[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To Infinity and Beyond: Expanding the Scope of Basic Sciences in Meeting Accreditation Standards” finished with its fifth seminar on Thursday, March 31, 2022, titled “Strategies for Incorporating Self-Directed Learning into Basic Sciences Education”. In this session, Samara Ginzburg, Dean for Education and Associate Professor of Medicine and Science Education, and Joanne Willey, Chair of the Department of Science Education, both from the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, presented strategies to promote the development of self-regulated learning skills needed for students to become self-directed.

Dr. Ginzburg started this interactive session by asking the audience to picture a colleague who practices self-directed learning (SDL). Throughout the session, she asked the audience questions about their behaviors and compared the audiences’ answers to published data. 

Dr. Willey stated that the literature is full of information on student characteristics and their relationship to SDL. However, they did not find studies with information on the understanding of SDL by faculty. Therefore, they conducted a national survey of medical educators designed to assess faculty needs on their understanding of SDL [1,2]. Specifically, do faculty value SDL for medical students? Are faculty familiar with strategies documented to promote SDL? They found that of the 350 undergraduate medical educators who responded, ~95% believed that SDL is essential for medical student success. However, when asked what, in their opinion, SDL encourages, answers were multifaceted. Among those, the team identified three layers: (1) highest layer: life-long learning values, self-reflection, curiosity, motivation, goal setting, and better equipped to meet challenges; (2) middle layer: better prepared for the classroom and clinical responsibilities, peer teaching, team-based skills; and (3) lowest layer: improving academic performance, communication skills.

Dr. Ginzburg continued by stating the actual definition as published by her team [3]. She explained that her institution’s curriculum is grounded on SDL with 12 years of experience. Self-directed learning is “a construct that embodies the process elements associated with self-regulated learning as well as the characteristics of the learner and the culture of the learning environment.” The concepts include three separate areas that have to fall together: (1) learner characteristics (motivation, curiosity, resilience); (2) the culture of the learning environment (assessment, resources, values, hidden curriculum); and (3) the self-regulated learning cycle. The latter is intrinsic to the entire SDL process and, although this process is innate to some personalities, it has to be learned and practiced by most faculty. The cycle encompasses planning, learning, assessing the knowledge to identify gaps, and adjusting behaviors to close these gaps.

LCME gives another definition (element 6.3) which is similar to those from other educational regulatory bodies for health professions schools. Educators need to make sure students know how to self-assess their learning, how to independently analyze, identify, and synthesize the relevant information (learning of the cycle), how to appraise the credibility of resources, and ensure that students receive feedback on their information-seeking skills. LCME asks to do this as a unified sequence, meaning altogether as part of the same learning activity. This element has driven many changes in curricula across the country to include SDL.

Dr. Willey continued by reviewing data from her national survey study [1,2]. In their study, her team created questions for medical educators addressing three SDL strategies: (1) Cognitive strategies, which make the material more accessible (e.g., what do you do to help students understand, relate to, and digest the material?). (2) Metacognitive strategies, which increase the ability to set goals, self-assess, and adjust. (3) Emotional & motivational strategies, which address learner attributes and culture of the learning environment. They found that faculty were overall familiar with the metacognitive and emotional & motivational strategies to promote SDL, but were much less comfortable with cognitive strategies despite having the most control over them as they teach. To highlight their findings, Dr. Willey posed several of their study questions to the audience and, after analyzing the polls, discussed the audience’s overall responses compared to the national overall responses.

To highlight the different question types, Dr. Ginzburg discussed Charles Grow’s model of staged SDL from the general education literature (1990s). In this model, Dr. Grow considers a student to pass through different levels of self-direction. A student starts as a dependent, becomes interested, then involved, and then self-directed. The student functions on different levels depending on the content; they may be on a higher level in one area but a lower level in another area. In his model, Dr. Grow also considers the role of the instructor from being an authority/coach, to motivator/guide, to facilitator, to consultant/delegator. Thus, as the student progresses through these levels, the faculty should also adjust their roles. Ideally, the instructor matches, or near matches, the level of the student. A mismatch, or severe mismatch, should be avoided.  If an instructor works with a group of students, the instructor should find the overall best level, accepting that one student may be a severe mismatch; the latter student is best helped by one-on-one meetings. The faculty’s task is to practice how to recognize and meet the learners on their level, as well as take learners step-by-step from one level to the next.

