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The Impact of Instruction on Undergraduates' Understanding of Homeostasis: Results from Administering the Homeostasis Concept Inventory

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Title: The Impact of Instruction on Undergraduates' Understanding of Homeostasis: Results from Administering the Homeostasis Concept Inventory
Language: English
Authors: Gregory J. Crowther (ORCID 0000-0003-0530-9130), Amy K. Hebert, Usha Sankar (ORCID 0009-0005-9516-6939), Joel Michael (ORCID 0000-0002-8132-6170)
Source: Advances in Physiology Education. 2025 49(2):423-429.
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: 7
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Undergraduate Students, Instructional Effectiveness, Science Instruction, Scientific Concepts, Science Tests, Physiology, Misconceptions
DOI: 10.1152/advan.00136.2024
ISSN: 1043-4046
1522-1229
Abstract: The Homeostasis Concept Inventory (HCI) is a validated instrument for measuring students' knowledge of homeostasis. It is comprised of 20 multiple-choice questions covering key components of the previously validated Homeostasis Conceptual Framework (HCF). In this paper, we present the first multi-institutional study of the impact of physiology instruction on students' HCI performance. Five cohorts of physiology or anatomy and physiology (A&P) students at four academic institutions took the HCI both at the start of their academic term (pretest) and at the end of their term (posttest). Statistically significant but relatively modest improvements in overall scores were seen from pretest to posttest. Among the 20 questions, 8 questions had incorrect choices identified as "attractive distractors" on the pretest, meaning that they were chosen at higher-than-random frequencies. From pretest to posttest, there were only modest declines in selections of incorrect answers generally and of attractive distractors in particular. Three attractive distractors that all target one specific misconception, that homeostatic mechanisms are active only when a regulated variable is not at its setpoint, remained persistently attractive except for students of one instructor who directly addressed that misconception in lecture and lab. These data are sobering in that they show a limited impact of instruction on HCI performance. However, these data also include encouraging evidence that instructional targeting of a specific misconception may help students overcome that misconception.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1467992
Database: ERIC
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  Value: <anid>AN0186108609;apu01jun.25;2025Jun25.03:34;v2.2.500</anid> <title id="AN0186108609-1">The impact of instruction on undergraduates' understanding of homeostasis: results from administering the homeostasis concept inventory </title> <p>The Homeostasis Concept Inventory (HCI) is a validated instrument for measuring students' knowledge of homeostasis. It is comprised of 20 multiple-choice questions covering key components of the previously validated Homeostasis Conceptual Framework (HCF). In this paper, we present the first multi-institutional study of the impact of physiology instruction on students' HCI performance. Five cohorts of physiology or anatomy and physiology (A&P) students at four academic institutions took the HCI both at the start of their academic term (pretest) and at the end of their term (posttest). Statistically significant but relatively modest improvements in overall scores were seen from pretest to posttest. Among the 20 questions, 8 questions had incorrect choices identified as "attractive distractors" on the pretest, meaning that they were chosen at higher-than-random frequencies. From pretest to posttest, there were only modest declines in selections of incorrect answers generally and of attractive distractors in particular. Three attractive distractors that all target one specific misconception, that homeostatic mechanisms are active only when a regulated variable is not at its setpoint, remained persistently attractive except for students of one instructor who directly addressed that misconception in lecture and lab. These data are sobering in that they show a limited impact of instruction on HCI performance. However, these data also include encouraging evidence that instructional targeting of a specific misconception may help students overcome that misconception. NEW & NOTEWORTHY: How is undergraduate students' understanding of homeostasis impacted by a physiology course? This study indicates that many students do not improve that much on a validated multiple-choice concept inventory but may improve noticeably on questions about a misconception if that misconception is specifically targeted by the instructor.</p> <p>Keywords: core concepts; concept inventories; homeostatic control mechanisms</p> <hd id="AN0186108609-2">INTRODUCTION</hd> <p>Physiology education can and should be built upon a foundation of disciplinary core concepts ([<reflink idref="bib1" id="ref1">1</reflink>]–[<reflink idref="bib3" id="ref2">3</reflink>]). Of these core concepts, homeostasis has been identified in multiple faculty surveys as one of those of greatest importance ([<reflink idref="bib3" id="ref3">3</reflink>], [<reflink idref="bib4" id="ref4">4</reflink>]).</p> <p>The concept of homeostasis, in the context of undergraduate physiology education, has been defined as "the internal environment of the organism is actively regulated [i.e., kept relatively constant] by the responses of cells, tissues, and organs through feedback systems" (Ref. [<reflink idref="bib3" id="ref5">3</reflink>], p. 423). Homeostasis thus encompasses several related subconcepts (e.g., setpoints, negative feedback), each of which in turn encompasses numerous details.</p> <p>The relationships between the core concept of homeostasis and its subconcepts and details have been clarified via a Homeostasis Conceptual Framework (HCF) developed by an American team ([<reflink idref="bib5" id="ref6">5</reflink>]). This multitiered HCF was subsequently evaluated by an Australian task force ([<reflink idref="bib6" id="ref7">6</reflink>]), which basically reaffirmed the five previously proposed underlying themes (top-level subconcepts) ([<reflink idref="bib5" id="ref8">5</reflink>]), while arguing for adjustment of some finer-grained subthemes.