><td align="char" char="(" rowspan="1" colspan="1">32 (73)</td><td align="char" char="(" rowspan="1" colspan="1">20 (71)</td></tr><tr><td align="left" rowspan="1" colspan="1"> Prefer not to answer</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td><td align="char" char="(" rowspan="1" colspan="1">0 (0)</td></tr></tbody></table> </ephtml> </p> <hd1 id="AN0183439567-11">Baseline Understanding of Health Risk in SGM and BIPOC Populations</hd1> <p>In response to the question about previous exposure to health disparities in SGM communities, most participants (68%) reported no or minimal previous exposure to health disparities in the SGM community (Fig. 2<emph>A</emph>). The next question asked about exposure to health disparities in BIPOC communities: almost half of participants (45%) reported no or minimal previous exposure to health disparities in the BIPOC community, and slightly more than half (55%) reported moderate or a lot of previous exposure (Fig. 2<emph>B</emph>).</p> <p>PHOTO (COLOR): Figure 2. A and B: bar graphs displaying the various levels of prior exposure to health-related content pertaining to marginalized communities as reported by participants in the preintervention survey. C and D: bar graphs displaying the various places or contexts in which respondents from A and B with at least minimal prior exposure to health-related content pertaining to marginalized communities had their experiences (N = 44 responses for A and B, N = 44 responses for C and D, with multiple responses possible). BIPOC, Black, Indigenous, and people of color; LGBTQIA2S+, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and Two-Spirit.</p> <p>Reports of previous exposures were broken down by category to gain insight into where students had received prior exposure regarding health disparities in the SGM and BIPOC groups. The largest faction of students with prior exposure to health disparities for the SGM group reported their exposure as being in the classroom (41%), whereas only 5% of students reported exposure in academic research (Fig. 2<emph>C</emph>). In response to a question regarding where participants were exposed to BIPOC health disparities, 52% selected "classroom," 7% selected academic research, 24% selected "personal/family experiences," 29% selected "personal internet exploration," and 0% selected "work/job" (Fig. 2<emph>D</emph>).</p> <hd1 id="AN0183439567-12">Pre- and Postintervention Survey Responses of Participant Agreement with Statements Regarding SGM Health Disparities</hd1> <p>Post curricular intervention, for all participants, there was no change on the Likert-scale agreement that there are population-specific health disparities in SGM individuals (<emph>P</emph> = 0.20) (Table 2). For all participants, there was an increase in agreement with the statement regarding understanding the mediating factors in population-specific health disparities faced by SGM individuals (preintervention median 3.0 vs. postintervention median 4.0; <emph>P</emph> < 0.001) (Table 2). Additionally, we identified a significant increase in all participants' agreement that they now possessed preparation to design inclusive research studies to reduce SGM-specific health disparities (preintervention median 3.0 vs. postintervention median 4.0; <emph>P</emph> = 0.002; Table 2).</p> <p>Table 2. Effect of curricular intervention on student understanding of health disparities pertaining to SGM communities</p> <p> <ephtml> <table><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1">Statement for Participant</th><th align="center" rowspan="1" colspan="1">Preintervention Survey</th><th align="center" rowspan="1" colspan="1">Postintervention Survey</th><th align="center" rowspan="1" colspan="1"><italic>P</italic> Value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">There are complex, population-specific health risks faced by sexual and gender minority (SGM) people in the United States that create a significant disparity in the health of this group.</td><td align="char" char="(" rowspan="1" colspan="1">5 (4, 5)</td><td align="char" char="(" rowspan="1" colspan="1">5 (5, 5)</td><td align="char" char="." rowspan="1" colspan="1">0.20</td></tr><tr><td align="left" rowspan="1" colspan="1">I have an understanding of the complex, population-specific health risks faced by sexual and gender minority (SGM) people in the United States.</td><td align="char" char="(" rowspan="1" colspan="1">3 (2, 4)</td><td align="char" char="(" rowspan="1" colspan="1">4 (4, 5)</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">I feel adequately prepared to properly include sexual and gender minorities in human research study designs in physiology.</td><td align="char" char="(" rowspan="1" colspan="1">3 (2, 4)</td><td align="char" char="(" rowspan="1" colspan="1">4 (3.3, 4.8)</td><td align="char" char="." rowspan="1" colspan="1">0.002</td></tr></tbody></table> </ephtml> </p> <p>1 Data presented as median (25%–75% interquartile range). Range of possible answers between 1 (strongly disagree) and 5 (strongly agree).