Innovative exploration of designing the ‘Host Defense and Immunology’ course based on the concept of seamless learning

Introduction

Immunology is a cutting-edge field in the development of life sciences. It is an emerging discipline that permeates and combines with molecular biology, cell biology, genetics, and neurobiology. As such, it is the primary support and bridge discipline for basic and clinical medicine.

In 2014, Shanghai Jiao Tong University School of Medicine began large-scale integration of courses in its clinical medicine major [1]. An integrated curriculum mixes the content of two or more subjects into a cohesive whole. They launched module integrated courses, which divide medical knowledge and skills into independent modules according to specific logical relationships, and organ-system integrated courses, which ignore traditional subjects, integrate different but interrelated subjects, and combine basic and clinical knowledge to form a new curriculum structure, at the basic and clinical medicine stages, respectively.

The teaching of immunology has evolved from a single discipline to a horizontally integrated course called ‘Host Defense and Immunology’. In the basic learning stage, the course is compulsory for undergraduate students majoring in clinical medicine with 2.5 credits and 41 class hours. It is offered in the first semester of the sophomore year at the Shanghai Jiao Tong University School of Medicine.

George Kuh first proposed the concept of seamless learning in higher education reform research [2]. Seamless learning can connect independent learning experiences in and out of class, academic and non-academic, and on and off campus. Subsequently, with the development and popularisation of mobile technology, Dehuai Chen from Taiwan, China proposed a concept and framework for seamless learning based on mobile learning [3]. Seamless learning is emphasising learner-centredness (Figure 1). Over the past decade, research on seamless learning has focused on cultivating autonomous learning abilities. The goal is to achieve self-directed learning through designing technological environments and developing situational activities, enabling students to adapt to this uncertain, diverse, and complex intelligent era [4–9]. Based on the above, designing teaching activities around ‘seamless learning’ will be beneficial in promoting students’ self-directed and active learning.

Figure 1:

Schematic diagram of seamless learning.

‘Host Defense and Immunology’ has been actively explored and practiced following seamless learning and has established innovative designs to integrate teaching contents, construct course resources, innovate course teaching modes, and reform learning assessments to facilitate seamless learning for students [10]. A learning feedback survey showed that students’ self-directed and active learning, logical analysis to solve clinical immunology problems, and scientific research innovation abilities were significantly improved. In 2020, this course was recognised by the Ministry of Education of the People’s Republic of China as among the first national first-class undergraduate courses [11].

Methods

Curriculum design

Course objective design

‘Host Defense and Immunology’ includes knowledge, skill, and attitude objectives.

1. Knowledge

   To describe the structure of the immune system.

   To summarize the functions of immune cells and molecules.

   To analyse and compare normal and abnormal immune responses.

   To describe common techniques in immunological research.

2. Skill

   To apply the mastered immunological knowledge to explain the pathogenesis of immune-related diseases and infer prevention, diagnosis and treatment of clinical immune diseases based on the mechanism.

   To read scientific research literature and write reviews.

   To design a research project.

   To conduct experiments, analyse data and write articles.

3. Attitude

   To have patriotic sentiments and a sense of mission.

   To have the kindness of doctors and the spirit of saving lives and aiding injuries.

   To have the spirit of science, the idea of immune health, and the ability to respond to major public health emergencies.

Integrating course contents

‘Host Defense and Immunology’ was formed by restructuring the system of basic immunology, immune system structure (histology and embryology), and immunological diseases (clinical immunology) using an objective-based learning-oriented teaching outline. The teaching contents are divided into five modules: Introduction (overall framework), Immune system structure and immune molecules (basis), Immune cells and immune responses (core), Immunological diseases (theoretical application in clinical practice), and Summary (Figure 2). The spiral-upward approach helps students achieve a logical understanding of the overall contents and apply them to clinical practice.

Figure 2:

Integrated teaching content in ‘host defense and Immunology’.

Compared with the original teaching contents, the new integrated course adds histology of the immune system to aid students in understanding the development process of immune organs, tissues, and cells from the perspective of tissue embryogenesis. It adds a ‘Putting it all together’ section, echoing the introduction, to provide a clearer overview of the course.

Immune molecules have two major categories of functions (recognition and effects) with logical coherence. Linking immune cells with their mediated responses helps students understand their overall function from development to maturity, differentiation, and mediated effects. Additionally, clinical lecture is given to guide students in integrating theory with practice.

Enrich offline and online resources

Based on seamless learning, we provide students with abundant paper resources (offline) and seamlessly integrate online learning resources, breaking the temporal and spatial limitations of learning resources and promoting self-directed learning, clinical application, innovation, and interdisciplinary connections.