</p> <p>With a detailed conceptualization of homeostasis thus established, a critical next step was to validate an instrument for measuring knowledge of homeostasis. Accordingly, McFarland and colleagues ([<reflink idref="bib7" id="ref9">7</reflink>]) created a 20-question multiple-choice instrument in which each question was designed to assess knowledge of one or more specific components of the HCF. This Homeostasis Concept Inventory (HCI) included 9 "Abstract" questions that reference the standard model of a homeostatic mechanism ([<reflink idref="bib8" id="ref10">8</reflink>]) and 11 "Applied" questions that reference specific physiological homeostatic mechanisms. HCI answer choices were constructed in light of common misconceptions about homeostasis as discovered through the HCF/HCI group's prior work ([<reflink idref="bib1" id="ref11">1</reflink>], [<reflink idref="bib9" id="ref12">9</reflink>], [<reflink idref="bib10" id="ref13">10</reflink>]). For example, the phrase "negative feedback" is often incorrectly believed to refer to processes that are physiologically unhealthy and/or that always drive concentrations and pressures downward, so HCI includes a question (<emph>question 1</emph>) with answers that espouse these incorrect ideas. The frequency with which these answers are chosen should therefore indicate the prevalence of the corresponding misconceptions.</p> <p>The main focus of the original HCI paper ([<reflink idref="bib7" id="ref14">7</reflink>]) was the validation of the HCI via testing of hundreds of students. The validation process included confirmations that various groups scored as expected for a valid instrument; e.g., undergraduate biology majors scored significantly higher than undergraduates with other majors, and biology graduate students scored significantly higher than undergraduates. However, only a small sample of undergraduate students (<emph>n</emph> = 16) were given the HCI both before and after they received instruction on homeostasis. Therefore, the original study ([<reflink idref="bib7" id="ref15">7</reflink>]), while laudable in linking validated learning objectives to validated assessment questions, did not extensively test the impact of instruction on knowledge of homeostasis.</p> <p>To address this gap in the literature, we present here the results of a larger-scale "pre/post" HCI study, in which undergraduate students from four different institutions took the HCI both before and after a physiology or A&P course. These data allow us to address two general questions. First, how do students' overall HCI scores change as a result of taking a physiology course? Second, do specific misconceptions ([<reflink idref="bib11" id="ref16">11</reflink>]) about homeostasis ([<reflink idref="bib1" id="ref17">1</reflink>], [<reflink idref="bib9" id="ref18">9</reflink>], [<reflink idref="bib10" id="ref19">10</reflink>]) get corrected as a result of instruction?</p> <hd id="AN0186108609-3">METHODS</hd> <hd1 id="AN0186108609-4">Students and Courses Studied</hd1> <p>We studied undergraduate students enrolled in courses in physiology or anatomy and physiology (A&P) at four postsecondary institutions which, to protect student confidentiality, are referenced here as <emph>school A</emph>, <emph>school B</emph>, <emph>school C</emph>, and <emph>school D</emph> (Table 1). <emph>School B</emph> is an open-enrollment community college, while the other institutions are somewhat selective 4-year universities with acceptance rates of 55%–90%. All of the courses were human-focused except for the course at <emph>school D</emph>, which was more comparative in nature. None of these students were included in the original HCI study ([<reflink idref="bib7" id="ref20">7</reflink>]).</p> <p>Table 1. Sources of student responses to the HCI</p> <p> <ephtml> <table><col align="left" span="1" /><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">Institution and Year</th><th align="center" rowspan="1" colspan="1">Title of Course (Instructional Modality)</th><th align="center" rowspan="1" colspan="1">Typical Major of Enrolled Students</th><th align="center" rowspan="1" colspan="1">Prerequisites/Previous Courses</th><th align="center" rowspan="1" colspan="1">Mode of Administering HCI</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><italic>School A 2020</italic></td><td rowspan="1" colspan="1">Human Anatomy & Physiology 1 (online)</td><td rowspan="2" colspan="1">∼85% Nursing</td><td rowspan="2" colspan="1">No college-level science prerequisites; likely to be first college science course taken</td><td rowspan="1" colspan="1">Remote (online)</td></tr><tr><td rowspan="1" colspan="1"><italic>School A 2022</italic></td><td rowspan="1" colspan="1">Human Anatomy & Physiology 1 (in person)</td><td rowspan="1" colspan="1">In class via computer</td></tr><tr><td rowspan="1" colspan="1"><italic>School B 2022</italic></td><td rowspan="1" colspan="1">Human Physiology (in person)</td><td rowspan="1" colspan="1">∼85% Nursing</td><td rowspan="1" colspan="1">General chemistry, cell biology, human anatomy (1 quarter each)</td><td rowspan="1" colspan="1">In class on paper</td></tr><tr><td rowspan="1" colspan="1"><italic>School C 2022</italic></td><td rowspan="1" colspan="1">Human Physiology (in person)</td><td rowspan="1" colspan="1">∼80% Biology</td><td rowspan="1" colspan="1">Intro biology and general chemistry (2 semesters each)</td><td rowspan="1" colspan="1">In class on paper</td></tr><tr><td rowspan="1" colspan="1"><italic>School D 2022</italic></td><td rowspan="1" colspan="1">Principles of Anatomy & Physiology 1 (in person)</td><td rowspan="1" colspan="1">∼60% Biology</td><td rowspan="1" colspan="1">Intro biology and general chemistry (3 quarters each), additional biology</td><td rowspan="1" colspan="1">Pretest: asynchronous, online; posttest, in class on paper</td></tr></tbody></table> </ephtml> </p> <p>1 HCI, Homeostasis Concept Inventory.</p> <hd1 id="AN0186108609-5">Instruction in Homeostasis</hd1> <p>As of the time of the study, each instructor had 5 or more years of experience teaching physiology and/or A&P and taught this subject with active-learning approaches such as "clicker" and "think-pair-share" questions, case studies, and worksheets, thus providing formative assessments in advance of summative assessments.