</p> <hd1 id="AN0183439567-13">Pre- and Postintervention Survey Responses of Participant Agreement with Statements Regarding BIPOC Health Disparities</hd1> <p>Among all participants, agreement response rates did not change between pre- and post-curricular intervention surveys that there are population-specific health disparities in BIPOC individuals (<emph>P</emph> = 0.4) (Table 3). For all participants, we saw a significant increase in agreement with the statement regarding having an understanding of the mediating factors in population-specific health disparities faced by BIPOC individuals (preintervention median 4.0 vs. postintervention median 5.0; <emph>P</emph> < 0.001) (Table 3) and increase in agreement that they now possessed preparation to design inclusive research studies to reduce BIPOC-specific health disparities (preintervention median 3.0 vs. postintervention median 4.0; <emph>P</emph> = 0.003) (Table 3).</p> <p>Table 3. Effect of curricular intervention on student understanding of health disparities pertaining to BIPOC communities</p> <p> <ephtml> <table><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1">Statement for Participant</th><th align="center" rowspan="1" colspan="1">Preintervention Survey</th><th align="center" rowspan="1" colspan="1">Postintervention Survey</th><th align="center" rowspan="1" colspan="1"><italic>P</italic> Value</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">There are complex, population-specific health risks faced by people belonging to marginalized racial and ethnic groups in the United States that create a significant disparity in the health of this group.</td><td align="char" char="." rowspan="1" colspan="1">5 (4, 5)</td><td align="char" char="." rowspan="1" colspan="1">5 (5, 5)</td><td align="char" char="." rowspan="1" colspan="1">0.45</td></tr><tr><td align="left" rowspan="1" colspan="1">I have an understanding of the complex, population-specific health risks faced by people belonging to marginalized racial and ethnic groups in the United States.</td><td align="char" char="." rowspan="1" colspan="1">4 (3, 4)</td><td align="char" char="." rowspan="1" colspan="1">5 (4, 5)</td><td align="char" char="." rowspan="1" colspan="1"><0.001</td></tr><tr><td align="left" rowspan="1" colspan="1">I feel adequately prepared to properly include people belonging to marginalized racial and ethnic groups in human research study designs in physiology.</td><td align="char" char="." rowspan="1" colspan="1">3 (3, 4)</td><td align="char" char="." rowspan="1" colspan="1">4 (4, 5)</td><td align="char" char="." rowspan="1" colspan="1">0.003</td></tr></tbody></table> </ephtml> </p> <p>2 BIPOC, Black, Indigenous, and people of color.</p> <hd1 id="AN0183439567-14">Effect of Curricular Intervention on Participant Ability to Describe and Demonstrate Objective Understanding of Health Disparities in Marginalized Communities</hd1> <p>Participants were asked to list and describe health risks and their mechanisms, as well as ways to reduce health disparities, in marginalized populations, using an open-ended format to assess objective understanding. In the preintervention survey, in response to a question asking participants to state a health risk faced by the transgender population, 23% stated "I do not know," 34% responded mental health-related risks, 2% lower life expectancy, and 16% higher sexual health-related risks, and 25% did not answer (Fig. 3<emph>A</emph>). In response to a question asking participants to describe the mechanisms mediating the association of psychosocial stress and CVD, 70% stated "I do not know" and 2% "diet," 6% discussed stress hormones, and 22% did not answer. After the curricular intervention, participants were asked to list one specific health risk faced by the transgender population. In response, 46% stated enhanced risk of CVD, and 11% systemic diseases, and 14% did not respond (Fig. 3<emph>B</emph>).</p> <p>PHOTO (COLOR): Figure 3. Bar graphs showing the response themes to pre- and postintervention survey questions regarding health risk to individuals in the transgender community (A and B) and the Black, Indigenous, and people of color (BIPOC) community (C and D). Number and percentage of respondents listing each theme listed above the respective bar.</p> <p>In the preintervention survey, participants were asked to state a health risk faced by the BIPOC community. Fourteen percent stated elevated risk of CVD, 17% higher risk of maternal mortality, 17% higher risk in other systemic diseases (e.g., chronic kidney disease, diabetes), 14% worse quality of or lack of medical care, 3% higher risk of domestic violence, and 3% higher risk of sexual health-related problems, 9% stated they did not know, and 23% did not respond (Fig. 3<emph>C</emph>). In the postintervention survey, in response to the same question, 46% of respondents listed higher risk of CVDs, 14% maternal mortality, 4% domestic violence, 4% sexual health disparities, and 11% higher risk for other systemic diseases (e.g., diabetes), 7% stated lack of inclusion in medical research, and 14% did not respond (Fig. 3<emph>D</emph>).