TOWARD AN INTEGRATED MEDICAL CURRICULUM

Medicine and Health Rhode Island, Aug 2005 by Smith, Stephen R

Medical schools around the world are moving from the traditional discipline-oriented curriculum toward an integrated curriculum. The Medical Curriculum Committee at Brown Medical School approved a vision for curriculum transformation that would create an integrated, patientcentered curriculum. In this article, I describe the historical evolution of curricula in American medical schools, the definition of integration, the rationale for integrated curricula and the evidence supporting it, concerns about potential negative consequences, and how the Brown curriculum may develop.

HISTORICAL EVOLUTION OF CURRICULA

Throughout the nineteenth century, many American medical schools relied primarily on an apprenticeship model of education.1 Yet even in these schools, students undertook a course of study in the basic medical sciences during the first two preclinical years that consisted of anatomy (including histology and embryology), physiology (including biochemistry), pharmacology, pathology, and bacteriology.2 As the twentieth century progressed, new areas of knowledge were added, such as immunology, virology, and genetics, but stayed within the discipline-oriented structure.

Case Western Reserve School of Medicine pioneered an organ-system based structure to its curriculum in the late 1950s.3 Most U.S. medical schools utilize an organ-system structure in the second year of the medical school curriculum, but maintain a disciplineoriented structure in the first year of medical school, though there are many variations on the theme.

The Liaison Committee on Medical Education (LCME), the accrediting body for medical schools, still refers to the traditional disciplines in its standards when specifying what the content of medical school curricula should contain. However, the LCME has also been stressing the idea of a "coherent and coordinated curriculum" in which content is integrated within and across the academic periods of study (horizontal and vertical integration).4

DEFINITIONS OF INTEGRATION

Harden offered a very useful construct for viewing integration as steps in a ladder.5 Hardens ladder of integration has 11 steps, each reflecting a greater effort at integration. (Figure 1)

At the lowest rung, labeled "isolation," each course is taught in isolation with the instructors of each course largely unaware of the content of the other courses. No attempt is made to modify what is taught based on what is being taught in the other courses.

At the next rung, teachers are made aware of what is being taught in other courses. Then come efforts to make connections between courses, followed by incorporation of common themes within separate courses.

The fifth rung in Hardens ladder is called "temporal coordination," in which the instruction in separate courses is deliberately lined up with one another. For example, lectures in the pathology of lung disease occur in the same week as lectures in the pharmacology of asthma. Many medical schools have reached this level of integration, which might better be referred to as coordination, or, as some have uncharitably called them, "stapled-together courses."

The higher rungs on the integtation ladder are much less common in medical education and are the ones that Brown Medical School aspires to reach. The sixth rung -sharing-involves joint planning and teaching in a deliberate way. A good example of this actually occurred already within the Brown medical curriculum. The human reproduction, growth, and development section of the former Integrated Medical Sciences course brought together teachers from pediatrics (Robert Schwartz), pathology (Donald Singer), and obstetrics and gynecology (John Evrard) during the 1970s. Dr. Schwartz had previously been on the faculty at case Western Reserve, so understood their model of integration. The faculty met nearly every weekend throughout the year to plan and refine the course. They planned the lectures together and attended each other's lectures.

At even higher rungs, the proportion of student time spent in specific subjects or disciplines recedes as the amount of time in tasks that involve an integrated approach to learning increases. At the highest level, the boundaries between disciplines disappear and the students focus entirely on a new construct of understanding that transcends the disciplines.

RATIONALE FOR INTEGRATION

Dividing medicine into disciplines is an artificial construct. The real world of medical practice is transdisciplinary in large part. Physicians begin their interactions with patients in an open-ended way, even if they are specialists. The internist must consider a surgical or obstetrical or psychiatric cause of abdominal pain when first encountering a patient with that complaint.

Dividing the basic sciences into disciplines is also an artificial scheme that serves a specific purpose, namely, scientific investigation. Medical research is largely a reductionistic enterprise, delving more deeply into ever more focused areas of research. This disciplinary approach has been very successful in advancing scientific knowledge.