</p> <p>While each instructor considered homeostasis a priority of their course, their instructional methods of presenting it were varied:</p> <p></p> <ulist> <item> The <emph>school A</emph> courses featured a week-long section on homeostasis including lectures, group activities, and homework; homeostasis was then discussed in the context of the integumentary, skeletal muscle, and nervous systems with examples of regulation presented by the instructor.</item> <p></p> <item> The <emph>school B</emph> course included exercises on plasma [glucose] and [calcium] regulation, as well as 13 homeostasis-related Test Question Templates (TQTs; Ref. [<reflink idref="bib12" id="ref21">12</reflink>]), distributed in the following modules: introduction (2 TQTs), endocrine (2 TQTs), cardiovascular (1 TQTs), respiratory (1 TQT), ECF regulation (5 TQTs), and digestion (2 TQTs).</item> <p></p> <item> The <emph>school C</emph> course included a worksheet on homeostasis ([<reflink idref="bib13" id="ref22">13</reflink>]) as well as periodic revisitation of the concept both in lectures and in labs. When covering homeostasis feedback loops, the instructor emphasized the role of the sensors as reporters, and the role of the integrating center as the decision-making center. In this context, the instructor addressed a specific misconception, that sensors are active only when there are deviations from the setpoint ([<reflink idref="bib9" id="ref23">9</reflink>], [<reflink idref="bib10" id="ref24">10</reflink>]), by asking questions about sensors being on or off in various circumstances relevant to different organ systems, using a classroom-response system (PollEverywhere).</item> <p></p> <item> The <emph>school D</emph> course included exercises on thermoregulation ([<reflink idref="bib14" id="ref25">14</reflink>]) and plasma [glucose] and [calcium] regulation. Ten homeostasis-related TQTs ([<reflink idref="bib12" id="ref26">12</reflink>]) were also presented to and discussed with students as practice and as preparation for exams; these TQTs were included in the following modules: introduction (2 TQTs), sensory/nervous (2 TQTs), and endocrine (6 TQTs).</item> </ulist> <hd1 id="AN0186108609-6">Administration of the HCI</hd1> <p>The HCI used here was identical to the previously published version (Ref. [<reflink idref="bib7" id="ref27">7</reflink>]; see supplementary materials of that paper for all questions and answers). The 20 multiple-choice questions included 9 "Abstract" questions (<emph>questions 1–4</emph>, <emph>7</emph>, <emph>13</emph>, <emph>16</emph>, <emph>18</emph>, and <emph>19</emph>), which reference the standard model of a homeostatic mechanism ([<reflink idref="bib8" id="ref28">8</reflink>]), and 11 "Applied" questions (<emph>questions 5</emph>, <emph>6</emph>, <emph>8–12</emph>, <emph>14</emph>, <emph>15</emph>, <emph>17</emph>, and <emph>20</emph>), which reference specific physiological homeostatic mechanisms. Students took the HCI at the beginning of their physiology or A&P course (pretest) and at the end of the course (posttest) in various formats (Table 1). At <emph>schools A</emph>, <emph>B</emph>, and <emph>D</emph>, students were rewarded for completing the HCI with a few points of regular or extra credit. In general, students took no more than 20 min to complete the HCI. Responses were collected, deidentified, and assigned codes that permitted comparisons of pretest and posttest data.</p> <p>This protocol was approved by the Institutional Review Boards of all participating institutions (<emph>school A</emph>, FY19-005; <emph>school B</emph>, letter of August 4, 2022; <emph>school C</emph>, Protocol No. 2302; and <emph>school D</emph>, participation was covered by the <emph>school B</emph> approval).</p> <hd1 id="AN0186108609-7">Data Analysis</hd1> <p>Since this study examined student performance changes from pretest to posttest, we excluded data from students who did not take both the pretest and the posttest. These exclusions amounted to an average of ∼30% of the students initially enrolled in the courses, a percentage that reflects <emph>1</emph>) the relatively high withdrawal rates in introductory A&P courses ([<reflink idref="bib15" id="ref29">15</reflink>]), and <emph>2</emph>) the fact that we could not force students to complete this nonrequired component of the course. This left us with a study population of 169 students.</p> <p>Since the main goal of the data analysis was to characterize students' responses to each HCI question (and not to compare students at different institutions), we combined all courses' data into a single dataset. While the effects of being in a specific course (e.g., <emph>school A 2022</emph> vs. <emph>school C</emph>) could be formally quantified via a linear regression model ([<reflink idref="bib16" id="ref30">16</reflink>]), we deemed that approach unnecessary for the basic goal of broadly understanding how undergraduates respond to instruction in physiology. However, for the specific issue of studying misconceptions that were addressed differently at different institutions, it was useful to report the data of each institution separately (see Table 6 below). Although the two <emph>school A</emph> cohorts were taught the same content by the same instructor, they were taught in quite different ways because of the COVID pandemic (<emph>school A 2020</emph> was taught online while <emph>school A 2022</emph> was taught in person), so we treated the students from these two terms as separate cohorts. Conversely, the <emph>school C</emph> cohort was made up of students in two sections (meeting at different times) of the same course taught by the same instructor in the same semester. Since the demographics of the two sections were similar, we combined those two datasets into one.</p> <p>Among the incorrect answers to the HCI questions, some were identified as "attractive distractors" as defined by Doherty et al. ([<reflink idref="bib17" id="ref31">17</reflink>]), i.e., as incorrect answers that were selected at a greater-than-chance level. Most HCI questions had four answer choices, in which case an incorrect answer chosen by >25% of students was considered an attractive distractor.