</p> <p>In the postintervention survey, participants were asked to describe a potential intervention designed to assess CVD health disparities and mechanisms in marginalized individuals. Twenty-five (89%) of 28 participants responded. In response, participants described needing to accurately collect detailed demographic information on study participants. Such demographic data for better study design could include sexual orientation, gender identity, whether someone is cisgender or transgender, as well as race, ethnicity, age, etc. ([<reflink idref="bib20" id="ref20">20</reflink>]). Additionally, participants described targeting recruitment efforts toward marginalized communities to ensure sufficient enrollment for data analysis. The participants described collecting additional baseline cardiovascular measures from those previously excluded in research such as SGM people, women, and BIPOC. Finally, the participants described collecting psychological stress- and mental health-related data from their participants to assess associations between stress and chronic diseases. Of the respondents, 11% described interventions that were accurate and not previously discussed during the class session, demonstrating some level of analytical skills as it pertains to Bloom's taxonomy; 78% described interventions discussed in class and did not display this higher-level skill.</p> <hd id="AN0183439567-15">DISCUSSION</hd> <p>The present study was designed to test the hypothesis that a targeted curricular intervention increases diverse thinking and understanding of CVD disparities among undergraduate physiology students. We conclude from our data that a single 75-min lecture covering minority stress theory and the proposed pathophysiological mechanisms of psychosocial stress in the cardiovascular system increases student understanding of marginalization-related disease states. Additionally, our study demonstrates that undergraduate students can understand their potential role in reducing SGM/BIPOC health disparities in their future professions as scientists and clinicians.</p> <p>Data from the preintervention survey reveal that fewer than half of students have meaningful prior experience learning about health disparities in marginalized communities, particularly the SGM community. Two in three students reported no or minimal prior experience with health disparities in SGM communities, and approximately half of students reported no or minimal prior experience with health disparities in BIPOC communities. Moreover, of the students who did report any level of previous experience with health disparities in marginalized communities, 41% reported their experience as being in a formal classroom setting regarding SGM communities and only 52% reported their experience learning about BIPOC communities in a formal classroom setting. Such data suggest a paucity of formal education in population-specific health disparities and are in alignment with previous work demonstrating that life science classrooms are not necessarily a welcoming space for those from minoritized backgrounds ([<reflink idref="bib27" id="ref21">27</reflink>]).</p> <p>Prior research suggests that implicit bias in clinicians is associated with adverse health outcomes in marginalized communities ([<reflink idref="bib28" id="ref22">28</reflink>]). Additionally, education on implicit bias reduces bias in health care providers ([<reflink idref="bib29" id="ref23">29</reflink>]), which translates to better health outcomes for people from minoritized groups. We hypothesize that earlier curricular intervention on health disparities in marginalized communities targeted toward biomedical science students, who make up a large proportion of students going into health care and scientific careers ([<reflink idref="bib30" id="ref24">30</reflink>]), will reduce implicit bias before medical education/graduate school in the sciences. Our data here show that even a single lecture can enhance student knowledge that there are population-specific health inequities for SGM communities and BIPOC and their understanding of the physiological mechanisms mediating adverse outcomes. Such early interventions may contribute to a reduction in health disparities through a generation of more inclusive-minded individuals in the medical and scientific workforce.</p> <p>When assessing the efficacy of the curricular intervention on student subjective assessment of their own understanding, no differences were observed in pre- to postintervention student understanding of the presence of health disparities in the SGM or BIPOC populations. We suspect that this is because students began with an already high level of understanding of health disparity presence in marginalized communities. We did, however, observe an improvement in the participants' understanding of the physiological mechanisms mediating health disparities in marginalized communities and that they now possessed preparation to design inclusive research studies to reduce these health disparities through inclusion of marginalized individuals and communities in research. We believe it is possible that we saw meaningful improvement