Integrated Learning in Medical Education: Are Our Students Ready?

Med.Sci.Educ. (2015) 25:549–551 DOI 10.1007/s40670-015-0172-0 COMMENTARY Integrated Learning in Medical Education: Are Our Students Ready? Amudha Kadirvelu 1 & Sunil Gurtu 1 Published online: 8 September 2015 # International Association of Medical Science Educators 2015 Integration in medical education means breaking the barriers between individual disciplines. As stated by Bradley and Mattick [1], Bintegrated curriculum aims to provide students with better learning opportunities that will facilitate the development of knowledge that is relevant and meaningful to clinical practice, is deep and retrievable and which is amenable to alteration, updating and development as a part of an ongoing process of lifelong learning.^ The expected outcomes of an integrated medical curriculum are undoubtedly admirable but are we overly optimistic? We are not voting for or against it, rather, in agreement with the medical education fraternity. Integration is essential to avoid the information overload that is associated with the traditional curriculum where information was delivered as a series of disciplinary blocks that is more focused on detail with little emphasis on the links between subjects and its clinical relevance. BIntegration seeks to deal more with principles and concepts that can be used to explore and understand problems and develop new solutions^ [1]. From the time Flexner’s report of 1910 on medical education [2] was published, medical school curricula around the world underwent a major evolution. Most medical schools adopted the B2+2^ curriculum in which the first 2 years of early foundational basic science education are separate from two later years of clinical training [3, 4]. This curriculum format however is viewed as an inadequate system to prepare * Amudha Kadirvelu Sunil Gurtu 1 Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor DE, Malaysia future physicians for twenty-first century medicine [5, 6]. A number of commentaries, curriculum maps, and guidelines centered on integration have since been published. However, recent major education reports [7, 8] continue to outline integration as a strategic priority for medical education suggesting that integration is a problem yet to be solved. Although the innovations and attempts to integrate basic sciences and clinical knowledge by the medical schools are significant and commendable, most are made at the level of programs, courses, and teaching sessions. We feel that the Blearners^ are sidelined in the process. Integration of the multiple domains of knowledge should depend on the cognitive activity that occurs within the learner. Simply creating an integrated curriculum will not mechanically lead to cognitive integraion. A number of possible reasons could be implicated for unsatisfactory outcomes of integration in medical schools. First, the institutions seem to expect that making logistical changes will lead to active integration of basic sciences and clinical knowledge. Creating an integrated curriculum and delivering it in a coordinated manner do not automatically establish integration. Integrated sessions should ideally be given by teachers from one scientific realm (foundational or applied/ clinical) with academic knowledge of the other or collaboratively by teachers from both realms. Trans-disciplinary cooperation among educators must be emphasized by the management or the schools should utilize staff with academic knowledge of both (basic and clinical) realms to deliver the integrated curriculum. Second, it is innovation(s) in curriculum that are loosely referred as integrated curriculum. Examples include introduction of medical ethics and law into the firstyear courses and integrating clinical exposure from the commencement phase of medical education. Third, there is a constant pressure to increase applied knowledge from the early years of the medical school. This has dramatically decreased the number of hours spent on theoretical/foundational 550 learning. It may result in students undervaluing the relevance of basic science in clinical problem solving resulting in weak foundational knowledge in the clinical years. Further, integrated curricula mostly follow a system-based approach where individual disciplines related to a particular block are delivered concurrently. However, certain topics have relevance across different systems. What would be the most suitable point for the introduction of such areas for example, physiology and pharmacology of autonomic nervous system, antibiotics, etc.? Evidently, integrating knowledge from the multifaceted medical curriculum necessary for the practice of medicine is an enduring challenge for medical students. It requires a certain level of cognitive maturity to understand, harmonize, and apply the knowledge in a meaningful way. It beats the purpose of having an integrated curriculum if it does not happen at the cognitive level of the learners. Ideally, integration should commence after a period of initial instruction in some basic and general concepts, especially in the basic sciences. For some students, these maybe unknown territories considering that some medical schools do not require related subjects, e.g., biology as an entry requirement. Expecting the students to integrate the information in the face of inadequate knowledge of basic concepts may lead to anxiety and mistrust in the system. Although activities such as PBL and shared teaching models may create proximity between knowledge domains and foster awareness in students, whether these logistical changes lead to active integration of basic sciences and clinical knowledge in the students at the cognitive level is unclear. Another modality which is emphasized in integrated curricula is Bself-directed learning^ (SDL) from the early years with the objective of producing independent lifelong learners. SDL is defined by Knowles [9] as a process in which, individuals take initiative in identifying their own learning needs, formulating goals, identifying human and material resources for learning, finding appropriate learning resources, choosing and implementing suitable learning strategies, and evaluating learning outcomes. In practice, we are assuming that students already possess the needed attributes of maturity, self-direction, responsibility, and individuality for independent learning on entry to medical schools. It is also hard to determine learner’s characteristics that are most suitable for SDL. Whether the learners are able to utilize these dedicated SDL sessions for attaining an integrated understanding of an area of study in the absence of specific guidance is neither clear nor easy to assess. Knowles and others implied that SDL is ideal for mature learners who already have a reservoir of knowledge and can apply their learning in relevance to their practices and past experiences [9, 10, 11]. Accordingly, graduat (...truncated)