Offline resources

‘Host Defense and Immunology’ is based on the characteristics of interdisciplinary integration. Experts were gathered from across the country to compile a new integrated textbook, Host Defense and Immunology which matches the designed teaching content. Table 1 lists the detailed chapter titles.

Table 1:

General chapters of Host Defense and Immunology.

Chapter no.	Chapter title
1	Introduction
2	Immune system structure
3	Immunogen
4	Immune recognition molecules
5	Immune effector molecules
6	Innate immune system and immune response
7	T cell and adaptive immune response
8	B cell and adaptive immune response
9	Mucosal immune response
10	Immune tolerance
11	Immune regulation
12	Hypersensitivity
13	Autoimmune diseases
14	Immunodeficiency diseases
15	Tumor immunology
16	Transplant
17	Immunological prevention and treatment

Online resources

1. Course website (https://i.mooc.chaoxing.com/space/index). The course website is fully constructed, including course introduction, teaching calendar, teaching outline, teaching materials, and interactive columns. Teaching materials include: courseware, recorded lecture videos, micro-lecture videos, clinical case library, collections of stories about scientists and doctors, and references. The website’s interactive section provides Q&A sessions between teachers and students as well as discussions on research progress and hot topics.

2. Jiaoyi Wisdom Classroom (https://oc.shsmu.edu.cn/studio/publicCourse/course). There is a ‘Medical Immunology’ massive open online course (MOOC).

3. Official WeChat account (account ID: HostDefense与Immunology). This account introduces relevant teaching information, follows the forefront, and posts new advances in immunology.

4. WeChat video account (account ID: 广说机体防御与免疫). This account posts 26 micro-lecture videos independently designed by the teacher team. Video resources are designed based on two key themes: (1) immune molecules and immune cells; (2) introducing the latest progress in clinical application of immune theory.

Innovate teaching modes

Based on building rich teaching resources, various innovative measures have been designed and implemented, including teaching methods that seamlessly connect teaching and learning before, during, and after classes.

Before class, we guide students to consume the corresponding micro-lecture videos and classic literature on the course website and WeChat video account and then communicate and interact with teachers and students on the website and in WeChat groups. They complete a small test after self-learning transitional chapters or knowledge points.

In the classroom, a ‘lecture plus flipped classroom’ format is used to cultivate students’ logical analysis and cross-integration abilities through classroom lectures and flipped discussions on setting topics and to cultivate their interdisciplinary thinking. The chapter on hypersensitivity adopts case-based learning (CBL) to enhance the combination of basic and clinical aspects and to exercise students’ ability to solve complex problems. Cutting-edge literature reading and discussion is introduced in the classroom, and students may review literature and write reviews after class to cultivate their scientific critical and innovative thinking and comprehensive abilities. The ‘Acquired immunodeficiency disease’ chapter is an example of how we adopt different teaching modes for teaching and learning (Figure 3).

Figure 3:

Diagram of various teaching modes adopted in the ‘acquired immunodeficiency disease’ chapter.

Before class, the students engage in self-study on the micro-lecture video. In-class time includes lectures and flipped classroom discussion combined with the latest literature readings. After class, students think through case studies and write an essay.

Reform learning assessments

Process and summative assessments are adopted for evaluation. We reformed the assessment requirements and increased the level of learning challenges. We promote clinical application and interdisciplinary collaboration by assessing comprehensive qualities through multiple assessments (Table 2).

Table 2:

Diversified assessment system for ‘Host Defense and Immunology’.

Assessment methods	Assessment contents	Related chapters
Process assessment (60 %)	Self-study assessment, 5 %	Immune molecules (self-learning section)
	CBL discussion, 20 %	Hypersensitivity
	Comprehensive mind map, 10 %	Putting it all together
	Comprehensive question, 10 %	Clinical immune related diseases
	Review, 15 %	Basic and clinical immunology
Summative assessment (40 %)	Noun interpretation, 6 %	All
	Choice questions, 16 %	All
	Fill in the blanks, 6 %	All
	Comprehensive questions, 12 %	Basic and clinical immunology

1. CBL, case-based learning.

Based on seamless learning, students take a website test after completing the self-learning chapter. Teachers rate students based on their preparation, presentation, and interaction in CBL, reflecting their comprehensive abilities in problem-solving, clinical care, and attention to new developments. Students must design a comprehensive immunological mind map for the theme. They are encouraged to search for information and integrate what they have learned to explore and think about questions. The students conduct literature reviews and extracurricular discussions and write a review.

Teaching tasks and learning resources are posted on the course website before class. In class and after class, teachers conduct teaching discussions and set up daily online homework, grade homework, and interactive Q&A sessions. In addition, teachers distribute mid-term survey feedback and a post-course questionnaire. Timely communication and Q&A guidance are provided through online discussion forums. Effective interactions are formed with students, and timely feedback is provided to improve teaching.