Dr. Willey explained that individuals usually stick to the same question type during their teaching. However, with practice, faculty may move between question types on purpose, depending on the students’ levels and environment. The type of questioning drives what happens before, during, and after an SDL session. She illustrated how faculty can covert a recall question into an analysis question, then into a synthesis question, based on work from the Stanford Faculty Development Program, Leland Stanford University (1998). Faculty should also be able to encourage students to rephrase their questions from the first level to higher-level questions to generate discussion and practice scaffolding. (1) Recall questions (what?) probe for basic facts and require prior knowledge or experience. Recall questions do not generate much discussion but engage learners in some form before the session. (2) Analysis and synthesis questions (how?) require learners to demonstrate deeper understanding, create context into which individual pieces of data fit, and apply deductive reasoning and logic to answer questions. Analysis questions generate reasonable discussions in advance, during, and after the SDL session. (3) Application questions are complex and require integrating different materials, but generate robust discussions. Application questions require preparation, highly stimulating discussions, and continue to impact after the SDL session.

The presentation lasted 45 minutes. Drs. Ginzburg and Willey then responded to questions from the audience: How do the cognitive, metacognitive, and motivational strategies discussed differ from learning versus SDL? How can you integrate the concepts you discussed to be used to meet LCME, which requires faculty feedback on citations? Does SDL affect team performance? Do you believe that Montessori students have an advantage?

1. Lim YS, Lyons VT, Willey JM. Supporting Self-Directed Learning: A National Needs Analysis. Med Sci Educ. 2021 Apr 6;31(3):1091-1099. doi: 10.1007/s40670-021-01278-y. eCollection 2021 Jun. PMID: 34457952
2. Lim YS, Lyons VT, Willey JM. Supporting Self-Directed Learning: Development of a Faculty Evaluation Scale.Teach Learn Med. 2021 Oct 13:1-10. doi: 10.1080/10401334.2021.1977136. Online ahead of print. PMID: 34645314
3. Ginzburg SB, Santen SA, Schwartzstein RM. Self-directed Learning: a New Look at an Old Concept. Med Sci Educ. 2020 Oct 20;31(1):229-230. doi: 10.1007/s40670-020-01121-w. eCollection 2021 Feb. PMID: 34457877 Free PMC article.

[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To Infinity and Beyond: Expanding the Scope of Basic Sciences in Meeting Accreditation Standards” continued with its fourth seminar on Thursday, March 24, 2022, titled “Towards Integrated Medical Education: Getting the best out of interdisciplinary teacher teams and leaders”. In this session, Mirjam oude Egbrink, Professor of Implementation of Educational Innovations and Vice Dean Education, and Stephanie Meeuwissen, an internal medicine resident, both from Maastricht University Medical Centre in the Netherlands, presented their research on interdisciplinary teacher teams working on integrated medical education.

Dr. Egbrink started by summarizing the shifting landscape of healthcare due to increased medical knowledge and technology and the increased presentation of patients with multiple chronic diseases that all together require a higher level of complexity and a growing need for collaboration between different health care professions. To address this shift, the Maastricht University Faculty of Health Medicine and Life Sciences has implemented an interdisciplinary, problem-based curriculum for undergraduate students. In contrast to traditional discipline-specific curricula, they organized their integrated curriculum by thematic case-based blocks, each 4-10 weeks long, in which students engage in small-group sessions focusing on relevant healthcare-related to real-life problems to stimulate meaningful and deep learning. Each thematic block includes contributions from a series of disciplines. Since these topics include basic, social, and clinical sciences, the educators who develop and organize these individual blocks need to come from different disciplines. At Maastricht University, these groups of teachers are called Planning Groups and consist of 3-5 faculty from different departments, including a team leader. With over 50 departments and over 300 blocks, this involves a complex organization.

Until recently, there was no data on how these Planning Groups functioned, how team members worked together, and how integrated and meaningful the content was. Therefore, Dr. Egbrink and her team studied the following questions: 1) How do interdisciplinary teacher teams function when working on an integrated curriculum? 2) How does their teamwork influence the quality of education? 3) What are important factors influencing team functioning? 4) How can we promote the successful functioning of interdisciplinary teacher teams?