in understanding of physiological mechanisms mediating the effect of psychosocial stress on CVD because students already held high levels of understanding in general physiology. For example, most physiology curricula already instruct students in autonomic control of blood pressure as a critical topic ([<reflink idref="bib31" id="ref25">31</reflink>]). It was not new to students to suggest that autonomic disturbance and increases in sympathetic outflow could raise blood pressure. All that was added was the context from recent studies that chronic sympathetic activation and cortisol release may occur in those marginalized individuals facing constant psychosocial stressors ([<reflink idref="bib32" id="ref26">32</reflink>], [<reflink idref="bib33" id="ref27">33</reflink>]). Together, our data support the notion that reframing physiological concepts students are already familiar with, just in a new context such as social determinants of health, is an effective way to raise their subjective assessment of their own understanding. Notably, high student self-efficacy has been shown to improve academic performance ([<reflink idref="bib34" id="ref28">34</reflink>]), so it is possible that the beneficial effect our intervention had on students' subjective appraisal of their own knowledge will eventually bolster academic success.</p> <p>To assess whether a bias existed in students' subjective assessment of their own understanding, we asked open-ended prompts to determine whether students could list, describe, and analyze their new knowledge on CVD disparities in marginalized populations. Different abilities represent various levels of learning on Bloom's taxonomy of cognitive learning objectives ([<reflink idref="bib35" id="ref29">35</reflink>]). Traditionally, skipping cognitive levels of Bloom's taxonomy can result in a failure to appropriately master higher-order skills ([<reflink idref="bib36" id="ref30">36</reflink>]). Moreover, traditional lectures, compared to alternative teaching models such as flipped classroom, generally yield lower-order cognitive skills ([<reflink idref="bib37" id="ref31">37</reflink>]). Nonetheless, higher skills, including analysis, were assessed as the students in this study have already been taught to remember and know the underlying cardiovascular and neurohumoral principles in CVD, so we hypothesized that higher-order skill could be demonstrated by some students.</p> <p>In the postintervention survey, 86% of student respondents were able to successfully list a health disparity related to the lecture intervention content. Almost all students successfully listing a disparity demonstrates that instructing students to know the basic mechanisms and physiology underlying psychosocial stress and CVD risk (low-level Bloom skill) can be efficacious within a single lecture period. When asked to describe possible interventions or study design changes to reduce the health disparities in marginalized communities, 89% of students responded. However, of the 89% of students that responded to the open-ended questions in the postintervention survey, only three students successfully demonstrated the analysis skill. No students demonstrated the highest-level skill of synthesis. As such, we cannot conclude that these students critically analyzed the new material to design a possible intervention. Of the three students who did demonstrate analysis, their answers demonstrated thoughtfulness toward participant safety in inclusion and appropriate methods to reduce participant traumatization. That few students demonstrated a higher Bloom skill simply reminds us that learning outcomes need to be scalable and content integrated over a curriculum as opposed to in a single course, with repeated exposure enhancing skills.</p> <p>Although our study demonstrates the efficacy of instructing students in the mechanisms of psychosocial stress and social determinants of health on disease disparities of marginalized communities, our study has several limitations. First, our sample size was small, and we were likely underpowered to detect differences in intervention effect stratified by racial, ethnic, and gender identities or by sexual orientation. We did not perform analyses by subgrouping sexual identity groups because the lived experiences of marginalized individuals will likely differ by identity group and from the intersectional effects of multiple identities ([<reflink idref="bib38" id="ref32">38</reflink>], [<reflink idref="bib39" id="ref33">39</reflink>]). Additionally, we did not want to assume homogeneity in the experiences of different groups. Any findings by further stratification may be confounded by our small sample size and are unlikely to be generalizable. We believe stratifying by individual identity group will be important in larger studies for the purpose of determining baseline understanding levels and which groups are most affected by curricular interventions. We suspect that those individuals in classrooms with intersectionality of marginalized identities will have the highest baseline understanding of the social determinants of health, and future studies need to be designed to be adequately powered when determining efficacy of curricular interventions among individuals with intersectional marginalized identities.