Integrated Medical Teaching - Current Scenario-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS ANATOMY PHYSIOLOGY & BIOCHEMISTRY INTERNATIONAL JOURNAL
Objective: To assess the level of success achieved by implementation of integrated teaching in first and second year of medical education.
Study Design: Literature survey based qualitative content analysis
Methodology: Online available literature from 1990 to 2105 was reviewed thoroughly and data/results were studied.
Results: Most of the data was
based on the personal views of faculty and the perception of students.
Outcome based studies regarding assessment, results, and performance in
annual exam were too scarce to reach conclusion.
Conclusion: Keeping in view the
requirement of ideal resources, PBL sessions for specific and easily
integrated contents of basic and clinical disciplines can be run along
with conventional teaching. Total reliance on integrated teaching is not
recommended until thorough studies prove a positive long term impact of
such system.
Keywords: Curriculum; Horizontal Integration; MITs; Problem Base Learning; Vertical Integration
Basic medical sciences have always been considered an
integral component of medical teaching. The fundamental role of basic
medical sciences i.e. anatomy, physiology and biochemistry was first
established in 1910 [1]. This unlatched the door leading us into an era
in which the initial two years were tirelessly devoted to the
establishment of profound, thorough knowledge of the basic sciences, a
foundation upon which clinical comprehension was fortified in the later
three years. This “Conventional Teaching System” was opted throughout
the world with a clear-cut demarcation among all basic and clinical
disciplines. This system of medical education engendered legions of
proficient and competent doctors who, with their meticulous skills and
meritorious prowess, revolutionized the world of medicine. As years
passed by, a need for integration of was felt in order to produce
doctors who are sufficiently adept to meet the challenges of the 21st
century head on – doctors with an augmented ability to think critically
and with apt reasoning. It was emphasized that relevant aspects of
clinical subjects should be incorporated into basic medical sciences. In
accordance with to enhance the effectiveness of integrated learning.
Present review is based on the data and informations gathered from
various review reports, research articles, and commentaries published on
PubMed, MEDLINE, and Google Scholar.
The main purpose of this review is to evaluate the
scope and success of the integration as a learning strategy in the first
and second years of medical education in the last 25 years (1990-2015);
moreover, this review assess the success this new system has had in
these years. Studies focused on integration of biomedical sciences like
anatomy, biochemistry, physiology, pathology, pharmacology (horizontal
integration), and surgery and allied as well as medicine and allied
(vertical integration) in first two years of medical teaching are
included in the review. All literature was explored under the guidelines
proposed by Goldman [2] who suggested that learning objectives of the
medical curriculum can be achieved successfully by applying integration
learning strategies at three levels. The first level was labeled as
“program”, a framework of curriculum encompassing all learning
strategies to be applied throughout the course of medical studies. The
second level was “course”, indicating various components of program. The
third level of integration was called “session”, which applies to the
learning strategies employed on a daily basis to achieve the required
level of knowledge. These three levels go hand in hand and determine the
actual success of the integrated teaching on the basis of logistics and
cognitive domain of learning [3]. Hence, present review aims to analyze
the integration extent, methodologies opted and the indicators
determining the success or failure of integration. Before the
implementation of an innovative idea, the stake holders, i.e. medical
students need to be taken under consideration. They are the fertile soil
upon which the gardens of knowledge and skill will bloom. The way we
nurture the soil will ultimately determine the fruits it will bear. It
is difficult to lay down uniform curriculum and learning strategies
throughout the world. In developing countries like Pakistan, students
enter medical college after 12 years of schooling with typical syllabi
with no remote relation to the basic sciences being taught in medical
schools [4].
The students are exposed to completely new
subjects upon entering medical school. In the first two years, their
knowledge has to be built from grass root level up to a stage where they
can successfully integrate it with applied clinical sciences. On the
other hand, in Canada, North and South America, students have to get BA
and BS degrees before qualifying for admission in medical schools. They
have already covered a major chunk of basic sciences like biochemistry
and physiology of cell in pre medical years [5]; therefore upon entering
the course of medical education, they are successfully able to
consolidate the basic knowledge with clinical learning. Before the
implementation of integration, accurate planning and evaluation of
medical curriculum is essential. According to taxonomy of the
integration ladder, eleven steps lie between the disciplines based
teaching (bottom) and integrated teaching (top) [6]. As we move up the
ladder, towards integrated teaching, boundaries of individual
disciplines diminish and a fundamentally organized curriculum structure
emerges. This highest level of integration requires extensive resources,
student selection criteria (including aptitude test), joint
contribution from trained faculty members from all disciplines in
formulation of curriculum and a friendly, interactive environment
between different departments. After mutual consensus, time table for
teaching sessions, learning objectives for each session and assessment
techniques are finalized accordingly. Displayed time table and contents
of curriculum indicate the level of integration. Time tables showing
higher level of integration will be no longer highlighting the
individual disciplines. Horizontal integration in first and second year
of medicine links basic sciences on the basis of practical and
philosophical approach, whereas vertical integration bridges basic and
clinical sciences, breaking the division between preclinical and
clinical teaching, and making learning more meaningful and productive.