Dr. Meeuwissen continued by asking, “What makes a successful team?” The answer is not self-evident as any team, not just medical teams, are complex and prone to conflicts. Literature on management sciences and business is rich in information about team learning. Team success depends on how members interact with each other. Team learning depends on how the team builds upon each other’s knowledge and experience. Team learning behavior depends on sharing information among team members in an open and respectful environment that leads to co-construction of content that further evolves to constructive conflict management. Constructive conflict is about the negotiation of different experiences, perspectives, and knowledge not leading to a conflict but agreement. Team learning influencing factors are based on individual (personal), team (interpersonal), and organizational knowledge, skills, and attitudes. Team learning outcomes and innovation are also better in high-level team learning [1].

When Dr. Meeuwissen’s team surveyed the faculty participating in the Planning Groups, they identified three different team approaches [2]. (1) Fragmented Team (“Hangout”): Team members shared their discipline but did not work with each other’s experience or build upon each other’s expertise. (2) Framework-guidance Team (“Distribution Center”): Team members built on each other’s knowledge and stayed outcome-centered. The team leader was more in charge of the different perspectives. (3) Integrated Team (“Melting Pot”): Teams worked well together, incorporated members’ knowledge, skills, and attitudes. The team leader and members together created student-centered education. When Dr. Meeuwissen measured the quality of education as perceived by students, they found that fragmented teams scored lowest in organization, structure, and learning effects. By contrast, the integrated teams scored highest in all aspects (organization, structure, learning effects, and cohesion). Team members confirmed these results since members of integrated teams were most satisfied with their work. They concluded that different team approaches produced varying levels of outcomes. An integrated team approach should be encouraged as they demonstrated the highest team learning levels.

Dr. Meeuwissen then discussed enabling and inhibitory factors that influenced interdisciplinary teacher team functioning [3]. They found several personal characteristics and team dynamics that influenced their respective team approach. (1) In the fragmented team, personal alignment was dominant, including members’ attributes, tendencies, and motivation. In essence, members in these teams did not align with the educational philosophy of integration, rather emphasized discipline-center education. (2) In framework-guided teams, team leadership was evident since leaders and members had a vision, took responsibility, and regularly reflect on their work. (3) Integrate teams, in addition to team-leadership attributes, also incorporated organizational processes like decision-making.

To investigate “What makes a successful team leader?”, Dr. Meeuwissen and her team observed (interactions and written correspondence) and interviewed select teams over a year [4]. She found that success was associated with the team leader’s inclusiveness behavior. Such inclusiveness included coordinating, explicating, inviting, connecting, and reflecting. The team leaders were on task, knew exactly what was going on, were mindful of deadlines, knew the different backgrounds, personalities, capabilities, and emotional states of all team members, gave clear and explicit directions and made sure each member was heard and contributed to the work. In return, team members’ participated actively, spoke up, and even mimicked the leader’s inclusiveness. In alignment with the literature, her results indicated a paradigm shift in health professions’ education leadership.

Lastly, Dr. Meeuwissen discussed how they set up a faculty development program on leadership identity formation for interdisciplinary teacher team leaders [5]. They used the method of Design-Based Research, which anchors on theoretical principles: competence-based learning, workplace learning, learning by doing, small-group learning, and tailor-made learning. The leader identity development process is an iterative, collaborative & continuous process that integrates knowledge, broader views on leadership, application, and reflection.

Dr. Meeuwissen summarized that leadership is an important asset that determines the culture and structure of the organization, a leader identity program can convert teachers’ views on leadership, thoughts on education and leadership are important to change behavior, all teams are groups but not all groups are teams, and that soft elements of interdisciplinary teams can have hard consequences for education.

The presentation lasted 35 minutes. Drs. Egbrink and Meeuwissen then responded to many questions from the audience: if there was a difference in team behaviors between individuals of different demographics. How did you determine which team falls into which category? Did you make any interventions when you found a low-performing team?