Design the survey questionnaire to provide feedback on achievement

Two sets of survey questionnaires were designed.

One set of survey questionnaires with written descriptions is provided to students in order to collect their feedback on the overall evaluation of the course, including main learning gains, advantages and suggestions for improvement of the course, improvement of the teaching materials, and advantages and suggestions for network resources such as the course website, WeChat official account, and video account. They also must share the titles of their three favourite micro-lecture videos and provide three examples of impressive scientist stories.

Another survey questionnaire is presented in the form of multiple-choice questions for students to provide feedback on more specific questions. The main contents include the following:

1. Teaching content they find interesting

2. Teaching content they think is difficult to learn

3. Evaluation of the teacher

4. Impact of the content on one’s future development

5. Aspects in which the comprehensive immunological mind map works for them – analysis of clinical immunological issues, overall understanding of immunological principles, understanding of the interrelationships between knowledge points, and self-learning ability

6. Aspects in which self-directed cooperative learning in CBL discussion classes affects them – proactive learning, understanding of teaching content, logical thinking ability, applying theory to clinical problem solving, and teamwork

7. Aspects in which micro-lecture video learning impacted them – proactive learning, understanding of teaching content, logical thinking, innovation, and humanistic literacy

8. Areas in which learning stories about scientists and doctors that affect them – proactive learning, understanding of teaching content, logical thinking, innovation, and humanistic literacy

The survey questionnaire was distributed to eight-year clinical medicine students in years 2021–2022; 294 questionnaires were distributed, and 234 were valid.

Results

Achievement of curriculum innovation

The teaching innovation of the course has been highly recognized by teachers and students, and has been rated A for five consecutive years, ranking in the top 3 % of the Shanghai Jiao Tong University School of Medicine.

Overall student feedback reveals the students mastered the basic theories of the immune system’s mechanism of action, normal and abnormal immune responses, and immunological research techniques and have acquired integrated systematic thinking. Furthermore, students also deepened their application of immune knowledge in clinical diseases through real cases, pursued clinical rigor and logic, and shaped their clinical thinking patterns. Students developed communication and collaboration skills through collaborative learning [4].

Analysis of the frequency of teaching feedback from students revealed that, before class, students had difficulties analysing the application of immunological theory and solving clinical problems, did not know where to start, and lacked confidence. After learning, students could flexibly apply it, which was rewarding and gave them a sense of achievement.

The survey questionnaire revealed that the comprehensive immunological mind map was very beneficial for students to analyse clinical immunological problems, have an overall understanding of immunological principles, understand the interrelationships of knowledge points, and have self-learning abilities (Table 3) with ‘very helpful’ percentages reaching 83 %, 71 %, 67 %, and 67 %, respectively. The ‘helpful’ percentages were 17 %, 25 %, 29 %, and 29 %, respectively. Very few of the students believed that it was not helpful.

Table 3:

Analysis of the learning effectiveness of the comprehensive mind map.

Comprehensive mind map	Very helpful n (%)	Helpful n (%)	No help n (%)
Analysis of clinical immunology issues	195 (3)	39 (17)	0 (0)
Wholistic understanding of the principles of immunology	166 (71)	59 (25)	9 (4)
Understanding the interrelationships between knowledge points	157 (67)	68 (29)	9 (4)
Training of self-directed learning	157 (67)	68 (29)	9 (4)

1. 234 valid questionnaires were collected for analysis.

The analysis of student survey questionnaires showed that CBL learning significantly benefited students by promoting active learning, deepening their understanding of key concepts, enhancing logical thinking, connecting theoretical knowledge with clinical practice, and improving teamwork. According to Figure 4, 86 %, 91 %, 90 %, 86 %, and 79 % of students reported improvements in these areas, respectively. A smaller proportion of students – 14 %, 9 %, 10 %, 14 %, and 20 %, respectively – rated the effects as moderate, with almost no students finding it ineffective.

Figure 4:

Analysis of the effectiveness of case-based learning (CBL).

Similarly, studying micro-lecture videos had a positive impact on active learning, comprehension of knowledge points, logical thinking, innovation, and humanistic literacy, with 90 %, 90 %, 92 %, 92 %, and 90 % of students, respectively, noting enhancements (Figure 5). The percentages of students who felt the effect was moderate were 9 %, 10 %, 8 %, 8 %, and 10 %, respectively, with negligible reports of ineffectiveness.

Figure 5:

Analysis of the learning effectiveness of micro-lecture videos.