</p> <p>To test whether statistically significant changes occurred from pretest to posttest we performed paired two-tailed <emph>t</emph> tests in Microsoft Excel, taking <emph>P</emph> values below 0.05 to indicate statistical significance. For clarity and simplicity, <emph>P</emph> values were not adjusted for multiple comparisons (e.g., via a Bonferroni correction). We acknowledge that, without such an adjustment, the likelihood of obtaining at least one <emph>P</emph> < 0.05 result increases as the number of comparisons increases.</p> <hd id="AN0186108609-8">RESULTS</hd> <hd1 id="AN0186108609-9">Overall HCI Performance</hd1> <p>Combining data from all institutions, pretest HCI scores (representing students' baseline knowledge of homeostasis) formed a roughly Gaussian distribution (Fig. 1). These scores had a mode of 10, a median of 11, a mean of 11.1, and a standard deviation of 3.5. Most students thus had plenty of "room for improvement" on the HCI as of the beginning of the term.</p> <p>PHOTO (COLOR): Figure 1. Overall distribution of students' Homeostasis Concept Inventory (HCI) scores (n = 169) at the pretest phase (start of academic term). Since the HCI included 20 questions, the maximum possible score was 20.</p> <p>From these starting points, the students' pretest-to-posttest changes in HCI scores are shown in Fig. 2. For example, a student who scored 11 on the pretest and 12 on the posttest would be included in the +1 bar of the Fig. 2 histogram. The mode improvement was 0, the median was +1, the mean was +1.2, and the standard deviation was 3.5.</p> <p>PHOTO (COLOR): Figure 2. Changes in Homeostasis Concept Inventory (HCI) scores from pretest to posttest. The data represent 169 students whose changes ranged from −9 to +13.</p> <p>Within the HCI, students showed statistically significant pre- to post improvements on both the Abstract questions and the Applied questions. Average scores on the nine Abstract questions rose from 5.7 ± 1.9 to 6.4 ± 1.8 (<emph>P</emph> < 0.001), while average scores on the 11 Applied questions rose from 5.4 ± 2.1 to 5.9 ± 2.4 (<emph>P</emph> = 0.009).</p> <p>Separation of the data by course revealed relatively modest differences among the different cohorts of students (Table 2). Although these cohorts started at somewhat different baselines according to mean pretest scores (range of averages: 9.8 to 13.6), each cohort (with the exception of <emph>school D</emph>) improved from pretest to posttest by an average of 1.0 to 1.6 questions.</p> <p>Table 2. Overall performance on the HCI</p> <p> <ephtml> <table><col align="left" span="1" /><col align="char" span="1" /><col align="char" span="1" /><col align="char" span="1" /><col align="char" span="1" /><col align="char" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1">Institution</th><th align="center" rowspan="1" colspan="1">Number of Students*</th><th align="center" rowspan="1" colspan="1">Pretest Score**</th><th align="center" rowspan="1" colspan="1">Posttest Score**</th><th align="center" rowspan="1" colspan="1">Pretest to Posttest Delta</th><th align="center" rowspan="1" colspan="1">Statistically Significant Improvement?</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><italic>School A 2020</italic></td><td rowspan="1" colspan="1">50</td><td rowspan="1" colspan="1">9.8 ± 2.9</td><td rowspan="1" colspan="1">11.4 ± 3.7</td><td rowspan="1" colspan="1">1.6</td><td rowspan="1" colspan="1">Yes (<italic>P</italic> = 0.002)</td></tr><tr><td rowspan="1" colspan="1"><italic>School A 2022</italic></td><td rowspan="1" colspan="1">61</td><td rowspan="1" colspan="1">10.3 ± 3.4</td><td rowspan="1" colspan="1">11.6 ± 4.1</td><td rowspan="1" colspan="1">1.3</td><td rowspan="1" colspan="1">Yes (<italic>P</italic> = 0.01)</td></tr><tr><td rowspan="1" colspan="1"><italic>School B</italic></td><td rowspan="1" colspan="1">9</td><td rowspan="1" colspan="1">12.2 ± 3.8</td><td rowspan="1" colspan="1">13.2 ± 4.1</td><td rowspan="1" colspan="1">1.0</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.08)</td></tr><tr><td rowspan="1" colspan="1"><italic>School C</italic></td><td rowspan="1" colspan="1">34</td><td rowspan="1" colspan="1">13.1 ± 2.8</td><td rowspan="1" colspan="1">14.2 ± 2.5</td><td rowspan="1" colspan="1">1.0</td><td rowspan="1" colspan="1">Yes (<italic>P</italic> = 0.0499)</td></tr><tr><td rowspan="1" colspan="1"><italic>School D</italic></td><td rowspan="1" colspan="1">15</td><td rowspan="1" colspan="1">13.6 ± 4.1</td><td rowspan="1" colspan="1">13.9 ± 3.5</td><td rowspan="1" colspan="1">0.3</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.8)</td></tr><tr><td rowspan="1" colspan="1">Overall</td><td rowspan="1" colspan="1">169</td><td rowspan="1" colspan="1">11.1 ± 3.5</td><td rowspan="1" colspan="1">12.4 ± 3.8</td><td rowspan="1" colspan="1">1.2</td><td rowspan="1" colspan="1">Yes (<italic>P</italic> = 0.0001)</td></tr></tbody></table> </ephtml> </p> <p>2 HCI, Homeostasis Concept Inventory. *Number who completed both the pretest and the posttest. **Mean (out of a maximum of 20) ± standard deviation.</p> <hd1 id="AN0186108609-10">Performance on Individual Questions</hd1> <p>Examining pretest and posttest performance on each individual question (Fig. 3) reveals that statistically significant improvements were seen on 8 of the 20 questions: <emph>questions 1</emph>, <emph>6</emph>, <emph>11</emph>, <emph>13</emph>, <emph>14</emph>, <emph>16</emph>, <emph>19</emph>, and 20. Four of these eight questions (<emph>questions 1</emph>, <emph>13</emph>, <emph>16</emph>, and <emph>19</emph>) were of the Abstract type, while the other four (<emph>questions 6</emph>, <emph>11</emph>, <emph>14</emph>, and <emph>20</emph>) were of the Applied type, consistent with the above-noted overall improvement on both types of questions.</p> <p>PHOTO (COLOR): Figure 3. Scores on each of the 20 Homeostasis Concept Inventory (HCI) questions for the pretest (gray) and the posttest (black). Questions 1–4, 7, 13, 16, 18, and 19 were classified as "Abstract" by a previous paper (Ref. [<reflink idref="bib7" id="ref32">7</reflink>]), while the remaining 11 questions were classified as "Applied." Statistically significant improvements are indicated with asterisks.