Quoting the philosophy attributed to Socrates, “I cannot teach anybody anything, I can only make them think.” When medical school curricular leaders push for change, we must ponder the question: How do we best revise medical school curricula to spark our students to think? Most curriculum revisions can be broadly categorized into one of two categories: instructional methods (pedagogical) reform or content reform.
Pedagogical reforms preserve existing curricular content but aim to maximize active learning relying on the principles of learning theories such as context theory and motivation theory. Content reforms on the other hand focus on prioritizing which content is more relevant to preparing healthcare professionals of the future. Curriculum integration has gained popularity in the past two decades as an approach to content reform. Outcome-based integrated curricula focus on specific medical education objectives, rather than a stack of courses and clerkships with siloed cultures, faculty, rules, and assessments. One key reality to keep in mind is that most curriculum reform initiatives for medical school curricula emphasize early inclusion of clinical experiences at the expense of time and content allocation for basic sciences.
Since content reform initiatives are inherently a zero-sum game, curricular additions, no matter how valuable and unanimously agreed upon by faculty, mandate discarding already existing content to make room for new curricular components. Of particular relevance is the concept of vertical integration, which links knowledge in a stepwise-fashion from fundamentals to advanced lessons across a program of study. In medical education, vertical integration implies the integration between the clinical and basic science curricular components where basic sciences are embedded in a clinical context throughout the program. Adoption of vertical integration at the University of Michigan Medical School resulted in a reduction of the didactic-based preclinical curriculum including basic sciences from 19 months to 13 months. However, this systematic reduction in the interest of more and earlier incorporation of clinical material is not without consequence. A 2003 Institute of Medicine report indicated that in spite of the rapidly expanding scientific evidence available for clinicians to guide their healthcare management decision making process, clinicians are not consistently exercising identification and appraisal of such evidence nor in its application to practice. Therefore, it seems only logical to reverse-integrate or in other words integrate pertinent basic science content back into the clerkship years.
The value proposition of basic sciences integration in undergraduate medical education as the foundation of clinical knowledge is undisputed. Medical students’ performance in the basic science curriculum has been demonstrated to be indicative of later success of physicians. It has further been suggested that revisiting the basic sciences in the clinical years can enhance understanding of how basic sciences support the practice of clinical sciences. Vertical integration with preservation of basic sciences promotes knowledge and skills essential for critical reasoning, problem solving and the practice of evidence-based medicine as indicated by reports from Canada, the United Kingdom, Australia and New Zealand. Robust basic science training also promotes professional identity formation as a clinician scientist and preparedness for a lifelong, learning-oriented clinical practice.
The exponentially increasing basic science content mandates the rigorous vetting of material for curricular inclusion. Ideally, conceptual frameworks outlining key basic science content are developed at the outset. As medical students progress through the curriculum and subsequently residency, additional information connecting clinical content to the preexisting basic science cognitive framework needs to be revisited.
We had the privilege of serving on a working group established by the Texas A&M University College of Medicine (TAMU COM) Curriculum Committee to develop a vertical integration intervention for the clerkship curriculum at the TAMU COM. Initial discussion with the six core clerkships director ensured faculty buy-in as well as incorporation of their feedback. The working group met on a weekly basis. The group developed a number of basic science integration exercises (BSIE) for each clerkship. Each exercise focused on one disease and a template used in the TAMU COM Engineering Medicine (EnMED) track was adapted for all exercises. Key template components included a clinical vignette, pertinent clinical findings and diagnostic studies, discussion of a differential diagnosis, applicable clinical practice guidelines, basic science correlates, and innovation applications. During the working group meetings, we selected relevant clinical practice and research publications for independent review by learners. The group also established written questions for students for each BSIE, and solicited feedback on early BSIE drafts from clerkship leadership.
In an obstetrics and gynecology clerkship case, we introduced an article to stimulate the students to integrate understanding of epigenetic inheritance of polycystic ovary syndrome (PCOS) into their clinical studies of this condition. The students were asked to explain the role of PCOS mouse models in elucidating how epigenetic modulation connected early-life exposures to subsequent phenotypes and contributed to the development and familial transmission of PCOS. In another BSIE in the family medicine clerkship utilized an article on the use of home stool tests to review the molecular underpinnings of colon carcinoma and to introduce the concept of liquid biopsy.
Our institution plans to measure curricular effectiveness through surveys to medical students and faculty members and review of new trends in NBME Customized Assessment Service (CAS) subscores. We intend to disseminate the process and preliminary results internally to the TAMU COM at one of the biannual Council for Course and Clerkship Directors retreats to demonstrate continued inclusion of TAMU COM faculty and student input and to raise awareness of the initiative among administrative leaders. In addition, we plan to present our experience at medical education and/or corresponding medical specialty conferences. Publication of our findings will inform current and future initiatives of vertical integration in the broader medical education community. At a later stage we plan to investigate the impact of basic science integration exercises on students’ attitudes towards basic science related career choices.
Socrates, we need your wisdom now more than ever! We appreciate the general consensus around the merits and necessity of vertical integration; however, we could not agree upon the most effective approach, the curricular changes that will reliably yield superior educational outcomes, or the strategies to overcome implementation challenges. Further, metrics with known validity evidence still need to be established to measure outcomes and assess student buy-in and ideally, the long-term impact on clinical practice and career choices.
Acknowledgement: We thank Dr. Dianne Chico, Professor and Chair of the Department of Medical Education at TAMU COM for her critical review of the article and insightful suggestions.
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Medhat Askar, MD, PhD, MSHPE (Educators, ’11; Assessment ’12; Leaders ’13) is a health professions educator and laboratory medicine clinician. Medhat is currently Professor of Medical Education at Texas A&M Health Science Center College of Medicine. Medhat’s areas of professional interest include transplant diagnostics, healthcare systems and continuous professional development. Medhat can be followed on LinkedIn or contacted via email.
Heather Hoffmann, MD is a medical educator and previously served as Instructional Associate Professor at the Texas A&M College of Medicine. Heather’s areas of interest are team-based learning, vertical integration of medical education, and virtual teaching. Heather can be followed on LinkedIn.
Rania Cannaday, MD is a medical educator and clinical assistant professor at the Texas A&M University College of Medicine, where she serves as chair of the Vertical Integration Working Group. Her areas of professional interest include hematology oncology, clinical case integration exercises and clinicopathologic correlations. Rania can be contacted via email.