Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript, “Integration of immunology in a systems-based osteopathic medical curriculum” outlines a guiding framework for integrating immunology “effectively” into an osteopathic curriculum. The authors introduce immunology as an essential discipline in osteopathic medicine and is a topic required by the National Board of Osteopathic Medical Examiners (NBOME) in the United States. Yet, how immunology content is structured into schools of osteopathic medicine and delivered with optimal retention and application to patient care remains elusive. The primary objective of this article is to identify the topics most relevant to immunology education and describe the integration points for reinforcement in disease-state or other medical contexts as a student progresses.
The authors are commended for providing a well-cited manuscript with an extensive list of topics purposefully curated for adoption into other DO programs. While the topic and presented arguments are useful as a resource, it is unclear due to limited data presented, whether a need to revise the immunology content delivered in osteopathic medicine exists or whether this approach supports learners in a meaningful way.
Major Comments:
- Introduction: Is there any evidence that osteopathic medical students are evolving or facing academic difficulty across the Academy that might support the approach? Are performance trends in these areas declining or is there evidence that a redesigned curriculum might have an academic benefit when compared to an alternative?
- Introduction: What are the present challenges facing osteopathic medicine that might motivate an integrated approach to foundational or biomedical topics? It appears that some schools might be closing their doors as the number of DO programs has decreased by 2 since the Reynolds et al. 2022 paper cited on page 2, line 74.
- Introduction: How similar is this approach to other integrated or accelerated health professional education programs (i.e. physician’s assistant (PA), nurse practitioner (NP), or pharmacy) in the U.S.?
- Introduction: Due to the responsibility of osteopathic medical programs to introduce immunology to its learners, use of the AAI Undergraduate Immunology Toolkit for comparison, reference, and discussion will improve this manuscript. Edith PorterEyal AmielNandita BoseAndrea BottaroWilliam H. CarrMichelle Swanson-MungersonSteven M. VargaJulie M. Jameson; American Association of Immunologists Recommendations for an Undergraduate Course in Immunology. Immunohorizons 1 June 2021; 5 (6): 448–465. https://doi.org/10.4049/immunohorizons.2100030
- Discussion: The inclusion of performance-related data providing evidence that integration of immunology as defined by the authors confers a benefit to learners or the program is strongly recommended to add value to the paper.
Minor points (inconsistencies, major typos)
- Table 1: Consider including point-of-care (POC) tests in the “Immunodiagnostics” as these have direct patient-care applications.
- Table 2: Are the CDC vaccine schedules introduced or explained in the context of “Vaccine and immunization programs”?
Author Response
Dear Reviewer,
We appreciate your review and suggestions for improving our manuscript. We have addressed your review comments and incorporated the suggested revisions wherever applicable (Please see our responses below your comments. We have also attached a PDF of the revised manuscript). We believe that the manuscript is substantially improved after making the suggested changes. Once again, we would like to extend our sincerest thanks for your excellent review and comments.
Major Comments:
1. Introduction: Is there any evidence that osteopathic medical students are evolving or facing academic difficulty across the Academy that might support the approach? Are performance trends in these areas declining or is there evidence that a redesigned curriculum might have an academic benefit when compared to an alternative?
In our review of the literature, we found that immunology stands out in the medical curricula as an abstract and a difficult-to-learn course for medical students regardless of their educational backgrounds or the types of institutions. Also, various delivery methods are used by various medical institutions. This was the basis for the suggestion of an integrative approach in our paper, as an effort to address the current challenge common to medical schools, including allopathic and osteopathic. The expected benefits of the suggested approach are enhanced student learning of immunological concepts, and better retention and application of the learned material throughout their clinical years and beyond. Integration of clinical approaches and patient cases with foundational sciences has been increasingly emphasized in medical education as an essential process to better prepare medical students for applying knowledge in their field of work. We have described this in the introduction section. Lines 83-114.
2. Introduction: What are the present challenges facing osteopathic medicine that might motivate an integrated approach to foundational or biomedical topics? It appears that some schools might be closing their doors as the number of DO programs has decreased by 2 since the Reynolds et al. 2022 paper cited on page 2, line 74.
The answer to the first question is explained in our previous response (please see above).
For the second question: We have added sentences that highlight the current status of osteopathic medicine colleges in the USA, as provided by the American Association of Colleges of Osteopathic Medicine. Lines 73-77. https://www.aacom.org/become-a-doctor/prepare-for-medical-school/us-colleges-of-osteopathic-medicine#:~:text=Osteopathic%20Medical%20Schools&text=There%20are%20currently%2041%20accredited,medicine%20in%20the%20United%20States).
3. Introduction: How similar is this approach to other integrated or accelerated health professional education programs (i.e. physician’s assistant (PA), nurse practitioner (NP), or pharmacy) in the U.S.?
The scope of the current paper is the instructional approach for immunology integration into a medical school curriculum. We plan to explore the instructional approaches for the integration of immunology in allied health programs in a future paper.