1. Meeuwissen, S.N.E., Gijselaers, W.H., Wolfhagen, I.H.A.P., oude Egbrink, M.G.A. When I say… team learning. Medical Education. 2020;54(9):784-5.
2. Meeuwissen, S.N.E., Gijselaers, W.H., Wolfhagen, I.H.A.P., oude Egbrink, M.G.A. How teachers meet in interdisciplinary teams: hangouts, distribution centers and melting pots. Academic Medicine. 2020;95(8):1265-73.
3. Meeuwissen, S.N.E., Gijselaers, W.H., Wolfhagen, I.H.A.P., oude Egbrink, M.G.A. Working beyond disciplines in teacher teams: teachers’ revelations on enablers and inhibitors. Perspectives on Medical Education. 2021;10(1):33-40.
4. Meeuwissen, S.N.E., Gijselaers, W.H., van Oorschot, T.D., Wolfhagen, I.H.A.P., oude Egbrink, M.G.A. Enhancing Team Learning through Leader Inclusiveness: a One-Year Ethnographic Case Study of an Interdisciplinary Teacher Team. Teaching and Learning in Medicine (2021);33(11).
5. Meeuwissen, S.N.E., Gijselaers, W.H., de Rijk, A.E., Huveneers, W.J.M, Wolfhagen, I.H.A.P., oude Egbrink, M.G.A. When Theory Joins Practice: Teachers’ Leader Identity Development in Health Professions Education. Medical Teacher (2021). Published online. doi:10.1080/0142159X.2021.2015532

[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To Infinity and Beyond: Expanding the Scope of Basic Sciences in Meeting Accreditation Standards” continued with its third seminar on Thursday, March 17, 2022, titled “Designing Outreach and Service Learning Programs to Effectively Meet the Needs of the Community, Faculty, and Medical Students”. In this session, Peter Vollbrecht, Assistant Professor of Biomedical Sciences at Western Michigan University Homer Stryker M.D. School of Medicine (WMed) in Kalamazoo, MI, reviewed considerations when developing service-learning (SL) programs including accreditation standards, community needs, and student impacts.

Dr. Vollbrecht opened the session by comparing “outreach” with “service-learning”. For outreach, also “community service”, one can find different descriptions with similar messages: “Outreach is the activity of providing services to any population that might not otherwise have access to those services”. They are designed to improve the quality of life for community residents or to solve particular problems related to their needs. Outreach opportunities provided by the medical school complement and reinforce the medical student’s educational program.

Service-Learning (SL), also “community-engaged learning”, is precisely defined by the Liaison Committee on Medical Education (LCME) Standard 6.6: “Educational experiences that involve all of the following components: 1) medical students’ service to the community in activities that respond to community-identified concerns; 2) student preparation; and 3) student reflection on the relationships among their participation in the activity, their medical school curriculum, and their roles as citizens and medical professionals.” In other words, SL is a form of experiential learning where students apply academic knowledge and critical thinking skills to address genuine community needs. SL combines service activities and academic learning objectives, with the intent that the activity will benefit both the recipient and the provider.

Both outreach and SL have incredible potential to provide meaningful impact to communities and the academic institution, faculty and students. Dr. Vollbrecht encouraged the audience, if they embark on an outreach project, to make this activity more impactful by adapting it to an SL experience. He suggested integrating the experience into the curriculum, e.g., in social determinants of health courses, and asking students to prepare before and reflect after the event as part of their grade. For example, a “meal delivery” outreach program could be converted into an SL activity by making it part of a nutrition curse that includes studying nutritional values and putting together a meal plan appropriate for the targeted community, then, after the event, reflect and troubleshoot.

Where does one start with creating an SL program? Dr. Vollbrecht explained that open and frequent communication with all stakeholders is most crucial. One has to identify what the targeted community specifically needs and if the institution and its faculty & students can address these needs, such as resources, time, ability (skills), and overall goals. Dr. Vollbrecht discussed stakeholders in more detail.

(1) Community: Never assume what the community needs, always ask them! Present your ideas for discussion but be open to their response and adjust to what they request. Not establishing needs correctly upfront is the most common reason for the failure.

(2) Event Participants: What service are you providing? Why should you participate? Who should participate? What goals do you and your community partners have for the participants?

(3) Medical Students: To make the event a true and meaningful SL experience, integrate it appropriately within the curriculum considering the students’ skills and time. Provide opportunities for preparation and structured reflection to help them tie back their experience to the course objectives. Clearly state what skills students will learn (e.g.: soft skills: communication, empathy, understanding, connection to community, serving; hard skills: taking vitals, going through insurance bills). Assure that students are appropriately compensated (credit).