</p> <p>Of these eight questions, by far the biggest improvement occurred on <emph>question 1</emph>, which asked about the general role of negative feedback in homeostasis (Table 3). From pretest to posttest, the overall percentage of students answering <emph>question 1</emph> correctly rose from 51.5% to 87.0% (<emph>P</emph> < 0.0001). This improvement was also statistically significant for each of the three largest cohorts (<emph>school A 2020</emph>, <emph>school A 2022</emph>, and <emph>school C</emph>) when considered separately (data not shown). The strong movement away from <emph>choices A</emph> and <emph>B</emph> on the posttest suggests progress on remediating the misconceptions that negative feedback is bad (<emph>choice A</emph>) and that negative feedback always drives values downward (<emph>choice B</emph>), respectively.</p> <p>Table 3. Pre- and postresponses to HCI question 1 (on homeostatic negative feedback)*</p> <p> <ephtml> <table><col align="left" span="1" /><tbody><tr><td rowspan="1" colspan="1"><italic>1</italic>. In organisms, like humans, homeostatic negative feedback mechanisms result in</td></tr><tr><td rowspan="1" colspan="1"><italic>A</italic>. an unfavorable, or damaging effect on the body. (20.2% → 2.4%)</td></tr><tr><td rowspan="1" colspan="1"><italic>B</italic>. a constant decrease in the regulated variable. (15.5% → 4.1%)</td></tr><tr><td rowspan="1" colspan="1"><italic>C</italic>. equilibrium among body cells and fluids. (12.5% → 6.5%)</td></tr><tr><td rowspan="1" colspan="1"><italic>D</italic>. maintenance of an internal variable within a 'normal' range of values. [correct] (51.5% → 87.0%)</td></tr></tbody></table> </ephtml> </p> <p>3 HCI, Homeostasis Concept Inventory. *Percentages shown are percentages of students from all institutions selecting that answer in the pretest and posttest, respectively.</p> <hd1 id="AN0186108609-11">Avoidance of "Attractive Distractors"</hd1> <p>Among the HCI's 20 multiple-choice questions, we identified eight incorrect choices in the pretest that met the definition of Doherty et al. ([<reflink idref="bib17" id="ref33">17</reflink>]) of an "attractive distractor" (i.e., an answer selected more frequently than would be expected from random guessing; Table 4). Overall, in the pretest, these eight attractive distractors were chosen even more frequently than the correct answers to those questions (combined average 43.0% vs. 39.6%; Table 4). From pretest to posttest, selection of these attractive distractors fell by ∼7% on average, while selection of the correct answers rose by ∼7% on average (Table 4). (An exception was <emph>question 17</emph>, for which, from pretest to posttest, the attractive distractor gained additional votes, suggesting that many students struggle to translate a break in the sensory pathway into an effect on the regulated variable.)</p> <p>Table 4. Attractive distractors in the HCI</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">Question No.</th><th align="center" rowspan="1" colspan="1">Attractive-Distractor Choice: Percent of Students Choosing It Pretest → Posttest</th><th align="center" rowspan="1" colspan="1">Correct Answer: Percent of Students Choosing It Pretest → Posttest</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><italic>4</italic></td><td rowspan="1" colspan="1"><italic>C</italic>: 52.4% → 47.3%</td><td rowspan="1" colspan="1"><italic>D</italic>: 43.5% → 43.8%</td></tr><tr><td rowspan="1" colspan="1"><italic>6</italic></td><td rowspan="1" colspan="1"><italic>B</italic>: 69.8% → 52.1%</td><td rowspan="1" colspan="1"><italic>C</italic>: 23.9% → 33.7%</td></tr><tr><td rowspan="1" colspan="1"><italic>9</italic></td><td rowspan="1" colspan="1"><italic>A</italic>: 50.9% → 48.5%</td><td rowspan="1" colspan="1"><italic>D</italic>: 37.3% → 42.6%</td></tr><tr><td rowspan="1" colspan="1"><italic>12</italic></td><td rowspan="1" colspan="1"><italic>E</italic>: 32.5% → 20.7%</td><td rowspan="1" colspan="1"><italic>D</italic>: 51.5% → 59.8%</td></tr><tr><td rowspan="1" colspan="1"><italic>13</italic></td><td rowspan="1" colspan="1"><italic>D</italic>: 25.6% → 17.8%</td><td rowspan="1" colspan="1"><italic>A</italic>: 52.4% → 63.9%</td></tr><tr><td rowspan="1" colspan="1"><italic>15</italic></td><td rowspan="1" colspan="1"><italic>B</italic>: 34.9% → 29.8%</td><td rowspan="1" colspan="1"><italic>D</italic>: 35.5% → 42.9%</td></tr><tr><td rowspan="1" colspan="1"><italic>17</italic></td><td rowspan="1" colspan="1"><italic>B</italic>: 32.0% → 37.9%</td><td rowspan="1" colspan="1"><italic>C</italic>: 25.4% → 26.6%</td></tr><tr><td rowspan="1" colspan="1"><italic>20</italic></td><td rowspan="1" colspan="1"><italic>C</italic>: 45.6% → 35.5%</td><td rowspan="1" colspan="1"><italic>D</italic>: 49.1% → 57.4%</td></tr><tr><td rowspan="1" colspan="1">Overall average</td><td rowspan="1" colspan="1">43.0% → 36.2%</td><td rowspan="1" colspan="1">39.6% → 46.3%</td></tr></tbody></table> </ephtml> </p> <p>4 HCI, Homeostasis Concept Inventory.</p> <p>Three of these attractive distractors (<emph>question 4</emph>, <emph>choice C</emph>; <emph>question 9</emph>, <emph>choice A</emph>; and <emph>question 20</emph>, <emph>choice C</emph>) were from questions about the misconception that homeostatic mechanisms turn on only when needed ([<reflink idref="bib1" id="ref34">1</reflink>], [<reflink idref="bib9" id="ref35">9</reflink>], [<reflink idref="bib10" id="ref36">10</reflink>]), as opposed to being operative all the time. Therefore, we also analyzed these three questions as a group (Table 5).</p> <p>Table 5. HCI questions on the conditions when homeostatic mechanisms are active</p> <p> <ephtml> <table><col align="left" span="1" /><col align="left" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1">Question No.