TOWARD AN INTEGRATED MEDICAL CURRICULUM

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

Learning to become a physician is different from research, however. Medical students need to fit things together as well as tease things apart. They need to learn the relationship between the parts, how to synthesize, how to see the big picture.

The classic educational paradigm, as pronounced by Alfred North Whitehead, was romance, precision, and synthesis, in that order.6 Once student interest was engendered in the romance phase, instruction focused on the details of what needed to be learned. This was taught in the traditional discipline-specific method. Only after a firm foundation of facts was accumulated would the teaching shift to synthesizing the information together.

This approach to teaching and learning has been called into question by educational researchers in the past few decades.7 Learning facts is easier when those facts are learned in a relevant and meaningful context. This premise led to the development of problem-based learning (PBL), first at McMaster University, then spreading throughout most medical schools. Students are presented with a case study of a patient with a problem. Students discuss the case to determine the explanation of the problem. Students will usually know only a small amount about the problem from their previous knowledge. They will decide what more they have to learn, divide the learning objectives up among the group, research their assignments, then reassemble to put what they've learned together to solve the problem.

PBL is often combined with discipline-oriented teaching to provide an integrating learning experience. A study by Schmidt et al.8 examined the effect that three different curricular approaches had on student performance on a test that measured their diagnostic abilities. Students at the medical school with an integrated curriculum (Amsterdam) performed significantly better than the other two groups (traditional discipline-oriented at the University of Groningen and PBL at the University of Limburg medical school in Maastricht in the Netherlands) in the second and third curriculum years, and better than the conventional curriculum, but not the PBL curriculum, in the fifth and sixth years.

Empirical studies attempting to evaluate the comparative effectiveness of these various approaches to teaching and learning have been few and inconsistent in their findings. Nevertheless, the momentum for curriculum integration has been building, fueled by theoretical arguments in its favor and by student preference for learning in this manner.

CONCERNS ABOUT NEGATIVE CONSEQUENCES

Despite the momentum in favor of integration, skeptics raise concerns about possible negative consequences. Drake listed nine concerns raised about integration in K-12 education that I will put into a medical education context.9

Students won't learn basic sciences. Some fear that students will focus exclusively on clinical aspects and ignore the basic sciences in an integrated curriculum. This won't happen if clear learning objectives are shared with the students and evaluations are aligned with those learning objectives. When students know what is expected of them, they will rise to the occasion.