state of the science Back from basics: integration of science and practice in medical education Glen Bandiera,1 Ayelet Kuper,2,3 Maria Mylopoulos,3,4 Cynthia Whitehead,3,5,6 Mariela Ruetalo,1 Kulamakan Kulasegaram3,5 & Nicole N. Woods3,5
CONTEXT In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. SCOPE OF REVIEW In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical
solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. CONCLUSIONS Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of ‘basic science’ relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.
Medical Education 2017 doi: 10.1111/medu.13386
1 PostMD Education, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada 2 Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada 3 The Wilson Centre, University of Toronto, Toronto, Ontario, Canada 4 Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada 5 Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
6 Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
Correspondence: Glen Bandiera, PostMD Education, University of Toronto, 500 University Avenue, 6th Floor, Toronto, Ontario M5G 1V7, Canada. Tel: 00 1 416 946 3844; E-mail: [email protected]
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
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G Bandiera et al
INTRODUCTION
Medical school curricula that integrate the teaching of basic and clinical sciences across diverse training contexts remain a much-vaunted potential solution to many of the challenges facing the practice of medicine. Abraham Flexner first recognised the complementary roles of basic and applied content, championing a model in which the former was regarded as a necessary foundation upon which subsequent education in the latter should be based.1,2 Almost 80 years after Flexner’s hallmark report,2 educators convened at the 1988 World Conference on Medical Education of the World Federation for Medical Education. The ‘Edinburgh Declaration’ that arose from the conference asserted that: ‘the aim of medical education is to produce doctors who will promote the health of all people’.3 In recognition of the view that medicine was falling short on this mandate in critical areas, the Edinburgh Declaration challenged the international medical education community to join ‘an organised and sustained programme to alter the character of medical education so that it truly meets the defined needs of the society in which it is situated’.3 The Declaration outlined eight recommendations that could be addressed within medical schools and a further four that were felt to require broader engagement. Of the former, Recommendation 7 states: ‘Pursue integration of education in science and education in practice, also using problem solving in clinical and community settings as a base for learning.’3 So, 30 years later, have we made good on this recommendation? In this paper, we examine the evolution of curricular integration in medical schools since the Edinburgh Declaration with an emphasis on establishing ongoing relevance, assessing the current state of integration and critically reflecting on what integration really is. We also investigate the importance of exposure to multiple training contexts, and treat problem solving not as a method unto itself, but as one means by which integration can manifest in curricula.
THE ONGOING PURSUIT OF INTEGRATION
Although a number of key changes have arisen in how the basic sciences pertinent to medicine are conceptualised and their role in clinical practice, the ideal of the integration of the basic and clinical sciences has continued to be a central issue in the years since the 1988 World Conference on Medical
2
Education. Several interim high-profile initiatives have emphasised the need to pursue integration. For example, the Association of American Medical Colleges and the Howard Hughes Medical Institute (AAMC–HHMI) released a document in 2009 acknowledging that the ‘application of scientific knowledge in medicine requires attention both to the patient as an individual and in a social context’ and that ‘the biology of individual patients is complex and variable and is influenced by genetic, social and environmental factors’, and further specifying that ‘the medical school curriculum should be integrated across disciplines and repeatedly emphasise the importance and relevance of the sciences basic to medicine’.4 Both the Edinburgh Declaration and the AAMC–HHMI documents link integration with an increased likelihood of graduates meeting broader societal health mandates. In 2009, the Association of Faculties of Medicine of Canada released a report entitled ‘The Future of Medical Education in Canada: A Collective Vision for MD Education’.5 Embedded within the recommendation to ‘[b]uild on the scientific basis of medicine’, the following detail emerges: ‘. . .both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience’, along with ‘[t]hese two complementary domains must be increasingly integrated so that students think about clinical applications as they learn basic sciences and about scientific principles as they learn clinical skills’.5 In relation to the Edinburgh Declaration’s reference to clinical and community settings, the report also includes a categorical recommendation to ensure learners experience ‘diversified training contexts’.5 The 2010 Lancet Commission report ‘Health Professionals for a New Century’ further recommends: ‘Alongside specific technical skills, interprofessional education should focus on crosscutting generic competencies, such as analytical abilities. . . leadership and management capabilities. . . and communication skills.’6 Accreditation has also been used as a lever for change in this direction. As examples, the Liaison Committee on Medical Education in the USA requires curricula to be ‘coherent’, ‘coordinated’ and ‘integrated’.7 The Australian Medical Council mandates that integration include: ‘. . .both horizontal (within a programme segment or year) and vertical (across successive programme segments or years) integration of related subject matter. . . [in a] process of integration [that] allows students to
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
Integration of science and practice see how scientific knowledge and clinical experience are combined to support good medical practice.’8 The UK General Medical Council mandates that schools provide ‘learning opportunities that integrate basic and clinical science, enabling them to link theory and practice’.9 Such expert documents and accreditation emphasis from multiple jurisdictions imply strong support for integration. We can infer that the face validity of pursuing integration and diversified learning contexts is alive and well. Despite the confidence implied in these decisive recommendations, however, recent research has started to shed some light on the nature and promise of integration that should cause the medical education community to revisit what, exactly, these accepted approaches are meant to accomplish.