Both types of integrations are required for formulation of Integrated
Curriculum. This main task triggers a debate among faculty members who
have their reservations in integrated teaching when compared with
discipline based teaching, the reason being the lack of resources and
inadequate logistics [7]. To avoid this state of polarization, faculty
should be encouraged to discuss and trained to search for integration
options within available resources. It would be unjustified to ignore
the viewpoints of experienced faculty members, organizational structure
of medical college and overall objectives of the curriculum. Transition
from conventional discipline based teaching to completely integrated
teaching requires major changes [6].
The next step, after formulation of medical
curriculum, is the selection of accurate learning methodology which may
be large group or small group interactive sessions, problem based
learning (PBL) and self-directed learning sessions, to achieve the
required objectives of integrated learning. Out of teaching tools, PBL
is considered to be the most effective and productive. It was first
introduced and implemented at McMaster University, Canada [8]. Later on
implementation of PBL sessions along with conventional curricula was
done in many countries including New Zealand, Pakistan and India. This
was given the name “hybrid system”. Hybrid integrated learning programs
(ILP) of small durations were introduced in first year MBBS class in few
medical school, as a supplementary tool to conventional teaching, to
promote thinking and reasoning skills among students. Results indicated
that only a few programs were able to integrate an even fewer number of
basic science disciplines (horizontal integration), leaving the rest on
regular conventional teaching. Small group laboratory sessions were also
organized to integrate with PBL content [9].
We, as part of a community are exposed to various
forms of integration, like sharing skills and problem solving. The ever
growing need for integration demands a change from conventional to
integration system. Students almost always gave a positive feedback
regarding integrated teaching, both in developed and developing
countries [10,11] as this strategy takes them away from rote learning of
facts to development of concepts of relevant information. In various
studies the outcome was usually determined by faculty feedback,
students’ perception, and assessment of the strengths and weaknesses of
individual students with the help of questionnaire [12]. It was also
noticed in a few studies, that students got themselves confined to their
allotted, specific learning objectives, while ignoring the remaining
targets; moreover most of them indulged into unnecessary details and
lost track of the topics due to lack of understanding of the difference
between facts that are “must to know” and those that are to be given
less attention at that particular stage. It was also observed that
number of absentees also increased in these sessions. Students also
considered PBLs insufficient and inadequate when employed as a singular
teaching method. They complained of minimal retention of the required
knowledge when topics were dealt with under PBLs alone. According to the
students, teaching has a stronger impact if done as a continuous
process with repetition of facts for knowledge retention, regular
assignments and finally, strict assessment for evaluation [13].
Few studies showed that students did not accept PBL
teaching sessions as a good learning option due to more burden of work
and time consumption [14]. Formulation and implementation of integrated
curriculum in initial two years of medical teaching is a complicated
process, having various impacts on different scenarios regarding
teaching methodologies and course content; however, final deciding
factor which determines the success and failure of any learning strategy
is the performance of the students in the annual assessment. Thorough
literature review revealed that in spite of great appreciation of PBL
sessions both by faculty and students, performance of those students who
were taught through structured, teacher oriented, conventional
curriculum was much better than that of students under integrated
problem based curriculum [15]. However, few studies could not find
significant difference statistically [8,16]. Apart from one medical
school in United States, which claimed better outcome by implementing
integrated problem based curriculum, we could not find any study which
can statistically prove this innovative learning strategy showing better
student performance in annual medical examination when compared to that
of conventional methods [17]. Literature review reinforced that
integrated sessions are more successful in clinical years as clinical
sciences can be integrated at the highest level, but this level of
integration does not exist between clinical and basic sciences.
Basic sciences have hidden content that cannot be
integrated, but lies in the foundation of the subject, often unexplored
by the student [18]. Hence, if only PBL is used as a major learning
tool, students might miss that basic core knowledge of physiology,
anatomy and biochemistry during initial two years of the course [19].
Moreover PBL trains the students in a particular direction. Facilitators
are more focused towards proper organization to conduct PBL session
rather than the teaching content; therefore, it is not advisable to rely
on PBL methodology alone. Instead, it can be used as supplementary
tool, along with large group interactive sessions and traditional
didactic lectures [20]. Basic sciences cannot be integrated at a
microscopic level, so few systems or learning objectives of anatomy,
biochemistry and physiology may be integrated in a PBL session, whereas
the rest of the teaching should follow the conventional methodology. The
shortcomings observed in PBL sessions can be overcome by ensuring 100%
attendance of students, involving each student in all learning
objectives and defining the role of facilitators. Moreover the number of
large group interactive sessions may be increased to make a PBL more
productive by enhancing the level of core knowledge of medical students.
