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 . 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  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 . 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 .
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 ; 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) . 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 . 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 .
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 . 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 .
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 . 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 .
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 . 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 . 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 . 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 . 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 . 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 . 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 . 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 .
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 . 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 . 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 .
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.