</p> <p>Although we were able to demonstrate efficacy of instruction in psychosocial stress and autonomic imbalance in CVD disparities, many other physiological mechanisms are operating in the association of marginalized identity and CVD ([<reflink idref="bib8" id="ref34">8</reflink>]), including coping behaviors such as tobacco use and diet, exercise, and sleep quality. Evidence shows that repeating concepts and introducing new concepts over longer amounts of time and across multiple courses in a curriculum is more effective for learning ([<reflink idref="bib40" id="ref35">40</reflink>]). As such, the social determinants of health and disease risk in marginalized communities should be integrated throughout a physiology curriculum to optimize learning, as there is relevance in discussing the social determinants of health in multiple organ systems beyond the cardiovascular system.</p> <p>Altogether, we demonstrate here proof of concept that a targeted curricular intervention introducing the pathophysiological mechanisms underlying social determinants of health is effective at increasing student understanding of CVD in marginalized communities. We demonstrate that a single lesson is effective at increasing lower-level Bloom's taxonomy outcomes, including student knowledge/remembering of information. It is likely that students of multiple backgrounds will benefit from the broad introduction of physiological mechanisms of the social determinants of health into pathophysiology classrooms at the undergraduate level. Marginalized students will likely benefit from being taught content that validates their experiences as marginalized people. Teaching about marginalized identities in STEM classrooms may reduce the already elevated rate at which marginalized students feel they do not belong and drop out of STEM majors ([<reflink idref="bib41" id="ref36">41</reflink>], [<reflink idref="bib42" id="ref37">42</reflink>]). All students will likely benefit by having to engage with their implicit biases and examine their own experiences. Students will learn how to appropriately identify the associated health disparities that come with a given marginalized identity as a function of social stressors. Finally, the enhanced retention of LGBTQIA2S+ in the STEM workforce to become clinicians and scientists, along with a broad awareness of implicit bias in this workforce, may result in longitudinal health benefits for marginalized communities ([<reflink idref="bib28" id="ref38">28</reflink>], [<reflink idref="bib29" id="ref39">29</reflink>], [<reflink idref="bib43" id="ref40">43</reflink>], [<reflink idref="bib44" id="ref41">44</reflink>]).</p> <hd id="AN0183439567-16">DATA AVAILABILITY</hd> <p>Data will be made available upon reasonable request.</p> <hd id="AN0183439567-17">SUPPLEMENTAL MATERIAL</hd> <p>Supplemental Tables S1 and S2: https://doi.org/10.6084/m9.figshare.27038077.</p> <hd id="AN0183439567-18">GRANTS</hd> <p>J.D.M.-B. reports support from National Heart, Lung, and Blood Institute Grant T32 HL007224-45 and Boston University Sargent College. C.G.S. reports support from a Boston University Chobanian and Avedisian School of Medicine Department of Medicine Career Investment Award, an American Heart Association career development grant (AHA 20CDA35320148), a National Heart, Lung, and Blood Institute career development grant (NHLBI 1K01HL151902-01A1), and Doris Duke Charitable Foundation (Grant #2022061). J.L.F. reports support from the National Heart, Lung, and Blood Institute (NHLBI K01HL143142).</p> <hd id="AN0183439567-19">DISCLAIMERS</hd> <p>The content of the article is the sole responsibility of the authors and does not necessarily represent the views of any institution.</p> <hd id="AN0183439567-20">DISCLOSURES</hd> <p>C.G.S. reports receiving consulting fees from EverlyWell, L'Oreal, the Texas Health Institute, the Research Institute for Gender Therapeutics, and the US Department of Justice unrelated to this work. None of the other authors has any conflicts of interest, financial or otherwise, to disclose.</p> <hd id="AN0183439567-21">AUTHOR CONTRIBUTIONS</hd> <p>J.D.M.-B., V.S., C.G.S., and J.L.F. conceived and designed research; J.D.M.-B. performed experiments; J.D.M.-B. and L.M.R. analyzed data; J.D.M.-B., L.M.R., K.K.S., and J.L.F. interpreted results of experiments; J.D.M.-B. and L.M.R. prepared figures; J.D.M.-B. drafted manuscript; J.D.M.-B., L.M.R., V.S., E.J.N., K.K.S., C.G.S., and J.L.F. edited and revised manuscript; J.D.M.-B., L.M.R., V.S., E.J.N., K.K.S., C.G.S., and J.L.F. approved final version of manuscript.</p> <ref id="AN0183439567-22"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Lopez Castillo H, Tfirn IC, Hegarty E, Bahamon I, Lescano CM. A meta-analysis of blood pressure disparities among sexual minority men. LGBT Health 8: 91–106, 2021. doi:10.1089/lgbt.2019.0121. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Modified Interteaching Sessions as Application-Based Examinations Reduce Student Exam Stress in an Upper-Level Pathophysiology Class