4. Introduction: Due to the responsibility of osteopathic medical programs to introduce immunology to its learners, use of the AAI Undergraduate Immunology Toolkit for comparison, reference, and discussion will improve this manuscript. Edith Porter, Eyal Amiel, Nandita Bose, Andrea Bottaro, William H. Carr, Michelle Swanson-Mungerson, Steven M. Varga, Julie M. Jameson; American Association of Immunologists Recommendations for an Undergraduate Course in Immunology. Immunohorizons 1 June 2021; 5 (6): 448–465. https://doi.org/10.4049/immunohorizons.2100030
We primarily utilized the NBOME guidelines, and the core competency in immunology recommended by the Association of Microbiology and Immunology Chairs (AMSMIC) for designing an immunology course for medical students, which factors in the AAI-recommended core competencies for undergraduates in immunology.
We have added descriptions of these in the methodology section. Lines 136-138, 141-144.
5. Discussion: The inclusion of performance-related data providing evidence that integration of immunology as defined by the authors confers a benefit to learners or the program is strongly recommended to add value to the paper.
We did not find any paper that provides evidence of improved performance by medical students as a result of the integration of immunology in MD, DO, or allied health programs.
Minor points (inconsistencies, major typos):
1.Table 1: Consider including point-of-care (POC) tests in the “Immunodiagnostics” as these have direct patient-care applications.
We have added POCT to the immunodiagnostics section in Table 1, and have also added a discussion on this. Lines 215-222.
2. Table 2: Are the CDC vaccine schedules introduced or explained in the context of “Vaccine and immunization programs”?
Yes. We have added “CDC vaccine schedules” to Table 2 and also included the topic in the narrative. [Vaccine schedules from birth to 15 months, 18 months to 18 years, along with recommended vaccines for teenagers, college students, and adults are covered in our current curriculum in the “vaccination” session].
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for Authors
Immunology has been an important part of both basic and applied sciences, both in foundational learning as well as research. With every growing body of research and evidence, immunology has become an incredibly exciting and broad area of the biomedical sciences, encompassing multiple disciplines such as cell biology, biochemistry, molecular chemistry, and oncology. It is also now becoming clear that immune responses are key to the development of many common disorders not traditionally viewed as immunological, including metabolic, cardiovascular, and neurodegenerative conditions. Particularly, immunology is an important part of medical education for many reasons. primarily being a core discipline to better understand disease and to be well versed in the current immunobased therapies and modern antibody therapies, cellular therapies, small-molecule drugs, vaccines, and 'biologics' (therapuetic biomolecules), which are very important to the next generation of medical professionals, so this current research at looking at better incorporation of immunology in osteopathic medical curriculum is very important and relevant in this current age of medicine.
During the review of literature, since there wasn't much literature on the conception of immunology cirriculum and osteopathic courses, did you look at other areas of medicine and degrees such as MD, veterinary decisions, etc. to see the current state of their integrated immunology curriculum and the depth of studies their disciples are getting in their training?
The tables are informative and easy to understand.
The areas are nicely divided, and they include major hallmarks in a particular area, such as renal vs. gastro-intestinal.
It would be a good idea to dig deeper into cellular stress and immonology since that is connected to diease (cancer) and normal helathy conditions (aging-associated illness). It would also be beneficial to add immunotherapy and molecular immunology, which would span many areas as described in the different tables.
Overall, the methodology and discussion are well written, and I enjoyed reviewing this piece. I would recommend accepting this for publication in English and doing a spell check.
Comments on the Quality of English LanguageWell written and needs minor garmmer/typo correction and spell check
Author Response
Dear Reviewer,
We appreciate your review and suggestions for improving our manuscript. We have addressed your review comments and incorporated the suggested revisions wherever applicable (Please see our responses below your comments. We have also attached a PDF of the revised manuscript). We believe that the manuscript is substantially improved after making the suggested changes. Once again, we would like to extend our sincerest thanks for your excellent review and comments.
1. During the review of literature, since there wasn't much literature on the conception of immunology cirriculum and osteopathic courses, did you look at other areas of medicine and degrees such as MD, veterinary decisions, etc. to see the current state of their integrated immunology curriculum and the depth of studies their disciples are getting in their training?
Yes. We utilized the available literature on the integration of immunology in medical curricula in DO-granting as well as MD-granting institutions. Additionally, we reviewed the literature on instructional strategies and applications and clinical connections in undergraduate immunology courses.
2. The tables are informative and easy to understand.
3. The areas are nicely divided, and they include major hallmarks in a particular area, such as renal vs. gastro-intestinal.
4. It would be a good idea to dig deeper into cellular stress and immonology since that is connected to diease (cancer) and normal helathy conditions (aging-associated illness). It would also be beneficial to add immunotherapy and molecular immunology, which would span many areas as described in the different tables.
We have added a paragraph discussing the inclusion of immunotherapy topics in the medical curriculum. Lines 223-234.
The basic concepts of molecular immunology and cellular stress are incorporated across multiple topics (ranging from immunopathogenesis, and neoplastic disorders to immunotherapy and immunodiagnostics) across the narrative.
5. Overall, the methodology and discussion are well written, and I enjoyed reviewing this piece. I would recommend accepting this for publication in English and doing a spell check.
6. Comments on the Quality of English Language
Well written and needs minor garmmer/typo correction and spell check
We have checked the text for grammar and spelling and made the needed corrections.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThank you for adequately addressing my concerns raised and I agree that your manuscript is improved by these edits.