</th><th align="center" rowspan="1" colspan="1">Stem and Answer Choices; Percent of Students Choosing It Pretest → Posttest)</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><italic>4</italic></td><td rowspan="1" colspan="1">A homeostatic control mechanism functions to maintain the concentration of X at a relatively constant level. This mechanism is functioning <italic>A</italic>. when the concentration of X gets too high (2.4% → 5.3%) <italic>B</italic>. when the concentration of X gets too low (1.8% → 3.6%) <italic>C</italic>. when the concentration of X gets too high or too low [attractive distractor] (52.4% → 47.3%) <italic>D</italic>. at all concentrations of X [correct] (43.5% → 43.8%)</td></tr><tr><td rowspan="1" colspan="1"><italic>9</italic></td><td rowspan="1" colspan="1">Baroreceptors detect blood pressure. Blood pressure is maintained relatively constant even when the internal or external environment changes. Under what conditions do the baroreceptors send signals to the brain? <italic>A</italic>. when blood pressure is not at its normal value. [attractive distractor] (50.9% → 48.5%) <italic>B</italic>. when blood pressure is increasing. (10.1% → 7.7%) <italic>C</italic>. when blood pressure is constant. (1.8% → 1.2%) <italic>D</italic>. at all levels of blood pressure. [correct] (37.3% → 42.6%)</td></tr><tr><td rowspan="1" colspan="1"><italic>20</italic></td><td rowspan="1" colspan="1">Samira is watching a movie and eats 3 chocolate bars. As Samira's digestive tract absorbs the sugar, there is an initial increase in her blood glucose. When are blood glucose sensors signaling? <italic>A</italic>. before eating (0.6% → 0.6%) <italic>B</italic>. during eating (4.7% → 5.9%) <italic>C</italic>. while eating and digesting the chocolate bars [attractive distractor] (45.6% → 35.5%) <italic>D</italic>. all the time [correct] (49.1% → 57.4%)</td></tr></tbody></table> </ephtml> </p> <p>5 HCI, Homeostasis Concept Inventory.</p> <p>Comparing pretest and posttest data for <emph>questions 4</emph>, <emph>9</emph>, and <emph>20</emph>, it is clear that the attractive distractors were persistently attractive even during the posttest (Table 5). However, the overall data for these three questions obscure important differences between institutions. The <emph>school C</emph> students, despite having the highest average pretest score on <emph>questions 4</emph>, <emph>9</emph>, and <emph>20</emph>, improved their three-question average from 1.68 (pretest) to 2.38 (posttest), an increase of 42%, while students in the other courses did not significantly improve their scores (Table 6). Of the 25 <emph>school C</emph> students who did not get a perfect pretest score on these three questions, 13 (52%) got a perfect posttest score on these questions.</p> <p>Table 6. Results by institution for HCI questions on the conditions when homeostatic mechanisms are active</p> <p> <ephtml> <table><col align="left" span="1" /><col align="char" span="1" /><col align="char" span="1" /><col align="char" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1">Institution</th><th align="center" rowspan="1" colspan="1">Pretest score* for <italic>questions 4</italic>, <italic>9</italic>, and <italic>20</italic></th><th align="center" rowspan="1" colspan="1">Posttest score* for <italic>questions 4</italic>, <italic>9</italic>, and <italic>20</italic></th><th align="center" rowspan="1" colspan="1">Statistically significant change?</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><italic>School A 2020</italic> (<italic>n</italic> = 50)</td><td rowspan="1" colspan="1">1.10 ± 0.99</td><td rowspan="1" colspan="1">1.18 ± 1.00</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.64)</td></tr><tr><td rowspan="1" colspan="1"><italic>School A 2022</italic> (<italic>n</italic> = 61)</td><td rowspan="1" colspan="1">1.10 ± 1.03</td><td rowspan="1" colspan="1">1.15 ± 1.12</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.71)</td></tr><tr><td rowspan="1" colspan="1"><italic>School B</italic> (<italic>n</italic> = 9)</td><td rowspan="1" colspan="1">1.56 ± 1.01</td><td rowspan="1" colspan="1">1.33 ± 1.22</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.59)</td></tr><tr><td rowspan="1" colspan="1"><italic>School C</italic> (<italic>n</italic> = 34)</td><td rowspan="1" colspan="1">1.68 ± 1.17</td><td rowspan="1" colspan="1">2.38 ± 0.95</td><td rowspan="1" colspan="1">Yes (<italic>P</italic> = 0.003)</td></tr><tr><td rowspan="1" colspan="1"><italic>School D</italic> (<italic>n</italic> = 15)</td><td rowspan="1" colspan="1">1.67 ± 0.98</td><td rowspan="1" colspan="1">1.33 ± 1.11</td><td rowspan="1" colspan="1">No (<italic>P</italic> = 0.31)</td></tr></tbody></table> </ephtml> </p> <p>6 HCI, Homeostasis Concept Inventory. *Out of a maximum of 3 possible correct answers; mean ± standard deviation.</p> <hd id="AN0186108609-12">DISCUSSION</hd> <p>The original paper introducing the HCI ([<reflink idref="bib7" id="ref37">7</reflink>]) included several datasets consistent with the hypothesis that instruction in biology improves students' understanding of homeostasis. For example, undergraduate biology majors scored significantly higher on the HCI than undergraduates with other majors, and biology graduate students scored significantly higher than undergraduates. However, most of these data were cross-sectional rather than following students longitudinally through one or more biology courses. The present study more directly assessed the impact of instruction by testing undergraduates immediately before and immediately after a physiology or A&P course. We found that, on average, students improved only slightly on HCI performance from preinstruction to postinstruction. This finding was evident in several ways: in overall HCI scores (Fig. 2; Table 2), in question-by-question scores (Fig. 3), and in the persistent appeal of attractive distractors (Tables 4–6).</p> <hd1 id="AN0186108609-13">Why Did Instruction Have So Little Impact on HCI Performance?</hd1> <p>Since all of the instructors saw homeostasis as one of the main topics of their course, we must ask why the HCI performance gains were so mild. Below is a (nonexhaustive) list of possibilities, in roughly increasing order of likely importance.</p> <p></p> <ulist> <item> In principle, the HCI could be flawed (i.e., it does not test what it intends to test), although this is unlikely in light of the extensive validation that it underwent ([<reflink idref="bib7" id="ref38">7</reflink>]).</item> <p></p> <item> The students' relatively poor performances might be partly attributable to the COVID-19 pandemic, with corresponding compromises in learning ([<reflink idref="bib18" id="ref39">18</reflink>]). Even for the 2022 in-person physiology courses, students may have been less prepared to learn due to taking prior courses online.</item> <p></p> <item> Students' answers may not always reflect their true knowledge. In particular, some students may have not been motivated to give a maximal effort, since they did not receive points for the correctness of their answers ([<reflink idref="bib19" id="ref40">19</reflink>]).