(4) Institution: Increase reputation (local, regional, national); offer formal and informal pathways for diverse students including for underrepresented minorities in STEM; introduce clinical experiences; and meet LCME accreditation standards (3.2 Community of Scholars/Research Opportunities, 3.3 Diversity/Pipeline Programs and Partnerships, 4.2 Scholarly Productivity, 6.6 [see above]).

(5) Faculty: Time is the first problem, budget the second. Other barriers include lack of FTE, effort not counted towards promotion, basic scientists do not have a service they can provide.

(6) Yourself: By converting an outreach to an SL experience, one can conduct research and publish data (scholarly work), thus making it count for your professional development, which should be valued by your institution. Including scholarly work is important for you and the community (shared ideas), but the program should be driven by the service.

Dr. Vollbrecht outlined how to create an SL event that works for all parties using backward design and evidence-based practices: (a) define clear and measurable goals, (b) create experiences that actually achieve these goals for the community, students, participants, institution, and yourself, and (c) appropriate assessment (important for scholarship). As an example, he shared his experiences with his project “Brain Explorers” [1, 2]. At the beginning, he just wanted to talk with kids about the brain. Over years, this project evolved into a SL program with scholarship activity. Today, the program focuses on “Providing neuroscience opportunities for K12 students” with a clear mission statement “Provide exciting, engaging, accessible, and assessable science engagement for underserved and underrepresented populations”.  To address the mission, it was crucial to talk to participants (students and teachers) to assure interest and purpose. The assessment strategies had to be adjusted over time. They had to ensure they reach the URM population. In his publications, he presented data on population, demographics, open house participation, school visit participants, and impact on students (quantitative and qualitative responses).

Dr. Vollbrecht concluded by encouraging the audience to reach out to him under CIRE (Community Outreach, Research, and Engagement) and PPB (Pathway Programs and Bridges). He will also present a focus session at the annual IAMSE 2022 meeting.

The presentation lasted about 40 minutes. During the ensuing discussion, Dr. Vollbrecht addressed several questions from the audience. To complying with LCME, must an SL program be part of the required curriculum or can it be extracurricular? How can we assure equal opportunity for the entire student body (logistics)? How do you handle IRB approval, particularly when minors are involved? How do you teach students to be aware of “saviorism”? How do you organize the reflection after service when students have different experiences possibly at different sites? How does an institution oversee different programs? How do you remediate (if a grade is involved)?

1. Gall AJ, Vollbrecht PJ, Tobias T. (2020) Developing outreach events that impact underrepresented students: Are we doing outreach right? European Journal of Neuroscience. 52 (6): 3499-3506
2. Vollbrecht, PJ, Frenette, RS, Gall, AJ (2019) An effective model for engaging faculty and undergraduate students in neuroscience outreach with middle schoolers. The Journal of Undergraduate Neuroscience Education. 17(2):A130-A144

[The following notes were generated by Sandra Haudek, PhD.]

The Spring 2022 IAMSE Webinar Seminar Series, titled “To infinity and Beyond: Expanding the scope of Basic Sciences in Meeting Accreditation standards” continued with its second seminar on Thursday March 10, 2022, titled “The Construction of a Social Medicine Curriculum at the University of Vermont”. In this session, Dr. Timothy Lahey, Professor of Medicine and Director of Ethics at the University of Vermont’s Larner College of Medicine, reviewed principles underlying social medicine, the collaborative design and implementation of a highly interactive preclinical social medicine curriculum including success and challenges encountered, and next steps in social medicine curriculum development.

Dr. Lahey started with stating that physicians need more time and better tools to address social medicine in practice. He mentioned two surveys, one estimated that only 24% of physician practices screen for the five major social determinates of health, the other revealed that although family medicine physicians are deeply concerned about diversity, inclusivity, and equity, most have too little time and inadequate staffing to address social determinates of health. Awareness is a challenge; many publications discuss the importance of social determinates of health and major organizations like AAMC call for enhanced social medicine training. He summarized that social inequity influences health and health care delivery, that not teaching social inequity delivers the message if being unimportant, and that simply knowing inequities exist is inadequate. The goal is to give trainees specific skills, not just awareness.