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Jesse+D%2E+Moreira-Bouchard%22">Jesse D. Moreira-Bouchard</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-5644-2540">0000-0002-5644-2540</externalLink>)<br /><searchLink fieldCode="AR" term="%22Lisa+M%2E+Roberts%22">Lisa M. Roberts</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Advances+in+Physiology+Education%22"><i>Advances in Physiology Education</i></searchLink>. 2025 49(1):41-46.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 6
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Test+Anxiety%22">Test Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Evaluation%22">Student Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Physiology%22">Physiology</searchLink><br /><searchLink fieldCode="DE" term="%22Advanced+Courses%22">Advanced Courses</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Instruction%22">Science Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Communication+Skills%22">Communication Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Critical+Thinking%22">Critical Thinking</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperative+Learning%22">Cooperative Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Evaluation+Methods%22">Evaluation Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1152/advan.00108.2024
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1043-4046<br />1522-1229
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Testing is a highly important tool, used ubiquitously in academia, to assess student comprehension and understanding of material. Unfortunately, the emphasis placed on test grades has resulted in a modern epidemic of test-related anxiety, which can have adverse health effects on students. Over time, novel testing strategies have been developed to more precisely assess individual skills such as remembering, analyzing, and synthesizing. Yet, there exist few strategies that were also developed to simultaneously reduce stress in the testing environment. We posit here a teaching innovation whereby we modified the classic interteaching session developed in the social sciences to serve as a stress-reduction testing format that also builds student communication and critical thinking skills in an upper-level pathophysiology course. After implementing this novel testing approach, we anonymously surveyed the students in the class to understand how the testing format affected their self-perceived stress levels and their self-perceived learning and to identify their testing preferences. Of 28 students, 12 responded (43%). Our survey data highlight that students largely preferred partnered, open-response, case-based exams to multiple-choice exams. Moreover, students perceived themselves as having lower test-related stress when taking partnered, open-response, case-based exams, as well as a strong overall agreement that partnered, open-response, case-based exams enhanced their learning. We posit this application of modified interteaching can be employed in upper-level physiology or pathophysiology courses as a stress-reduction testing strategy.
– Name: AbstractInfo
  Label: Abstractor
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1464074
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1464074
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      – Type: doi
        Value: 10.1152/advan.00108.2024
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 6
        StartPage: 41
    Subjects:
      – SubjectFull: Test Anxiety
        Type: general
      – SubjectFull: Stress Variables
        Type: general
      – SubjectFull: Student Evaluation
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      – SubjectFull: Physiology
        Type: general
      – SubjectFull: Advanced Courses
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      – SubjectFull: Science Instruction
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      – SubjectFull: Communication Skills
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      – SubjectFull: Critical Thinking
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      – SubjectFull: Student Attitudes
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      – SubjectFull: Cooperative Learning
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      – SubjectFull: Evaluation Methods
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      – SubjectFull: Teaching Methods
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      – SubjectFull: Instructional Effectiveness
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    Titles:
      – TitleFull: Modified Interteaching Sessions as Application-Based Examinations Reduce Student Exam Stress in an Upper-Level Pathophysiology Class
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            NameFull: Jesse D. Moreira-Bouchard
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            NameFull: Lisa M. Roberts
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