</item> <p></p> <item> It is possible that the multiple-choice format of the HCI is not ideal for students to demonstrate their understanding of homeostasis ([<reflink idref="bib20" id="ref41">20</reflink>], [<reflink idref="bib21" id="ref42">21</reflink>]). For example, the TQTs ([<reflink idref="bib10" id="ref43">10</reflink>]) used at <emph>schools B</emph> and <emph>D</emph> trained students primarily on short-answer questions, which constitute the bulk of their exam points, so these students may be less practiced at multiple-choice questions.</item> <p></p> <item> There could have been imperfect matching of the HCI and the physiology instruction such that instruction increased students' knowledge of aspects of homeostasis not covered by the instrument. McFarland et al. ([<reflink idref="bib7" id="ref44">7</reflink>]) acknowledge that their 20-question assessment instrument does not cover every important idea about homeostasis. As an illustration, some homeostasis TQTs used at at <emph>schools B</emph> and <emph>D</emph> focused on the difference between negative feedback (necessary for homeostasis) and positive feedback (often counterproductive to homeostasis), while the HCI did not ask about this difference.</item> </ulist> <hd1 id="AN0186108609-14">Inferring Misconceptions from Multiple-Choice Answers</hd1> <p>Students' incorrect answers were not random; some incorrect answers were chosen much more frequently than others. The selection of a wrong answer does not necessarily indicate a coherent misconception; it may simply reflect a loose association or a guess based on a surface feature of the choice ([<reflink idref="bib22" id="ref45">22</reflink>]). Nevertheless, the frequent pretest selection of incorrect answers to HCI <emph>question 1</emph> suggests that many of these students harbored previously documented misconceptions ([<reflink idref="bib1" id="ref46">1</reflink>], [<reflink idref="bib9" id="ref47">9</reflink>], [<reflink idref="bib10" id="ref48">10</reflink>]) that negative feedback is bad (<emph>choice A</emph>) or that negative feedback always drives values downward (<emph>choice B</emph>). Another misconception reported previously ([<reflink idref="bib1" id="ref49">1</reflink>], [<reflink idref="bib9" id="ref50">9</reflink>], [<reflink idref="bib10" id="ref51">10</reflink>]) and represented in the HCI is the notion that homeostasis operates only when the value of a regulated variable drifts away from its setpoint. (This exemplifies a general trend of inappropriate teleological thinking; Ref. [<reflink idref="bib17" id="ref52">17</reflink>].) The frequent pretest selection of three related attractive distractors from different questions (<emph>question 4</emph>, <emph>choice C</emph>; <emph>question 9</emph>, <emph>choice A</emph>; and <emph>question 20</emph>, <emph>choice C</emph>; Table 5) strongly suggests that many students hold this misconception.</p> <p>In considering whether meaningful progress on remediating misconceptions can be made during a single academic term, the data of Tables 3 and 6 offer some hope and some guidance. Relatively simple misconceptions about negative feedback, i.e., that it is detrimental or leads to declining values, seem substantially remediated by instruction (Table 3). In contrast, for the trickier misconception that homeostatic mechanisms are not always active, instructors who did not emphasize this point in their teaching did not see much progress on the corresponding HCI questions. However, the <emph>school C</emph> instructor did achieve progress on these questions (Table 6), presumably by targeting this misconception in their teaching (though we cannot exclude other explanations relating to, e.g., the <emph>school C</emph> students' relatively extensive background knowledge and/or capacity for improvement). The implication is that if one focuses on a specific misconception in one's teaching, one might see clear evidence of improvement in postcourse assessments.</p> <p>Beyond focusing instruction on particularly challenging misconceptions, what pedagogical strategies might help extinguish these misconceptions? Since active learning is well-known to improve student thinking and performance ([<reflink idref="bib23" id="ref53">23</reflink>], [<reflink idref="bib24" id="ref54">24</reflink>]), the use of active learning strategies (e.g., in which students make predictions and then notice errors in those predictions) may be more efficacious than instructors simply explaining to students why a misconception is flawed. In addition, for physiological misconceptions that transcend individual organ systems, revisiting the misconception in multiple organ systems via multiple related questions ([<reflink idref="bib12" id="ref55">12</reflink>]) may have stronger long-term effects than a single session devoted to that misconception.</p> <hd1 id="AN0186108609-15">Limitations, Future Work, and Conclusion</hd1> <p>Aside from limitations mentioned above (e.g., use of multiple-choice questions, uncertain student effort), perhaps the biggest limitation of the present study was that, while we studied the impact of "instruction" on HCI performance, no attempt was made either to standardize the lessons about homeostasis across institutions or to vary the lessons intentionally to see whether certain approaches work better than others. (The fact that only the <emph>school C</emph> instructor emphasized the misconception covered in Table 5 was accidental and was discovered retrospectively.) A more ambitious version of the current study could build on the current one by recruiting instructors to teach homeostasis in more carefully prescribed ways. For example, we could imagine several instructors developing and implementing a "homeostasis curriculum" that explicitly covers all of the information needed to successfully answer all 20 of the HCI questions. We could then determine whether larger pre- to postgains are achievable under those circumstances.</p> <p>For now, the present study might be perceived as a "good news/bad news" study. The bad news is that, overall, according to their performance on a validated instrument, students' understanding of homeostasis was changed little by instruction in physiology. The good news is that the data were consistent with meaningful progress on certain misconceptions, especially one consciously targeted by an instructor. The latter finding was strengthened by the instrument's inclusion of three related questions that addressed the same misconception, though such evidence would ideally be corroborated by students' free responses, which we did not collect. Our data suggest the value of "teaching to the test" in the sense of carefully aligning learning objectives, learning activities, and summative assessments ([<reflink idref="bib25" id="ref56">25</reflink>]).