Dr. Lahey stated that there are several benefits for a medical school to offer a social medicine curriculum: Students will be better prepared for the realities of clinical practice, like risk of illness, access to care likelihood of presentation, quality of care, and access to medications. It will also empower trainees to faster rectification of health inequities (system reform and individual care), and it will be compelling to students who often enter medical school to make a difference. He then confessed that we do not know how the most competent physician should look like, how such competencies are best assessed, what the ideal instructional approach to teach social medicine content is, and what the long-term outcomes will be. Yet practicing physicians are confronted with health inequities far more often than what is tested on USMLE step 1.

Dr. Lahey then explained that he was involved in a social justice curriculum design at Dartmouth’s Geisel School of Medicine but unfortunately left before its implementation [1]. When he started at the University of Vermont, there was a team, faculty and students, already working on a similar curriculum (Social Justice Coalition) [2]. Their institutional strategy was the following: (1) Integration of social medicine material with foundational science content is better than having it segregated apart from other materials. (2) Rich in active learning (discussions, TBL). (3) Curricular change equals QI training for student leaders. (4) Complement service learning.

The Social Justice Coalition team started with terrain mapping by performing needs assessments among patients, students, faculty, and administration. He illustrated the curriculum before intervention which included secrete sections in which ethics, public health, global health, palliative care, and similar were scheduled throughout the 4 years of medical school. Yet feedback from students was not encouraging: “Although SDH content existed, this content was separated from the foundational sciences curriculum in discrete courses, informally assessed, lacked space for critical reflection, had no centralized coordination, and lacked direct clinical integration.” He speculated that many schools have similar issues despite efforts to cover social medicine content.

The Social Justice Coalition team then continued with setting high-level curricular objectives, followed by more specific learning objectives that can be mapped to all the courses and integration with other learning objectives [2]. They then strategically identified appropriate courses across the curriculum in which the social medicine content can be incorporated. The team reached out to course directors to initiate and support this integration. Dr. Lahey gave several examples of topics. He then reviewed the Social Medicine Theme of the Week initiative. This initiative was developed by students, and is lead and taught by students (with faculty oversight). It contained strategically located sessions across the curriculum (mostly linked to foundational content) addressing social medicine themes and providing infographics and links to reading material.

Dr. Lahey illustrated how the curriculum changed after intervention: The courses itself did not change, yet the core social medicine content was distributed throughout the foundational science phase with every week having a theme and offering regular Social Determinates of Health Rounds during the clinical years.

Dr. Lahey then discussed successes and challenges. His team realized that there were numerous curricular points of attachment, yet only few deeply engaged faculty champions. The theme of the week initiative was compelling but fragile since it was run by students and would need durable centralized oversight and linkages to faculty curricular oversight and competencies. Lastly, they noticed a hidden curriculum, meaning topics can be inspiring but also alienating if said in a way that pays lip service. He concludes that the curriculum is continuously driven by circular evaluation, changes, and faculty development. He mentioned several examples of lessons learned based on surveys of first-year medical students and social medicine faculty that included Likert responses and free text input [3]. The survey revealed that most students were aware of the social medicine curriculum, thought the curriculum was helpful, a good variety of topics was addressed (race, sex & gender, LGBTQ, poverty, global health, structural violence), and adequate pedagogy was used, with emphasis on the importance of storytelling. By contrast, the faculty was less aware and engaged. Specifically, faculty asked for more guidance and orientation to the curriculum. He then stated that the team used these data to develop a road map for developing the social determinates of health curriculum.

The presentation lasted about 45 minutes. During the ensuing discussion, Dr. Lahey addressed several questions from the audience, including: How do you measure outcomes? How do you define the difference between public health and social medicine? Do you incorporate other health are providers other than faculty? What type of training was provided to faculty and was this mandatory?

1. Coria at al. Academic Medicine (2013). The design of a medical school social justices curriculum
2. Goyal et al. BMC Medical Education (2021) 21:131. The design and implementation of a longitudinal social medicine curriculum at the University of Vermont’s Larner College of Medicine.
3. Finnie at al. BMC Medical Education (2021) 21:442. A new roadmap for social medicine curriculum design based on mixed methods student and faculty evaluations of the preclinical curriculum.