CURRENT CONCEPTIONS OF INTEGRATION
The Edinburgh Declaration strongly implied that the use of integrated models situated in various learning environments held promise to improve learning through both increased retention and increased ability to apply knowledge for the betterment of human health. A model of integration was envisioned in which learners would encounter early in their training a clinical environment that would provide opportunities not only to learn the applied skills required, but also to solidify learning around relevant aspects of basic sciences. At the time of the Declaration, the assumption that basic science training positively influences clinical competence was largely taken at face value. Since then, empirical demonstration of the role of basic science and the effectiveness of integration has been an elusive goal. There have been a number of attempts to systemically study whether the basic science content covered in the early years of medical training has any impact on the acquisition and use of clinical content in later years. Structural equation modelling employed by Donnon and Violato10 found that basic science knowledge and clinical knowledge independently contribute to performance on clinical competency assessments in medical school. This was positioned as support for the theoretical perspective that basic science and clinical content acquired in the first 2 years of training within a single medical curriculum can separately influence later clinical reasoning.10 By contrast, other studies examining the clinical reasoning of both medical students and practising physicians have suggested the two forms of knowledge can in fact be integrated, supporting
an encapsulation model in which the contribution of basic science knowledge to diagnostic reasoning is mediated by its relationship to clinical knowledge.11–13 In a thorough analysis of the current state of Canadian medical education conducted in 2010, two authors of this paper (GB, AK) and others explored the role of basic sciences.14 Through the synthesis of data arising from a literature review, key informant interviews and several panel symposia, it became clear that there is not uniform agreement on the proper degree of integration or on the relative balance of basic versus applied sciences. Moreover, debate regarding the importance of basic sciences is largely limited to those within the professional field; to those outside the field, the importance of basic sciences in clinical practice is paramount. Within the field, there was a clear rift between the camp that felt that basic sciences is a necessary foundation for further training in clinical medicine and that this foundational knowledge is in fact a defining characteristic of the medical practitioner, and another camp that felt the role of basic sciences should be limited to the minimum required to ensure effective practice and that the role of the medical practitioner is primarily to solve problems using an array of skills acquired from a broad swathe of content areas. Indeed, as identified in the analysis of Canadian medical education and reinforced by Brauer and Ferguson in a more recent review, there remains a great deal of concern that early introduction of clinical experiences may result in a devaluing of basic science knowledge and in the displacement of key content from the curriculum.14,15 It is important to note that there are multiple competing conceptions of integration within medical education curricula.16 Although integration is often seen as a way to introduce broader clinical content earlier in medical training and to establish the basis for contextual learning, it should not be forgotten that integration can also be seen as a way to continue the inclusion of basic sciences over time, in an ever more sophisticated manner, throughout the curriculum. This latter aspect of integrative models has received less focus in the literature, which may be a reason for the lingering concern about the vulnerability of basic science content. Still, some theoretical challenges to retaining a basic sciences presence throughout training have been raised, among which the key barriers include the difficulty of translating knowledge to new contexts, the transition of
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
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G Bandiera et al students’ cognitive focus towards advanced problem solving, and time constraints during the period of clinical training.17 To add another perspective to understanding integration, several authors of this paper (NNW, MM, CW, KK) have raised concerns about the conflation of curricular integration with cognitive integration (i.e. the creation of integrated understanding of basic and clinical sciences within the mind of the individual learner).18,19 The promise of integrated models may in fact be contingent upon the achievement of cognitive integration specifically. Woods and others have demonstrated the benefits of cognitive integration in positively influencing subsequent diagnosis and prioritisation.18–20 Implicit in many calls for integration, including the Edinburgh Declaration, is the assumption that a focus on curricular integration guarantees that cognitive integration will follow. This link may not be so solid. Kulasegaram et al.17, in their review of the integration of basic sciences, introduce the concept of learner-centricity rather than programmatic design as a nexus for integration, cautioning that the real measure of integration should be the degree to which individual learners achieve cognitive integration of knowledge. They argue that ‘simply creating “integrated” curricula will not automatically create cognitive integration’.17 Brauer and Ferguson15 also address this issue in discussing the advent of integrated courses and clerkship models. Further work on the relative roles of curricular design, individual teaching practice and the preparation of learners for achieving cognitive integration of knowledge is required.