</p> <hd id="AN0186108609-16">DATA AVAILABILITY</hd> <p>Data will be made available upon reasonable request.</p> <hd id="AN0186108609-17">DISCLOSURES</hd> <p>No conflicts of interest, financial or otherwise, are declared by the authors.</p> <hd id="AN0186108609-18">AUTHOR CONTRIBUTIONS</hd> <p>J.M. conceived and designed research; G.J.C., A.K.H., and U.S. performed experiments; G.J.C., A.K.H., and U.S. analyzed data; G.J.C., U.S., and J.M. interpreted results of experiments; G.C. prepared figures; G.J.C. and J.M. drafted manuscript; G.J.C., A.K.H., U.S., and J.M. edited and revised manuscript; G.J.C., A.K.H., U.S., and J.M. approved final version of manuscript.</p> <ref id="AN0186108609-19"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Michael J, Cliff W, McFarland J, Modell H, Wright A. 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  Label: Title
  Group: Ti
  Data: The Impact of Instruction on Undergraduates' Understanding of Homeostasis: Results from Administering the Homeostasis Concept Inventory
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Gregory+J%2E+Crowther%22">Gregory J. Crowther</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-0530-9130">0000-0003-0530-9130</externalLink>)<br /><searchLink fieldCode="AR" term="%22Amy+K%2E+Hebert%22">Amy K. Hebert</searchLink><br /><searchLink fieldCode="AR" term="%22Usha+Sankar%22">Usha Sankar</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0005-9516-6939">0009-0005-9516-6939</externalLink>)<br /><searchLink fieldCode="AR" term="%22Joel+Michael%22">Joel Michael</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8132-6170">0000-0002-8132-6170</externalLink>)
– 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(2):423-429.
– 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: 7
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Undergraduate+Students%22">Undergraduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Instruction%22">Science Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Scientific+Concepts%22">Scientific Concepts</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Tests%22">Science Tests</searchLink><br /><searchLink fieldCode="DE" term="%22Physiology%22">Physiology</searchLink><br /><searchLink fieldCode="DE" term="%22Misconceptions%22">Misconceptions</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1152/advan.00136.2024
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1043-4046<br />1522-1229
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The Homeostasis Concept Inventory (HCI) is a validated instrument for measuring students' knowledge of homeostasis. It is comprised of 20 multiple-choice questions covering key components of the previously validated Homeostasis Conceptual Framework (HCF). In this paper, we present the first multi-institutional study of the impact of physiology instruction on students' HCI performance. Five cohorts of physiology or anatomy and physiology (A&P) students at four academic institutions took the HCI both at the start of their academic term (pretest) and at the end of their term (posttest). Statistically significant but relatively modest improvements in overall scores were seen from pretest to posttest. Among the 20 questions, 8 questions had incorrect choices identified as "attractive distractors" on the pretest, meaning that they were chosen at higher-than-random frequencies. From pretest to posttest, there were only modest declines in selections of incorrect answers generally and of attractive distractors in particular. Three attractive distractors that all target one specific misconception, that homeostatic mechanisms are active only when a regulated variable is not at its setpoint, remained persistently attractive except for students of one instructor who directly addressed that misconception in lecture and lab. These data are sobering in that they show a limited impact of instruction on HCI performance. However, these data also include encouraging evidence that instructional targeting of a specific misconception may help students overcome that misconception.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
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  Label: Accession Number
  Group: ID
  Data: EJ1467992
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1467992
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1152/advan.00136.2024
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 7
        StartPage: 423
    Subjects:
      – SubjectFull: Undergraduate Students
        Type: general
      – SubjectFull: Instructional Effectiveness
        Type: general
      – SubjectFull: Science Instruction
        Type: general
      – SubjectFull: Scientific Concepts
        Type: general
      – SubjectFull: Science Tests
        Type: general
      – SubjectFull: Physiology
        Type: general
      – SubjectFull: Misconceptions
        Type: general
    Titles:
      – TitleFull: The Impact of Instruction on Undergraduates' Understanding of Homeostasis: Results from Administering the Homeostasis Concept Inventory
        Type: main
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            NameFull: Gregory J. Crowther
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            NameFull: Amy K. Hebert
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            NameFull: Usha Sankar
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            NameFull: Joel Michael
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          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
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            – Type: issn-print
              Value: 1043-4046
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              Value: 49
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              Value: 2
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            – TitleFull: Advances in Physiology Education
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