Facilitators should be trained to keep a check on students by keeping
them on track. Most of the studies showed that in integration sessions
in the initial two years of medical schooling, clinical subjects were
over emphasized instead of basic sciences because most of the
facilitators were from clinical sciences; hence, faculty from basic
sciences should be encouraged to participate in these sessions too.
In developing countries, academics, particularly
medical education, face a different set of problems. As developing
countries have inadequate resource at hand, implementation of integrated
teaching in medical colleges is quite challenging. Few private sector
medical universities in Pakistan have already switched from conventional
to integrated curriculum partially or completely [21]. Unfortunately
while reviewing the literature on integration, we could not find
statistically significant data that assesses its long term success and
impact. It can only be done by evaluating and comparing the conventional
and integrated teaching outcomes in the existing local environment,
over a specified period of time, in the form of students performance in
assessment, both formative and summative [22-25]. To reinforce the basic
idea of integration, specific, identified learning objectives of basic
medical sciences may be merged with those of clinical sciences, hence
continuing teaching of basic disciplines in later years of medical
education [26].
Most of the literature revealed that different setups
adopted different methodologies and their results were merely the
reflection of the personal opinions of the faculty and perception of the
students [27]. Our review is based on subjective quality rating and the
researchers’ opinions and points of views, making it very hard to reach
a decisive conclusion. The issue regarding formulation of integrated
medical curriculum, categorization, detail and depth of cognitive
domain, and methodologies adopted to integrate basic sciences with
clinical subjects are still mysteries of evolving the concept of
integration. If integrated learning strategies are applied in true
spirit, they will enhance students’ levels and depths of knowledge,
perception, motivation, skills and approach towards solving health
problems. It requires meaningful connection among various components of
curriculum as well as students and facilitators [28]. Studies also
revealed that integration is basically characterized by teaching
strategies and rearrangement of various curricular contents. Instead of
relying on the parameters mentioned above, it is better to focus on
cognitive integration within the students. Integrated curriculum alone
cannot truly integrate and interrelate various disciplines within the
learners. The best way of integration is to build robust, fortified
concepts of basic sciences in relevance with clinical sciences within
the available resources and learning environment. This should be
followed by an assessment to determine the level of comprehension,
retention of the content of basic sciences, and its practical
application with reasoning and skill [3].
Conclusion
If integration is in accordance with the cognitive domain, then specific learning objectives can be integrated without any extra effort. In order to organize a fruitful PBL session, it is essential to identify and focus on selected and precisely defined learning objectives of basic sciences that easily integrate with clinical sciences. Instead of implementing the highest level of integration at once, small PBL sessions with easily integrated learning objectives can be introduced. This can hone the students’ communicative skills, their ability to access and extract required knowledge and utilize it in practical life; however, further studies on conventional and integrated system are required to evaluate and compare the results based on the performance of students in annual undergraduate examinations as well as post graduate examinations to assess the level of knowledge acquired and retained by the students as well as their ability to apply this knowledge in practical life - our ultimate objective.
If integration is in accordance with the cognitive domain, then specific learning objectives can be integrated without any extra effort. In order to organize a fruitful PBL session, it is essential to identify and focus on selected and precisely defined learning objectives of basic sciences that easily integrate with clinical sciences. Instead of implementing the highest level of integration at once, small PBL sessions with easily integrated learning objectives can be introduced. This can hone the students’ communicative skills, their ability to access and extract required knowledge and utilize it in practical life; however, further studies on conventional and integrated system are required to evaluate and compare the results based on the performance of students in annual undergraduate examinations as well as post graduate examinations to assess the level of knowledge acquired and retained by the students as well as their ability to apply this knowledge in practical life - our ultimate objective.
For
more Open Access Journals in Juniper Publishers please
click on: https://juniperpublishers.com
For more articles in Anatomy Physiology & Biochemistry International Journal please click
on: https://juniperpublishers.com/apbij/index.php
For more Open Access Journals please click on: https://juniperpublishers.com
To know more about Juniper Publishers please click on: https://juniperpublishers.business.site/
For more articles in Anatomy Physiology & Biochemistry International Journal please click
on: https://juniperpublishers.com/apbij/index.php
For more Open Access Journals please click on: https://juniperpublishers.com
To know more about Juniper Publishers please click on: https://juniperpublishers.business.site/
Comments
Post a Comment