RECENT TRENDS IN INTEGRATION PRACTICE
Despite recent advances in the theory of integration and concerns related thereto, it appears that the curricular integration train has left the station. There has been a marked increase in the number of publications related to integrated curricula in the last 10 years, which have included several comprehensive review articles. In their 2015 guide, Brauer and Ferguson15 outline the traditional rationale and current best practices for integration. Particular emphasis is placed on spiral integration (across both time and subject matter). One of the early programmes to embrace an integrated approach, wherein learning was carried out within body systems and across basic and applied sciences using a problem-based model, was that of McMaster
4
University. In one of the few outcomes-based programme evaluations, Shin et al.21 were able to show that graduates from the McMaster programme were more likely to be aware of current guidelines post-graduation and to more fully embrace techniques to enhance behaviour change in patients. This is one of the few studies to link curriculum design to an outcome that reflects the hopes placed in integrated curricula (those of greater patient-centricity and ability to influence patient behaviour). One liability of this design is that it still employs a sequential model whereby topic matter is explored once in a pre-clinical environment and then potentially again in the clinical phase, subject to the variability of clinical experiences encountered by individual students. Thus this model does not take advantage of the potential benefits of a repetitive or ‘spiral’ model, which is seen as supporting integration. Subsequent analyses of problem-based curricula demonstrate substantial equivalency of outcome compared with traditional curricula, albeit with higher learner satisfaction.22,23 An example of the early adoption of a fully integrated programme is that of the University of Dundee, where a spiral model is used to ensure programmed repeat exposure to concepts and increasing levels of sophistication.24 In the years since the adoption of the new Dundee curriculum in 1995, estimates of the prevalences of integrated curricula within jurisdictions have ranged from 50% to almost 90%.25 At present, few studies definitively demonstrate the benefits of integration to patient care or future practice patterns. The variation in programme design worldwide creates both an opportunity to identify best practices and a large number of confounding variables, which makes direct comparisons between programmes difficult.17 In a 1996 study, Schmidt et al.26 found that students exposed to an integrated curriculum progress faster in problem solving throughout their training, including in both the pre-clinical and clinical years, as measured by their accuracy in developing differential diagnosis lists for a standardised group of scripted patient presentations. In this study, students exposed to a problem-based training model did eventually demonstrate a level of performance similar to that of students in the integrated curriculum, and students in both of these models performed better than those in a traditional model.26 There have been a number of individual outcome studies of variable quality and, more recently, several meta-analyses and systematic reviews of educational outcomes of new integrated
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
Integration of science and practice models. However, none of the existing studies are definitive and many look at low-level outcomes such as learner satisfaction. It also remains unclear whether the benefits of integration relate only to the acquisition and retention of knowledge, or whether problem solving during clinical practice is also improved. Norman and Schmidt, in 2000, pointed out the limitations of curriculum-centred approaches and provided a current state analysis of research opportunities to further explore the impact of integrated curricula.27 As a result, the synthesised literature lends some support to the notion that integrated curricula can provide benefits in terms of the basic retention and application of knowledge, but leaves many questions unanswered with respect to behavioural outcomes and specific design features of effective integrated curricula.17,26,28 Empirical studies investigating higher-level learning outcomes and exploring the impact of integration on everyday clinical activity remain elusive. It should be noted that other attempts at integration have occurred in parallel, often in the pursuit of other goals unrelated to basic science integration. Longitudinal integrated clerkships, for example, seek to improve on continuity of care, increase the learner’s appreciation for the patient experience in navigating the system, and reduce the attrition of empathy and caring seen in traditional models.29 Such examples of integration may indeed yield positive results in the intended areas, but they should not be seen as representing the full integration of curricular elements for the purposes of achieving cognitive integration. Cognitive integration is not something that can be achieved by requiring that students learn in multiple clinical contexts or by presenting them with basic science and clinical content in parallel settings. Several studies suggest that expecting cognitive integration to occur spontaneously as students ‘bring’ their basic science to various contexts may not be effective.17,30 Although the Edinburgh Declaration may have encouraged problem solving in clinical and community settings as a basis for learning, it is becoming clear that a more comprehensive approach that requires deliberate focus on cognitive integration as a teaching and learning strategy across a breadth of contexts, rather than a simple dichotomy, is probably required. A more important lesson for educators may refer to the emphasis of instruction that explicitly integrates basic science mechanisms with clinical manifestations, including knowledge
about the ways in which contexts might impact understanding. This is not to say that learning in diverse clinical and community settings has no value. For example, offering trainees opportunities to experience various practice settings may provide them with exposure to a variety of health systems, an understanding of diverse patient populations and opportunities to better learn about the needs of the broader community.31 However, these are not the goals of learning in multiple contexts as described in the Edinburgh Declaration. Norman and Schmidt outline the futility of relying solely on large-scale curriculum design at the expense of deliberately teaching towards cognitive integration.27
WHAT ARE ‘BASIC SCIENCES’?
