Integrated learning

Chapter 22


Integrated learning




Introduction


Medical education courses draw on disciplines from the physical, human and biological sciences, humanities and the social and behavioural sciences and clinical sciences. Traditionally, in a Flexnerian manner, the disciplines were taught separately with an emphasis on the basic sciences in the early years and clinical experiences in the later years. Students, however, were expected to combine all the knowledge and skills from the disciplines and apply them to their clinical work.


In the later part of the 20th century medical education reformers advocated the combination of the disciplines and the organization of integrated learning experiences for students where they called upon knowledge and skills from across the disciplines in addressing patient cases, problems and issues. Integration was promoted in teaching and learning approaches rather than assuming that students would somehow integrate their disciplinary knowledge on their own. While integration was once regarded as a mark of innovation in medical education, it is now more widely accepted as a feature of all programmes. The degree of integration varies. Harden (2000) conceptualized a ‘ladder’ of integration with 11 steps or stages ranging from treating the disciplines in ‘isolation’ from each other to ‘interdisciplinary’ and ‘transdisciplinary’ designs (Fig. 22.1).




Types of integration in medical education


There are two main types of integration in medical education: integration through dedicated approaches and integration through specific contexts. In the first of these the programme is deliberately structured to organize or facilitate learning across the disciplines around key concepts, themes or problems. There are two common approaches in medical education:



In horizontal integration there is integration among the various disciplines within any one or each year of the course such as in courses organized on a body systems basis. In vertical integration there is integration of disciplines taught in the different phases or years of the course. The early introduction of clinical skills and their development alongside basic and clinical sciences is a good example of vertical integration.


Integrated learning through context is more common in the clinical components of medical courses. As clinical services become more integrated so too do the learning experiences available for students. The increased emphasis on clinical experience in community, ambulatory, primary care and general practice settings has brought additional opportunities for integrated learning in current medical school curricula.



The rationale for integrated learning


The rationale for integrated learning is frequently unstated or not argued strongly. It is assumed that integrated learning will result in a more relevant, meaningful and student-centred curriculum, but the assumption often remains untested.


A rationale for integrated learning can be found, however, in some of the writings in cognitive psychology. Regehr and Norman (1996) have summarized these writings. It is easier to retrieve and use information when it is combined in meaningful schemata.





Regehr and Norman (1996) also refer to the concept of ‘context specificity’. The ability to retrieve an item from memory depends on the similarity between the condition or context in which it was originally learned and the context in which it is retrieved.



image Context specificity: what is learned in one context is more readily retrieved in another similar context.


There are at least three ways to address context specificity for curriculum integration. One is to promote students’ elaboration of knowledge in ‘richer’ and ‘wider’ contexts. Horizontally integrated system or case-based curricula can provide opportunities for such elaboration. Repeated opportunities to use information in different system or case contexts can also reduce the effects of context specificity. Such opportunities can be found in vertically integrated courses where there is revisiting of knowledge in different situations and in different combinations of disciplines.


A third way of reducing the effect of context is to make the learning contexts as close as possible to the context in which the information is to be retrieved. This provides an argument for integrated learning within integrated clinical contexts such as in community settings, primary care, family medicine or general practice and for providing a clinical context for learning of basic knowledge prior to clinical placements.



Approaches to integration



Horizontal integration


In horizontally integrated courses the disciplines are combined, organised around concepts or ideas in each year or level of the course. Commonly this is done using a body system approach. The early years of medical courses are frequently organized into blocks or units corresponding to body systems such as:



Within these blocks students learn the basic sciences of anatomy, physiology and biochemistry together with social and behavioural sciences and clinical sciences as applied to normal and abnormal structures and functions within the systems (Fig. 22.2). More recently, some schools have adopted the concept of life cycle as a means of integrating content. The blocks or units which provide the basis for integration are organized according to stages in the life cycle.



Horizontally integrated courses are becoming more popular as increasing numbers of medical schools around the world adopt problem-based or case-based learning approaches. In these approaches, specifically constructed cases become the focus for a week or 2 weeks of study. The cases may be organized by system or life cycle blocks, but each case in itself is also integrated. They are designed so that students must draw on knowledge, ideas and concepts from across the disciplines in order to generate and pursue learning goals. Problem-based learning, in particular, emphasizes elaboration of learning as students generate learning goals and discuss them in small groups, calling on all relevant knowledge across the disciplines.



Vertical integration


In vertically integrated courses the disciplines are organized into themes or domains which run throughout all years of the course. Many medical courses are now organized around four main themes which, while given different names, generally deal with the following:



A common way of organizing a vertically integrated curriculum through the themes is to use a spiral approach. Within each of the themes there may be sub-themes or blocks which provide the basis for integration across the years of the medical course. For example, there may be a sub-theme such as growth, development and ageing which is present in each year of the course in one or more themes. The studies in each year revisit those from the previous year or years, build upon the sub-theme and extend the learning to higher levels and greater complexity. Each turn of the spiral represents an extension of the studies from the previous turn (Fig. 22.3).



There are few medical courses which now rigidly maintain a preclinical/clinical divide, with the former presented in the earlier years of the course and the latter towards the end. Students now have early clinical learning experiences which increase in emphasis as they proceed through the course. There is a corresponding decrease in emphasis on the basic sciences, but they still have an important part to play in the clinical years in providing an explanation of the mechanisms of disease and disease processes. This increases the potential for integration of clinical and science disciplines. For example, anatomy and imaging are being presented in an integrated approach throughout medical courses. The establishment of clinical skills units, where students have opportunities to learn and practise skills in an intensive way, has also fostered integration, including the immediate application of concurrently learned anatomy and physiology. Dent et al (2001) have reported on an Ambulatory Care Teaching Centre (ACTC) in which students’ early experiences in the clinical skills centre integrate with patient-based experiences in the ACTC during subsequent system blocks.



Contexts for integrated learning


In the rationale for integrated learning set out here it is argued that one way to achieve such learning is to ensure that the learning context is itself integrated. With medical practice becoming more specialized, particularly in large teaching hospitals, this is becoming increasingly difficult to achieve. This is one of the reasons underlying the calls for more clinical experiences for students in community settings, ambulatory services, general practice, family medicine and primary care. It is claimed that these contexts will provide opportunities for students to experience a patient-centred approach rather than a disease-oriented one and will enable them to experience a broad spectrum of illness to which they can apply the integrated knowledge from the studies in their medical courses.




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Related posts:

  1. Clinical skills centre teaching
  2. Postgraduate training
  3. Student support
  4. Basic sciences and curriculum outcomes

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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Integrated learning

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