W. Pawlina and N. Lachman

Introduction

The role of the basic sciences and, consequently, the role of the basic science educators in the medical curriculum have undergone significant change in the context of even more dramatic change in both healthcare delivery systems and medical education. Over the last two decades, a debate has ensued challenging the very existence of medical basic science departments. From this argument, it has been shown that a traditional delivery of the basic sciences no longer has a place within the medical curriculum. As medical curriculum evolves, conventional courses need to adopt a new system of basic science instruction. As our understanding of the science of learning progresses, new knowledge transforms educational strategies in basic science.

The changing medical curriculum

With the dissolution of input-based curricula that nurtured the traditional format of basic science teaching, the challenge now lies in teaching an ‘old subject in a new world’ (Haase 2000). Regarding undergraduate programmes, a multiplicity of forces have changed the roles and responsibilities of medical educators. These forces include:

Therefore, educators must now produce scientifically competent graduates able to function as professionals in the climate change of healthcare reform. This means that they must practise evidence-based medicine, adhere to outcomes-based standards of care, translate scientific discoveries into clinical applications, utilize electronic information technology, comply with safety and quality measures and provide accessible, affordable, accountable and affable medical care (Srinivasan et al 2006).

The overarching objective of a basic medical science course is to provide fundamental scientific theories and concepts for clinical application. Traditionally, basic science subjects have included anatomy, histology, physiology, biochemistry and pathology. The current teaching model includes genetics, cell and molecular biology, epidemiology, nutrition and energy metabolism and the science of healthcare delivery and bioinformatics. The medical curriculum has shifted from the Flexner model to an integrated model in which basic science courses are either paired with related clinical disciplines (e.g. anatomy/radiology, immunology/pathology, neuroscience/psychiatry) or taught in blocks by organ system. Blocks are coordinated by faculty from both basic science and clinical departments, ensuring that students are given early exposure to patients in a clinical setting (Gregory et al 2009).

Basic science courses that used to focus on content knowledge are morphing to incorporate the longitudinal objectives of the medical arts. Often termed ‘holistic education’, this movement encourages intellectual, social, creative and emotional development alongside knowledge acquisition. Technology offers new platforms upon which to build integrative innovations, but its use comes with many challenges. In e-learning, entire curricula are accessible via electronic content management systems on websites. This non-classroom didactic setting creates a challenge for the teacher when presented with the imperative to incorporate basic science into lessons in clinical medicine and professionalism through holistic learning. Teachers and learners alike must be flexible and adapt to this rapidly changing educational environment.

The active learning environment

Another didactic shift in this movement is the transition away from passive learning towards a more active learning environment. In active learning, students learn to restructure the new information and their prior knowledge into new knowledge (McManus 2001). Among the most utilized formats for active learning are discussions in small groups (problem-based learning [PBL]), learning through clinical scenarios (case-based learning [CBL]), team-based learning (TBL) and learning through reflection (Lachman & Pawlina 2006).

One of these approaches has become a commonly applied strategy in basic sciences: PBL (Bowman & Hughes 2005, Kinkade 2005). PBL shifts the emphasis from didactic instruction to self-directed learning. So for teachers with more experience in traditional education, the implementation of PBL requires not only a change in mindset, but also major adjustments in preparation to teach in this programme. The PBL approach is labour intensive, demanding more time for preliminary work to integrate appropriate skills and knowledge within the programme.

To facilitate student-centred learning, the TBL approach supports small-group activities where students teach one another. TBL was designed for use in large classrooms, and so TBL is often used in undergraduate courses such as anatomy, histology and microbiology during medical training. There is evidence that TBL has the ability to balance cognitive skills through group interaction of factual assimilation and application (Michaelsen et al 2008, Vasan et al 2008). Since this type of strategy requires a small-group set-up and is highly collaborative in nature, teachers must master group facilitator skills while serving as content experts. Rather than lecturing, teachers debrief on the problems presented during TBL sessions (Michaelsen et al 2008). While this level of interaction usually requires more in-depth understanding of the subject material by the facilitator, it also promotes more critical thinking and reflection.

CBL is learning stimulated by active discussion on clinical cases specifically constructed to emphasize basic science principles. Cases should portray authentic, often complex, problems resolved by applying basic science knowledge and critical analysis. Independently or in extracurricular study groups, students review the case ahead of the CBL session to identify and research the critical concept. During the CBL session, a facilitator advances learning objectives by asking a sequence of trigger questions that stimulate students to articulate their perspective: proposing problem-solving strategies, actively listening to group discussion and promoting reflection (Bowe et al 2009). The multidisciplinary basic and clinical science faculty collaboration may enhance the outcomes of CBL sessions.

As coaches and facilitators instead of lecturers, teachers still manage the overall instructional process in which students have the opportunity to master course objectives and solve problems. As teachers continue to learn alongside their students, they serve as role models of lifelong learning. Additionally, mentorship may develop among teachers and students that self-select to serve as teaching assistants. In these apprenticeships, students find themselves on the way to becoming colleagues of their teachers, capable of working in effective, self-managed interprofessional teams and moving education forward.

Use of reflective practice, critical thinking and clinical reasoning

The use of reflection as a practical tool has become an important component of curriculum design for basic science. Reflective exercises support the practice of critical thinking for problem solving and the development of humanistic qualities desired in healthcare practitioners.

Within the learning environment, students may reflect individually through writing, or they may engage a team to explore or share experiences that lead to better comprehension and understanding. Reflection involves the synthesis of fragmented lessons, integration into one’s personal experience, and application to the larger narrative in which students find themselves in the world. In this process students cease to be educational automatons and develop personal epistemological initiative based on their values, which usually champion knowledge as a form of progress. From a theoretical standpoint, a student reflects by making an association with the learning objective, integrating the new concept with prior knowledge, validating the knowledge and, finally, applying the material (Lachman & Pawlina 2006).

In designing a curriculum to include critical thinking through reflective exercises, it is important to leave the course methods open to challenge and review. Explicit training in clinical reasoning naturally begins with the basic science courses, as it is important for the development of a systematic and efficient approach to clinical cases. This foundation serves medical trainees well indeed in all subsequent educational endeavors to come (Elizondo-Omaña et al 2010). It entails bridging the gap between theory and practice, a chasm that can be crossed through reflection.

The implementation of reflective exercises may be achieved through the application of various techniques and learning activities. An effective way of teaching critical thinking and reflection in basic sciences is to encourage self-directed learning. Again, in this setting, the educator takes on the role of a facilitator rather than a director of knowledge. When assigned tasks that require investigation outside of the classroom, the student must reflect on the information given and decide upon a relevant interpretation of core objectives for the subject to be mastered. Critical thinking skills are further enhanced through collaboration and team interaction. The use of teamwork to facilitate conceptual understanding has proved to be effective in stimulating collective thinking. In many cases, this can be accomplished by utilizing e-learning technologies.

Reflection and clinical reasoning should also be incorporated into assessment strategies. Questions may be designed for critical thinking by including clinical cases that demonstrate core basic science concepts. Providing formative assessment allows students to monitor their own learning process. In many institutions, audience response systems (ARSs) are used to provide immediate feedback on individual student performance in relation to overall performance within the group. The use of a combination of questioning styles such as multiple-choice questions (MCQs) and short answer questions (SAQs) promotes both discernment and writing skills. Additionally, peer and self-evaluation are effective assessments of critical analysis of teamwork dynamics.

 Conceptual knowledge:

• Understanding the process and concept rather than memorizing details

• Providing knowledge of resources for obtaining detailed information (e.g. finding gene structure and location on variety of genetic databases).

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