The emergence of an appreciation for the importance of a broad range of physician competencies such as communication and health advocacy has called into question the singular importance of the ‘basic science versus clinical science’ dichotomy. Instead, there is a need for a more nuanced conceptualisation of science that incorporates a broader knowledge base to account for these broader competencies.14,15 A recently published framework of the ‘non-bioscientific knowledge’ that underpins a range of clinical competencies highlights this point.32 For example, interacting in a culturally safe manner33 with indigenous communities and similarly structurally marginalised groups requires an understanding of several fundamental social constructs and an overview of their underlying theoretical bases. Formalised calls to view these content areas as ‘science’ and to integrate them into medical curricula, such as that of the Institute of Medicine in the USA, support this notion.34 As in other areas of clinical medicine, it may not be sufficient to teach the clinical content without the underlying basic science. For example, Beagan found that merely exposing students to the existence of social determinants of health without providing foundational teaching about the nature of such determinants did not result in any improvement in attitudes and awareness.35,36 This shift is indeed taking place in medical school curricula and even in medical school admissions, as manifested in recent changes to the Medical College Admission Test (MCAT) to include more social science content.37–40 Moreover, in the context of a shift from curricular integration to cognitive integration, the definition
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
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G Bandiera et al of basic sciences relevant to medical expert knowledge is further expanded to allow for any form of knowledge that can be used to establish meaningful, conceptual understanding of clinical knowledge and experiences.30,35,36 Integration is achieved when the learner or practitioner develops a coherent mental representation of medical knowledge, including explicit connections between the signs and symptoms of disease and underlying biological, psychological and sociological mechanisms. This integrated understanding allows learners to more effectively solve clinical problems and serves as a foundation upon which new knowledge can be built.41 The model of ‘new’ basic and clinical sciences proposed by Lucey, which includes knowledge of psychology, anthropology, human factors engineering and economics as basic sciences fundamental to medical expertise in the future, is consistent with this new conception of integration and sets a whole new standard for knowledge integration that could not have been imagined in 1988.42
MOVING FORWARD: IMPLICATIONS FOR MEDICAL EDUCATION
In the 30 years since the Edinburgh Declaration called for integrated curricula, there has been ongoing support for the basic premise of integration, but little progress in terms of either evidence-based strategies for curricular integration or demonstration of impact. With the emergence of a new and broader definition of basic science and a focus on cognitive as well as curricular integration comes an opportunity to reconsider the purpose of integration and to renew efforts to achieve the intended vision. To avoid the endless pursuit of an ill-formed idea,43 teachers, curriculum designers and education researchers must carefully consider this expanded definition of integration in the deliberate construction of instructional tools, problem-solving activities, clinical experiences and research questions. The current conception of integration suggests that it has more value that extends beyond supporting better acquisition and retention of knowledge. An integrated understanding of the basic and clinical sciences can prepare future clinicians to use their knowledge productively to acquire new knowledge, perform in a complex system and work to recognise and rectify health disparities.39,41,44 Future research on the cognitive integration of many forms of science should focus on the impact of integration on knowledge acquisition and clinical activity in order
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to best advance our theoretical understanding and serve as a guide for instructional and curricular design. Moving our thinking forward on integration through these theoretical and empirical advances can allow us to finally make good on the challenge raised in the Edinburgh Declaration.
Contributors: GB and NNW contributed to the drafting of this paper. All authors contributed to the conceptualising of this paper and to its critical revision. All authors approved the final manuscript for publication. Acknowledgements: None. Funding: None. Conflicts of interest: None. Ethical approval: Not applicable.
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ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
Integration of science and practice 11 de Bruin AB, Schmidt HG, Rikers RM. The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modelling approach. Acad Med 2005;80 (8):765–73. 12 Rikers RMJP, Loyens SMM, Schmidt HG. The role of encapsulated knowledge in clinical case representations of medical students and family doctors. Med Educ 2004;38 (10):1035–43. 13 Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ 2015;49 (10):961–73. 14 Bandiera G, Boucher A, Neville A, Kuper A, Hodges B. Integration and timing of basic and clinical sciences education. Med Teach 2013;35 (5):381–7. 15 Brauer DG, Ferguson KJ. The integrated curriculum in medical education: AMEE Guide No. 96. Med Teach 2015;37 (4):312–22. 16 Harden RM. The integration ladder: a tool for curriculum planning and evaluation. Med Educ 2000;34 (7):551–7. 17 Kulasegaram KM, Martimianakis MA, Mylopoulos M, Whitehead CR, Woods NN. Cognition before curriculum: rethinking the integration of basic science and clinical learning. Acad Med 2013;88 (10):1578–85. 18 Woods NN. Science is fundamental: the role of biomedical knowledge in clinical reasoning. Med Educ 2007;41 (12):1173–7. 19 Woods NN, Brooks LR, Norman GR. It all makes sense: biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract 2007;12 (4):405. 20 Baghdady MT, Carnahan H, Lam EW, Woods NN. Integration of basic sciences and clinical sciences in oral radiology education for dental students. J Dent Educ 2013;77 (6):757–63. 21 Shin JH, Haynes RB, Johnston ME. Effect of problembased, self-directed undergraduate education on lifelong learning. CMAJ 1993;148 (6):969–76. 22 Koh GC-H, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178 (1):34–41. 23 Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med 1993;68 (7):550–63. 24 Harden RM, Davis MH, Crosby JR. The new Dundee medical curriculum: a whole that is greater than the sum of the parts. Med Educ 1997;31 (4):264–71. 25 Elliott M. Are we going in the right direction? A survey of the undergraduate medical education in Canada, Australia and the United Kingdom from a general practice perspective. Med Teach 1999;21 (1):53–60. 26 Schmidt HG, Machiels-Bongaerts M, Hermans H, ten Cate TJ, Venekamp R, Boshuizen H. The development of diagnostic competence: comparison of a problem-based, an integrated, and a