Learning about the stories of scientists and doctors also had a favorable impact, promoting active learning, understanding of concepts, logical thinking, innovation, and humanistic literacy. As shown in Figure 6, 88 %, 86 %, 89 %, 83 %, and 90 % of students reported a ‘good effect’ in these areas, respectively. Moderate improvements were reported by 11 %, 12 %, 10 %, 14 %, and 9 % of students, respectively, while very few considered it ineffective.

Figure 6:

Analysis of the learning effectiveness of stories about scientists and doctors.

Discussion

The previous medical teaching model required students to complete their theoretical medical learning before engaging in clinical practice. This separation of knowledge and practice was not conducive to medical students’ integration and expansion. Therefore, we aimed to integrate basic and clinical immunology into the early stages of medical student training by adopting a horizontal integration approach.

Teaching emphasises cultivating students’ clinical thinking. The integrated teaching mode creates opportunities and situations for students to think and explore independently, allowing them to absorb theoretical knowledge while exploring its transfer and application independently. Correspondingly, teachers must consider their instructional designs from the perspective of supporting and promoting self-directed learning among students.

In teaching ‘Host Defense and Immunology’, seamless learning is mainly reflected in the construction and integration of teaching resources as well as the innovation of teaching methods, striving to maximise the creation of sustainable and autonomous learning conditions and platforms for students.

Seamless learning bridges individual and group learning spaces, striving to fill learning gaps in different contexts, making learning coherent and complete. It also supports transferring learning experiences obtained in a seamless environment to classroom learning, promoting effective integration of cross-situational learning [12, 13]. In seamless learning, learners can learn anytime and anywhere in various situations, using personal mobile devices as intermediaries to easily and quickly switch between scenarios while maintaining learning continuity across technologies and settings.

Over the past decade, research on seamless learning has focused on cultivating autonomous learning abilities to achieve self-directed learning through the design of technological environments and the development of situational activities, enabling students to adapt to this uncertain, diverse, and complex intelligent era [6]. The exploration and practice of ‘Host Defense and Immunology’ provides a good example of integrating seamless learning concepts into teaching.

First, the teaching content and textbook developed for this course reflect the characteristics of integration. The chapters and content are rearranged to combine immunological knowledge with immune system structure and clinical immunological diseases, which can better assist students in self-directed learning.

To support seamless learning for students, teachers must move away from textbooks being the sole source of teaching and consider students’ learning within the broader context of online resources. Modern technology is constantly changing, and ways to obtaining information and learning habits are changing accordingly. Students tend to search for online resources to assist in their studies while reviewing and previewing, and mobile phones and computers, as indispensable parts of their daily lives, can become good second classrooms. Therefore, the course provides a framework for students to engage in seamless learning using diverse information technologies.

The teaching team is trying to build course-related electronic learning resources on multiple platforms. Students can access original micro-lecture videos, original high-quality MOOCs, the latest immunology research results, and related science articles anytime and anywhere on different learning platforms using mobile phones and/or computers. They can also interact with teachers and classmates in real time, achieving seamless learning anytime, anywhere, and on multiple terminals. Students can enhance their professional ethics and humanistic sentiments by independently learning about the experiences of Nobel laureates, contributions of researchers, and stories of doctors in the collection of stories about scientists [14]. Rich electronic resources can not only meet the personalised learning needs of students but also help cultivate their ability to connect theory with clinical practice and solve practical problems as well as to explore independently.

Finally, integrating seamless learning concepts into teaching is reflected not only in the richness of teaching resources but also in the innovation of teaching modes. Composite teaching is another characteristic of seamless learning, and diverse teaching modes give students channels and space for independent learning. Selecting transitional chapters or knowledge points for students to self-study is not only a consolidation of existing knowledge but also a preview of subsequent course content, which helps students integrate knowledge. After explaining basic knowledge and theories based on the CBL teaching method, teachers provide clinical cases of hypersensitivity reactions and design relevant questions for them to discuss and report in small groups.

The course ends with a ‘Putting it all together’ summary module where students are responsible for drawing a mind map of certain knowledge. Alternately, the teacher interacts with students, or the whole class may participate in producing the mind map. Drawing a mind map allows students to review and organise their learning, strengthens their memory of theoretical knowledge visualisation and systematic thinking, and provides important feedback on teaching effectiveness 15], [16], [17.

Conclusions

The teaching model of ‘Host Defense and Immunology’, based on seamless learning, integrates formal learning and informal learning, combines individual self-directed learning with collective learning, and breaks the temporal and spatial limitations of learning resources. As mentioned above, students acquired integrated systematic thinking through the course, shaped clinical thinking patterns, developed communication and collaboration skills, and enhanced their ability to analyse and solve clinical problems in the application of immunological theory. In the era of rapid development of information technology, educational reform promotion and innovation, AI, and other applications will make seamless learning more convenient and bring greater challenges on teachers 18], [19], [20.