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conventional medical curriculum. Acad Med 1996;71 (6):658–64. Norman GR, Schmidt HG. Effectiveness of problembased learning curricula: theory, practice and paper darts. Med Educ 2000;34 (9):721–8. Nouns Z, Schauber S, Witt C, Kingreen H, Sch€ uttpelzBrauns K. Development of knowledge in basic sciences: a comparison of two medical curricula. Med Educ 2012;46 (12):1206–14. Hudson JN, Poncelet AN, Weston KM, Bushnell JA, Farmer EA. Longitudinal integrated clerkships. Med Teach 2017;39 (1):7–13. Kulasegaram K, Manzone JC, Ku C, Skye A, Wadey V, Woods NN. Cause and effect: testing a mechanism and method for the cognitive integration of basic science. Acad Med 2015;90 (11 Suppl):63–9. Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: systematic review. BMJ 2005;331 (7513):387–91. Kuper A, Veinot P, Leavitt J, Levitt S, Li A, Goguen J, Schreiber M, Richardson L, Whitehead CR. Epistemology, culture, justice and power: nonbioscientific knowledge for medical training. Med Educ 2017;51 (2):158–73. Smye V, Josewski V, Kendall E. Cultural Safety: An Overview. Draft report for the First Nations, Inuit and M etis Advisory Committee, Mental Health Commission of Canada 2010. Vanselow N, Cuff PA. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: National Academies Press 2004. Beagan BL. Teaching social and cultural awareness to medical students: ‘It’s all very nice to talk about it in theory, but ultimately it makes no difference’. Acad Med 2003;78 (6):605–14. Goldszmidt M, Minda JP, Devantier SL, Skye AL, Woods NN. Expanding the basic science debate: the role of physics knowledge in interpreting clinical findings. Adv Health Sci Educ Theory Pract 2012;17 (4):547–55. Kaplan RM, Satterfield JM, Kington RS. Building a better physician – the case for the new MCAT. N Engl J Med 2012;366 (14):1265–8. Kasper J, Greene JA, Farmer PE, Jones DS. All health is global health, all medicine is social medicine: integrating the social sciences into the preclinical curriculum. Acad Med 2016;91 (5):628–32. Kuper A, D’Eon M. Rethinking the basis of medical knowledge. Med Educ 2011;45 (1):36–43. Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The necessity of social medicine in medical education. Acad Med 2015;90 (5):565–8. Mylopoulos M, Woods N. Preparing medical students for future learning using basic science instruction. Med Educ 2014;48 (7):667–73.
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G Bandiera et al 42 Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med 2013;173 (17):1639–43. 43 Whitehead CR, Hodges BD, Austin Z. Captive on a carousel: discourses of ‘new’ in medical education 1910–2010. Adv Health Sci Educ Theory Pract 2013;18 (4):755–68.
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44 Sockalingam S, Mulsant BH, Mylopoulos M. Beyond integrated care competencies: the imperative for adaptive expertise. Gen Hosp Psychiatr 2016;43: 30–1. Received 1 March 2017; editorial comments to author 10 April 2017, accepted for publication 31 May 2017
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
CONTEXT In 1988, the Edinburgh Declaration challenged medical teachers, curriculum designers and leaders to make an organised effort to change medical education for the better. Among a series of recommendations was a call to integrate training in science and clinical practice across a breadth of clinical contexts. The aim was to create physicians who could serve the needs of all people and provide care in a multitude of contexts. In the years since, in the numerous efforts towards integration, new models of curricula have been proposed and implemented with varying levels of success. SCOPE OF REVIEW In this paper, we examine the evolution of curricular integration since the Edinburgh Declaration, and discuss theoretical advances and practical
solutions. In doing so, we draw on recent consensus reports on the state of medical education, emblematic initiatives reported in the literature, and developments in education theory pertinent to the role of integrated curricula. CONCLUSIONS Interest in integration persists despite 30 years of efforts to respond to the Edinburgh Declaration. We argue, however, that a critical shift has taken place with respect to the conception of integration, whereby empirical models support a view of integration as pertaining to both cognitive activity and curricular structure. In addition, we describe a broader definition of ‘basic science’ relevant to clinical practice that encompasses social and behavioural sciences, as well as knowledge derived from biomedical science.
Medical Education 2017 doi: 10.1111/medu.13386
1 PostMD Education, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada 2 Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada 3 The Wilson Centre, University of Toronto, Toronto, Ontario, Canada 4 Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada 5 Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
6 Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
Correspondence: Glen Bandiera, PostMD Education, University of Toronto, 500 University Avenue, 6th Floor, Toronto, Ontario M5G 1V7, Canada. Tel: 00 1 416 946 3844; E-mail: [email protected]
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
1
G Bandiera et al
INTRODUCTION
Medical school curricula that integrate the teaching of basic and clinical sciences across diverse training contexts remain a much-vaunted potential solution to many of the challenges facing the practice of medicine. Abraham Flexner first recognised the complementary roles of basic and applied content, championing a model in which the former was regarded as a necessary foundation upon which subsequent education in the latter should be based.1,2 Almost 80 years after Flexner’s hallmark report,2 educators convened at the 1988 World Conference on Medical Education of the World Federation for Medical Education. The ‘Edinburgh Declaration’ that arose from the conference asserted that: ‘the aim of medical education is to produce doctors who will promote the health of all people’.3 In recognition of the view that medicine was falling short on this mandate in critical areas, the Edinburgh Declaration challenged the international medical education community to join ‘an organised and sustained programme to alter the character of medical education so that it truly meets the defined needs of the society in which it is situated’.3 The Declaration outlined eight recommendations that could be addressed within medical schools and a further four that were felt to require broader engagement. Of the former, Recommendation 7 states: ‘Pursue integration of education in science and education in practice, also using problem solving in clinical and community settings as a base for learning.’3 So, 30 years later, have we made good on this recommendation? In this paper, we examine the evolution of curricular integration in medical schools since the Edinburgh Declaration with an emphasis on establishing ongoing relevance, assessing the current state of integration and critically reflecting on what integration really is. We also investigate the importance of exposure to multiple training contexts, and treat problem solving not as a method unto itself, but as one means by which integration can manifest in curricula.
THE ONGOING PURSUIT OF INTEGRATION
Although a number of key changes have arisen in how the basic sciences pertinent to medicine are conceptualised and their role in clinical practice, the ideal of the integration of the basic and clinical sciences has continued to be a central issue in the years since the 1988 World Conference on Medical
2
Education. Several interim high-profile initiatives have emphasised the need to pursue integration. For example, the Association of American Medical Colleges and the Howard Hughes Medical Institute (AAMC–HHMI) released a document in 2009 acknowledging that the ‘application of scientific knowledge in medicine requires attention both to the patient as an individual and in a social context’ and that ‘the biology of individual patients is complex and variable and is influenced by genetic, social and environmental factors’, and further specifying that ‘the medical school curriculum should be integrated across disciplines and repeatedly emphasise the importance and relevance of the sciences basic to medicine’.4 Both the Edinburgh Declaration and the AAMC–HHMI documents link integration with an increased likelihood of graduates meeting broader societal health mandates. In 2009, the Association of Faculties of Medicine of Canada released a report entitled ‘The Future of Medical Education in Canada: A Collective Vision for MD Education’.5 Embedded within the recommendation to ‘[b]uild on the scientific basis of medicine’, the following detail emerges: ‘. . .both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience’, along with ‘[t]hese two complementary domains must be increasingly integrated so that students think about clinical applications as they learn basic sciences and about scientific principles as they learn clinical skills’.5 In relation to the Edinburgh Declaration’s reference to clinical and community settings, the report also includes a categorical recommendation to ensure learners experience ‘diversified training contexts’.5 The 2010 Lancet Commission report ‘Health Professionals for a New Century’ further recommends: ‘Alongside specific technical skills, interprofessional education should focus on crosscutting generic competencies, such as analytical abilities. . . leadership and management capabilities. . . and communication skills.’6 Accreditation has also been used as a lever for change in this direction. As examples, the Liaison Committee on Medical Education in the USA requires curricula to be ‘coherent’, ‘coordinated’ and ‘integrated’.7 The Australian Medical Council mandates that integration include: ‘. . .both horizontal (within a programme segment or year) and vertical (across successive programme segments or years) integration of related subject matter. . . [in a] process of integration [that] allows students to
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
Integration of science and practice see how scientific knowledge and clinical experience are combined to support good medical practice.’8 The UK General Medical Council mandates that schools provide ‘learning opportunities that integrate basic and clinical science, enabling them to link theory and practice’.9 Such expert documents and accreditation emphasis from multiple jurisdictions imply strong support for integration. We can infer that the face validity of pursuing integration and diversified learning contexts is alive and well. Despite the confidence implied in these decisive recommendations, however, recent research has started to shed some light on the nature and promise of integration that should cause the medical education community to revisit what, exactly, these accepted approaches are meant to accomplish.
CURRENT CONCEPTIONS OF INTEGRATION
The Edinburgh Declaration strongly implied that the use of integrated models situated in various learning environments held promise to improve learning through both increased retention and increased ability to apply knowledge for the betterment of human health. A model of integration was envisioned in which learners would encounter early in their training a clinical environment that would provide opportunities not only to learn the applied skills required, but also to solidify learning around relevant aspects of basic sciences. At the time of the Declaration, the assumption that basic science training positively influences clinical competence was largely taken at face value. Since then, empirical demonstration of the role of basic science and the effectiveness of integration has been an elusive goal. There have been a number of attempts to systemically study whether the basic science content covered in the early years of medical training has any impact on the acquisition and use of clinical content in later years. Structural equation modelling employed by Donnon and Violato10 found that basic science knowledge and clinical knowledge independently contribute to performance on clinical competency assessments in medical school. This was positioned as support for the theoretical perspective that basic science and clinical content acquired in the first 2 years of training within a single medical curriculum can separately influence later clinical reasoning.10 By contrast, other studies examining the clinical reasoning of both medical students and practising physicians have suggested the two forms of knowledge can in fact be integrated, supporting
an encapsulation model in which the contribution of basic science knowledge to diagnostic reasoning is mediated by its relationship to clinical knowledge.11–13 In a thorough analysis of the current state of Canadian medical education conducted in 2010, two authors of this paper (GB, AK) and others explored the role of basic sciences.14 Through the synthesis of data arising from a literature review, key informant interviews and several panel symposia, it became clear that there is not uniform agreement on the proper degree of integration or on the relative balance of basic versus applied sciences. Moreover, debate regarding the importance of basic sciences is largely limited to those within the professional field; to those outside the field, the importance of basic sciences in clinical practice is paramount. Within the field, there was a clear rift between the camp that felt that basic sciences is a necessary foundation for further training in clinical medicine and that this foundational knowledge is in fact a defining characteristic of the medical practitioner, and another camp that felt the role of basic sciences should be limited to the minimum required to ensure effective practice and that the role of the medical practitioner is primarily to solve problems using an array of skills acquired from a broad swathe of content areas. Indeed, as identified in the analysis of Canadian medical education and reinforced by Brauer and Ferguson in a more recent review, there remains a great deal of concern that early introduction of clinical experiences may result in a devaluing of basic science knowledge and in the displacement of key content from the curriculum.14,15 It is important to note that there are multiple competing conceptions of integration within medical education curricula.16 Although integration is often seen as a way to introduce broader clinical content earlier in medical training and to establish the basis for contextual learning, it should not be forgotten that integration can also be seen as a way to continue the inclusion of basic sciences over time, in an ever more sophisticated manner, throughout the curriculum. This latter aspect of integrative models has received less focus in the literature, which may be a reason for the lingering concern about the vulnerability of basic science content. Still, some theoretical challenges to retaining a basic sciences presence throughout training have been raised, among which the key barriers include the difficulty of translating knowledge to new contexts, the transition of
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G Bandiera et al students’ cognitive focus towards advanced problem solving, and time constraints during the period of clinical training.17 To add another perspective to understanding integration, several authors of this paper (NNW, MM, CW, KK) have raised concerns about the conflation of curricular integration with cognitive integration (i.e. the creation of integrated understanding of basic and clinical sciences within the mind of the individual learner).18,19 The promise of integrated models may in fact be contingent upon the achievement of cognitive integration specifically. Woods and others have demonstrated the benefits of cognitive integration in positively influencing subsequent diagnosis and prioritisation.18–20 Implicit in many calls for integration, including the Edinburgh Declaration, is the assumption that a focus on curricular integration guarantees that cognitive integration will follow. This link may not be so solid. Kulasegaram et al.17, in their review of the integration of basic sciences, introduce the concept of learner-centricity rather than programmatic design as a nexus for integration, cautioning that the real measure of integration should be the degree to which individual learners achieve cognitive integration of knowledge. They argue that ‘simply creating “integrated” curricula will not automatically create cognitive integration’.17 Brauer and Ferguson15 also address this issue in discussing the advent of integrated courses and clerkship models. Further work on the relative roles of curricular design, individual teaching practice and the preparation of learners for achieving cognitive integration of knowledge is required.
RECENT TRENDS IN INTEGRATION PRACTICE
Despite recent advances in the theory of integration and concerns related thereto, it appears that the curricular integration train has left the station. There has been a marked increase in the number of publications related to integrated curricula in the last 10 years, which have included several comprehensive review articles. In their 2015 guide, Brauer and Ferguson15 outline the traditional rationale and current best practices for integration. Particular emphasis is placed on spiral integration (across both time and subject matter). One of the early programmes to embrace an integrated approach, wherein learning was carried out within body systems and across basic and applied sciences using a problem-based model, was that of McMaster
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University. In one of the few outcomes-based programme evaluations, Shin et al.21 were able to show that graduates from the McMaster programme were more likely to be aware of current guidelines post-graduation and to more fully embrace techniques to enhance behaviour change in patients. This is one of the few studies to link curriculum design to an outcome that reflects the hopes placed in integrated curricula (those of greater patient-centricity and ability to influence patient behaviour). One liability of this design is that it still employs a sequential model whereby topic matter is explored once in a pre-clinical environment and then potentially again in the clinical phase, subject to the variability of clinical experiences encountered by individual students. Thus this model does not take advantage of the potential benefits of a repetitive or ‘spiral’ model, which is seen as supporting integration. Subsequent analyses of problem-based curricula demonstrate substantial equivalency of outcome compared with traditional curricula, albeit with higher learner satisfaction.22,23 An example of the early adoption of a fully integrated programme is that of the University of Dundee, where a spiral model is used to ensure programmed repeat exposure to concepts and increasing levels of sophistication.24 In the years since the adoption of the new Dundee curriculum in 1995, estimates of the prevalences of integrated curricula within jurisdictions have ranged from 50% to almost 90%.25 At present, few studies definitively demonstrate the benefits of integration to patient care or future practice patterns. The variation in programme design worldwide creates both an opportunity to identify best practices and a large number of confounding variables, which makes direct comparisons between programmes difficult.17 In a 1996 study, Schmidt et al.26 found that students exposed to an integrated curriculum progress faster in problem solving throughout their training, including in both the pre-clinical and clinical years, as measured by their accuracy in developing differential diagnosis lists for a standardised group of scripted patient presentations. In this study, students exposed to a problem-based training model did eventually demonstrate a level of performance similar to that of students in the integrated curriculum, and students in both of these models performed better than those in a traditional model.26 There have been a number of individual outcome studies of variable quality and, more recently, several meta-analyses and systematic reviews of educational outcomes of new integrated
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
Integration of science and practice models. However, none of the existing studies are definitive and many look at low-level outcomes such as learner satisfaction. It also remains unclear whether the benefits of integration relate only to the acquisition and retention of knowledge, or whether problem solving during clinical practice is also improved. Norman and Schmidt, in 2000, pointed out the limitations of curriculum-centred approaches and provided a current state analysis of research opportunities to further explore the impact of integrated curricula.27 As a result, the synthesised literature lends some support to the notion that integrated curricula can provide benefits in terms of the basic retention and application of knowledge, but leaves many questions unanswered with respect to behavioural outcomes and specific design features of effective integrated curricula.17,26,28 Empirical studies investigating higher-level learning outcomes and exploring the impact of integration on everyday clinical activity remain elusive. It should be noted that other attempts at integration have occurred in parallel, often in the pursuit of other goals unrelated to basic science integration. Longitudinal integrated clerkships, for example, seek to improve on continuity of care, increase the learner’s appreciation for the patient experience in navigating the system, and reduce the attrition of empathy and caring seen in traditional models.29 Such examples of integration may indeed yield positive results in the intended areas, but they should not be seen as representing the full integration of curricular elements for the purposes of achieving cognitive integration. Cognitive integration is not something that can be achieved by requiring that students learn in multiple clinical contexts or by presenting them with basic science and clinical content in parallel settings. Several studies suggest that expecting cognitive integration to occur spontaneously as students ‘bring’ their basic science to various contexts may not be effective.17,30 Although the Edinburgh Declaration may have encouraged problem solving in clinical and community settings as a basis for learning, it is becoming clear that a more comprehensive approach that requires deliberate focus on cognitive integration as a teaching and learning strategy across a breadth of contexts, rather than a simple dichotomy, is probably required. A more important lesson for educators may refer to the emphasis of instruction that explicitly integrates basic science mechanisms with clinical manifestations, including knowledge
about the ways in which contexts might impact understanding. This is not to say that learning in diverse clinical and community settings has no value. For example, offering trainees opportunities to experience various practice settings may provide them with exposure to a variety of health systems, an understanding of diverse patient populations and opportunities to better learn about the needs of the broader community.31 However, these are not the goals of learning in multiple contexts as described in the Edinburgh Declaration. Norman and Schmidt outline the futility of relying solely on large-scale curriculum design at the expense of deliberately teaching towards cognitive integration.27
WHAT ARE ‘BASIC SCIENCES’?
The emergence of an appreciation for the importance of a broad range of physician competencies such as communication and health advocacy has called into question the singular importance of the ‘basic science versus clinical science’ dichotomy. Instead, there is a need for a more nuanced conceptualisation of science that incorporates a broader knowledge base to account for these broader competencies.14,15 A recently published framework of the ‘non-bioscientific knowledge’ that underpins a range of clinical competencies highlights this point.32 For example, interacting in a culturally safe manner33 with indigenous communities and similarly structurally marginalised groups requires an understanding of several fundamental social constructs and an overview of their underlying theoretical bases. Formalised calls to view these content areas as ‘science’ and to integrate them into medical curricula, such as that of the Institute of Medicine in the USA, support this notion.34 As in other areas of clinical medicine, it may not be sufficient to teach the clinical content without the underlying basic science. For example, Beagan found that merely exposing students to the existence of social determinants of health without providing foundational teaching about the nature of such determinants did not result in any improvement in attitudes and awareness.35,36 This shift is indeed taking place in medical school curricula and even in medical school admissions, as manifested in recent changes to the Medical College Admission Test (MCAT) to include more social science content.37–40 Moreover, in the context of a shift from curricular integration to cognitive integration, the definition
ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education. MEDICAL EDUCATION 2017
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G Bandiera et al of basic sciences relevant to medical expert knowledge is further expanded to allow for any form of knowledge that can be used to establish meaningful, conceptual understanding of clinical knowledge and experiences.30,35,36 Integration is achieved when the learner or practitioner develops a coherent mental representation of medical knowledge, including explicit connections between the signs and symptoms of disease and underlying biological, psychological and sociological mechanisms. This integrated understanding allows learners to more effectively solve clinical problems and serves as a foundation upon which new knowledge can be built.41 The model of ‘new’ basic and clinical sciences proposed by Lucey, which includes knowledge of psychology, anthropology, human factors engineering and economics as basic sciences fundamental to medical expertise in the future, is consistent with this new conception of integration and sets a whole new standard for knowledge integration that could not have been imagined in 1988.42
MOVING FORWARD: IMPLICATIONS FOR MEDICAL EDUCATION
In the 30 years since the Edinburgh Declaration called for integrated curricula, there has been ongoing support for the basic premise of integration, but little progress in terms of either evidence-based strategies for curricular integration or demonstration of impact. With the emergence of a new and broader definition of basic science and a focus on cognitive as well as curricular integration comes an opportunity to reconsider the purpose of integration and to renew efforts to achieve the intended vision. To avoid the endless pursuit of an ill-formed idea,43 teachers, curriculum designers and education researchers must carefully consider this expanded definition of integration in the deliberate construction of instructional tools, problem-solving activities, clinical experiences and research questions. The current conception of integration suggests that it has more value that extends beyond supporting better acquisition and retention of knowledge. An integrated understanding of the basic and clinical sciences can prepare future clinicians to use their knowledge productively to acquire new knowledge, perform in a complex system and work to recognise and rectify health disparities.39,41,44 Future research on the cognitive integration of many forms of science should focus on the impact of integration on knowledge acquisition and clinical activity in order
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to best advance our theoretical understanding and serve as a guide for instructional and curricular design. Moving our thinking forward on integration through these theoretical and empirical advances can allow us to finally make good on the challenge raised in the Edinburgh Declaration.
Contributors: GB and NNW contributed to the drafting of this paper. All authors contributed to the conceptualising of this paper and to its critical revision. All authors approved the final manuscript for publication. Acknowledgements: None. Funding: None. Conflicts of interest: None. Ethical approval: Not applicable.
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